gs in m et ea re t G D 's NH on e as th Se om fr
D N H NETWORK HEALTH DIGEST The Magazine for Dietitians, Nutritionists and Healthcare Professionals
NHDmag.com
Dec 2018 / Jan 2019: Issue 140
MND: A MULTIDISCIPLINARY APPROACH IBS: A NEW SERVICE FOODBANKS: UK DEMAND CROHN’S AND FODMAPS US ANIMAL PRODUCTS
Enhanced recovery after surgery Pages 17-22
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FROM THE EDITOR gs in et am re te G D 's NH on e as th Se om fr
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NHDmag.com
Dec 2018 / Jan 2019: Issue 140
POLLEN FOOD SYNDROME PANCREATITIS
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.
& DIETARY MANAGEMENT FALTERING GROWTH:CARE OF THE NICE guidelines ELDERLY MALNUTRITION CRITICAL CARE & ECMO INSECT PROTEIN EXPLAINED METABOLIC DIETETICS
CARE HOME NUTRITION Autism: diet
CLINICAL RESEARCH nutrition DYSPHAGIA:and CURRENT PRACTICE IMD: PRESCRIBING pagesCHALLENGES 23-26
BILE ACIDNutrition MALABSORPTION &
INFANT WEANING Non-IgE-mediated
ADULT MALNUTRITION MALNUTRITION MAP Hydration Week allergy: home KETOGENIC DIET THERAPY ONS AND OBESITY page 23-25 introduction guides DEMENTIA: CLINICALLY ASSISTED NUTRITION WHOLEGRAINS
FIBRE AND INFLAMMATORYNUTRITION AND MALABSORPTION WEIGHT MANAGEMENT AND MND: A MULTIDISCIPLINARY FOOD ALLERGY EXAMINED: BOWEL DISEASE BONE HEALTH AFTER SURGERY SPORTS NUTRITION APPROACH WHERE WE ARE NOW BREASTFEEDING
FOCUS ON iMAP GUIDELINES ONS PRESCRIBING PKU THE ALKALINE DIET 49-58 pages
GLUTEN-FREE DIET Multidisciplinary CHRONIC RENAL DISEASE VITAMIN D IN team THE UKwork pages 35-37 FOOD-BASED ACTIVITY
Egg competition: SWEETENERS
PAEDIATRIC FOOD ALLERGY winner's article EATING DISORDERS IN OLDER PEOPLE pages 23-25 DYSPHAGIA
GASTROSTOMY PretermFEEDING infant PROBIOTICS & GUT HEALTH feeding HEAD TRAUMA & NUTRITION PLANT-BASED pages DIETS 29-31
TODDLERS & NUTRITION Join the NHD TEENAGERS & HEALTHY EATING community at ELDERLY MALNUTRITION NHDmag.com BOLUS FEEDING EXAMINED
NETWORK HEALTH DIGEST
IBS: A NEW SERVICE Diabetes and FOODBANKS: UK DEMAND carbohydrates CROHN’S AND FODMAPS Pages 41-45 US ANIMAL PRODUCTS
Enhanced recovery after surgery Pages 17-22
Goodbye 2018, Hello 2019! As we move forward into another year, here at NHD we are revelling in the success of the last 12 months. Looking back, we’ve created 10 great issues, which showcase the rich diversity of skills, experience and knowledge that nutrition and dietetics provide to many walks of life. At the heart of our success are our dedicated and passionate writers, who have provided the wide-ranging content for each issue. We raise a glass to each and every one of you for your excellent contributions. But before we get too carried away with the glasses of fizz and nibbles, we’ll take you through the goodies nestling under the tree in this issue. Deep into winter now and with the season of goodwill upon us, the difficulties many people face will be all too evident. The growing use of food banks in the UK is being highlighted in the media with frightening figures recently released by The Trussell Trust, one of the UK’s largest food bank providers. Emma Berry takes a timely look at the impact of food insecurity and the limitations of emergency food provision. We welcome Lucy Williams with this month’s Cover Story, exploring the nutritional management of motor neurone disease (MND) and the timely placement of gastrostomy. She stresses the importance of the multidisciplinary team (MDT), which more often than not is essential in the successful treatment of illness and disease. ERAS (Enhanced Recovery After Surgery) is another important MDT area and here, Rebecca Gasche focuses on the current guidelines and evidence to support its use. Rebecca also provides an overview of her experience in setting up a dietetic-led IBS service and pathway, highlighting group sessions on the low-FODMAP solution. The lowFODMAP diet has been seen to help in
the management of Crohn’s disease too, and Priya Tew shares current research in this area. In her second article, Priya talks us through the little-big world of pre- and probiotics and the microbiome. Where did you complete your dietetic placements as a student? Would you have considered a social care placement at the time? Highlands based Evelyn Newman discusses the development of innovative social care dietetic placements and how they may potentially benefit the future profile of the profession. With Brexit in mind, Maeve Hanan reports on animal products from the US, notably the use of chlorine and antibiotics in meat production. Lucy Aphramor analyses healthism and how public health messages simplify the complex issues surrounding overweight and obesity. And in our Student Zone this month, Erin Kelly, takes a look at the difficulty in meeting nutritional requirements during cancer treatment. We also have our regular features including Face to Face, which sees Ursula meeting up with Nutrition Consultant, Margaret Ashwell; and A Day in the Life . . . provided by Vanessa Bara, Specialist Dietitian in Adult Cystic Fibrosis, who shares some case examples from her busy schedule. So, we’ve raised a glass to our contributors but what about you guys, the readers? Well here’s an extra special toast to you. Cheers! Merry Christmas and a Happy and Healthy New Year from us all at NHD. Emma
www.NHDmag.com December 2018/January 2019 - Issue 140
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CONTENTS
12 COVER STORY MND: A multidisciplinary approach
News
7
Latest industry and product updates
Free from bites
8
News and festive fare products
How safe are they?
