Network Health Digest (NHD) - June 2018

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NETWORK HEALTH DIGEST The Magazine for Dietitians, Nutritionists and Healthcare Professionals

NHDmag.com

June 2018: Issue 135

FIBRE AND INFLAMMATORY BOWEL DISEASE BREASTFEEDING iMAP GUIDELINES ONS PRESCRIBING THE ALKALINE DIET

Multidisciplinary team work pages 35-37

FROM THE EDITOR

WELCOME Emma Coates Editor Emma has been a registered dietitian for 12 years, with experience of adult and paediatric dietetics.

If you have important news or research updates to share with NHD, or would like to send a letter to the Editor, please email us at info@network healthgroup.co.uk We would love to hear from you.

So we’re slap bang in the middle; at the midpoint of another year. Hopefully, we can look back on our achievements so far and plan for further success to see the year out. How has your first half of the 2018 game been? Ready for round two, or do you need to make some adjustments for the next six-month run? Whether your glass is half full or looking a bit empty, NHD is here to keep you learning and developing - and June’s issue is no different. The role of dietary fibre in IBD is the topic of conversation for Rebecca Gasche and also features as our Cover Story this issue. Rebecca’s article looks at the current evidence for dietary advice and IBD, with a particular focus on fibre. We always enjoy hearing from Dr Rosan Meyer, along with Lisa Waddell and Carina Venter, in her expert role as Paediatric Research Dietitian at Imperial College London. They report on the important updates to the iMAP guidelines for cow’s milk allergy, including the revised milk ladder, as well as discussing steps for future improvements. Our paediatric articles in this issue also include breastfeeding, as Priya Tew explores the potential lifelong effects of breastfeeding on the microbiome and the possible metabolic and long-term health effects. Maeve Hanan's weight management article examines the controversial alkaline diet which has gained popularity over recent years. Maeve investigates how this diet emerged and looks at the current evidence base surrounding it. Clarity, of course, is hugely important when providing advice on weight management, but also in many other fields relating to nutrition. Hannah Pearse, who is based at the Institute

JUNE

X X X X X X X X X X X X

of Grocery Distribution (IGD), joins us this month to explain a little more about the development of nutritional labelling. She highlights the barriers that consumers are facing when trying to understand front-of-pack nutrition labels. The research from IGD makes for interesting reading. Malnutrition is never far away for anyone working in health or social care, with more than three million people in the UK estimated to be either malnourished or at risk of malnutrition. The task to tackle this largely preventable, yet growing problem is huge. Katherine Sykes from the BSNA lays out the requirements for individual circumstances when considering the prescribing of ONS. Reading about the variety of roles in dietetics and nutrition can be inspirational and this month Claire Chaudhry gives us an insight into multidisciplinary team work, particularly her role in primary care working with patients with diabetes. We have a fascinating Day in the Life too, from Maryam Bader who tells us about the work she undertakes as an Early Years Community Food Worker in the busy London boroughs of Lambeth and Southwark. So, along with our regular columns, we have another fine issue of NHD in half a nutshell. Rock on NHD fans! “Woah, we’re half way there." Emma www.NHDmag.com June 2018 - Issue 135

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, CONTENTS

11 COVER STORY Fibre and inflammatory bowel disease

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News

8

Nutrition labelling

Latest industry and product updates

Unlocking the barriers for consumers

17 NON-IGE MEDIATED COW'S MILK ALLERGY iMAP guidelines

35 MDT IN PRIMARY CARE Diabetes delivery plan for Wales 38 Free-from bites News and product updates

21 Breastfeeding The effect on the microbiome

25 ONS PRESCRIBING Individual clinical requirements 30 The alkaline diet examined A look at the current evidence base

40 Face to face with Barbara Bray, Nutritionist 42 A day in the life of . . . An Early Years Community

Food Worker

44 Book review 40 Chances: finding

hope in a hungry world

46 Events & courses Dates for your diary

34 Dysphagia at mealtimes The challenges for HCPs

47 Dietitian's life Top 10 pet hates

Copyright 2018. All rights reserved. NH Publishing Ltd. Errors and omissions are not the responsibility of the publishers or the editorial staff. Opinions expressed are not necessarily those of the publisher or the editorial staff. Unless specifically stated, goods and/or services are not formally endorsed by NH Publishing Ltd which does not guarantee or endorse or accept any liability for any goods, services and/or job roles featured in this publication. Contributions and letters are welcome. Please email only to info@networkhealthgroup.co.uk and include daytime contact phone number for verification purposes. Unless previously agreed all unsolicited contributions will not receive payment if published. All paid and unpaid submissions may be edited for space, taste and style reasons.

Editor Emma Coates RD Publishing Director Julieanne Murray Publishing Editor Lisa Jackson Publishing Assistant Katie Dennis Special Features Ursula Arens News Dr Emma Derbyshire Design Heather Dewhurst

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Advertising Richard Mair Tel 01342 824073 richard@networkhealthgroup.co.uk Phone 0845 450 2125 (local call rate) Fax 0844 774 7514 Email info@networkhealthgroup.co.uk www.NHDmag.com www.dieteticJOBS.co.uk Address Suite 1 Freshfield Hall, The Square, Lewes Road, Forest Row, East Sussex RH18 5ES

www.NHDmag.com June 2018 - Issue 135

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NEWS

Emma Coates Editor Emma has been a registered dietitian for 12 years, with experience of adult and paediatric dietetics.

FOLIC ACID COULD REDUCE RISK OF STROKE Folic acid could help to reduce the risk cells and the of stroke in people with high levels of synthesis and homocysteine and a low platelet count, repair of DNA according to a new study about to be and RNA. published in The Journal of the American "Folic acid is College of Cardiology.1 also capable of Commenting on the study, Dr Gill lowering homoJenkins, a GP and advisor to the Health cysteine levels & Food Supplements Information in the blood. Service (HSIS), notes: "Most strikingly, This is important because high levels in this large analysis involving over of homocysteine are associated with 10,000 people with high blood pressure, increased risk of cardiovascular disease, those with a low blood platelet count including stroke." and high levels of homocysteine who During the study’s follow-up period took a combined daily dose of both of 4.2 years, a total of 210 first strokes enalapril (a prescription medication occurred in the enalapril-only group, used to treat high blood pressure) and and 161 first strokes in the enalapril-folic folic acid saw a 73% reduction in their acid group. The researchers found the risk of first stroke compared to people risk of first stroke reduced from 5.6% to who took only enalapril daily. 1.8% among patients with a low platelet "Folic acid is an essential B vitamin, count and high homocysteine levels, which is required for making red blood creating a 73% risk reduction in stroke. The Journal of the American College of Cardiology; Platelet Count Affects Efficacy of Folic Acid in Preventing First

1.

Stroke. Volume 71, Issue 19, May 2018 DOI: 10.1016/j.jacc.2018.02.072

To book your

UNDIAGNOSED AT RISK WITH DELAYS IN COELIAC DISEASE DIAGNOSIS Coeliac UK, the largest independent charity for people who need to live gluten free, product news says that delayed diagnosis of coeliac disease is creating a growing health problem across the UK with undiagnosed patients at risk of suffering with complications of for the next the disease, including irreversible neurological damage. In a study of patients with newly diagnosed coeliac disease, who had been issue of referred to a gastroenterology clinic, around three out of five had established NHD call neurological symptoms, including severe headache (45%), balance problems 01342 824073 (26%) and sensory symptoms (14%).¹ The treatment of gluten-related neurological conditions like coeliac disease, is a lifelong strict gluten-free diet. The longer the symptoms go untreated, the more likely there will be no or limited improvement in the condition. When there is gluten-related neurological damage, the glutenfree diet can make a difference, with improvements being related to earlier diagnosis. The charity launched a Research Fund in March this year to raise £5 million towards research into coeliac disease and other gluten-related autoimmune conditions. As part of the launch, the charity has thrown more light on the association with neurological conditions, along with the more severe and lifethreatening form of the disease, refractory coeliac disease type II, which is rare and affects a very small proportion of the coeliac population. For more information and video of case studies see: www.coeliac.org.uk/researchfund<http://www.coeliac. org.uk/researchfund

company's

1

Hadjivassiliou M et al. Neurological evaluation of patients with newly diagnosed coeliac disease presenting to

gastroenterologists (manuscript submitted)

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www.NHDmag.com June 2018 - Issue 135

NEWS

PRODUCT / INDUSTRY NEWS

SYMPTOMS OF OSTEOARTHRITIS REDUCED WITH SIMPLE CHANGES TO THE DIET One gram of fish oil a day could help reduce the pain of patients with osteoarthritis, a new study in Rheumatology reports.1 In the largest, most up-to-date study of its kind, researchers from the University of Surrey examined the link between diet and the effective self-management of osteoarthritis. Analysing 68 previous studies in the field, researchers found that a low-dose supplement of fish oil (one and a half standard capsules) could result in pain reduction for patients with osteoarthritis and help improve their cardiovascular health. Essential fatty acids in fish oil reduce inflammation in joints, helping to alleviate pain. Researchers also found that a reduction of weight for overweight and obese patients and the introduction of exercise tailored to mobility could also help ease the symptoms of osteoarthritis. A calorie restricted diet, combined with strengthening, flexibility and aerobic exercises, was identified as an effective approach in reducing pain in overweight patients. There is no evidence that a calorie restricted diet does anything beneficial for lean patients with the condition. Adopting a healthier lifestyle will also help reduce cholesterol levels in the blood - high blood cholesterol is known to be associated with osteoarthritis. An increase in foods rich in vitamin K such as kale, spinach and parsley was also found to deliver benefits to patients with osteoarthritis. Vitamin K is needed for vitamin-K-dependent

NETWORK HEALTH DIGEST

NUTRIUM IS A ONE-STOP-SHOP FOR ALL DIETITIANS AND NUTRITIONISTS

For professionals:  Complete nutritional assessment  Creation and analysis of meal plans and recipes  Appointments schedule  GDPR compliant For patients:  Reminders at mealtimes  Water intake reminders  Appointments confirmation  Chat with their dietitian You can try it for free at: www.nutrium.io (VKD) proteins, which are found in bone and cartilage. An inadequate intake of the vitamin adversely affects the working of the protein, affecting bone growth and repair and increasing the risk of osteoarthritis. 1

Thomas S et al (2018). What is the evidence for a role for diet and

nutrition in osteoarthritis? Rheumatology (Oxford). May; 57(Suppl 4): iv61-iv74. Published online 17/04/18. doi: 10.1093/rheumatology/key011

Coming in the July digital-only issue. View it online at www.NHDmag.com

• Chronic Obstructive Pulmonary Disease • Nutrition and bone health

• Dysphagia in hospital settings • Vitamin D update

www.NHDmag.com June 2018 - Issue 135

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PUBLIC HEALTH

UNLOCKING NUTRITION LABELLING FOR EVERYONE Hannah Pearse (RNutr) Head of Nutrition and Scientific Affairs, IGD (Institute of Grocery Distribution) Hannah has over 10 years of experience working in nutrition and technical roles in both retail and manufacturing. She currently heads up IGD's nutrition and science team, looking at how food and drink companies can work together to drive healthier eating in the UK.

REFERENCES Please visit the Subscriber zone at NHDmag.com

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Nearly half (46%) of shoppers feel that nutritional labels are too difficult to read; with that in mind, this article explores the barriers that consumers are facing when trying to understand front-of-pack nutrition labels and offers solutions from IGD (Institute of Grocery Distribution). Companies are legally required to provide huge amounts of information on their food and drink products, including the ingredients, the use by date and nutrition information. In addition, more than 80% of products on the market voluntarily display frontof-pack nutrition information so that shoppers can see at a glance how much energy, fat, saturates, sugars and salt are in a serving of food. However, nearly half of shoppers (46%) feel that nutrition labels are too difficult to read and, despite this information being widespread, it passes many of us by while we are out shopping making our daily food and drink choices. Research shows that only about a quarter (27%)1 of us use nutrition information, yet 46% agree they should read nutrition information on food labels more often. To help consumers make better use of front-of-pack nutrition information, IGD had to understand what was stopping people from using the information. The journey started in 2015 when the IGD research2 began, which included desk-based reviews of existing reports and papers. The research then moved to in-store observations and eye tracking while people shopped, focus groups, message testing and quantitative surveys. Seeing shoppers in a reallife environment was invaluable, demonstrating all the competing factors when food shopping and how confusing it can be to navigate healthier choices.

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As one shopper said, “It’s all grams and percentages. I came in here to do my shopping not a maths degree.” THE COMMON AREAS OF CONFUSION

Our research identified some common areas of confusion, including the following: Calories: It is not surprising that calories are confusing for consumers since companies must display information in kilocalories, kilojoules and the energy per 100g. Consumers also found the term ‘energy’ confusing, often associating energy as a good thing and calories as bad. One shopper said, “Children need their energy for sport. Don’t see why calories is listed under energy.” Reference Intakes (RI): The term ‘Reference Intakes’ was not as intuitive for consumers as the previous term - guideline daily amounts. One shopper commented, “I don’t know what it means. What is RI? I wouldn't have noticed it.” However, once Reference Intakes was explained, that the percentage represents how many calories, how much fat, saturates, sugars and salt a portion of food or drink contains, as a share of their daily allowance, shoppers did consider it a useful tool. Portion size: Despite the portion information being integral to the numbers on the front of pack, many ignored the stated portion, considered it irrelevant, unrealistic, or simply went on to consume a different amount.

Colour coding: Shoppers generally like and understand the traffic light concept. Some were confused about the criteria behind the colours and some struggled with how to negotiate a mixture of reds and greens. Products that don’t feature colour coding were not viewed positively, with consumers assuming there is something to hide. One shopper said, “They don’t put them on because they are worried there will be reds and it would stop you buying it.” Inconsistency: Even when products are displaying front-of-pack nutrition information, the inconsistent way it is displayed leads to confusion and requires additional effort to compare products at a glance. This included where the information is displayed on pack, the font size and the amount that is coloured. WHAT ARE IGD’S SOLUTIONS?