10 Foodbanks
35 ANIMAL PRODUCTS FROM THE USA 38 Healthism
The growing need and use in the UK
Creating knowledge for transformation
42 Social care
Developing a dietetic workforce
44 Face to Face
With Margaret Ashwell
28 IBS: A PATIENT SERVICE Reducing pressures in secondary care
An adult cystic fibrosis dietitian
49 Book review
The Omega Principal by Paul Greenberg
51 Dietitian's life
32 Crohn's disease
46 A day in the life of . . .
The effect of the low-FODMAP diet
How to improve gut health
23 Pre-, Probiotics & the microbiome
ERAS 17 Post surgery dietary support 21 Nutritional care through cancer treatment
Festive fare
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 Columnist Ursula Arens Design Heather Dewhurst
4
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NEWS
LOW-CARB DIET 'COULD INCREASE LONG-TERM WEIGHT LOSS' A study1 hit the media recently, with headlines such as ‘Low-carb dieters can lose more than 1.5 stone over three years’, being reported by The Daily Telegraph.2 Researchers at the Boston Children's Hospital, Framingham State University, Emma Coates the University of Arkansas and Baylor College of Medicine carried out this Editor randomised controlled study, which included 234 participants, aged 18 to 65, with a BMI of 25 or above. Emma has been a Initially, over a 10-week period, each participant was expected to follow the same weight registered dietitian for 12 years, with loss diet, with the aim that they’d lose 12% of their body weight. The diet provided around experience of adult 60% of their estimated calorie requirements. After 10 weeks on the diet, 70% of participants and paediatric dietetics. achieved the weight loss goal, with an average weight loss of 9.6kg. For the second part of the study, the 164 successful weight loss participants were randomly allocated one of three weight maintenance diets to follow for 20 weeks. Each diet adjusted the calorie intake with the aim maintain body weight. This produced varying success for the participants, with 120 of the 164 participants remaining within the target of 2kg of their post-weight loss weight (38 in the high-carb group, 39 in the moderate-carb group, 43 in the low-carb group). During this maintenance phase, the average body weight change was less than 1kg. There was no significant difference in body weight change between each diet group. The average energy expenditure of the participants on the various diets at specific weights was compared via isotopically labelled water. The results were as follows: • High-carb group - energy expenditure fell by 19kcal a day. • Moderate carb group - energy expenditure rose by 71kcal a day. • Low carb group - energy expenditure rose by 190kcal. • Compared with the high-carb group, the low-carb group had a daily energy expenditure of 209kcal a day. To book your • The hormone ghrelin was lower in people following the low-carb diet. company's It was hypothesised by the researchers that if the alteration in energy expenditure product news were to continue for three years, without any change to the diet and activity levels, it would equate to an estimated 10kg weight loss for a 100kg 1.78m tall 30-year-old for the next male. The researchers concluded that ’dietary composition seems to affect energy expenditure independently of body weight’, and a low-carb diet ‘might facilitate issue of weight loss maintenance beyond the conventional focus on restricting energy NHD call intake and encouraging physical activity’. 01342 824073 The study has a variety of limitations, including that the results are theoretical and so don’t demonstrate any physical evidence of improved weight maintenance or greater weight loss in those who followed a low-carb diet, when compared with those on a high or moderate carb diet. The study only lasted 20 weeks, so we do not have any actual evidence that the weight loss will be maintained and although participants lost a significant amount of weight within the first 10 weeks of the study, during this time, the food they ate was prepared for them and prescriptively calculated for calories and the balance of the fat, protein and carbohydrate. This is unachievable for most people in day-to-day life. Whilst the study has not provided any long term or realistic outcomes to demonstrate whether or not low carb diets work, or whether there may be any risks associated with such diets, the results provide some interesting information about how the body may metabolise varying combinations of foods within the diet. 1 Effects of a low carbohydrate diet on energy expenditure during weight loss maintenance: randomised trial. BMJ 2018; 363: k4583. Available at www.bmj.com/content/363/bmj.k4583 <accessed 15/11/18> 2 www.telegraph.co.uk/news/0/low-carb-dieters-can-lose-15-stone-three-years-study-claims/ <accessed 15/11/18>
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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
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NIMA COMES TO UK SHORES The Free From Show Winter held in Liverpool at the beginning of November saw the UK launch of the Nima portable gluten sensor, which has already been making waves among the coeliac community and beyond in the US. Promising ‘peace of mind at meal time’, the sensor is designed to accept pea-sized samples of foods, inserted within single-use capsules and to then test for the presence of gluten. There are limitations. Some forms of gluten cannot be detected or tested, including fermented or hydrolysed products (soy sauce, beer, malt vinegar) and alcohol. Uneven distribution of theoretical gluten contamination in a meal means that any peasized sample may not be representative of the whole. Particulates can be missed. Each test takes three minutes, meaning a long wait and cold food if several items on the plate are analysed. Test data on food samples containing gluten at above 20 parts per million (20ppm) seem good, with the Nima accurately reporting ‘gluten found’ around 95% of the time. Where results seem far less reliable are in the middle-range of the gluten-free ‘zone’. Independent evaluation of the device by the Food Allergy Research & Resource Program at the University of Nebraska-Lincoln, the results of which are published by The Journal of Food Protection, found that over half of tested samples of prepared food at 10ppm – safely within glutenfree levels – returned ‘gluten found’. A third did likewise at 5ppm. One concern here is that consumers would likely refuse these potentially safe foods and unfairly register a ‘gluten found’ mark against the food service provider via the app to which the Nima can be linked. In early October, some of this ‘real’ reported data from US Nima customers was collated, analysed and published in a paper by Columbia University scientists and Shireen Yates, Nima’s CEO. The widely publicised headline claim resulting from this – ‘one third of restaurant foods labelled gluten free contained at least 20ppm of gluten’ – caused alarm. One critic of both the Nima and this study is dietitian Tricia Thompson, who runs independent food testing agency Gluten Free Watchdog (www. glutenfreewatchdog.org), and has written extensively on the subject. She argues that the Nima is not scientifically validated according to the US Food and Drug Administration’s own definition, and that the key claim was misleading, given that Nima is not a quantifiable test. With half of 10ppm meals likely to test positive, the one in three figure likely overestimates the scale of the problem. Having previously stated that it could not recommend the sensor, Coeliac UK has now taken a more neutral approach based on informed choice in guidance to its members. The charity has emphasised its limitations and advises coeliacs to always ask for more information on food preparation. Debates will continue to rumble, and at £189.99 for the gadget and 12 capsules, which cost £59.99 separately (both from ALK’s https://uk.klarify.me), it is unlikely to be within budget for all coeliacs.
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FREE FROM BITES How easy is it to have a nut-free Christmas? Coeliacs and, increasingly, dairy intolerants and vegans are very well catered for, not least in the free-from aisle, but those dealing with nut and peanut allergies can struggle – the ‘may contain traces’ warnings being sadly ubiquitous. If you need to advise patients for some seasonal treats, here are some nut-safe suggestions. For Christmas Puddings the supermarkets are your best bet. Choose from Co-op’s Free From Christmas Pudding (100g, £1.50), Sainsbury’s Free From Christmas Pudding (£2/£4, 100g/454g), and Asda Nut & Alcohol Free Christmas Pudding (454g, £2.50). Cole’s Free From Christmas Pudding (112g/454g, £2.99, £8.99) is gluten free, dairy free, nut free and alcohol free (www.colespuddings.com). For chocolate: D&D Chocolates (www.danddchocolates.com) have a huge selection of chocolate gifts, including Christmas decorations and advent calendars. So Free Chocolate (www.plamilfoods.co.uk/ so-free) is also excellent. They have an Organic Advent Calendar and a White Chocolate Alternative Advent Calendar (£4.95, 100g), as well as chocolate penguins and snowmen for kids. Worth checking out too are Cocoa Libre (www.cocoalibre.co.uk) and Essy & Bella (www.essyandbella.com). For panettone, it’s worth mentioning the first nut-safe option available in the UK. Free From Italy (www.freefromitaly.co.uk) have two: the GoVegan! Organic Christmas Wheat Panettone (500g, £12.99) and GoVegan! Organic Spelt Panettone (500g, £14.99) are both milk free and egg free as well as nut free. An excellent Facebook resource to recommend to patients is the Nutfreeliving Food Guide Facebook page, which provides regular updates on safe products. Find it at www.facebook.com/ groups/144276012728604.
PRET AND NATASHA’S LAW
Allergy news in recent months has been dominated by one tragic story – that of Natasha Ednan-Laperouse, a teenager who collapsed on a flight to France in July 2016 after eating a sandwich she’d bought from Pret A Manger which contained sesame, to which she was allergic. The baguette was unlabelled, due to a legal exemption on ingredient/ allergen labelling for products made at the site at which they are sold, and this seems to have falsely reassured Natasha into assuming the sandwich was safe for her. Despite the administration of adrenaline and other medical intervention, she later died. Following the September inquest into her death earlier this year, coroner Dr Séan Cummings raised a number of concerns in his report, among which that Pret A Manger was evading the ‘spirit’ of the labelling regulation on which they were capitalising, which was designed to assist local kitchens and small independents, and that the food chain had ‘no coherent or coordinated system for monitoring customer allergic reactions’. Even before the report was published, Pret had made some positive changes, declaring allergens on shelf tickets in front of each item, boosting the generic allergen signage in store, and improving their published Allergen Guide, which is available in each branch and online. Although they haven’t yet commented on introducing an allergy reaction monitoring system, they have promised to move towards full ingredient labelling declaration, with highlighted allergens – essentially what is required by all food products made off-site. This will be trialled and phased in very soon. From a legal perspective, Michael Gove, Secretary of State and a recipient of the report, has promised to look at changing the law to make it an obligation. ‘Natasha’s Law’ could come into effect in 2019.
www.NHDmag.com December 2018/January 2019 - Issue 140
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PUBLIC HEALTH
FOOD BANKS: A GROWING DEMAND Emma Berry Associate Nutritionist (Registered) Emma is working in Research and Development and is enjoying writing freelance nutrition articles.
REFERENCES Please visit the Subscriber zone at NHDmag.com
Food banks provide an important emergency service for many families and individuals. Recently, the media has highlighted the growing need and use of food banks in the UK due to the benefit system failing to cover the cost of living.1 The Trussell Trust has a large network of food banks across the UK which provide emergency food parcels to individuals or families in need.2 This is a major operation with food donations being brought to the food banks and then organised and stored. People who use the food banks exchange a voucher for an emergency parcel.2,3 This covers food for three days and the food bank staff can signpost individuals to services, such as financial advice, if they need additional help.2,3 The food banks are only possible through generous donations, support and time given by individuals and organisations.3 The Trust’s foodbank network provided 658,048 emergency supplies to people in crisis between April and September 2018, a 13% increase on the same period in 2017.2 The Trussell Trust also has an ongoing programme called ‘It’s More Than Food’, which works to identify and address the problems resulting in ‘food insecurity’, ie, consistent limited access to adequate food by a lack of money and other resources, and those requiring emergency food provisions.10 This programme started in 2014 and includes a number of schemes, such as holiday clubs, working to reduce fuel poverty, finance support and courses on food budgeting and cooking skills.10 COMMUNITY FOOD INITIATIVES NORTH EAST (CFINE)
With the ever-changing UK financial climate, running food banks has required an adaptation to support them and their charitable efforts. This involves the running of social enterprises and projects to cover the running costs. One example 10
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of a food bank that aims to be selfsustaining is Community Food Initiatives North East (CFINE) in Aberdeen. CFINE is the lead member of Food Poverty Action Aberdeen (FPAA) - a group of organisations working to support individuals experiencing food insecurity.4 CFINE runs numerous social enterprises from which the income is used to support local social and community projects. Most of the businesses and social projects are related to food.4 These projects include selling healthy snacks and produce to offices, along with working to improve access of fruits and vegetables to communities with limited supply.4,5 CFINE offers numerous services to help individuals who have problems which result in long-term food insecurity. Services include financial advice about debt, budgeting and help with benefits.4,5 They offer help and training on eating on a budget, including reducing food waste and how to cook healthy foods.4,5 They are also a partner for AHEAD+ (Action Health Education/ Employment Against Disadvantage Plus), which provides coordinated help for individuals on education, housing and employment for disadvantaged communities.5 CFINE identifies that food insecurity is often part of a larger issue, and without support, food insecurity will continue to be a problem.4,5 LIMITATIONS OF EMERGENCY FOOD PROVISIONS
Emergency food provisions are supplied through donations, but these parcels often need to consist of food that can be stored for a long period of time without refrigeration or the need to cook.
Individuals who require these food provisions could be limited in the cooking equipment that they have access to. This can make healthy eating challenging, given the limited resources and likely isn’t the first priority for many in these situations. It is important to establish that emergency food provisions do not just include food - they also include items such as sanitary products. CFINE runs the ‘Access to Free Sanitary Products’ which was a pilot scheme,4,5 leading to the Scottish Government’s decision to provide free sanitary products for individuals who cannot afford them.9 Although some may think that this does not have an impact on food insecurity, a decision to reduce any regular monetary outgoings could have a massive impact on some families who are struggling, allowing them to put this money towards food. THE IMPACT OF FOOD INSECURITY
Unfortunately, food insecurity is on the rise. FPAA’s report from July 2017 found that since November 2016, they had seen a large rise in the demand for emergency food provisions.4 In the North East of Scotland, the downturn of the oil industry in recent years has resulted in 10s of thousands of individuals losing their jobs.4 many individuals have struggled to pay their mortgages and have other financial burdens on top, resulting in a high demand for emergency food provisions.4 Although this group of individuals is not likely to be seen in other parts of the country, nationally, food insecurity is on the rise.8 The Trussell Trust’s Annual Report from March 2017 found that, during the previous year, they had distributed over one million emergency food provisions, which was a 6% increase on the year before that.8 As mentioned earlier in this article, recent figures from the Trust show a 13% increase in 2018.2 The Annual Report stated that low income benefit delays due to the introduction of Universal Credit and charges were the main reasons for referrals to their food banks.8 FPAA also identified the changes in the benefit system to be a major issue and a reason for individuals using food banks.4 Loopstra et al9 found that as the number of benefit sanctions rose, the number of emergency food provisions also rose, although this may not be due to the sanctions alone. Further research would be beneficial to determine the current food security climate in the UK and why people turn to food banks.
Although the UK hasn’t published extensive reports on food insecurity and food bank usage, other countries have. A study by Kaur et al10 examined the relationship of food insecurity in children and the risk of obesity by examining the US National Health and Nutrition Examination Survey data of 2001-2010. The study found a significant relationship between food insecurity of children aged six to 11 years and obesity, whereby a higher level of food insecurity was linked to a higher risk of obesity.10 If this link between food insecurity and obesity is also found in children in the UK, then the government’s current plan to tackle childhood obesity11 could be failing families and children who are most in need. Although the Healthy Start scheme offers vouchers for families so that they can get fresh or frozen fruits and vegetables, it requires individuals to apply online. It also limits individuals to fresh or frozen foods only, but this assumes that the person or families can store such foods.12 The Trussell Trust’s Annual Report from 2017 showed that of all the emergency food supplies handed out in the previous year, 436,938 went to children - which is approximately one third.8 Perhaps, working towards having healthy options for all families and reducing food insecurity could have an impact on obesity levels and health outcomes for these children in the future. CONCLUSION
The importance of food banks for struggling communities is clear. The current benefits system is resulting in more individuals struggling and needing emergency food provisions. As food banks rely on donations and volunteers, it can be hard to meet demand. Food banks, such as CFINE, are coming up with innovative ways to provide services which allow them to reinvest any profits back into their services to support communities and individuals who are struggling. Food banks are also working with partners to offer support in tackling the problems that result in individuals needing emergency food provisions, including services such as financial or debt management advice. Although these services are offered to support individuals and families in becoming food secure, there is limited research into food insecurity in the UK. Further research into food insecurity and the current benefit’s system’s impact on this issue could be beneficial to identify possible solutions.
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COVER STORY
MOTOR NEURONE DISEASE: NUTRITIONAL MANAGEMENT Lucy Williams RD Specialist Neurosciences Dietitian: Salford Royal NHS Foundation Trust Lucy is a Specialist Dietitian working in the Greater Manchester MND Care Centre. She is Team Lead for Neurosciences at Salford Royal NHS Foundation Trust.
REFERENCES Please visit the Subscriber zone at NHDmag.com
12
This article gives an overview of the multidisciplinary approach to the management of motor neurone disease (MND) and timely placement of gastrostomy. MND is the name given to a group of closely related disorders characterised by progressive degeneration of lower (spinal and bulbar) and upper (corticospinal) motor neurones, leading to muscle atrophy, paralysis and death.1 The disease can be classified into four main types depending on the pattern of motor neurone involvement and the part of the body where symptoms begin. Amyotrophic Lateral Sclerosis (ALS) is the most common type, accounting for over 75% of the total MND cases.2 It is characterised by muscle weakness and stiffness, over-active reflexes and, in some cases, rapidly changing emotions. Initially, the limbs cease to work properly and later the muscles of speech, swallowing and breathing can become affected. Whilst the greater number of patients present with progressive weakness of the arms and legs, between 25-30% of all patients initially present with bulbar symptoms.3 When MND begins in the muscles of speech and swallowing, it is described as Progressive Bulbar Palsy (PBP). The limb muscles may also become affected in PBP and it generally carries a poorer prognosis. Progressive muscular atrophy (PMA) and Primary lateral sclerosis (PLS) are much rarer forms of MND. In their true form, they have a slower rate of progression which may not significantly reduce life expectancy, but levels of disability can be high. As of yet, there is no clear cause for MND, but it is likely to be due to a combination of environmental, lifestyle and subtle genetic factors. In combination, they may ‘tip the balance’ towards
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someone developing the disease. In rare cases, there is a familial link for MND that is passed down through generations. Research shows abnormalities in the gene C9ORF72 in up to 46% of familial cases and 23% in sporadic cases.4 There is currently no cure for MND and most people die within two to three years of developing symptoms.5 THE IMPACT OF MND ON NUTRITIONAL STATUS
As MND progresses, it causes loss to the upper and lower motor neurones, resulting in weakness and wasting to the muscles involved in movement, mobility, breathing, swallowing and speech. This has a profound impact on a person’s ability to eat and drink and, therefore, on their ability to meet and maintain their nutritional needs. As the condition deteriorates, so too does the risk to nutritional status, which in itself impacts further on the deterioration of the clinical status of the patient, causing a vicious cycle that, without appropriate intervention, worsens prognosis.6 There are a number of factors that can influence nutritional status in MND, as shown in Table 1. These include: swallowing difficulties, which preclude safe oral intake; physical difficulties, which affect the ability to prepare food and feed one’s self; physiological changes, which cause a hypermetabolic state; and psychological factors affecting appetite and enjoyment of meals, amongst others.7 Dysphagia Dysphagia is perhaps one of the most challenging symptoms to manage; it is a significant problem for 90% of
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CONDITIONS & DISORDERS Table 1: Causes of malnutrition Dysphagia Problems with salivary secretion and mastication Loss of dexterity of the upper limbs affecting ability to prepare and eat foods Hypermetabolism
Cognitive impairment Depression
Respiratory insufficiency
Constipation
Fatigue
Polypharmacy
patients with MND8 and is a major cause of morbidity and mortality.9 Dysphagia results from damage to either corticobulbar pathways or brainstem motor nuclei, causing spasticity and weakness to the tongue, lips, facial muscles, pharynx and larynx, as well as impacting upon the management and clearance of saliva and respiratory secretions. This difficulty in swallowing can lead to prolonged and effortful mealtimes, distressing episodes of coughing and choking, increased chest infections caused by aspiration pneumonia, dehydration, weight loss and malnutrition.10-11 The clinical assessment of bulbar symptoms requires a multidisciplinary approach, comprising of history taking, evaluation of weight and BMI, respiratory function assessment and clinical examination of swallowing and speech. Hypermetabolism Hypermetabolism is now widely considered a feature of MND, although the exact origins are not yet clear. Some studies suggest it exists as a result of the increased effort of breathing and metabolic demands on the remaining functional muscles, thus increasing energy requirements.10 More recent research, however, suggests that a number of other factors correlate with a hypermetabolic state, including fat-free mass, age, sex and weight, as well as the possibility that the sympathetic nervous system and mitochondrial derangements (causing excessive heat production and energy deficit) may also play a role.12 Further research is clearly required; however, regardless of its origin, hypermetabolism itself poses a further challenge in meeting the nutritional requirements of patients with MND. THE PREVALENCE OF MALNUTRITION
Malnutrition is a major concern in MND, occurring in approximately 55% of patients13 and several 14
Anxiety Embarrassment when eating
studies demonstrate that nutritional status is an independent prognostic factor for survival, with malnourished patients having an eightfold increased risk of premature death.14-15 Notably, whilst patients with dysphagia may have a poorer prognosis, they are not considered any more likely to be malnourished than those without.14,16-17 As discussed previously, MND is associated with an altered nutritional state, energy intake and expenditure; 70% of patients have a decreased calorific intake and consume less than the recommended dietary allowance for energy.16,18 THE MANAGEMENT OF NUTRITIONAL STATUS