To help shoppers better understand the aspects of the front-of-pack labelling they find most confusing, IGD has worked with behaviour change specialists, marketeers and nutritionists, to develop simple messages to explain the main areas of confusion. These messages have been been rigorously tested to make sure that most people can understand them. ‘Know your . . .’ messages The overarching theme of the message ‘Know your…’ was developed because consumers want inclusive language that encourages them to act and learn more. We know from our research that 45% of people would like to learn more about nutrition information on labels to help make healthier choices. The messages cover five areas and consist of ‘core’ and ‘support’ messages depending on where the messages are displayed, for example at the point of sale in a shop, along the aisles in a store, or online. The five messages are: • Know your label - an introduction or summary of the front-of-pack label. • Know your colours - since most consumers like colour coding, this is a good starting point before explaining any numbers. • Know your portions - raising awareness, making consumers stop and think about the quantities they eat.

• Know your daily allowance - this is the most complex part of the label; RI is not a well understood term, whereas ‘daily allowance’ resonates better and encourages engagement. • Know your calories - awareness of calories is high, but often seen as the preserve of dieters, so focus is on driving personal relevance. All the messages and imagery have been developed in a simple-to-use guide and toolkit tailored for both industry and non-industry organisations available at www.igd.com/healthyeating. Improving consistency Our research found that 72% of shoppers agreed that it would be easier to understand food labels if they were consistently displayed across all products. To tackle this issue, IGD worked with nutritionists, regulatory and packaging experts, and consulted with a semiotic specialist - an expert in signs, symbols and meaningful communication - to develop best-practice guidance detailing how front-ofpack information should be displayed. IGD have built on existing guidance and regulations and have full support from the Department of Health. HOW CAN YOU GET INVOLVED?

To cut through this confusion, we need people to see these messages wherever they go from online shopping, to posters in stores, health websites, magazines - the possibilities are endless. IGD needs many companies and organisations to download our guide and share the messages with their audiences. We already have great commitment from many major retailers and manufactures including Aldi, Asda, Brakes, Compass, Kingsmill, Morrisons, Musgrave, Nestlé UK, Premier Foods, Sainsbury’s, Tesco and Waitrose - but we need more to truly have an impact. In addition, for companies already displaying, or wanting to display front-ofpack nutrition labels, we encourage them to download our best practice guide and adopt our recommendations. The guides can be accessed here: www.igd. com/healthyeating. www.NHDmag.com June 2018 - Issue 135

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COVER STORY

Rebecca Gasche Registered Dietitian, Countess of Chester Hospital NHS Trust Rebecca has a keen interest and specialises in gastroenterology dietetics. She currently works in the community setting in the Chester area, running clinics and group sessions to manage a wide range of gastroenterology conditions.

REFERENCES Please visit the Subscriber zone at NHDmag.com

FIBRE AND INFLAMMATORY BOWEL DISEASE In this article, the latest evidence for dietary advice and inflammatory bowel disease (IBD) will be reviewed, with particular focus on dietary fibre. IBD includes the diseases ulcerative colitis (UC) and Crohn’s disease, which are long-term conditions that cause inflammation of the gut. Crohn’s disease can result in inflammation anywhere in the digestive tract, from the mouth to the anus; however, it is most commonly seen in the small intestine or colon. Inflammation caused by UC is seen only in the colon and rectum and usually only the inner lining of the bowel is inflamed.1 It is unclear what causes IBD, but it is thought to be a combination of genetics and individual immune systems. Smoking is linked with an increased risk of developing Crohn’s disease.2 IBD can cause unpleasant symptoms, such as abdominal pain, loose and frequent bowel movements, fatigue and weight loss as a result of malabsorption. CURRENT DIETARY ADVICE

NICE guidance states that patients with Crohn’s disease should be offered advice on diet and nutrition, however, in the guidelines for UC, advice on diet is only mentioned when a patient is considering surgery.3,4 This only very brief advice in the guidance is likely due to the lack of robust evidence when it comes to diet and IBD, meaning that clinicians need to delve a little into the research to provide nutritional support to IBD patients. Currently, there are no proven dietary recommendations for IBD, as dietary intervention trials have been

limited by their lack of a placebo control group and the difficulty in capturing dietary intake with the potential for complex interactions between foods. Furthermore, dietary trials may not detect significant differences for patients on specific drug therapies.5 Despite a lack of robust evidence for diet and IBD, there are a number of diets which patients have been known to turn to in order to improve the symptoms caused by IBD. These include: the specific carbohydrate diet (SCD); the low fermentable oligosaccharide, disaccharide, monosaccharide and polyol (FODMAP) diet; the Paleolithic diet (Paleo) and the anti-inflammatory diet (IBD-AID).5 These diets have been mentioned in literature, but only through anecdotal evidence, and are, therefore, not in the official guidelines for managing IBD. Saying this, if these are the diets that patients are trialling to manage their diseases, it is important that healthcare professionals are aware of them and can advise accordingly. Despite the lack of evidence for diets to manage IBD, there is some evidence to support specific diets in certain situations, for example, enteral nutrition may be used during a flare up of Crohn’s disease, or a low residue (low fibre) diet may be used if there are strictures (narrowing of the bowel). The www.NHDmag.com June 2018 - Issue 135

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CONDITIONS & DISORDERS

Therapeutically, a low-fibre diet is part of the treatment in acute relapses of IBD (as well as other conditions such as irritable bowel syndrome and diverticulitis). . . . upon achieving remission, the amount of fibre should be systematically increased until achieving the recommended amount of fibre in a healthy diet. use of enteral nutrition for the management of Crohn’s disease was first described in the 1970s.6 Exclusive enteral nutrition has been seen to improve the symptoms of Crohn’s disease as it gives the bowel ‘rest’ and allows for mucosal healing, as well as being shown to reduce the production of bacterial metabolites within two weeks and reducing the bacterial coating with immunoglobulin.7 Enteral nutrition is usually taken for six to eight weeks and can use elemental or polymeric oral nutritional supplements, or feeds. If patients experience stricturing Crohn’s, the ESPEN guidelines recommend that a diet with modified texture or enteral nutrition may be advised.8 The guidelines go on to say that in patients with radiologically identified but asymptomatic stenosis of the intestine, it is common to recommend a diet which is low in fibre, but there is no robust data to support this apparently logical approach. When symptoms are present, it may be necessary to adapt the diet to one of soft consistency, perhaps predominantly of nutritious fluids.8 A literature review by Rhodes and Richman9 reported that indirect evidence for diet and IBD suggests that Crohn’s patients should have a diet that is low in animal fat, avoids foods that are high in insoluble fibre and avoids processed fatty foods. Supplementary vitamin D should be considered and dairy products, if tolerated, 12

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can be consumed to help ensure adequate calcium intakes. For UC, there were again fewer recommendations, stating that patient’s diets should be low in meat - particularly red meat and processed meats - and margarine should be avoided. There is weak evidence that olive oil might be protective and that strict avoidance of dairy products and/or lactose is not justified on the basis of current evidence. However, this advice keeps in line with other research on diet and IBD, stating that there is little robust evidence for these recommendations, indicating that further research into this field is needed. The published guidance provided by professional bodies varies considerably between different sources and is often based on consensus of opinion rather than evidence. DIETARY FIBRE

I wanted to focus this article on dietary fibre, as from my own clinical experience it is something that is often talked about with IBD patients, but understand that actual evidence for dietary recommendations and fibre in IBD is poor. Firstly, what is dietary fibre? Dietary fibre can be described as a component of food that ‘includes all carbohydrates that are neither digested nor absorbed in the small intestine and have a degree of polymerisation of three or more monomeric units, plus lignin’.10 If

that’s a little too wordy for you, it is also often described as the ‘roughage’ in our diet. It helps to regulate our bowel movements and diets high in fibre have been linked to reducing the risk of diabetes and bowel cancer, as well as helping to lower cholesterol. Historically, it has been broken down into insoluble fibre and soluble fibre. Insoluble fibre is more of the definition of that roughage; it isn’t digested and adds bulk to our stools. It can be found in wholegrains and the skins/seeds/piths of fruits and vegetables. Soluble fibre helps draw water into our stools, as well as binding to substances such as cholesterol and glucose, slowing their absorption. It is largely found in oats, beans, pulses and the inner flesh of fruits and vegetables. The terms ‘insoluble’ and ‘soluble’ have, however, been discouraged from being used in the clinical setting, with the argument that all fibrous foods contain a mixture of both. Recent research undertaken by Wedlake et al concluded that excluding gastrointestinal obstruction, there was no evidence that fibre intake should be restricted in patients with IBD, and that some studies suggest that dietary fibre in UC may be beneficial, stating that a reduced relapsed rate was seen in diets with fibre, compared to a no fibre diet. The general consensus of this review is that fibre should be encouraged in IBD, unless there is stricturing. It also discussed the potential anti-inflammatory role of fibre and that this merits further investigation.11 A review on the literature conducted in 2013 by the British Dietetic Association (BDA) gastroenterology specialist group, also largely discussed dietary fibre only in relation to

stricturing Crohn’s disease. They concluded that there are no clinical trials to support the use of decreasing dietary fibre to reduce the risk of bowel obstruction or to reduce gastrointestinal symptoms in stricturing Crohn’s disease, and that dietary fibre is contraindicated. This is due to the fact that, again, there is no data to give evidence-based recommendations. Despite the lack of evidence to support it, the review paper goes on to say that avoidance of coarse and poorly fermented fibre is mandatory in the presence of strictures and that fermentable fibre may contribute to the production of large quantities of gas close to a stricture, which in turn could induce uncomfortable symptoms and that a low-fibre diet would be less likely to produce obstructive symptoms in patients with inflammatory strictures and reduce the risk of bowel obstructions. This evidence has limited clinical impact because it is only expert opinion. There are no national guidelines that have examined the evidence for this practice. Furthermore, they concluded that the distinction between a low-fibre and a low-residue diet is unclear and there are no universally agreed definitions. Consequently, there is wide variation in clinical practice.12 The review concludes with practical recommendations of dietary advice for stricturing Crohn’s disease, which excludes any foods that may cause a mechanical obstruction or prestenotic pain as a result of excessive gas production (e.g. fibrous parts of fruits and vegetables, wholegrains, nuts and seeds, gristle on meat, skin on meat or fish, edible fish bones). It also writes that patients following dietary advice for stricturing Crohn’s disease should be assessed and reviewed by a

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CONDITIONS & DISORDERS

If there’s one thing I’ve learnt from writing this article, it is that there is a definite lack of evidence when it comes to diet, but in particular fibre and IBD! dietitian to ensure that the diet is nutritionally complete. The degree of dietary modification will depend on the nature and extent of the stricture and should be reviewed in line with the medical and/or surgical management in discussion with the IBD team.12 An additional study published by the BDA agrees that strictures lead to localised, persistent narrowing and can be inflammatory or fibrotic and, based on expert opinion, only dietary fibre is contraindicated.13 There have been a number of further studies which demonstrate that a diet high in fibre is beneficial to both patients with UC and Crohn’s disease and may decrease the incidence of the disease.14,15 Interestingly, despite the number of studies that recommended a healthy, high fibre diet in IBD (without strictures), it is known in clinical practice to advise patients to follow a short-term low residue diet if they are experiencing the symptoms of loose, frequent and urgent bowel movements, usually during an acute flare up of the disease state. In case of a flare-up, a low residue diet can reduce the frequency and volume of stools and induce a primary remission in disease. Therapeutically, a low fibre diet is part of the treatment in acute relapses of IBD (as well as

other conditions such as irritable bowel syndrome and diverticulitis). As previous evidence suggests, upon achieving remission, the amount of fibre should be systematically increased until achieving the recommended amount of fibre in a healthy diet.16 I do feel that this needs to be tailored to individuals, as from my own clinical experience, I understand that some patients struggle to tolerate a high fibre diet. CONCLUSION

If there’s one thing I’ve learnt from writing this article, it is that there is a definite lack of evidence when it comes to diet, but in particular fibre and IBD! Most literature reviews concluded that further research is required. The most robust evidence suggests that reducing fibre is only suitable in stricturing Crohn’s disease; however, we know therapeutically that it is also beneficial during an acute flare up of IBD and may relieve symptoms during this time. When looking at general dietary advice for IBD, the use of additional diets such as the specific carbohydrate diet and low FODMAP diet may be used. Nevertheless, the current evidence base is not strong enough to be advising these at present.

NETWORK HEALTH DIGEST

A wealth of useful dietetic resources for all dietitians and nutritionists

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STUCK WITH SOMETHING THAT’S NOT YOUR THING?

Sip feeds weren’t made for bolus feeding, but TwoCal is. It’s a unique 2kcal/ml tube feed in a 200 ml bottle with a higher electrolyte content than other commonly used ONS.1 And because there’s no decanting, there’s less mess and less kit, too. Isn’t it time you gave your bolus fed patients, a bolus feed?

Date of preparation: May 2018 ANUKANI180098a

1. Data on file. Abbott Laboratories Ltd, 2018 (TwoCal electrolyte comparison).

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PAEDIATRIC

Dr Rosan Meyer, RD,PhD Paediatric Research Dietitian, Honorary Senior Lecturer, Imperial College, London and Chair of the BDA Food Allergy and Intolerance Specialist Group

Dr Lisa Waddell, RD,PhD Specialist Community Paediatric Allergy Dietitian and Director of Food Allergy Nottingham Service (FANS)

Dr Carina Venter RD,PhD Assistant Professor, University of Colorado Denver School of Medicine, USA

REFERENCES Please visit the Subscriber zone at NHDmag.com

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WHERE NEXT AFTER PUBLICATION OF IMAP GUIDELINES FOR NON-IGE MEDIATED COW’S MILK ALLERGY? The successful iMAP guidelines provide suitable guidance for any child with a mild-to-moderate presentation of non-IgE mediated cow's milk allergy (CMA). This article reports on the updated guidelines and revised six-step milk ladder and looks at next steps in future improvements. CMA remains one of the most common food allergies worldwide, with a prevalence in the United Kingdom of 2-3% in one- to three-year-olds.1 This allergy can present with immediate onset of symptoms; including pruritus and eczema flares, urticaria (hives) and angioedema and, in the most severe cases, anaphylaxis.2 These type of reactions are referred to as Immunoglobulin E (IgE)-mediated food allergy and the pathophysiologic mechanism is well described, with tests available to support the diagnosis. However, this allergy can also present with delayed symptoms, called non-IgE mediated CMA, which can include symptoms like vomiting, feeding difficulties, colic-like abdominal pain, faltering growth, diarrhoea, blood in stools, constipation and exacerbation of atopic eczema.3 The latter group of symptoms overlap with other common disorders in early childhood, such as infantile colic and gastro-oesophageal reflux, lactose intolerance, constipation and atopic eczema, which complicates the recognition and diagnosis of cow’s milk allergy. The pathophysiology of non-IgE mediated CMA is not well established and no accurate non-invasive tests exist to support the healthcare professional (HCP) to make the diagnosis, which includes a spectrum of gastrointestinal conditions (i.e. food induced proctocolitis, enterocolitis, enteropathy).3 It was, therefore, not surprising that in 2010, Sladkevicius et al4 reported that it took on average 4.5 visits to a general practitioner (GP)

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over an average of 2.2 months in the UK for children with atopic eczema and gastrointestinal symptoms to be started on the correct treatment. The delayed nature of diagnosis of non-IgE mediated CMA was recognised by a group of HCPs as a particular area that required improvement in the UK and, therefore, the Milk Allergy in Primary (MAP) guidelines were published, targeting mild to moderate non-IgE mediated CMA.5 These guidelines have proven to be extremely successful, not only in the UK, but worldwide, with more than 74,000 downloads (download and citation history is available from http://citations.springer.com/item?d oi=10.1186/2045-7022-3-23), providing the authors with four years of feedback to allow for publication of the improved international (i)MAP guidelines.6 WHAT HAS CHANGED IN THE IMAP GUIDELINES?

The iMAP guideline authors consisted of well-known allergists and dietitians from all over the world, including from resource-poor countries, to provide guidance suitable for any child with a mild-to-moderate presentation of nonIgE mediated CMA. The diagnosis and management of the severe spectrum of non-IgE mediated CMA, including eosinophilic oesophagitis (EoE), food protein enterocolitis syndrome (FPIES) and food protein induced enteropathy with faltering growth, were, therefore, not covered in these guidelines.6

PAEDIATRIC

Cow’s milk allergy remains one of the most common food allergies worldwide, with a prevalence in the United Kingdom of 2-3% in one- to three-year-olds. The iMAP guidelines had some minor additions with regard to the well-known symptoms of non-IgE mediated CMA, acknowledging that this condition would usually present as multiple symptoms and that treatment resistance to atopic eczema, gastro-oesophageal reflux and constipation may increase the likelihood of the diagnosis of a non-IgE mediated CMA.6 As before, an elimination diet of four weeks (minimum two weeks) is recommended,7 followed by the reintroduction of cow’s milk. Following feedback from the MAP guidelines, the authors of the iMAP guidelines recognised that HCPs required a range of supporting materials to aid diagnosis and to prime parents on the process of diagnosis, including the reintroduction phase to confirm/ refute the diagnosis of a delayed CMA. These supporting documents were developed and are not only available as appendices in the original article, but are available in an easy-to-use format from the Allergy UK Website (www.allergyuk. org/health-professionals/mapguideline). Although changes to the recognition and diagnosis sections within the iMAP guidelines were minor, there have been two major changes in the recommendations of hypoallergenic formulas. As the iMAP guidelines also included representation from resource-poor countries, soya formulas were recognised as an alternative if children (of all ages) were not sensitised to soya.6 However, for the UK (and other European countries and the USA) the guidelines clearly state the avoidance of soya formulas below six months and that these formulas were not a first line choice for mild-moderate non-IgE mediated allergies. This is in line with all current European and US guidelines on CMA.8-11

In the MAP guidelines from 2013, amino acid formulas (AAF) were recommended for breastfed infants with non-IgE mediated CMA who required a top-up formula.5 Those recommendations originated from data produced by Host et al,12 who found that β-lactoglobulin, one of the cow’s milk proteins, was present in the vast majority of cow’s milk consuming breastfeeding mothers at levels that were comparable to the residual β-lactoglobulin detected in both whey or casein extensively hydrolysed formulas (EHF). This implied that breastfed infants with CMA would also react to an EHF. However, a recent review on the appropriate use of AAF has not found sufficient evidence to justify such a recommendation.13 Data on FPIES and food protein induced proctocolitis found that the majority of children had symptom resolution with an EHF.14,15 It was found that infants with non-IgE mediated CMA who presented with a combination of multiple food eliminations, enteropathy/enterocolitis syndromes and faltering growth, as well as EoE, would benefit from an AAF.13 However, these aforementioned conditions were deemed severe presentations of non-IgE mediated CMA and, therefore, not covered in the iMAP guidelines. As a result, the guidelines now suggest that an EHF be considered in breastfed infants with mild to moderate non-IgE mediated CMA as a top-up formula.6 THE MILK LADDER

The original MAP guidelines in 2013 included the first published milk ladder, which has proven to be a very popular worldwide, as a home-based method of reintroducing cow’s milk in a graded way, based on the effects of heating and fermentation on the allergenicity of cow’s www.NHDmag.com June 2018 - Issue 135

17

Figure 1: MAP (left) and the new iMAP milk ladder (right)5,6

milk proteins.5,16 Although very limited data was available at the time of writing the first milk ladder on tolerance of heated/fermented milk products in non-IgE mediated CMA, a recent study by Uncuoglu et al,17 found that significantly more children with this form of CMA tolerated heated and fermented cow’s milk products than did those with IgE mediated CMA. A study by Athanasopolou et al18 found that baked milk challenges were commonly used in non-IgE mediated CMA and were particularly useful in settings with insufficient facilities for hospital challenge. This study, however, acknowledged country specific differences which require further exploration. User feedback of the MAP ladder included the high refined sugar (>5% refined sugar as recommended by the World Health Organisation) and salt content (i.e. biscuits, cupcakes, lasagne, etc) of foods in the ladder, the length of the ladder (12 steps) and finally the absence of exact milk protein dosages, to allow for the ladder to be studied further.19,20 All of these aspects were addressed in the new iMAP ladder that is now shorter (six steps), has recipes that are salt free, low in sugar and describe the exact milk protein dosages. 18

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WHERE DO WE GO NEXT?

The iMAP guidelines have allowed for the update of both diagnosis and management of non-IgE mediated allergies, reflecting the newly published data and also addressing feedback from HCPs. However, with every new published guideline comes the responsibility of reviewing and updating to reflect new research. This is also the case for the iMAP guidelines; feedback has already been received on content and for the milk ladder. Authors have already been made aware of new publications, most notably, the joint ESPGHAN and NASPGHAN guidelines on diagnosis and management of gastroesophageal reflux disease, which will need to be taken into account with future review of iMAP guidelines.21 These guidelines now suggest a trial of maternal elimination of cow’s milk in breastfed infants, or hypoallergenic formula following conservative management, before the use of antacid medications (H2 receptor antagonists/proton pump inhibitors). The European Academy for Allergy and Clinical Immunology also has a Task Force that is working on practice guidelines for non-IgE mediated allergies, with an imminent publication on breastfed infants with non-IgE

mediated allergies and a future publication on controversies of non-IgE mediated allergies in non-breastfed infants. Although the new iMAP ladder recipes have made it possible to provide standardised recipes across different countries that can be made at home and can be used in research settings, the practicality also needs to be considered. Great care was taken to trial the recipes of the biscuits/muffins/pancakes in many countries, although it is acknowledged that associated cooking methods (baking/frying) may not be universally accepted; in Asia for example, steaming is more common. In addition, not all parents have the time or skills to make these recipes at home and acceptance of foods in all children has also been highlighted. In particular, younger children need to be considered who may not yet have the oral motor skills for chewing biscuits/muffins. Challenges remain for the authors of the milk ladder to adapt the current ladder to include commercial foods and recipes that are suitable for all cultures and that can be adjusted for children without the necessary oral motor skills.

20

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Although the current milk ladder offers practical challenges for parents, it does for the first time allow research centres to study each step from an immunological perspective, due to the known amount of milk protein, the type of milk protein (milk powder versus fresh milk) and the exact cooking methods (i.e. temperature of baking and frying). There is a need to establish in vitro and, subsequently, in vivo, effects of each step immunologically to determine the role of the milk ladder in clinical practice. CONCLUSION

The iMAP guidelines on mild to moderate non-IgE mediated CMA have contributed significantly towards improving the diagnosis and management of CMA in the UK and now worldwide. They offer easy-to-use algorithms and newly added supporting material, as well as an updated milk ladder. The next step for the authors of this guideline is to ensure optimal dissemination and implementation, but also to stay abreast of new research and listen to HCPs on how to improve the guidelines further in the future.

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19

REASSURE

FOR HEALTHCARE PROFESSIONAL USE ONLY Breastfeeding is best for babies

WITH THE

UK’S MOST PALATABLE EHF1*

Aptamil Pepti HCPs believe palatability increases compliance1

the

step st ep in the effective management of

cows’ milk allergy is extensively hydrolysed formula†

For the management of mild to moderate cows’ milk allergy, the iMAP guideline2 recommends an Extensively Hydrolysed Formula (EHF) as the fi rst step for formula feeding or mixed feeding (if symptoms only with introduction of top-up feeds) infants.

†

References: 1. Campden BRI conducted a blind taste test using a home usage design with a sample of 100 Dietitians and General Practitioners from 16.11.2016 to 09.12.16. Participants rank ordered the extensively hydrolysed formula (EHF) milk samples (Danone Aptamil Pepti, Abbott Similac Alimentum, Nestle SMA Althera and Mead Johnson Nutramigen LGG) in term of overall liking and answered a series of attitudinal questions in relation to the impact of EHF’s palatability on infants with CMA and their families. The results from the ranking showed that the Danone Aptamil Pepti sample was liked significantly more than all the other three samples tested. 2. Venter C et al , 2017. Better recognition, diagnosis and management of non-IgE-mediated cow’s milk allergy in infancy: iMAP-an international interpretation of the MAP (Milk Allergy in Primary Care) guideline. Clin Transl Allergy. August, vol. 7, no. 26. *A home usage test assessment was carried out between 16/11/16 and 9/12/16 on the 4 products indicated for cows’ milk allergy from birth and included 100 UK healthcare professionals.

IMPORTANT NOTICE: Aptamil Pepti 1 & 2 are foods for special medical purposes for the dietary management of cows’ milk allergy. They should only be used under medical supervision, after full consideration of the feeding options available including breastfeeding. Aptamil Pepti 1 is suitable for use as the sole source of nutrition for infants from birth, and/or as part of a balanced diet from 6-12 months. Aptamil Pepti 2 is suitable for babies over 6 months as part of a mixed diet.

Healthcare Professional Helpline: 0800

18-044 (Palatability)/Date of Prep: March 2018 © Danone Nutricia Early Life Nutrition 2018

996 1234 www.eln.nutricia.co.uk/cma

PAEDIATRIC

Priya Tew Freelance Dietitian, Dietitian UK Priya runs Dietitian UK, a freelance dietetic service that specialises in social media and media work, consultancy for food companies, eating disorder support, IBS and chronic fatigue. She works with NHS services, The Priory Hospital Group and private clinics, as well as providing Skype support to clients nationwide.

REFERENCES Please visit the Subscriber zone at NHDmag.com

BREASTFEEDING AND THE MICROBIOME This article focuses on the effect of breastfeeding on the microbiome. We know that breastfeeding leads to altered body composition compared to formula feeding, with formula-fed babies having a higher fat mass at 12 months, so it makes sense that there will be other differences in the body.1 Knowing the influences of feeding on the infant microbiota could be a key to lifelong health, it is important to support the message that breastfeeding is best. The rates of breastfeeding in the UK are low, with only 1% of babies being breastfed exclusively until six months versus 36% globally.6,7 The DOH and WHO guidelines are for exclusive breastfeeding for the first six months and then to continue breastfeeding alongside solid foods until age two years or older. However, it is rare to see mums breastfeeding two-year-olds in the UK. A lot of mums start off breastfeeding and then stop due to a range of factors. Having breastfed three children myself for an extended period, I can understand and empathise with the difficulties. As a culture, it is not always easy to breastfeed and it can be frowned upon if you are feeding a toddler. However, breastfeeding can have a hugely positive effect on the long-term health of a child, which, in turn, can have a knock-on effect on our healthcare costs. Having all the information to hand on how breastfeeding can help improve a child’s health can be a great way to encourage mums to continue when breastfeeding is proving tricky. MICROBIOTA

Bacterial colonisation of a baby begins at birth. When the baby is born, the

infant microbiota is sterile, the microbes then change rapidly from birth until two to three years of age, progressing to a dense mixture in adulthood.2 Both the way the baby is born and the mother’s microbiome impact on the infant’s gut bacteria. Infants born by caesarean section have different microbial composition compared to infants born vaginally, due to the way they pick up bacterial communities. In vaginal births, this is largely from the birth canal or the skin, whilst in a C-section birth, this is influenced by maternal skin, hospital staff and the environment.4,10 For example, a 24week study compared the microbiota of full-term infants who had a spontaneous vaginal birth with those delivered by C-section (cohort 192). Infants born full-term by a C-section had an increased amount of Firmicutes and less Actinobacteria after the first week of life. At week one, vaginally delivered babies had higher Actinobacteria. The microbiome of the C-section infants gradually changed over eight weeks to closer resemble that of the vaginally birthed infants, but at 24 weeks, there were still significant differences, with C-section infants having a less www.NHDmag.com June 2018 - Issue 135

21

Professional Helping mums breastfeed longer

Breastmilk is the best form of nutrition for infants, and exclusive breastfeeding is recommended for the first 6 months (26 weeks) of an infant’s life. Thereafter breastfeeding should continue for as long as the mother and baby wish, while gradually including a more varied diet. NHS England. (2015). Statistical Release. Breastfeeding Initiation and Breastfeeding.