In the absence of a cure, symptomatic and palliative treatment is the priority for optimising quality of life.21 Management of nutritional status throughout the course of disease progression is pivotal for enhancing quality of life and optimising the timing of appropriate interventions.22 It is recommended that nutritional assessment should commence as soon as the diagnosis of MND is suspected23 and be reviewed on a three-monthly basis through measurement of body weight.9 Involvement of a speech and language therapist and a dietitian is essential from an early stage to assess, monitor and review the individualâ&#x20AC;&#x2122;s nutritional intake so that practical oral and non-oral dietary advice can be given to enable nutritional needs to be met. Nutritional insufficiency may evolve gradually and asymptomatically and, therefore, a proactive approach for early recognition and intervention may delay or minimise associated complications.24 It is important that patients with MND are not screened for nutritional risk based solely on the Malnutrition Universal Screening Tool (MUST) score. These patients are at high risk of rapid deterioration in nutritional status and will benefit from early discussions regarding
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Table 2: Members of the MDT29 Core MDT members
Other specialists
Neurologist Neurology specialist nurse Palliative care specialist Dietitian Physiotherapists Occupational therapists Respiratory physiologist Speech and language therapist
Psychology and counselling services Social care Respiratory medicine Gastroenterology Community neurology teams Equipment services
preferences for treatment as the condition progresses and early interventions to avoid crisis situations. There are a number of strategies that can be implemented to optimise nutritional intake, including the use of adaptive cutlery and posture support, modified texture diets and safer swallowing techniques, such as a chin tuck swallow, increasing the frequency of meals and fortifying the energy density, as well as using ONS.10,21,22 However, due to the progressive nature of the disease, over time these measures usually become insufficient and enteral feeding is then indicated.9 THE ROLE OF THE MULTIDISCIPLINARY TEAM (MDT)
The MDT is widely considered a fundamental part of the management of MND due to the diverse and interlinking symptoms.26 Evidence suggests that multidisciplinary care can show improvements to both quality and quantity of life, by not only improving timely access to supportive interventions such as gastrostomy and non-invasive ventilation (NIV), but by providing tailored support and education to families and carers.27,28 Table 2 shows the recommended core practitioners for an MDT, along with other specialists that may need to be accessed for additional support. The MDT can provide early holistic assessment of nutritional status and supportive measures that can optimise intake. This may prolong the time period before more invasive supportive measures are required. GASTROSTOMY FEEDING - WHEN IS THE RIGHT TIME?
For both professionals and many patients discussions around enteral feeding can be a source of intense discomfort and considering this at an early stage can be difficult due to uncertainty
about disease course. Discussions can bring to the fore the reality of the progressive nature of the condition and patients are frequently reluctant to consider further deterioration at an early stage. Gastrostomy feeding is recommended to provide long-term nutritional support for patients with amyotrophic lateral sclerosis with severe dysphagia.9 The European Federation of Neurological Societies (EFNS) guidelines26 recommend early insertion of gastrostomy based on considerations of the quality of bulbar function, weight loss (>10% of premorbid), respiratory function and general condition of the patient. As MND progresses, there is an increased risk of developing respiratory compromise, making gastrostomy insertion a more risky procedure. This is supported by the American Academy of Neurologists (AAN) recommending gastrostomy insertion when forced vital capacity (FVC) is greater than 50% to reduce procedural risks.9 This means that the opportunity for safe placement of gastrostomy should be seized at the earliest opportunity and this necessitates early robust discussion about future management of nutritional needs. An important part of this process is to encourage the patient to take an active role in the management of their condition and limit situations in which the patient must make difficult decisions for themselves under pressure of rapidly deteriorating clinical status. It is useful to consider the following points when supporting discussions around gastrostomy: • The patient is given sufficient background information to help in the decision. • Information is provided in a sympathetic and empathic way, with both sides of the argument given. • Time is spent explaining the various points and aims of any interventions or treatments.
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CONDITIONS & DISORDERS • The person is supported, if they wish, by family or friends. • Written information may be of help to allow further consideration.30 It is important to dispel any myths surrounding gastrostomy, so that patients are aware that the main function of the tube is to improve quality of life. Conversations about gastrostomy insertion can be particularly distressing for patients who are in the early stages of their disease and still eating and drinking well. The gastrostomy, when used appropriately, can be significant in reducing episodes of distress associated with eating and drinking, such as fears of choking, optimising nutrition and hydration and improving social isolation experienced from prolonged mealtimes.31 The www.mytube.mymnd.org.uk website32 is a fantastic resource to assist patients through the decision-making process. It allows them to access safe and reliable information about gastrostomy placement and management within the comfort and privacy of their own homes. Many patients find it easier to process this information in their own time and this enables them to be more open in later discussions. There are three main methods of gastrostomy insertion currently used in patients with MND: • percutaneous endoscopic gastrostomy (PEG) • radiologically inserted gastrostomy (RIG) • per-oral image-guided gastrostomy (PIG)33 The ProGas study34 is the most recent large scale prospective cohort study that has looked at the optimum timing and method of gastrostomy in patients with ALS. The study made a number of key findings and recommendations that may be used to influence and guide future practice. Firstly, the study recommends that it may be more beneficial to consider placement of gastrostomy at approximately 5% weight loss. This was based on a number of factors: • The odds for 30-day mortality were greatest for patients who had lost >10% of their prediagnosis weight. • Gastrostomy feeding only prevented further weight loss in approximately half of the study participants. 16
• In those patients who gained weight, these gains were small and the clinical benefit was not clear. • The greater the percentage of weight loss at the time of gastrostomy from diagnosis, the less likely it was for patients to recover this loss after gastrostomy. This was most evident in the subgroup of patients who had lost >10% of their diagnosis weight. • Those patients whose weight loss continued following gastrostomy had poorer survival rates. The study also recommends that PEG is the optimal method of placement in patients where respiratory function is largely unimpaired, followed by PIG when respiratory function is significantly compromised. These recommendations relate primarily to the fact that patients who underwent RIG experienced a higher rate of gastrostomy tube-related complications such as displacement/leakage. Some patients choose to decline additional supportive options such as gastrostomy. In these cases, it is important to ensure that any misconceptions are corrected, but if ultimately the decision remains the same, it is essential that they are given reassurance that supportive care will continue to be provided, with the ongoing aim of managing symptoms and minimising any discomfort or distress. SUMMARY
Patients with MND are at high nutritional risk and poor nutritional status is an independent prognostic factor for survival. Early assessment and ongoing review are essential to optimise the timing of interventions to support nutritional needs, with the role of the MDT being essential. Gastrostomy is recommended to provide long-term nutritional support for patients with MND. It may be more beneficial to consider placement of gastrostomy at approximately 5% weight loss from pre-diagnosis weight. PEG is the optimal method of placement in patients where respiratory function is largely unimpaired, followed by PIG when respiratory function is significantly compromised. For patients who decline interventions, they must be reassured that supportive care will continue.
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CLINICAL
ENHANCED RECOVERY AFTER SURGERY (ERAS) 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
How we treat patients before, during and after surgical procedures has changed dramatically over recent years. Due to evidence showing that surgical intervention leads to an endocrine and metabolic stress reaction, which slows down recovery,1 ERAS programmes were developed to support patient’s recovery post-surgery. ERAS was first described in 2000, with the first protocol being published in 2005 by Professor Henri Kehlet. ERAS programmes are patient-centred, optimising surgical outcomes. They integrate a range of perioperative interventions which have been proven to maintain physiological function, reduce stress response and facilitate postoperative recovery.2 The ERAS team is often multidisciplinary, made up of preassessment and ward nurses, theatre staff, consultant surgeons, consultant anaesthetists, physiotherapists, occupational therapists, dietitians, stoma nurse specialists, pain control specialists, colorectal nurse specialists and ERAS nurse specialists.3 It is recommended that continual research into and audits on ERAS programmes are undertaken to ensure developments are made. The ERAS Society is dedicated to this, with its mission statement being ‘to develop perioperative care and to improve recovery through research, education, audit and implementation of evidence-based practice’.4 WHAT DOES ERAS INVOLVE?
ERAS programmes are a collection of strategies aiming to ease the loss of, and improve the restoration of, functional capacity after surgery. Morbidity is reduced and recovery enhanced by reducing surgical stress - usually involving strategies such as optimal control of pain, early oral diet and early
mobilisation. As a consequence, length of stay in hospital and, therefore, costs are reduced. ERAS targets pre-, peri- and postoperative surgery. Examples of preoperative interventions include patient education, ensuring good nutritional status and the use of ONS if indicated. Perioperatively, Trusts have implemented strategies such as goal directed fluid therapy, minimal tissue handling and minimising operating times. Postoperative examples of ERAS could be early enteral nutrition, postoperative drugs to manage nausea and vomiting and ensuring follow-up after discharge. THE EVIDENCE
There have been many studies showing that measures to reduce the stress of surgery can minimise catabolism (the breakdown of complex molecules into simpler forms) and support anabolism (the building of larger molecules from simpler forms) throughout surgical treatment, improving recovery time, even after major operations.5 A cohort study by Pascal et al6 compared mortality, morbidity and length of stay between ERAS patients and historical controls. The study concluded that ERAS reduces morbidity and length of hospital stay for patients undergoing elective colonic or rectal surgery. The strongest evidence for ERAS implementation is in the care of patients undergoing open colonic resection. Many interventions which have previously shown to benefit outcomes
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Getting Nan back to her old tricks again!
is a powdered, neutral-tasting carbohydrate loading drink mix for the pre-operative dietary management of patients undergoing surgery. has been shown An Enhanced Recovery Programme including the use of to significantly reduce post-operative hospital stay with a return towards earlier gut function when compared with fasting or supplementary water.1 Helping patients get back to doing the things that they enjoy sooner.
Preload™ is a Food for Special Medical Purposes and must be used under strict medical supervision. 1. Noblett S, Watson D, Huong H, Davidson B, Hainsworth P, Horgan A (2006) Pre-operative oral carbohydrate loading in colorectal surgery: A randomized controlled trial. Colorectal Disease: 8, 563-569.
A Nestlé Health Science Company
www.vitaflo.co.uk Nutritional Helpine: 0151 702 4937
® Reg. Trademarks of Société des Produits Nestlé S.A.
CLINICAL in this population, have now been successfully applied to laparoscopic colon resections, as well as to other surgical specialties such as urology, orthopaedics, and gynaecology.7 Until quite recently, patients undergoing colorectal resection were counselled to accept a 20 to 25% risk of complications and a seven- to 10-day postoperative stay in hospital. Studies throughout the 1980s to 1990s showed that the length of stay in hospital and complication rates improved even if a single component of care was changed. With this, the idea of incorporating many of these elements into a comprehensive care pathway was developed.8 NUTRITION AND ERAS
Nutrition plays an important role in ERAS, with many of its interventions linked directly, or indirectly, to nutrition. ERAS advocates that nutritional management becomes an integral component for all patients undergoing major surgery.9 WHAT ARE THE GUIDELINES?
The ESPEN guidelines on clinical nutrition in surgery,10 released in 2017, outline a number of recommendations, summarised here: Preoperatively • Preoperative fasting from midnight is unnecessary in most patients. Patients undergoing surgery, who are considered to have no specific risk of aspiration, can drink clear fluids until two hours before anaesthesia. Solids are allowed until six hours before anaesthesia. • In order to reduce perioperative discomfort and to impact postoperative insulin resistance and hospital length of stay, oral preoperative carbohydrates can be considered in patients undergoing major surgery. This can be administered the night before and two hours before surgery. • It is recommended to assess the nutritional status before and after major surgery. • Patients with severe nutritional risk should receive nutritional therapy for a period of around seven to 14 days, prior to major surgery. • ONS should be given to all malnourished cancer and high-risk patients undergoing major abdominal surgery.
• Enteral nutrition/ONS should preferably be administered prior to hospital admission to avoid unnecessary hospitalisation and to lower the risk of infections. • Preoperative parental nutrition should be administered only in patients with malnutrition or at severe nutritional risk where energy requirements cannot be adequately met by enteral nutrition. A period of seven to 14 days is recommended. • Regular assessment of nutritional status and qualified dietary counselling is required while monitoring patients on the waiting list before transplantation. • There is currently no clear evidence for the use of formulae enriched with immunonutrients vs standard ONS exclusively in the preoperative period. Perioperatively • Perioperative nutritional therapy is recommended to start as soon as possible in patients with malnutrition and those at nutritional risk, and/or if it is anticipated that the patient will be unable to eat for more than five days. It is also recommended in patients expected to have low oral intake and who cannot maintain above 50% of recommended intake for more than seven days. • Peri- or at least postoperative administration of specific formula enriched with immunonutrients (arginine, omega-3 fatty acids, ribonucleotides) should be given in malnourished patients undergoing major cancer surgery. • Establish metabolic control, eg, of blood glucose. • Minimised time on paralytic agents for ventilator management in the postoperative period. • Early mobilisation to facilitate protein synthesis and muscle function. Postoperatively • Oral nutritional intake should be continued after surgery without interruption, with oral intake (including clear liquids) being initiated within hours after surgery in most patients. • Regular reassessment of nutritional status during the stay in hospital and, if necessary, continuation of nutrition therapy, including qualified dietary counselling after discharge, is advised for patients who have received
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CLINICAL nutrition therapy perioperatively and still do not cover appropriately their energy requirements via the oral route. • After heart, lung, liver, pancreas and kidney transplantation, early intake of normal food, or enteral nutrition, is recommended within 24 hours. • Even after transplantation of the small intestine, enteral nutrition can be initiated early, but should be increased very carefully within the first week. • Early oral intake can be recommended after bariatric surgery. Enteral nutrition • It is recommended to adapt oral intake according to individual tolerance and to the type of surgery carried out, with special caution to elderly patients. • If the energy and nutrient requirements cannot be met by oral and enteral intake alone (<50% of calorific requirement) for more than seven days, a combination of enteral and parenteral nutrition is recommended. • Whenever feasible, the oral/enteral route is preferred. • Early tube feeding (within 24 hours) should be initiated in patients whose early oral nutrition cannot be started and their oral intake will be inadequate. • In most patients, a standard whole protein formula is appropriate. • Due to risk of tube blockages and the risk of infection, the use of kitchen-made (blended) diets for tube feeding is not recommended. • With special regard to malnourished patients, placement of a nasojejunal tube (NJ), or needle catheter jejunostomy (NCJ), should be considered for all candidates for tube feeding who are undergoing major upper gastrointestinal and pancreatic surgery. • If tube feeding is indicated, it should be initiated within 24 hours after surgery. • It is recommended to start tube feeding with a low flow rate and to increase the feeding rate carefully and individually due to limited intestinal tolerance. The time to reach the target intake can be very different and may take five to seven days. 20
• If long-term tube feeding (>4 weeks) is necessary, such as in severe head injury, placement of a percutaneous tube (eg, percutaneous endoscopic gastrostomy [PEG]) is recommended. Parenteral nutrition (PN) • Parenteral glutamine supplementation may be considered in patients who cannot be fed adequately enterally and, therefore, require exclusive PN. • Postoperative PN including omega-3 fatty acids should be considered only in patients who cannot be adequately fed enterally and, therefore, require PN. • PN should be administered as soon as possible if nutrition therapy is indicated and there is a contraindication for enteral nutrition, such as in intestinal obstruction. ONS • When patients do not meet their energy needs from diet alone it is recommended to encourage these patients to take ONS. • Malnutrition is a major factor influencing outcome after transplantation, so monitoring of the nutritional status is recommended. In malnutrition, additional ONS or even tube feeding is advised. • Standardised operating procedures (SOP) for nutritional support are recommended to secure an effective nutritional support therapy. CONCLUSION
ERAS has been proven to improve outcomes for patients undergoing not only colorectal surgery, but for a number of other surgical procedures too. An ERAS team should be in place to ensure procedures are implemented and followed correctly, thus improving patient outcomes. Nutrition plays a key role in ERAS from preventing malnutrition pre- and postoperatively, to initiating feeding soon after surgery and the use of enteral nutrition and PN when required. All components of ERAS help to improve outcomes for patients, speed up recovery times and ultimately reduce the costs of surgeries happening in our hospitals every day.