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Infants born by caesarean section have different microbial composition compared to infants born vaginally, due to the way they pick up bacterial communities. beneficial array of bacteria.2 This bacteria is shown by some studies to still exist up to six months of age.10 This may explain why babies born by C-section are at higher risk for allergy and obesity later in life.10 A mother cannot always choose the way she births the baby, but the information I present below suggests that breastfeeding can help alter the gut bacteria and microbiome of an infant, so the method of feeding baby could make a difference. INFLUENCES ON THE MIOCROBIOME

Prolonged breastfeeding has been found to have a significant effect on the gut bacteria of full-term C-section delivered infants.2 No differences were seen in those infants breastfed for less than four months, but in those breastfed for longer than four months, there was a significant affect seen. Five genera of bacteria were more abundant in infants who were breastfed for longer and four genera were more abundant in those breastfed for a shorter time.2 A 12-month study on 107 mother-infant pairs found that almost 30% of the infants’ gut bacteria came from breast milk and 10% from areolar skin in the first 30 days of life.5 So, it is not just the breastmilk alone that influences the microbiome, but the mother and the environment. Exclusively breasted infants have been shown to have lower bacterial counts and higher levels of Staphylococcus bacteria. This is the most dominant bacteria in the infant gut.10 A study comparing the impact of breastfeeding versus mixed feeding on the infant microbiome, in vaginally delivered fullterm infants, found no impact in the first week. However, at four and 12 months, there was a marked difference with the formula-fed babies,

as having a seemingly older microbiota, their microbes were changing to the diverse adult strains sooner. This was also found in a study of C-section infants at four months.3 Increasing evidence suggests that this early colonisation can influence gut maturation, immune, brain and metabolic development.10 At four months, notable differences exist in the types of bacteria found in the gut. Exclusive breastfed babies have increased levels of probiotics (L. johnsoii/L. gasseri, L. paracasei/L. casei, B. bifidum and B. longum) and formula-fed infants have elevated levels of C. difficile, G. adiacens, Citrobacter, C. leptim and E. allocate.3,10 Results of a study on 108 infants suggests that vaginal delivery combined with breastfeeding favours the colonisation by B. bifidum and L. gasseri and that C-section infants who are breastfed tend to catch up on their gut bacteria, having more of these species than formula-fed babies. Infants born by C-section and formula fed were colonised more by L. reuteri, which is a strain that is found in formula-fed babies only.10 Variations in the gut microbial profile are associated with immune-related disease in infants. For example, greater abundances of E. coli and C. difficile are associated with a higher risk of developing eczema, recurrent wheeze and allergic sensitisation.4 There has been an increase in the incidence of CDI (Clostridium difficile infection) seen in children.9 So, any advice we can give to parents to help decrease this, other than reducing antibiotic use, is helpful. It is likely that the lower levels of www.NHDmag.com June 2018 - Issue 135

23

PAEDIATRIC

There are potential lifelong effects of breastfeeding on the microbiome, with possible metabolic and long-term health effects. diarrhoea and GI infections seen in breastfed babies is due to these difference in gut bacteria such as C. difficile. The finding of lower bacterial richness in formula-fed infants is proposed to be due to the presence of oligosaccharides found in breastmilk which act as selective food substrates for certain microbiota.4 The gut microbiome is an important producer of vitamins and essential amino acids for the body. At four months, the transporters in the gut indicate that the newborn is starting to move towards a more mature stage and, interestingly, breastfeeding has an impact on this. Infants who were formula fed had different transporters in their system and more adult systems available to them, for things like bile acid biosynthesis and methanogenesis for example, whereas breastfed infants had higher levels of modules involved in oxidative phosphorylation and B vitamin synthesis.3 THE EFFECT OF STOPPING BREASTFEEDING

The cessation of breastfeeding also has profound effects on the microbiome of the infant. Studies comparing infants who stopped breastfeeding at 12 months to those who continued, show large differences. In infants not breastfed past 12 months, there was a shift of the microbiota towards a more adult like state containing Bacteroides, Bilophila, Roseburia, Clostridium and Anaerostipes, which makes the microbiota

age of these infants appear older.3 This shows a role for extended breastfeeding and how it shapes the gut bacteria for the first year of life. It is the cessation of breastfeeding rather than the introduction of solid foods that was the major influencer in the development of a more mature microbiome. SUMMARY

There are potential lifelong effects of breastfeeding on the microbiome, with possible metabolic and long-term health effects. Having information to hand to explain to mothers how breastfeeding can have a long-term impact on their child’s health can be a positive motivator. Other good reasons for encouraging a mum to breastfeed include that it protects against infections and decreases the risk of ear infections, GI infections and of diarrhoea. It can also improve IQ and school readiness, which in turn is linked to higher income in adult life. It also has positives for the mother’s health too, as it decreases the risk of breast cancer. We also know that antibiotics and birth age have an effect, with pre-term babies and those receiving antibiotics having more GI problems and altered gut bacteria. So, can the type of feeding also play a role in influencing the microbiota for these infants too? It certainly looks likely. This would be a great area for more research.

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IN ASSOCIATION WITH THE BSNA

CLINICAL

PRESCRIBING ONS: THE REQUIREMENTS FOR INDIVIDUAL CLINICAL CIRCUMSTANCES Katherine Sykes Health and Policy Consultant, BSNA Katherine specialises in health and nutrition policy and since 2005 has worked both in-house and in consultancy

REFERENCES Please visit the Subscriber zone at NHDmag.com

NHS England Guidance on Commissioning Excellent Nutrition and Hydration 2015-2018,1 NICE Clinical Guideline 32 on Nutrition Support in Adults (CG32)2 and NICE Quality Standard 24 (QS24),3 support the use of Oral Nutritional Supplements (ONS) whenever there is a clinical need to do so. The provision of ONS on prescription ensures that under the supervision of a healthcare professional, all patients, including the most vulnerable, are able to access the products that are most appropriate for their care, whenever they are needed. Which prescriptions are available in any given area depends on the policy of each Clinical Commissioning Group (CCG), the clinically-led statutory bodies responsible for the planning and commissioning of healthcare services for their local area. Facing significant pressure to cut costs, some CCGs are limiting, or restricting, prescriptions of ONS - with health ramifications that are increasingly worrying. Malnutrition continues to be a serious problem in modern Britain, with more than three million people in the UK estimated to be either malnourished or at risk of malnutrition.4 The number of deaths from underlying malnutrition, or where malnutrition was named as a contributory factor, is also increasing, having risen by more than 30% from 2007 to 2016.5 This is unacceptable in any modern healthcare system. To be tackled effectively, malnutrition needs to be screened, identified and managed appropriately. However, it appears that there are fundamental inconsistencies in the implementation of CG32, QS24 and the other recommended strategies. Malnutrition remains a growing problem, yet is largely preventable and can be better managed if the right guidance is followed.

HOW DO ONS SUPPORT GOOD PATIENT OUTCOMES?

ONS are evidence-based nutritional solutions for disease-related malnutrition.6 These highly regulated products7 can partially, or wholly, replace a normal diet to provide patients with the essential nutrients they need when food alone is insufficient to meet their daily needs.2,3,8 QS24 recognises that ONS are a clinically effective way to help manage disease-related malnutrition: ‘It is important that nutrition support goes beyond just providing sufficient calories and looks to provide all the relevant nutrients that should be contained in a nutritionally complete diet. A management care plan aims to provide that and identifies condition specific circumstances and associated needs linked to nutrition support requirements.’ Healthcare professionals are best placed to evaluate whether patients need ONS and if so, for how long patients should be taking them. They can also provide patients with the most appropriate products for their individual clinical conditions and circumstances. ONS can play an essential part in medical management, acting as invaluable support when food alone is insufficient, either for short periods of time, or for life. Receiving timely ONS is essential in the prevention and management of malnutrition and patients should only be prescribed ONS www.NHDmag.com June 2018 - Issue 135

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CLINICAL when they cannot meet their daily nutritional requirements from food alone, and/or are at risk of malnutrition due to a disease, disorder, medical condition or surgical intervention. Combined with regular monitoring and review of patients’ individual needs and circumstances by a healthcare professional, as outlined in CG32, QS24 and the Managing Adult Malnutrition in the Community Pathway,8 ONS provide the most effective management solution for patients who are malnourished, or at risk of malnutrition. ONS should be discontinued when an individual is no longer malnourished, has met their nutritional goal(s) and is able to meet their nutritional needs through food alone. POWDER OR LIQUID?

ONS are available in two different forms: powders (which are made up to form a liquid), or readymade liquids. The decision about which form to prescribe is an important one and should be carefully considered. Both have their advantage, but ultimately the decision about which is the best option should come down to the specific clinical circumstances and requirements of the patient; there is no blanket approach. Factors to consider might include the level of the patient’s dexterity, mobility and sight and: whether they can tolerate volume; can tolerate milk; are able to make up the product accurately; are able to access milk; are able to swallow safely; and their individual preferences. ADHERENCE TO NUTRITION MANAGEMENT GUIDELINES

CG32 and QS24 set the standard for appropriate and timely nutritional care and should be followed in all care settings. The Malnutrition Universal Screening Tool (‘MUST’)9 is a recommended screening tool with five steps, which allows healthcare professionals to identify and manage nutritional issues, including both malnutrition and obesity. It includes the use of BMI calculation, consideration of unplanned weight loss and the effect of acute disease, as well as guidelines that can then be used to help establish a care plan for the individual based on their level of risk. Unfortunately, even though patients, care home residents and those receiving support in the

community, should - and can easily be - screened and assessed for malnutrition, this is not always the case. Even in the cases where ‘MUST’ is being used, it can sometimes be viewed as a tick box exercise, meaning that patients do not always receive an appropriate management plan when they should. The Managing Adult Malnutrition in the Community Pathway8 is an evidence-based tool founded on clinical experience and evidence alongside accepted best practice that can be used across all care settings, and which is endorsed by professional organisations such as the British Dietetic Association (BDA), British Association for Parenteral and Enteral Nutrition (BAPEN), Royal College of Nursing (RCN) and Royal College of General Practitioners (RCGP). The document includes a pathway to assist in the appropriate use of ONS. Healthcare professionals managing patients who have had a recent stay in hospital should find it particularly useful. Revised and updated in December 2017, it has been endorsed by NICE as follows: ‘This booklet supports the implementation of recommendations in the NICE guideline on nutrition support for adults (CG32). It also supports statements 1, 2 and 5 in the NICE quality standard for nutrition support in adults (QS24).' For more information on the pathway and updated supporting documents available to download, visit www. malnutritionpathway.co.uk. UNDER-REPORTING OF MALNUTRITION

The increasing number of cases of malnutrition in hospital and associated deaths reflect a system-wide failure to consistently screen and manage patients who are either malnourished or at risk of malnutrition.4 Drawing upon malnutrition data broken down by NHS Trust for 2015/16,12 new research commissioned by the British Specialist Nutrition Association (BSNA)13 explored the current reporting of malnutrition in hospitals in England. Using the latest publicly available data to analyse malnutrition rates across 221 English NHS Trusts, the research identified Trusts where the recording of malnutrition is significantly below expectation. The research found that more than half the hospital Trusts in England are significantly under-reporting malnutrition rates compared to accepted national estimates. www.NHDmag.com June 2018 - Issue 135

27

CLINICAL

It costs more NOT to treat malnutrition than to do so. It is estimated that £5,000 could be saved per patient through better nutrition management.