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CONDITIONS & DISORDERS
NUTRITION THROUGH CANCER TREATMENT Erin Kelly Student, Nutrition and Dietetics, University of Surrey Erin is currently in her final year at the University of Surrey after successfully completing two 12-week clinical placements. She has a strong interest in oncology, cystic fibrosis and inherited metabolic disorders.
REFERENCES Please visit the Subscriber zone at NHDmag.com
This article looks at the difficulty in meeting nutritional requirements during cancer treatment, the changes and effects of taste and appetite and the development of Enhanced Recovery After Surgery (ERAS). Every two minutes, someone in the UK is diagnosed with cancer.1 A startling fact, but one which is becoming ever more present, with cancer causing one in eight deaths worldwide. It is now predicted that, by 2030, there will be 21.7 million new cases of cancer globally and 13 million cancer deaths, as we have an increasingly ageing population.2 Nutrition plays a major role in cancer treatment and ensuring that nutritious foods are eaten before, during and after cancer treatment can help patients feel better and stay stronger. It can sometimes be difficult to meet our own nutritional requirements, but what about if you have cancer and are having treatment? People with cancer are at a higher risk of malnutrition due to both the psychological and physical effects of a diagnosis. Psychological effects can result in anxiety and/or depression which can affect appetite, whilst physical symptoms of cancer, including pain, dysphagia, vomiting and diarrhoea, can also impair appetite, affect nutrient absorption and increase nutrient losses.3 WEIGHT LOSS
A prolonged catabolic response to a tumour can cause unplanned weight loss and wasting muscle.4 It is extremely important to eat well during cancer treatment as it affects the way cells grow and divide, which may also affect normal cells and can result in the patient feeling unwell. Patients often complain of taste changes, a loss of appetite and fatigue/tiredness. Research has shown that people who remain a stable
weight during cancer treatment often have a better quality of life and live longer, which is why, even if a person is overweight, it is recommended that all patients keep their weight stable. Any weight loss can cause the medical team to delay treatment if they deem the patient is not well enough, as it can increase side effects and is more likely due to muscle loss which can hamper motility.7 So, what can we as dietitians do to help support our patients and help ensure we minimise any weight loss whilst patients are receiving treatment? A healthy balanced diet is recommended for people who, through treatment, are coping well, have minimal side effects and are not losing any weight. If a patient is finding it difficult to meet their nutritional requirements and, hence, are losing weight, there are several firstline dietary interventions which can be encouraged: • Choose richer foods, ie, high energy foods and full fat products such as cakes, biscuits, milk and cheese. • Fortify foods by adding extra ingredients to increase energy content without increasing portion size, for example, adding full cream to soups, smoothies, or adding cheese to mashed potato. • Eat regular bitesize high energy snacks, such as cheese and crackers, mini sausage rolls and nuts. • Drink nourishing fluids including full fat milk and milkshakes. If a patient continues to lose weight despite food fortification advice, they may be offered ONS.
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CONDITIONS & DISORDERS INTERVENTIONS AFTER SURGERY
EFFECTS OF TREATMENT
Chemotherapy and particular medications can cause patients to become nauseous and experience vomiting, that can have a severe impact on their appetite. There are different anti-sickness medications that patients can try; however, it may also be useful to suggest patients have dry, bland foods first thing in the morning to help settle their stomach, to eat little and often throughout the day and to eat cold foods if cooking smells cause the patient to experience nausea.6 Patients having cancer treatment often complain of taste changes, for instance, sweet and salty foods often become stronger; some develop a metallic taste, whilst others may lose all of their taste senses.6 To overcome these taste changes, it is often recommended to add herbs and spices to try to enhance flavours. Sharp tastes such as fruit juices can be refreshing, whilst using plastic cutlery can sometimes help with metallic taste.6 People also can experience dry mouth during treatment and in order to cope with these changes, patients are recommended to drink at least two litres of water a day, eat softer foods which are easier to chew and swallow and to add lots of gravy and sauces to foods.7 Using sugar-free gum and/or sucking on boiled sweets can also help to stimulate salivary glands to help with dry mouth. General tiredness and fatigue is a common side effect of cancer treatment and can affect a person’s appetite and/or motivation to eat. Being prepared and planning ahead by cooking batch meals and bulk freezing them when the patient feels well, can be a great option for when the patient is not feeling so good. Ready meals, tinned and frozen foods can also be a great nutritious option. 22
One of the main treatments for cancer is to have surgery to remove tissue from the body. For patients undergoing surgery, the avoidance of any post complications is the main objective and whilst there are many influences which can affect recovery, nutritional intervention can play a vital role. Malnutrition can have a negative effect on wound healing by delaying the process and in patients who are undernourished before surgery, there is a higher risk of postoperative complications such as morbidity and mortality. More than three million people in the UK are malnourished at any one time, with an estimated 30% of people admitted to acute hospitals or care homes at risk of becoming malnourished.7 In the past, nutritional support was used postoperatively. However, many patients would remain nil by mouth for a week after surgery. Parenteral nutrition (PN) was also used to provide nutritional support after surgery, but it tended to be delayed and only used after major surgical complications.3 The development of ERAS has since revolutionised the care of major elective surgical patients across the UK and Europe.3 The aim of ERAS is to improve the quality of care to all patients who undergo major elective surgery, as it is thought that improved care and reduced harm will shorten length of hospital stays and, therefore, also free up bed space.5 Enhanced recovery principles include: • optimising the patient’s health/medical condition preoperatively; • assessing risk and fitness for surgery at preoperative assessment; • reducing starvation by using carbohydrate loading drinks up to two hours before surgery; • using minimally invasive surgery where possible; • using a clear and structured approach to postoperative management, including pain relief; • early mobilisation and early nutrition.3 CONCLUSION
Having a cancer diagnosis can be an extremely difficult time for a patient and their families. The role of a specialist oncology dietitian is to give specific tailored nutrition evidence-based advice in order to optimise the patient’s nutritional status and quality of life and to provide support.
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FOOD & DRINK
PREBIOTICS, PROBIOTICS AND THE MICROBIOME Priya Tew Freelance Dietitian and Specialist in Eating Disorders 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
The world of prebiotics, probiotics and the microbiome has exploded lately and it is definitely an area to stay abreast of and be ready to explain to people in simple terms. There are instant dietary changes that people can make to improve their gut health, potentially their mental health and overall physical health too. The microbiome is an exciting area of research right now. It has the potential to make some big changes to how we approach nutrition. The gut microbiota is a vast and diverse community of micro-organisms in the human intestinal tract, including bacteria, viruses, archaea and unicellular eukaryotes.3 There are 10 times more microbial cells than there are human cells in the body. The diversity and number of microbes increases through the GI tract from the stomach with the colon containing the most. This is affected by the current bacterial composition (types of microorganisms) and the abundance. PREBIOTICS
Prebiotics are natural, non-digestible food components which help promote the growth of beneficial bacteria (probiotics) in the gut. They alter the colonic microbiota in favour of a healthier composition. Fermentation
in the colon leads to the production of energy, metabolites and micronutrients and an increase in probiotics. Prebiotics are found naturally in a range of fibre rich foods. These include fermentable oligosaccharides, consisting of three to 10 monosaccharide units. These foods are fermented in the large intestine, giving rise to their benefits. Examples include: • fructans found in main fruit and veg, grains legumes, nuts and inulin; • galacto-oligosaccharides (GOS) found in legumes and beans. It’s worth noting here that a different class of GOS (β-linked lactose-derived) has been shown to have multiple beneficial prebiotic properties.
Table 1: Foods which are a natural source of prebiotics Fructans
Galacto-oligosaccharides
Fruit: nectarines, watermelon, plums, pomegranate, grapefruit, ripe bananas
Legumes: chickpeas, lentils, beans
Veggies: artichokes, cabbage, onions, shallots, spring onions, leeks, garlic, asparagus, broccoli, Brussels sprouts, fennel Grains: wholewheat, rye and barley Legumes and nuts: chickpeas, lentils, beans, pistachios, cashews, almonds Other: inulin, dandelion tea www.NHDmag.com December 2018/January 2019 - Issue 140
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WHAT TO LOOK FOR IN A PROBIOTIC A guide for healthcare professionals CHECK THE LABEL AND QUALITY
Does the label state the full strain name of the microorganism(s) in the product?
Does the label state the number of live cells of the probiotic strain(s) in the product?
NOTE: This should comprise three components: genus, species and strain identifier.
Yakult contains 1010 Lactobacillus casei Shirota per 100 ml, when refrigerated.
Genus (e.g. Lactobacillus), species (e.g. casei) and strain (e.g. Shirota) is stated in full on Yakult’s packaging.
This is equivalent to 6.5 billion live cells per 65ml bottle.
Contact the company. Are there quality control procedures in place? NOTE: This is necessary to ensure the product contains the correct strains and number of live microbial cells as stated on the label.
Yakult is acknowledged by experts to be a quality probiotic.
CHECK THE SCIENTIFIC EVIDENCE
Contact the company or access their HCP website, to find the supporting research. NOTE: (i) Regulatory restrictions mean companies can share research information with HCPs but not the general public; (ii) Not all probiotic research papers can be found on medical literature databases.
The research evidence for Lactobacillus casei Shirota can be found at www.yakult.co.uk/hcp or by contacting science@yakult.co.uk
CHECK FOR GI TRACT SURVIVAL
CHECK FOR EFFICACY OF THE STRAIN
For oral probiotics, are there human intervention trials showing survival of the probiotic strain(s) through the gut?
Check for trials and studies for the probiotic and the particular patient problem
NOTE : In vitro or model studies are not proof of gut survival in vivo.
(important for assessment of safety).
There are several research papers describing human studies showing the gut survival of Lactobacillus casei Shirota.
See expert advice in ‘LcS Insight: HCP Study Day 2014’ and ‘Your Guide to Probiotics’.
For further support on what to look for in a probiotic or to access the research behind Yakult, then please visit www.yakult.co.uk/hcp contact science@yakult.co.uk or call 020 8842 7600 This resource is intended for healthcare professionals. Not to be distributed to patients.
Table 2: Examples of fermented foods Fermented Foods Live yoghurt Kefir Aged cheeses Kimchi Sauerkraut Miso
Tempeh Sourdough bread Soy-fermented foods Fermented sausage Pickles
PROBIOTICS
Probiotics are live organisms, which when administered in adequate amounts confer a health benefit.1 These can change/repopulate the intestinal bacteria in order to rebalance the gut flora and include live cultures and fermented foods. They can stimulate the immune system and help decrease the risk of infections by affecting the balance of pathogenic and commensal bacteria. They can reduce the production of pro-inflammatory cytokines, thus counteracting inflammation and cell damage.3 FERMENTED FOODS
There has been a resurgence in the popularity of fermented foods recently. These foods are as old as humans, but we have lost some of the traditional methods from our diet culture. As soon as farming and hunting began, fermentation was used as a means of preserving food. The varieties we have now in the shops will vary widely depending on the method of manufacture, the bacterial cultures added in, plus duration of storage.7 This makes it hard to know if certain products contain enough live cultures to have a benefit. This is where it becomes tricky - how do we know there are enough live cultures in a product to be of benefit? On the other hand, at least we know they are unlikely to have a negative effect, so are worth trying. A study on retail food samples of fermented foods found many contained 105-7 cfu per g of live bacteria which was classed in the study as a â&#x20AC;&#x2DC;good amountâ&#x20AC;&#x2122;. However, there is no legislation on what a relevant dose is or to check that these foods contain the beneficial bacteria at all.2 The health benefits of probiotics include positives for gut health, improvements in glucose tolerance, blood lipid profiles and digestive function. However, this is evolving research and we need more RCTs to help us really see the effects.6
The phyla firmicutes and bacteroidetes make up around 90% of the bacteria in the gut; however, there are also smaller genus that have important roles and shouldnâ&#x20AC;&#x2122;t be forgotten, eg, Bifidobacteria and Lactobacillus. The gut microbiota influences the whole body and GI tract in various ways, including affecting gut permeability and tight junction formation. Fermentation of oligosaccharides and fibre, including beta glucans and psyllium, leads to the production of short-chain fatty acids, acetate, propionate and butyrate. These are used by the intestinal epithelial for energy and can lower the luminal pH and so inhibit pathogen growth. The production of these chemicals can also affect immunomodulation via stimulating the production of certain cytokines, inhibiting others, thus playing a role in the regulation of proinflammatory and anti-inflammatory cascades.3 GUT HEALTH STUDY
The link between gut microbe diversity and diet was investigated in more than 1500 people in an observational study. The American Gut project4 used citizen scientists, so the public donated their time and personal data for analysis. The results showed that eating 30 or more-plant based foods a week compared to 10 or less plant foods a week leads to a more diverse microbiome. Those eating more plant foods had fewer genes for antibiotic resistance in faecal samples. There was a potential positive mental health effect seen too. Those with PTSD, schizophrenia, depression, or bipolar disorder had more bacteria in common with others suffering from similar conditions than the controls, suggesting a bacterial link that could potentially be changed via diet.4 One key thing to note from this study is that diversity was key, so, eating a variety of plant foods over the week and not the same ones day in and day out is more beneficial.
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FOOD & DRINK SUPPLEMENTATION
In the UK, most people do not eat enough fibre (the average intake is 17.2/day for women and 20.1g/day for men).8 The recommended average intake for adults is 30g per day. Certain supplements may be helpful to bridge the fibre gap. Regarding probiotics, many products are available, but these are often expensive, so which are the right ones to direct people to without them wasting money? This is where it gets complicated as many probiotics are strain specific. There can be several thousand strains of one species (eg, Lactobacillus) and each strain has its own unique properties and impact on the body. One big issue we face as clinicians is which probiotic to recommend. The market is huge and the evidence is very much up and coming. Telling people to just “take a probiotic” is too broad and is pretty much a lucky dip. Much of the research conducted either fails to mention the specific strains used, or pools different strains together, therefore diluting down the results. The other
complication is that formulations of probiotics can change over time. Not only is it important to look at the strain of probiotics, but also the impact a particular strain has on a disease. Obviously, there is no point recommending a strain of probiotic that is useful for diarrhoea prevention for a patient who has H. pylori infection! A recent systematic review looked at the research from 1970-2017, specifically focusing on strains and disease states.5 A total of 228 trials were included. Strong evidence was found for the efficacy of specific probiotics for six disease states: antibiotic associated diarrhoea (AAD), clostridium difficile infections (CDI), IBD, IBS, traveller’s diarrhoea (TD), acute paediatric diarrhoea, as well as for H. pylori infections. The strongest evidence was found for the VSL#3 mixture (B. breve BB02, B. longum BL03, B. infantis BI04, L. acidophilus BA05, L. plantarum BP06, L. paracasei BP07, L. helveticus BD08, Strept thermophiles BT01). There were six trials with significant efficacy for the treatment of IBD.
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www.NHDmag.com December 2018/January 2019 - Issue 140
Bimuno® naturally increases good bacteria in your gut in iust 7 days• • Bimuno is a daily prebiotic supplement • Helps with digestive discomfort • Suitable to be used alongside a low FODMAP diet
s1muno'v'
e1mund
Available from Boots, Holland & Barrett and at www.bimuno.com For more information please contact hcp@bimuno.com 'Scientific data shows that daily use of Bimuno® increases gut bifidobacteria levels within 7 days, results may vary.
Table 3: Strength of efficacy for probiotics with identified strain designations and at least two randomised controlled trials with significant findings for the prevention or treatment of disease5 Net ≥ 2 significant randomised clinical trials (RCTs) (number of significant RCTs/nonsignificant RCTs)
At least two RCTs with significant efficacy (number of significant RCTs/non-significant RCTs)
Prevention AAD
Saccharomyces boulardii I-745 (11+/6−) Lactobacillus acidophilus CL1285+ Lactobacillus casei LBC80R+ Lactobacillus rham-nosus CLR2 (4+/0)a L. casei DN114001 (2+/0−)
Enterococcus faecalis SF68 (2+/1−) L. rhamnosus GG (2+/4−) Lactobacillus reuteri 55730 (2+/1−)
Paid AAD
S. boulardii I-745 (7+/3−)
L. helveticus R52 + L. rhamnosus R11 (2+/1−)
CDI-primary
None
L. acidophilus CL1285 + L. casei LBC80R + L. rhamnosus CLR2 (2+/2−)a
Nosocomial infections
None
L. rhamnosus GG (2+/2−)
Traveller’s diarrhoea
S. boulardii I-745 (2+/0−)
Treatment Paediatric acute diarrhea
S. boulardii I-745 (25+/4−) L. rhamnosus GG (12+/3−) L. reuteri DSN 17938 (3+/0−) L. acidophilus LB (3+/1−) L. casei DN114001 (3+/0−) VSL#3b (2+/0−) Bac. clausii OC/SN/R (3+/1−)
L. helveticus R52 + L. rhamnosus R11 (2+/1−)
Irritable bowel syndrome
B. infantis 35624 (2+/0−) L. rhamnosus GG (2+/2−) L. plantarum 299v (4+/1−) S. boulardii I I-745 (2+/2−)
L. rhamnosus GG+ L. rhamnosus VSL#3b (2+/2−) LC705 + B. breve Bb99 + Prop. freudenreichii shermanii Jc (2+/0−)
Helicobacter pylori eradication
L. helveticus R52 + L. rhamnosus R11 (4+/1−)
S. boulardii I-745 (5+/11−) L. reuteri 55730 (2+/2−) L. acidophilus La5 + B. animalis spp. lactis Bb12 (3+/2−)
Inflammatory bowel disease
VSL#3b (8+/2−)
S. boulardii I-745 (2+/1−)
CDI-recurrences
S. boulardii I-745 (2+/0−)
Disease indication
AAD, antibiotic-associated diarrhoea; B., Bifidobacterium; Bac, Bacillus; CDI, clostridium difficile infections; E. Enterococcus; L. Lactobacillus; Prop. Propionibacterium; S. saccharomyces. a Includes two dose treatment arms from one trial. b VSL#3, a mix of eight strains (B. breve, B. longum, B. infantis, L. acidophilus, L. plantarum, L. paracasei, L. debrueckii spp. bulgaricus, and Streptococcs thermophilus).