This means that the overall incidence of malnutrition is likely to be significantly under recorded, pointing to a much more significant problem than the available data suggests. NICE Quality Standards are designed to measure and improve quality of care in specific areas. Estimates point to malnutrition as a sustained problem across the country, but the data is incomplete due to the non-mandatory nature of nutrition reporting and management. Were CG32 and QS24 implemented in full, comprehensive records would exist on the nutritional status of all in-patients, care home residents and people receiving care in the community. However, because adherence to Quality Standards and Clinical Guidelines is not mandatory, this is not the case. THE COST OF MALNUTRITION

The cost of doing nothing significantly outweighs the cost of early intervention, such as dietetic support and provision of ONS if appropriate. Malnutrition results in various adverse health outcomes for patients, including high numbers of non-elective admissions, greater dependency on hospital beds for longer and progression to long-term care sooner. Managing patients in a crisis situation results in high levels of inefficiency, which could be avoided or minimised if more focus were placed on prevention and early intervention. The health and social care costs associated with malnutrition are estimated to be £19.6 billion per year in England alone, amounting 28

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to more than 15% of the total public health expenditure on health and social care.14 About half of this expenditure is on older people (>65 years). A BAPEN report published in 2015 stated that, ‘interventions with nutritional support (to implement the NICE clinical guidelines/quality standard), including ONS, enteral tube feeding (ETF) and parenteral nutrition (PN) in hospital and community settings, were found to lead to greater net cost savings than those reported by NICE. The savings were even greater when the prevalence of malnutrition was high, when hospital admission rates were high, and when the gap between current care and desirable nutritional care was high.’14 From the BAPEN report, five different models, which involved nutritional support in 85% of subjects with a high malnutrition risk, all resulted in cost savings. It costs more NOT to treat malnutrition than to do so. It is estimated that £5,000 could be saved per patient through better nutrition management.14 The provision of nutritional support to 85% of patients at medium and high risk of malnutrition would lead to a cost saving of £325,000 to £432,000 per 100,000 people.14 On average it costs £7,408 per year to care for a malnourished patient, compared to £2,155 for a well-nourished patient.14 Implementing NICE CG32 and QS24 in 85% of patients at medium and high risk of malnutrition would lead to a net saving of £172.2-£229.2 million, which equates to £324,800 to £432,300 per 100,000 people.14 NICE has also found that the implementation of CG32 and QS24 into a pathway of nutritional care would produce an overall cost saving, while improving quality of care. Nutritional support in adults was ranked as the third highest amongst a wide range of other cost saving interventions associated with implementation of NICE guidelines/standards.14

The impact on local areas is considerable, since 93% of malnutrition is estimated to occur in community settings. However, the largest cost comes from the management of malnourished people in hospitals, even though they only account for 2% of cases.4 Comprehensive, effective screening, prevention and treatment, and the introduction of incentives, are essential across all settings to protect those at risk of malnutrition and reduce costs to taxpayers. A study conducted in the USA in 201715 has also demonstrated the clinical and economic value of nutritional intervention. The study assessed the potential cost-savings associated with decreased 30-day readmissions and hospital length of stay in malnourished inpatients through a nutrition-focused quality improvement programme. The reduction in readmission rate and length of stay for 1,269 patients enrolled in the quality improvement programme were compared with pre-quality improvement programme baseline and validation cohorts to calculate potential cost savings. The reduction in hospital readmissions and reduced number of days in hospital for patients in the quality improvement programme resulted in cost savings of $1,902,933 versus the pre-quality improvement programme baseline cohort, and $4,896,758 versus the pre-quality improvement programme in the validation cohort. After assessment of the entire patient population, per patient net savings of $1,499 when using the baseline cohort as the comparator and savings per patient of $3,858 when using the validated cohort as the competitor were achieved. The study showed that nutritional interventions improve health outcomes and reduce the overall costs of care in malnourished hospitalised patients. MANAGING PATIENTS' NUTRITIONAL NEEDS

Prevention and management of malnutrition require early action to reduce the risk of longerterm complications. Prescribed whenever there is a clinical need to do so, ONS can ensure that patients’ nutritional needs are managed adequately and that further complications do not arise. They are an integral part of the

management of long-term conditions that require nutritional support and should be accessible to all patients who need them. There is little evidence of efficacy of managing disease-related malnutrition with food-based strategies alone compared to the use of ONS.16 Yet, despite this, against a backdrop of increasing cost pressures on the NHS, some CCGs have started to restrict prescribing of ONS, which requires an initial outlay, but consistently brings savings arising from the prevention of later associated complications. Fortified food has been provided instead in some cases, but this approach is over-simplified and often does not account adequately for patients’ individual clinical requirements, or the clinical assessments made by healthcare professionals.17 Healthcare professionals, commissioners and policymakers across all settings must balance investment in ONS and dietetic services against consideration of unintended consequences and longerterm burdens, to both patients and the NHS, that can be exacerbated without action. The provision of dietary advice and ONS to malnourished patients reduces complications such as infections and wound breakdown by 70% and mortality by 40%.18 When CCGs are looking to reduce their overall expenditure on prescription costs, it is important to look at the burden of malnutrition in the local health economy, in terms of hospital admissions and readmissions, and to ensure that the nutritional needs of patients are being managed appropriately. Immediate savings from cutting ONS can lead to higher costs due to increased healthcare use in the longer term. CONCLUSION

The importance of good nutrition should not be understated. Whilst considerable focus has been given to obesity in recent times, malnutrition still remains the poor relation, notwithstanding the size and scale of the problem. Yet, obesity and malnutrition are both states on the nutritional spectrum and the goal of public health intervention should be to ensure good nutritional status for the population as a whole. www.NHDmag.com June 2018 - Issue 135

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WEIGHT MANAGEMENT

THE ALKALINE DIET EXAMINED Maeve Hanan UK Registered Dietitian Freelance Maeve works as a Freelance Dietitian and also runs the blog Dietetically Speaking.com, which promotes evidence-based nutrition and fights nutritional nonsense.

This article will examine how the alkaline diet emerged and gained popularity, as well as the current evidence base related to this. The alkaline diet is also known as: the alkaline ash or the acid-alkaline diet. This diet promotes replacing so called ‘acid forming foods’ with ‘alkaline forming foods’ in order to promote better health by altering the pH of our blood. The proposed action of this diet is of course flawed, as the processes of homeostasis and digestion (including the acidic pH of our stomach) maintains the pH of our blood between about 7.35 and 7.45, regardless of the type of food eaten (see Figure 1). This mechanism keeps us healthy and avoids the harmful effects of alkalosis or acidosis.1 DEVELOPMENT OF THE ALKALINE DIET

REFERENCES Please visit the Subscriber zone at NHDmag.com

In the 1850s, the French physiologist Claude Bernard (who is also known for discovering glycogen and the role of pancreatic juice) conducted experiments

in which rabbits were fed boiled beef in place of their usual herbivorous diet. In response to this, the rabbits were observed to develop acidic urine in contrast to their usual alkaline urine.2,3 This phenomenon was later explained due to the metabolism of methionine and cysteine found in meat, which produces sulphuric acid and in turn causes more acidic urine.4 In the early 20th century, our understanding of acid-base disorders evolved further; for example, in 1908, the Henderson-Hasselbalch equation was developed, which is used to calculate the pH of a buffer solution.5 It also became possible to determine in a laboratory setting whether the ‘ash’ content of a food was acid, alkaline or neutral.6,7 This experiment is conducted by heating the

Figure 1: Infographic from the BDA about the alkaline diet

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Table 1: List of acid and alkaline foods8 Acid-ash Foods White bread Whole wheat bread Rye Bread Cake Corn cereal Macaroni Oatmeal Rice Mayonnaise Cranberries Plums Prunes Corn Lentils

Brazil nuts Peanuts Walnuts Bacon Beef Cheddar & cottage cheese Chicken Eggs Fish Ham Pork Lamb

Neutral-ash Foods Arrowroot starch Butter Coffee Corn-starch Lard Margarine Sugar Syrup Tapioca Tea Vegetable oil

food along with oxidising agents until the water and organic matter is removed and then analysing the mineral content of the remaining ash.8 Acidforming minerals include chlorine, phosphorus and sulphur, whereas calcium, magnesium, potassium and sodium are alkaline-forming minerals (also referred to as base-forming minerals).8 In conjunction with these discoveries, theories about how acid and alkaline forming foods can affect health were emerging. The Report of the Committee on Nutritional Problems of the American Public Health Association for 1935-1936, Food Fallacies and Nutritional Quackery, highlighted that, ‘elaborate menus are offered for “alkaliforming” meals and systems of dieting which can be had by purchasing their books or enlisting their services and special courses'.7 Another article published in The American Journal of Public Health that year also reported that, ‘one widely publicised system of diet is based on the erroneous theory that proteins and starches and fruits and starches should not be mixed in any one meal. As a reason for this perverted idea, it is declared that protein digestion takes place in the acid contents of the stomach, while starch can be digested only in the alkaline intestine, and that carbohydrates encounter some sort of baleful interference when associated with protein in the stomach’.6 As a response to these ‘food fallacies’ related to acid and alkaline forming foods, the Committee on Nutritional Problems reported that ‘there is no evidence that a preponderantly acid diet is injurious. That the body reaction remains practically unaltered even when a wide range of amount of acid or base is ingested has been pointed

Alkaline-ash Foods Apples Bananas Blackberries Cherries Dates Grapefruit Lemon Lime Mango Oranges Pear Peach Strawberries Asparagus

Beans Broccoli Carrots Aubergine Kale Lettuce Mushrooms Almonds Coconuts Milk Jam Ice cream Cream

out by Henderson.’7 This report also highlighted that acidosis only occurs in response to certain medical conditions such as: diabetes, kidney disease and metabolic disorders.7 So, although foods can be classified according to the pH of its ash (see Table 1), it was known by academics and medical professionals at the time that this does not significantly impact the pH of our blood, as a healthy body maintains homeostasis via our buffer, respiratory and renal systems.6 More recently, the concept of promoting alkaline forming foods for health made a comeback in the 1990s in conjunction with the trend for low carb diets. In 1992, One Sickness, One Disease, One Treatment by Robert O Young was published, which warns about ‘over-acidification of the blood and then tissues due to an acidic lifestyle and diet’. Robert O Young, who has been referred to as ‘father of the alkaline diet’, has published numerous other books on similar topics, including The pH Miracle, which was first released in 2002 and has sold more than four million copies worldwide.9 The pH Miracle advises ‘striking the optimum 80/20 balance between an alkaline and acidic environment provided by eating certain foods’ including low carb options, a ‘liquid detox’, drinking water, taking specific supplements and, of course, eating mainly ‘alkaline foods.’10 Foods which are considered ‘highly alkaline’ include: ‘pH 9.5 water drinks’, ‘green drinks’, salt, avocado, broccoli, cabbage, celery, kale, spinach and tomato.11 Foods which are considered ‘highly acidic’ include: alcohol, miso, dried fruit, honey, eggs, beef, pork, chicken, farmed fish, shellfish, white rice, cheese and artificial sweeteners.11 www.NHDmag.com June 2018 - Issue 135

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WEIGHT MANAGEMENT The popularity of the alkaline diet has also been boosted by endorsement from celebrities such as Gwyneth Paltrow, Kirsten Dunst and Jennifer Aniston. There are also numerous products related to the alkaline diet including supplements, alkaline water, ‘water ionisers’, books and videos.12 Recently, there has been some controversy related to the alkaline diet, including the news story from January 2017 about Naima HouderMohammed, a British Army Officer with terminal cancer who ‘paid thousands of dollars for [Robert O Young’s] alkaline treatment, which consisted mainly of intravenous infusions of baking soda’.9 Sadly, Naima died three months into this treatment. In June 2017, Robert O Young was jailed for five months ‘after admitting that he illegally treated patients at his luxury Valley Centre ranch without any medical or scientific training’.13 Robert O Young was also previously convicted for practicing medicine without a license.13 EXAMINING THE EVIDENCE-BASE

Numerous health claims have been associated with the alkaline diet,14,15 one of the most worrying claims being that the alkaline diet can be used as a cancer treatment. This idea is based on studies which have found that cancer cells thrive in an acidic environment in vitro.16,17 However, a recent systematic review concluded that, ‘promotion of the alkaline diet and alkaline water to the public for cancer prevention or treatment is not justified’ due to a lack of actual research.17 Arguments in relation to bone health are also common among alkaline diet supporters. The theory is that a high ‘acidic load’ causes minerals, such as calcium, to leach from our bones to counteract an acidic blood pH. However systematic review data has not found a causal relationship between dietary acid load and osteoporosis and there is ‘no evidence that an alkaline diet is protective of bone health’.14,18 Conversely, in April 2017, the National Osteoporosis Society (NOS) released a statement which associated increased bone fracture rates in young people with diets which exclude dairy (such as clean eating and the alkaline diet).19 Some low quality studies have found an association between the modern Western diet (which has a high ‘acid load’) and an increase 32

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risk of cardiovascular disease.14,20 However, this ‘acid load’ is based on the food that the modern Western diet contains, rather than the effect of those foods in our body. Therefore, it is too simplistic to assume that it is purely the ‘acid load’ which affects disease risk. There have also been some similar findings in relation to diabetes.14 As the alkaline diet is low in carbohydrates, this style of eating may be effective for some people with type two diabetes.21 However, there appears to be no evidence from systematic reviews or randomised controlled trials that following an alkaline diet or altering the dietary ‘acid load’ can prevent or cure Type 2 diabetes.14 In October 2017, the UK Advertising Standards Authority (ASA) actually banned an advertisement for ‘ADrop’ which claimed that, ‘ionised alkaline water [is] a natural way to improve your circulation’ in the context of treating Diabetes.22 Similarly, certain characteristics of the alkaline diet may be effective for some people in terms of weight management, as it is low carbohydrate and mainly plant-based. But there doesn’t appear to be any experimental evidence to test whether an ‘acidic dietary load’ directly affects weight management.14 There is also ‘no evidence to support the assertion that an alkaline diet may prevent or cure depression, or yeast overgrowth, or cellulite’.14 Certain human studies have identified specific risks associated with ‘alkaline water’, including reduced gallbladder emptying, inhibited gastric secretion and even toxic reactions.17 As with all diets which exclude food groups, there is also a risk of nutritional deficiency, as the alkaline diet can be low in protein, calcium, iron and calories. CONCLUSION

Theories about the alkaline diet have been in circulation for more than 100 years. However, there is still no good evidence that reducing the ‘acidic load’ of our diet has any real health benefits. There may be some positive side-effects to this diet in certain contexts as it promotes a plant-based diet which is low in refined sugar. But there are also significant risks to consider, such as nutritional deficiency and spreading harmful messages about using the alkaline diet to treat serious medical conditions.

TASTE

FOR YOURSELF

Book a free tasting session and discover the joy that our tasty, nutritious meals can bring to patient mealtimes. For your free session call

0800 066 3169 or visit wiltshirefarmfoods.com

OVER 300 DELICIOUS DISHES NUTRITIONAL EXPERTISE SPECIALIST DIET RANGES

CONDITIONS & DISORDERS

HELPING THOSE WITH DYSPHAGIA AT MEALTIMES Helen Willis, Wiltshire Farm Foods Dietitian. Helen Willis is a member of the British Dietetic Association and National Association of Care Catering. She previously worked in the NHS in both Acute and Community Dietetics.

REFERENCES Please visit the Subscriber zone at NHDmag.com

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For someone living with dysphagia, the enjoyment of mealtimes can be completely diminished. The challenge for healthcare professionals is to ensure that patients receive the correct nutrition through meals of the right texture, whilst encouraging them to eat in the first place. Dysphagia is a dynamic condition, so there is no such thing as a onetime diagnosis. There is likely to be deterioration, or alternatively, when the patient has suffered a stroke for example, there is often improvement. Speech and Language Therapists should frequently assess the patient, then work together in a multidisciplinary team to ensure the safest diet. Once this is achieved, the patient can be more confident in the safety of their meals; a crucial step towards reducing the stress experienced at mealtimes. Elements to be considered are the appropriate texture of the meal, the visual presentation and taste of the food offered. The nutritional value of a meal left uneaten is zero, so it is essential that meals are presented in an appealing manner. Blending all the components of a meal together is often the process followed to make a meal ‘safe,’ but serving a meal like this can be unappealing to the patient. Each component of the meal should resemble its original form - foods should be blended separately and moulds used when possible. Making meals recognisable is especially important for those living with dementia, which commonly presents with dysphagia. The importance of food that tastes good should never be overlooked. When blending food together, water and other liquids are often added to achieve a good consistency, but this can impact on taste. Ensuring food tastes delicious and offering plenty of options which take preferences, dietary and cultural requirements into account is a vital part of helping patients to eat. Healthcare professionals must also focus on recommending a diet which meets the patient’s nutritional needs.

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Those with dysphagia often have reduced appetite and are at risk of malnutrition; it’s crucial, therefore, that their food contains the appropriate nutritional content, often needing to be high in calories and protein. Dietitians should assess each individual patient, monitor their nutritional intake and advise accordingly. Knowing that the food they are eating is part of their treatment may encourage patients to finish their meal. A final element which is often overlooked is the dining experience. Whether at home, in hospital or in care, the patient’s dining environment should be pleasant and comfortable. Case studies often describe patients who choose to dine alone, as they are too embarrassed1 to eat in front of family. This problem is exacerbated when eating out in public. A fear of choking and coughing, or of being unable to eat their meal with dignity, leads individuals to report that they avoid social dining altogether. However, research has shown that being part of a group is a rewarding experience.2 Eating with others also enhances our enjoyment of food. As well as helping patients to eat amply and healthily, a social situation stimulates the mind and makes mealtimes more enjoyable. Therefore, healthcare professionals should take it upon themselves to encourage patients to dine with family and friends, or attend lunch clubs whenever possible. Helping individuals to have confidence in the safety of their diet and encouraging them with ways of creating great tasting, nutritional meals to enjoy in a pleasant environment, are steps a healthcare professional can take to improve the overall wellness and health of their patient.

SKILLS & LEARNING

MDT WORK: DIABETES IN PRIMARY CARE Claire Chaudhry Community NHS Dietitian/ Private Dietitian, from Betsi Cadwallader University Health Board; Freelance

“Wales has the highest prevalence of diabetes in the UK,” quotes Dr Julia Platts, National Clinical Lead for Diabetes in Wales.1 The plan for primary care services in Wales up to 2018 identifies the need to invest in the development of the wider primary care workforce and suggests using a wide range of professions according to prudent healthcare principles.2

In Claire’s 16 years’ experience, she has worked in acute and community NHS settings. Claire has taught Nutrition topics at universities and colleges and regularly provides talks to groups, NHS and private.

The diabetes delivery plan for Wales also highlights the need for a range of healthcare professionals working together with national structures and initiatives of local diabetes service planning. Multidisciplinary teams (MDTs) working together will have a significant benefit to all those living with diabetes in Wales.3

www.dietitian claire.com

REFERENCES Please visit the Subscriber zone at NHDmag.com

Thank you to Teresa Davies, Diabetes Specialist Nurse, for her contribution and to Elaine Jennings, Diabetes Lead Dietitian, for her continued support and contribution.

A NEW WAY OF WORKING

Funding opportunities have enabled the development of a new innovative model of diabetes care across Wales. Through a range of funding from Betsi Cadwallader University Health Board (BCUHB) and/ or the locality general practitioner (GP) clusters, diabetes MDTs are currently working within North Wales. The aim of the service is to promote joint working between primary, community and specialist services for the benefit of people living with diabetes in each identified locality. Each team consists of a full-time Diabetes Specialist Nurse (DSN), parttime Diabetes Specialist Dietitian (DSD) and a part-time Diabetes Health Care Assistant (DHCA). These MDTs are currently in Anglesey, Arfon, Conwy West, Meirionnydd, North Denbighshire and South Wrexham. My role of DSD for South Wrexham locality commenced in October 2016. I work alongside Teresa Davies DSN who started in March 2017. Teresa and I cover eight GP surgeries within the South Wrexham locality. There are currently over 3055 patients with diabetes registered within this cluster. Teresa and I explained our roles and the

services we intended to provide to the HCPs of South Wrexham at the cluster locality meeting July 2017. WHAT HAVE WE ACHIEVED?

“Dietitians in primary care ...”4,5 1 Enabling self-care of long-term conditions. 2 Reducing demand on GP time. 3 Make prevention happen. 4 Managing usage of borderline substances. 5 Managing prescribed medicines. 6 Reducing referrals to secondary care. 7 Reducing need for hospitalisation. We have enabled patients to selfmanage their conditions, which for the future will reduce demand on GP time. Teresa and I are both X-PERT educators and between us we have delivered five X-PERT courses within the locality with positive feedback from patients and family members who have attended.6 We meet bi-annually with other X-PERT educators across North Wales. I deliver a monthly two-hour group session aimed at newly diagnosed Type 2 patients. Patients are referred from primary care and are seen within four to six weeks from diagnosis, average attendance per group is 10 participants. What is diabetes, portion sizes of food groups; labelling, alcohol, snacks, eating out and addressing any misconceptions of the group are part of the session. In order to make prevention possible in primary care, we provide Nurse Link meetings every two months for nursing staff. Practice Nurses (PNs), District www.NHDmag.com June 2018 - Issue 135

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SKILLS & LEARNING Nurses (DNs), student Nurses and Healthcare Assistants (HCA) are all invited to attend for networking and training and to discuss individual patient concerns. We have so far provided updates on insulin, blood glucose monitoring machines, structured education and Podiatry. We have run a half-day Diabetes Study Day, aimed at Managers, Registered General Nurses (RGNs) and HCAs employed within nursing homes and residential homes in the Wrexham and Flintshire area. This Study Day was attended by 25 HCPs with positive feedback. Teresa and I have also taught TOPICAL to GPs and PNs. TOPICAL is a three-day course incorporating various topics on diabetes prevention and management.7 Feedback included: “Informative, relevant” and “Excellent speakers!” I have also been providing updates on dietary diabetes prevention and management to staff in the GP surgeries when requested. Feedback included: “A highly enjoyable overview of diet with practical advice.”; “Excellent content.”; “Very useful and thoroughly interesting session.”; “Come again please!” I have been working closely with Elaine Jennings (Diabetes Clinical Lead Dietitian for North Wales) and the diabetologists in Wrexham Maelor Hospital looking at managing medicines effectively and efficiently. Very Low calorie diets (VLCD) are being offered to secondary care patients with Type 2 diabetes. Patients attending VLCD group sessions are provided with information, literature, instructions on individual deprescribing and individual weekly support as telephone follow ups. The publication of the DiRECT study has highlighted the effectiveness of the VLCD in the remission of Type 2 diabetes, plus the reduction and discontinuation in prescribing antihypertensive medication.8 The Diabetes nutritional guidelines were also updated in March 2018 to incorporate the DiRECT study.9 The diabetes delivery plan highlights the importance of changing behaviours through education. Lifestyle interventions aimed at changing an individual’s diet and increasing the amount of physical activity, aims to halve the number of people with impaired glucose tolerance who go on to develop Type 2 diabetes.3 The Cost of Diabetes report 2014 states: “The best way to reduce the cost of diabetes is to prevent 36

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Type 2 diabetes...”.10 In January 2018, with a GP, I undertook a VLCD pilot for patients with an HbA1c between 42-47 (pre-diabetes); four patients undertook a VLCD for eight weeks. The results of this local service improvement were very encouraging: • Total weight loss 39.1kg (average weight loss 9.75kg) • BMI range reduction 1.9-4.8kg/m2 • HbA1c range reduction 2-5mmol/mol • Feedback: “I have more energy.”; “I have a reduction in cravings.” Education for primary care HCPs is paramount, with the aim of reducing the need for expensive referrals to secondary care and reducing the need for hospitalisation. The super six model of diabetes care was developed in South East Hampshire and Portsmouth hospitals. The super six is based on defining clearly with local GPs, commissioners and specialists as to which services need to exist within the settings of an acute Trust. This was due to the need for MDT or a higher expertise involvement.11 The six services defined for secondary care diabetes care were: 1 Inpatient diabetes 2 Foot diabetes (with predefined criteria) 3 Poorly controlled Type 1 diabetes, including adolescents 4 Insulin pump services 5 Low eGFR or patients on renal dialysis 6 Antenatal diabetes Discussions are currently taking place across North Wales regarding the return of patients from secondary care into primary care that do not come under the super six. Thus further training is required from us regarding the long term management of these patients within the community. Hypoglycaemia what do you use? The feedback from South Wrexham residential and nursing homes was “Anything to hand!”. Teresa designed a ‘Hypo Box’ with quick acting glucose examples and easy-to-read instructions on treatment, which cost less than £3. During Hypo Awareness Week back in October 2017, Teresa and I visited care homes and nursing homes to demonstrate the cheap and effectiveness of the hypo box.

Utilising technology effectively is using both EMIS (primary care) and Therapy Manager (secondary care) whilst ensuring that ‘Information sharing’ is conducted safely, transparently, confidentially and with patient’s knowledge. All of the teams across North Wales are asked to provide one Microsoft PowerPoint slide on a monthly basis to show their contribution, worth and activity over a monthly period. This is called ‘A day in the life’ and is used to highlight and celebrate our work whilst sharing workable ideas across North Wales. WHAT HAVE I LEARNED?

Being patient and sticking to our aims Some healthcare centres/surgeries were unwilling for us to be integrated into their practice at first. Other surgeries wanted us to take over their entire diabetes case load. Being patient and sticking to our aims was very important. Educating healthcare professionals on understanding individual dietary goals There were HCPs who were ‘one size fits all’ in recommending a dietary approach. Ultimately, the patient’s choice of what works for them is the key to successfully managing their diabetes and and could also reduce GP time. More knowledge about VLCD and Script analysis The VLCD was introduced to me whilst as a student dietitian in Glasgow Hospital in 2001. Since working alongside Elaine and the Diabetologists on the VLCD, I have learned a wealth of knowledge. Getting to know the patients participating on the VLCD, through weekly follow ups has provided me with further experience on eating behaviours and how they have developed throughout their lives. Whilst on the VLCD patients have reported that their eating behaviours have completely changed. Feedback from the VLCD: “I really appreciated the introduction of foods; I am enjoying all foods now. I had got into a rut and was eating without thinking and the VLCD has put the thinking into perspective.” Script analysis is part of the counselling theory of Transactional Analysis by Dr E Berne and is the

Locality Specialist Diabetes Dietitians in North Wales

method of uncovering the early decisions, made unconsciously, as to how each of our lives are lived, e.g. what and why we eat. THE FUTURE OF THE DIABETES MDT

I am currently developing a VLCD tier service. The VLCD triangle tiered service will be part of the intervention across the complexity of patients with Type 2 diabetes and will take place between primary and secondary care as a prudent healthcare approach.12 Parts of the education will be complementary across the tiers with those at Tier 3 and 4 requiring core education and further individualised support. The aim is to develop the tier service so that level 1 could be delivered in primary care by a trained HCA. I am planning on another prediabetes VLCD cohort this summer within the same GP surgery. The next rung of the triangle level 2 will be primary care patients with newly diagnosed diabetes who are on single therapy. Teresa and I are hoping to recruit a diabetes HCA for two and half days a week, which will help us considerably in our future goals. Traditionally, GPs and specialist prescribing pharmacists are the HCPs responsible for prescribing. With the changing role of dietitians and the possibility of future supplementary prescribing, this is exciting times ahead for diabetes dietitians within the primary care setting. www.NHDmag.com June 2018 - Issue 135

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FREE FROM BITES

Alex Gazzola Freelance Journalist Alex is a writer specialising in food intolerance, coeliac disease, IBS, restricted diets and ‘freefrom’ food. He is the author of five books and regularly blogs at his site: www. allergy-insight.com

FREE FROM FOOD AWARDS April saw the announcement of the winners of the Free From Food Awards - an annual celebration of the finest in gluten free, dairy free and allergen free. Launched in 2008 by doyenne of ‘free from’ and editor of FoodsMatter.com, Michelle Berriedale-Johnson, the awards serve as an invaluable guide to those with dietary restrictions and a great way to signpost tried and tested products, including from small producers who may otherwise evade the radar of even the most eagle-eyed free-from gourmands. Products are judged on a number of criteria such as usefulness, innovation, versatility, nutritional profile, and judging panels are drawn from all sectors. These include food developers, healthcare professionals including dietitians, cookery writers and those with food hypersensitivities - with both Dr Megan Rossi of King’s College and Julia Marriott of the Alimentary Bites blog serving this year. Overall champion in 2018, was Orgran’s Vegan Easy Egg, a savoury egg replacer with corn, chickpea, vegetable gums, starches, turmeric and seasoning, which was praised by judges for its adaptability to various uses, including omelettes, quiches and scrambled ‘eggs’. A bonus: it is free from all 14 EUspecified food allergens. Other gold-medal winners included Sweetcorn & Quinoa Bites by Gosh! (No Top 14 category), Amila’s Sauces’ Fruity Mild Curry Sauce (FODMAP Friendly) and Wildcraft Bakery’s Buckwheat Sourdough Loaf and Asda’s Free From 4 Seeded Brown Rolls (joint winners, Bread). 2019 entry opens in September. For more information, and full results and stockists of 2018 winners, go to www.freefromfoodawards.co.uk

BEST OF ITALIAN Perhaps surprisingly, the land of pasta and pizza has a highly developed gluten-free food sector, and while its vegan produce lags a little behind, it’s fast catching up. Capitalising on all this growth is Free From Italy, UK importers of the finest Italy has to offer. Among its portfolio of brands are Le Conserve Della Nonna (a brand of vegan sauces whose rice-based Béchamel took a Silver in the Free From Food Awards’ No Top 14 category) and Probios (whose vegan MayoRice mayonnaise 38

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alternative took Bronze in Store Cupboard). Three of their Taste Italia wraps are 14 allergens-free too. Their newest import, launching later this spring, is Castagno Bruno’s organic ‘Rice Style’ legume pasta/rice alternative, with varieties made with chickpea, green pea and red lentil, which can be used as a replacement in rice dishes or pasta-based soups, for example. At the time of writing, the precautionary allergen labelling was being reviewed, but boxes will retail at £3.49 for 250g. Check www.freefromitaly. co.uk for updates.

LOCO FOR COCO Cocofina is an upcoming brand of coconut-based products launching welcome innovations onto the market. These include a fish-free ‘Nish Sauce’, an alternative for vegans and fish allergy sufferers, made with coconut sap and seaweed (£5.99, 250ml). Most exciting is the new Make Your Own Coconut Yogurt Alternative (75g, £3.99) a milk-free powder made with coconut yoghurt, maltodextrin, pectin and acacia fibre. Simply add hot water and sweetener if desired, and leave to chill overnight. Probiotics can be added before refrigeration when cooled. The pack makes 350g yoghurt and is a superb portable option, especially for dairy-free kids when travelling. To learn more about the brand, and its products, which also include coconutbased vinegars and coconut snack bars, see www.cocofina.com FREE FROM BITES Orgran, Free From Italy and Cocofina were among hundreds of exhibitors showcasing goods at the Natural & Organic Products Europe (NOPE) (www.naturalproducts.co.uk) trade event held in London in April, and which happens to be open to dietitians and nutritionists, as well as food buyers, developers and industry experts. Although the focus is not specifically on ‘free from’, it invariably offers good insight into new developments for those on restricted diets and this year, the unprecedented growth in veganism was amply reflected in the numerous exhibitors dedicated to this increasingly popular ethical lifestyle. Among them were The Heart of Nature, a Polish company who produces high-fibre grainand seed-rich breads. Their new gluten-free breads are exceptional. The Original Pure Grain Bread contains gluten-free oat flakes, various seeds (linseeds, millet, pumpkin, sunflower), plus seasonings and water - and nothing else. Several flavour varieties - with cranberries, prunes, chia and quinoa - complete the set, which are available from Ocado and Planet Organic. See www. puregrainbread.com. Windmill Organics manage a number of niche organic and free-from brands, including Amisa Organic. Although non-gluten containing flours are widely available on the market, flours which are safe for coeliacs (i.e. free from cross contamination and certified gluten free) aren’t always as easy to come by. To their already established quinoa flour, buckwheat flour and brown rice flour, Amisa are adding chickpea flour (£3.29, 400g) and red lentil flour (£3.69, 400g) in May, both high fibre and high protein, and the latter of which bears a precautionary warning for soya. Windmill are

also introducing a new vegan brand, Bonsan, to their portfolio. Among the products promised are ‘almond crème spreads’ and vegan grill sausages with tofu. Updates at www.windmillorganics.com. Another NOPE exhibitor was Belly Goodness, the newest low-FODMAP brand to hit this growing market. Like FODMAPPED and Bay’s Kitchen, both featured in March’s NHD, Belly Goodness make sauces, but with several twists. Those with tomato allergy who fondly remember the Nomato range from around a decade ago, will be pleased to hear of Belly Goodness’s tomatofree Mediterranean Sauce and Nomato Sauce, which use red pepper, sweet potato, beetroot and carrot. There’s also a coconut-based White Sauce. Fun attractive packaging. Available online from this month. www.bellygoodness.com. Organic free-from pastas which are bronze-cut (and, therefore, have a rough texture which sauce clings to) are hard to come by, but Seggiano are about to launch a five-strong range which include buckwheat and corn fettuccine and rice and teff tagliolini. All are made free of the 14 allergens, so are likely to be a good gourmet option to both coeliacs and those with multiple allergies. RRP £4.60/£4.90, 250g. See www.seggiano.com. Koko, who produce coconut-based ‘milks’ and ‘yoghurt’, as well as coconut oil and spread, will be adding two ‘cheeses’ to their range in June. There’s an alternative to soft cream cheese (£1.99, 150g), plus a hard dairy-free alternative to Cheddar (£2.29, 200g), the latter of which contains 736mg calcium per 100g, almost identical to that of Cheddar itself. Both are free of the 14 allergens and will launch in Waitrose initially, with other outlets following throughout the year. See www.kokodairyfree.com.

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F2F

FACE TO FACE Ursula meets:

BARBARA BRAY Fruit and vegetable expert Nutritionist, Nuffield Scholar Food Safety Consultant

Ursula Arens Writer; Nutrition & Dietetics Ursula has a degree in dietetics, and currently works as a freelance nutrition writer. She has been a columnist on nutrition for more than 30 years.

If you would like to suggest a F2F date (someone who is a ‘mover and shaker’ in UK nutrition) for Ursula, please contact: info@ network healthgroup. co.uk 40

Ursula meets amazing people who influence nutrition policies and practices in the UK.

They say that opposites attract and Barbara has always bedazzled me. She is so positive and bright and breezy; the first person you would choose to be on your team (sports; quiz; work; travel). We met late morning, but already the café in Welwyn Garden City was completely full of glamorous women. This was the ladies-who-lunch crowd something we both aspire to, of course. She always loved food. Her mother inspired her with kitchen-fun and her dad led the food adventures remit: let’s make yoghurt, let’s watch apple oxidation, let’s measure pH levels of foods etc. So, after A levels in Biology, Chemistry and Statistics, Barbara went to the University of Reading to study Food Technology. “I had two really great placements in my practical year. The science lab at Waitrose head office was an eye-opener on food quality testing and I also got out and about to visit stores and suppliers. Then I had half a year in Munich in Germany with the Kraft development laboratory. At the time, fat reduction was the company mission, so the entire focus was on the development of salad dressings and sauces with less fat,” she said. But Barbara had an inkling that some aspects of food technology were a bit ‘every day the same’. So she decided to take a left turn in the food supply chain and study Agriculture at Silsoe College (part of Cranfield University.) Her MSc was on postharvest technologies specialising in tropical crops; little did she realize that cold chain logistics and gas flushing techniques would become

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the explosive areas of growth that we now enjoy the daily benefits of. After graduation in 1996, doing good works in a land of permanent sunshine, Uganda, seemed attractive. Barbara was sponsored by the Silsoe college charity SAFAD and then the UK Kulika Charitable Trust, to advise on postharvest management of durable crops for subsistence farmers. Barbara also became an expert on the issues of growing vegetables for export, especially beans. “There was some local confusion on why beans had to be so uniform in size and shape, but this was the buying specification. Fortunately, nothing went to waste because other shaped beans went to the local markets,” said Barbara. Back in the UK, Barbara joined the Accelerated Management Scheme of fresh produce supplier Bakkavor. Perhaps you have not heard of this company, but they are the major supplier of prepared fruit and vegetables to all UK supermarkets. Barbara covered every aspect of the supply chain, from walking muddy fields with shy farmers, to meeting less-shy supermarket buyers. “Bagged salads were being introduced in early 2000 and there was great excitement about different flavours and colours of leaves. So adieu to iceberg footballs,” said Barbara. But she had to laugh at some surprise product successes. “No research could have predicted how popular prepared mashed potato has become. It was the project that everyone would have questioned. Also frustrating was the commercial success of battered

potato slices, when the sharpest marketing stars at Bakkavor were in such a battle to make salads sexy,” said Barbara. In 2001, she had a bad car accident, which required a few months off work; even now, some of her aches require further medical attention. On her return, she was made responsible for tomato procurement (annual turnover of £40 million, so a lot of tomatoes). Barbara enjoyed lots of international travel to tomato-growing regions and also enjoyed extending the looseround tomato market into the more diverse and flavoursome varieties we enjoy today. For more than 10 years, Barbara zigzagged her way up the technical and management levels within Bakkavor. She came to understand in great depth all the issues affecting the growing, processing and distribution of fresh foods, both in the UK and abroad. But she also observed the consumer. “It is so frustrating that all sorts of messages and claims promote packaged foods, but that there is so little communication about the great health benefits of fresh fruits and vegetables. It is also frustrating that so many products are formulated back to front: starting with desired labelling (with nothing ‘red’ on traffic lights of course) and working back to a recipe. It should be about healthy ingredients and great taste,” said Barbara. Having been involved in the M&S highselenium tomato project, Barbara developed an interest in the nutrient manipulation of vegetables. In 2014, she decided to get back to being a student, and did an MSc degree in Human Nutrition at the University of Chester. Her project was on the nutritional knowledge of those enrolled in slimming clubs: she found that understanding the energy content of foods was good, but there was some confusion over the nutrient balance in diets. Barbara has now set up her own technical and nutrition consultancy (www.alo-solutions. com). Fresh produce businesses wanting advice on audits, or retailer specifications, or any other aspect of food safety and quality, know that Barbara will deliver straight-talking robust critique followed by pragmatic problem solving. And of course she will always try to insert some nutrition-sense into the project.

Last year, she successfully became a Nuffield Scholar. This is a travel fund worth about £12,000 given to the 20 applicants who, ‘have the ability to lead positive change in farming and horticulture, as well as inspiring passion and potential in others.’ Barbara very much fits this description. Her Nuffield project is on vegetable production for specific nutritional needs, which she will present in autumn 2018. As a Nuffield Scholar, she has been invited to observe agriculture and food production in Singapore, Indonesia, Japan, Israel and the USA. She also travelled to China, South Korea, Tasmania and New Zealand to consider vegetable marketing and the use of health claims. We chat about 5-A-Day, but she is full of descriptions of smarter, ‘cuter’ food messaging in other countries. Nutrition communication in the UK seemed dry to Barbara and divorced from food producers (starting at the top with the split between DEFRA and PHE, in contrast to the pulling in the same direction together in the US, under USDA). I first met Barbara when she joined the selfemployed nutritionists group SENSE (www. sense-nutrition.org.uk). She is now the meetings’ organiser; the shepherd to us flock of freelancers. Because of her many years in fruit and vegetable production and marketing, she must be unique in her deep understanding of ‘field to fork’, and I am sure that her skills and insights will be much needed to support UK food producers in the upcoming challenging BREXIT years. It is wonderful to find someone so nutrition focused, planted so deeply into decisions at the start of the food chain. And now I think about Barbara every time I go shopping (for bagged salads, tomatoes, beans, kiwi fruits, bananas, courgettes, sweetcorn…). www.NHDmag.com June 2018 - Issue 135

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A DAY IN THE LIFE OF . . .

AN EARLY YEARS COMMUNITY FOOD WORKER Maryam Bader Associate Nutritionist, Evelina London Since graduating from King’s College London, Maryam has worked for various nutrition charities. She now works for the NHS in the Nutrition and Dietetics service at Evelina London.

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Evelina London is the second largest provider of children’s services in London and is part of Guy’s and St Thomas’ NHS Foundation Trust. The children’s community nutrition and dietetics service works with children aged 0-4 years and their families. The service also works with specialist paediatric dietitians who work with children with special needs in the London boroughs of Lambeth and Southwark. The service is made up of two subservices: the Clinical service made up of specialist paediatric dietitians for children with special needs and the nonclinical service consisting of early years community dietitians, nutritionists, community food workers and a vitamin D coordinator who all work with children and families aged 0-4 years. Our team works with parents and children’s centre staff across Lambeth and Southwark, focusing on specific aspects of the children obesity programme by improving the nutrition of children aged 0-4 years through a number of important initiatives. These include: raising awareness of the importance of breastfeeding; working with children’s centre staff to implement the UNICEF Baby Friendly Initiative; offering ‘Introduction to solids’ sessions to support weaning; offering practical cooking sessions for children and their families and offering a Free-Vitamin D supplement scheme for pregnant women and breastfeeding mothers in the area. The clinical paediatric dietitians work with parents of children with special needs providing one-to-one clinics at special needs schools and neurodisability multidisciplinary clinics, as well as being part of the behavioural feeding clinics in Lambeth and Southwark. As an Early Years Community Food Worker, my role is to deliver practical

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cooking courses for parents of children aged 0-4 in children’s centres across Lambeth. I deliver ‘Cook and Eat Well’ sessions for parents and ‘Cook and Taste’ for parents and their children. During a typical day or week, I tend to split my time across four main activities: session preparation, session delivery, session review and analysis, and time for internal meetings and CPD. SESSION PREPARATION

Each session requires planning to ensure that I’m providing advice and tips that will prove useful and relevant to the participants. In a community role, it’s particularly important to understand the specific backgrounds, cultures and lifestyles of the community in which you work. The recipes used for the sessions are not only healthy, but are suitable in terms of budget, time consumption and reflect the diverse social and cultural needs of the communities. I believe that this element of understanding is crucial in developing a rapport with the participants and in helping to deliver suitable advice and lasting change. I carry out detailed analysis to help maximise the health benefits of each recipe using our nutrition software, Nutritics, to help to adapt each meal to reduce the fat, salt and sugar content. Finally, as part of my preparation for each session, I also spend time preparing handouts, leaflets and other resources that participants can take away and use at home in their daily lives. These generally include useful hints, tips and

We cover a range of topics from practical cooking tips and techniques to increasing participants’ confidence in using food labels to make healthy food choices for their families . . . information and allow them to remain engaged with what they have learnt in the sessions. ‘COOK AND EAT WELL’ AND ‘COOK AND TASTE’ SESSIONS

On average, I usually deliver three, two-hour sessions per week, each one in a different children’s centre to a different audience. The sessions are primarily aimed at increasing families’ knowledge and confidence in cooking traditional home meals on a budget, whilst ensuring low sugar, salt and fat content. We cover a range of topics from practical cooking tips and techniques to increasing participants’ confidence in using food labels to make healthy food choices for their families, and modelling positive mealtime behaviour to help prevent or manage difficult mealtimes in children. The sessions themselves are usually very interactive. I find it’s important to ensure that sessions are engaging, and that I encourage group discussion and active participation as it provides a better learning experience for everyone. It also allows us all to better understand each other’s challenges and to feel a sense of community and teamwork in approaching these challenges together. This can be hugely important, as group contact can also help to reduce many participants’ feelings of social isolation. As part of each three- to six-week course, I encourage parents to set and reflect on goals each week, to create and review food diaries and to discuss their progress and challenges as a group. I find that these kind of exercises help them to reflect and gradually adopt better and more sustainable eating habits over time. The sessions with children are more geared towards cooking together (this is also great for their motor skills) and getting them more familiar to different types of fruit and vegetables that they might not have seen or tasted before.

SESSION REVIEW AND FEEDBACK

Outside of preparing and delivering sessions, much of my time is spent collating and analysing feedback to reflect on the quality of our service, its impact and how we can continually improve our service and impact within the community. Typically, we measure the improvement in knowledge of the participants and improvements in their eating habits. INTERNAL MEETINGS AND CPD

The remainder of my time is spent on internal activities aimed at improving and developing our service, as well as improving my own technical knowledge and professional development. This includes attending internal team meetings to discuss and review progress and plans, creating marketing materials for our sessions, such as flyers and leaflets for children centres, or posting recipes, healthy eating tips, upcoming session details and interesting news articles on social media. As a team, we are also very passionate about promoting evidence-based nutrition messages, in a simple way that the community will understand. As part of this, the team holds a bi-monthly journal club. A different member of the team selects a journal for every member of the team to read and subsequently discuss and analyse together as a team. From time to time, we also have the opportunity to attend conferences on various nutrition-related topics. Earlier this year, I was able to attend an inspiring breakfast conference hosted by Guy’s & St Thomas’ Charity with Jamie Oliver as one of the panel guests discussing inner city childhood obesity. All of these are great opportunities to continuously learn new things and develop personally and professionally. www.NHDmag.com June 2018 - Issue 135

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PAEDIATRIC BOOK REVIEW

FORTY CHANCES

FINDING HOPE IN A HUNGRY WORLD

Review by Ursula Arens Writer; Nutrition & Dietetics Ursula has a degree in dietetics, and currently works as a freelance nutrition writer. She has been a columnist on nutrition for more than 30 years.

HOWARD G BUFFETT PUBLISHER: SIMON & SCHUSTER, 2014, ISBN: 978-1451687873 PRICE: £12.26

It’s not easy having a billionaire father (ask Ivanka Trump). There is only so much champagne you can drink whilst soaking up the sun on a tropical beach before it gets boring. It is difficult to remember the names of all the servants and butlers and ‘friends’, and you can never get away from being watched, pestered and judged. However, some billionaire offspring have found other ways to spend their time and parental money. Howard Buffett received more than three billion dollars ($3,000,000,000) from his father Warren, who is number three on the US rich list (after Microsoft-Gates and Amazon-Bezos). The only instruction from his father was to, “accomplish something great in the world.” Howard chose to challenge world hunger and this book is his story. Howard Buffett loves food and even more, he really loves farmers. He decided not to complete college, but he does remember a ‘click’ moment whilst listening to a lecture on farming. The speaker explained that most farmers had 40 cycles of crop in their lives; 40 chances to perfect the cycle of planting to harvesting. For young Howard, this thought set him into a panic: he had all the money in the world, but not all the time. He had to rush to grab the unique opportunities that he had to make a dent into the statistics on world hunger. There are not many college dropouts whose first jobs allow being on the board of the largest multibillion food processor in the world - Archer Daniels Midland (ADM) company. He is still on the boards of many companies and is a

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United Nations Goodwill Ambassador Against Hunger. But now, most of his time is in the management of his own foundation. A benefit of being very rich, is not having to play office politics: no tiresome professional hierarchies to slither around, or muddled going-incircles committees to have to placate - it is all your money, so it is all your decision. The book is 40 chapters of thoughts on food production and distribution. Howard Buffett describes his travels in the most extreme environments and his encounters with the poorest people. He especially loves talking to sweatbeaded and dusty farmers: why they do things this way and not that. His book is full of anecdotes from personal and professional encounters and from these, his attempts to improve food production and distribution via his foundation. Howard Buffett has some repeat themes in his observations. The Green Revolution, which is the development of high-yield seeds and the use of artificial fertilizer and pesticide, has achieved much to improve crop outputs. But relative improvements are now smaller and there is an urgent need to research and promote the Brown Revolution, which are practices to improve soil

Howard Buffett loves food and even more, he really loves farmers . . . most farmers had 40 cycles of crop in their lives; 40 chances to perfect the cycle of planting to harvesting. quality. This translates as no-till post-harvest practices. The concepts of crimper rollers, and ‘zai pits’ are inspiring examples of Americans learning from Africans. Other repeat themes are the essential concepts of value chains in supporting agricultural development, protecting local food producers in situations of emergency food relief, and critiques of monetization by food aid charities. Buffett shares many examples of disconnects: situations where American agricultural experts, after much thought and data examination, recommend practice A, which cannot ever be implemented by poor farmers in countries in South America and Africa, because of problems B, C and D. One illustration of this is the chapter about mouse-catchers in southern Malawi. Fields in Malawi are cleared post-harvest with small controlled fires, but Howard’s experts tried to advise against this because it resulted in the loss of organic matter essential to support soil fertility in areas where artificial fertilizer was not available or too expensive. Despite this advice, fire setting continued. Eventually, the delicate issues were explained to Howard: land was not owned by individuals, but rather by tribes. Post-harvest, fires were set for many reasons, including that it allowed the efficient capturing of mice, allowing the double benefit of providing a tasty protein snack for locals as well as protecting crops from vermin damage. Mouse-hunters had a longstanding tribal right to burn any fields post-harvest, and keeping them happy was a new challenge for Howard’s American agricultural advisors. Another disconnect that Howard Buffett despairs about, is American foreign aid monetization. What does this mean? Briefly, it is the selling of food in recipient countries, sent via food aid funding, to pay for other aspects of charity work. This results in bizarre outcomes,

so that American wheat sent via government aid routes appears in the foods served in finedining environments in African hotels and restaurants. Of course, there is method behind the madness. The US government supports farmers via price and purchase commitments, which factor in foreign aid commitments. Further, the US government supports commercial shipping viability by requirements for their use to distribute food aid: often, Howard notes, the cost of shipping exceeds the value of the cargo. So, for example, would it not be better for US tax payers to donate $8.4 million to purchase food and support agricultural projects in local markets rather than spend $3.9 million on wheat and $4.5 million on shipping costs? It is politically difficult for US foreign-aid charities to get further public funding via Washington decision makers, but they are allowed to ‘monetize’, i.e. sell food aid goods. So, what does any of this have to do with dietetics? Dietitians work at the far end of the food chain, usually between food-shop to forks. Farms and fertilizer and forklifts are far away (professionally). Of course, dietitians cannot contribute meaningfully to agricultural assessments and debates around the economics of food production and distribution. However, nutrition is a strong driver in many of these decisions, particularly as the pressure of more mouths to feed increases and hi-tech solutions (agri-tech) propose the balance between most human health against least environmental damage. For better outcomes, perhaps dietitians should be joining these discussions? Perhaps this starts with understanding the vocabulary of agri-tech? Listening to The Archers is good; reading this book by Howard Buffett is (much) better. www.NHDmag.com June 2018 - Issue 135

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DATES FOR YOUR DIARY Managing the Paediatric Gastrointestinal Patient Supporting Infants and Children with Tolerance Issues 12th June Free webinar www.nutricialtd.co.uk/p/1LL1-8QE Probiotics in Practice: Workshops for Dietitians and Nutritionists 13th June 9am-2:30pm Rossette Hall Hotel, Wrexham LL12 0DE. www.hcp.yakult.co.uk/symposia/ie-events-test-page# Perspectives on Paediatrics: faltering growth, gut health and blended diets West Midlands BDA Branch annual AGM and study evening 13th June 4.45pm at The Clayton Hotel, Albert Street, Birmingham B5 5JE www.eventbrite.co.uk/o/the-west-midlandsbda-8533984634

Nutricia Paediatric Allergy Symposium 14th June Birmingham Botanical Gardens, Westbourne Road, Edgbaston B15 3TR www.neocate.co.uk/Events Matthew’s Friends KetoCollege Ketogenic Dietary Therapies 19th to 21st June Crowne Plaza Felbridge, West Sussex, UK. www.mfclinics.com/keto-college Nutricia Anthropometric Study Day 28th June 11 Portland Street, Manchester, M1 3HU nutricia.ie/events/view/anthropometric_study_day BNF lunchtime webinar Why is everybody talking about gut microbiota? 28th June www.nutrition.org.uk/component/rseventspro/ event/50-why-is-everybody-talking-about-gutmicrobiota.html

dieteticJOBS.co.uk dieteticJOBS.co.uk

• Quarter page to full page • Premier & Universal placement listings • NHD website, NH-eNews and Network Health Digest placements

To place an ad or discuss your requirements please call: 46

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01342 824073

A DIETITIAN’S TOP 10 PET HATES! Louise Robertson Specialist Dietitian Louise is an experienced NHS dietitian who has been specialising in the fascinating area of Inherited Metabolic Disorders in adults for the last 10 years. In her spare time she enjoys running her blog Dietitian's Life with her colleague and good friend Sarah Howe, playing the cello and keeping up with her two little girls! www. dietitianslife.com

A little tongue in cheek this month. Not everyone appreciates what dietitians or registered nutritionists do, or how they gain their qualifications. This can lead to misinformation about our job roles. So, this got me thinking about the funny things people say to us sometimes. I asked some of my fellow blogging dietitians on Facebook what are their pet hates about the world of nutrition and being a dietitian. Here are my top 10 favourites:

1

Of course, number one is spelling ‘dietitian’ with a 'c' instead if a 't'. Blooming spell check always changes the spelling to 'dietician'. Not that we get upset about this or anything!

2

When someone discovers that you are a dietitian and the questions start coming. “Can you give me a diet?” “What is the best food to eat?” ‘I don't know why I can't lose weight as I hardly eat anything!” Do you ignore, or do you give the standard spiel? “There are no good or bad foods, everyone is different.” “Sorry I can't give you specific advice without knowing your full medical, social and drug history.”

3

When people don't realise that we actually had to go to university to study nutrition and dietetics at degree or post-grad level. No, you can't become a dietitian or registered nutritionist by doing a weekend course on the Internet. You can't compare years of study and experience with an online course.

4

When people think that all we do is weight management. There are so many specialities in dietetics, with so many therapeutic diets for different diseases and disorders. Although it gets quite complicated when I try to explain to non-medical people what I do when I work with people with inherited metabolic disorders.

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When working on the wards and doctors are still referring patients for advice for low albumin concentrations. How many times do we have to repeat ourselves? “The half-life of albumin is very long, so this is not an indicator of nutritional status.”’ Oh yeah, four times a year when the junior doctors rotate!

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When the latest celebrity announces that they look fabulous because they are on a new diet that has cut most food groups out! Come on public, have we not learnt this by now?

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When you expect a full busy day and then people don't turn up to their clinic appointments. Yes, sometimes it’s nice to have time to write up your notes, but seriously, you are wasting precious NHS time and money!

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Companies which are still promoting detox and quick fix diets to the public. This annoys me, brands cashing in on the words ‘detox’ or ‘quick fix’ to sell their products when most of us have a perfectly capable liver and kidneys.

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The word ‘clean’ eating. Trendy Instagram accounts increasing in momentum, labelling their way of eating ‘clean’. But what does this actually mean? To me, it sounds like we are labelling all other food as dirty! No, no, just wrong! Labelling food as clean and dirty is just leading to disordered eating.

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When the crisps and cakes get hidden when you enter the room. Come on guys, we like a treat too. We are just fitting it into our healthy balanced diet! www.NHDmag.com June 2018 - Issue 135

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Oral nutritional supplements (ONS) might contain milk protein, but that doesn’t mean they all have to taste like milk. If your patients are getting bored with their milkshake-style ONS, why not try them on Ensure Plus juce? It packs balanced nutrition into a refreshingly different juice-style supplement, and comes in a wide range of flavours, so there’s always a taste to match theirs. ENSURE PLUS JUCE. FOR MORE INFORMATION, VISIT OUR WEBSITE NUTRITION.ABBOTT/UK

Date of preparation: May 2018 ANUKANI180120b

Like all juice style ONS, Ensure Plus juce contains milk protein, and is not suitable for patients on a milk protein restricted diet.