TAKE HOME MESSAGES
1 Encourage people to eat a diverse amount of plant-based foods. Variety is key. This doesn’t have to mean that they go vegetarian or vegan, but just the message of eating more plant foods every day. 30 or more plant foods may seem a lot in a week, but everyone can start by increasing from where they are, adding five different portions a week. 2 Prebiotic foods are plentiful and link into the message of eating more plant-based foods. Using the message that these foods are prebiotics may encourage some people to eat more of them. 3 Fermented foods may be a useful source of probiotics. Adding live yoghurt and pickles can be a simple way to do this. 4 When recommending probiotic supplements for disease states, check the evidence for the specific strains that work. www.NHDmag.com December 2018/January 2019 - Issue 140
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PAEDIATRIC COMMUNITY
IBS: SETTING UP A PATIENT SERVICE 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
The IBS pathway discussed in this article can be viewed at www. NHDmag. com/ibspathway.html
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When I started my post in April 2016, my initial task was to help set up a dietetic-led irritable bowel syndrome (IBS) service. Following on from successful dietetic-led coeliac services, my Trust wanted to create a similar pathway for patients with IBS, to help reduce pressures in secondary care, wait times and improve patient outcomes. IBS is a long-term condition affecting the digestive tract. It can most commonly cause symptoms such as abdominal discomfort, an altered bowel habit and bloating, and can have a huge impact on a patient’s quality of life. It is known that diet and lifestyle factors play a huge role in managing symptoms, hence why NICE guidance on management of IBS suggests the use of avoidance and exclusion diets to only be advised by a healthcare professional with expertise in dietary management.1 When looking at the low-FODMAP diet more specifically, which is used as second-line treatment for IBS, studies have supported dietitians being the healthcare professionals to deliver the dietary guidance, stating that dietitians have an extensive knowledge of nutrition, health and disease and are the leading experts in educating patients on disease-specific dietary management, including IBS.2 One study concluded that dieteticled implementation of the low-FODMAP diet is an effective strategy for the management of IBS and that the trend for non-dietetic-led implementation of the diet is of concern, as there is no evidence of the clinical effectiveness or risks associated with such practices. The study also stressed the importance of dietetic-led management in IBS needing an increased recognition in clinical practice.2 Despite the evidence, it is thought that IBS referrals account for up to 60% of outpatient gastroenterology referrals.3,4 By using a thorough referral system to rule out other potential gastrointestinal causes, a dietetic-led
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clinic with access to a gastroenterologist is suitable to manage this patient group. AIMS OF THE IBS SERVICE
The aim of the IBS service at Chester was to ultimately reduce the pressure from the gastroenterology consultants, who were finding that a large amount of their clinical time was being spent with IBS patients. They would often refer these patients onto the dietitians after seeing them initially. Reducing consultant pressure would lead to a reduction in consultant wait times, as well as patient wait times to be treated, with the aim that patient satisfaction would, therefore, increase. The pathway also hoped to reduce unnecessary investigations, such as colonoscopies. The policy aimed for patients to be seen within four weeks of receiving the referral, and that they would be seen by a dietitian before, or instead of, seeing a consultant. It was made clear that patients must be screened for any ‘red flags’, and that the dietitians had the relevant specialist skill set to be able to identify abnormal results/symptoms and link in with the gastroenterology consultants when needed. If dietary manipulation did not improve a patient’s symptoms, they could be referred directly into secondary care, without delay to their care. LOGISTICS
First and foremost, the policy had to be written and agreed with the gastroenterology team. We knew that if the dietitians were to see these patients
The aim of the IBS service at Chester was to ultimately reduce the pressure from the gastroenterology consultants . . . instead of the consultants, it was crucial that thorough screening methods were in place to ensure that patients weren’t misdiagnosed. The NICE guidance emphasises the importance of excluding other diagnoses in patients presenting with symptoms of IBS.1 Therefore, we requested that those referring into the service had to ensure that all patients presenting with symptoms, such as abdominal pain or discomfort, bloating and/or a change in bowel habit for at least six months, were assessed for the following ‘red flags’: • unintentional and unexplained weight loss; • rectal bleeding; • a family history of bowel or ovarian cancer, or signs and symptoms of cancer in line with the NICE guidance on recognition and referral for suspected cancer; • anaemia; • aged over 50 years. Any patient presenting with IBS symptoms alongside one or more red flags were to be referred directly into secondary care. As well as assessing for red flags, patients would be seen by the dietitian on the basis that the following tests had been ordered and returned within normal range: • FBC • tTGA • ESR • TFTs • CRP • Faecal calprotectin These could be completed by the referrer or the dietitian once the referral had been received. We ensured that our policy allowed the dietitian to order any bloods/stool samples that had not been checked, to avoid having to reject referrals for this reason and allow patients to be seen sooner. Testing for these bloods/stool samples helps to rule out conditions which present similarly to IBS, such as coeliac disease, inflammatory bowel disease or infections.
Once the policy was approved by the gastroenterology and dietetics teams, and had gone through the relevant governance meetings, the next step was to set up the clinics in which these patients would be seen. Logistics of finding clinic rooms, dates, times and admin letters attached to the clinics all takes time! The service began with two clinics per week, 30 minutes for each patient for both an initial or review. A lot of work went into promoting the service in primary care, working closely with the clinical commissioning group (CCG), encouraging GPs to refer to the ‘dietitian first’. The consultants were aware to redirect any referrals they received, with no red flags, to the service, and they were also on hand to support the dietitian if required. GROUP EDUCATION SESSIONS
The IBS clinics ran from 2016-2017 and were proving a success in reducing wait times both for patients and consultants. However, as the service was promoted within the gastroenterology team, GPs and other community settings, the numbers of referrals increased. We opened additional clinics and set up an ‘opt-in’ appointment scheme to reduce the number of ‘did not attends’, but soon found that we were at our capacity and risked patients waiting longer than the four weeks set out in the IBS policy. Our next step was to look at treating patients in a group setting, which has proven to work well for other conditions such as coeliac disease and diabetes. Evidence from a number of studies demonstrates how group education enhances patient acceptability of a treatment through a sharing of experiences with others with similar conditions.5,6 One of the first studies to look at group session delivery of the low-FODMAP diet was conducted in 20137 and a further study in 20178
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COMMUNITY which had similar findings. Both studies found that the low-FODMAP diet group sessions reduced wait times and increased capacity, and that there was significant symptom relief from baseline to follow up. Ultimately, it was seen that dietitian-led FODMAP group education was clinically effective and that the costs associated with a FODMAP group pathway were worthy of further consideration for routine clinical care. The 2013 study did recognise that a significant minority attending the group sessions would have preferred one-onone sessions, but also noted that there are several possible advantages to group sessions including peer-support and sharing of experiences.7 OUTCOMES
A telephone clinic and low-FODMAP group sessions commenced in January 2018 and altered the pathway (visit www.NHDmag.com/ IBSpatientservicepathway for more on the Chester IBS service). In setting up the group sessions, we saw a definite reduction in wait times. However, we have encountered other barriers, for example, some patients don’t want to engage in the group setting; some need that one-on-one appointment to help adapt their diet on an individual basis. This has emphasised the importance of correct triaging of patients for the group setting, and enabling those who are not suited for group education to be seen in a one-on-one appointment. On the other hand, we have had many patients who enjoyed the group setting. A particular quote has been: “It’s nice to meet other people who understand my condition”, and it has been great to hear patients share low-FODMAP recipe ideas and details of local support groups etc. As it stands, the groups will continue and we will continue to adapt them to be as user friendly as possible, given the improvement it has made with the wait times. So far, we have found the following outcomes: • 75% of patients seen in the service report that their symptoms have improved. • Wait times for patients to be seen reduced from ~12 weeks to ~4 weeks. • <7% of patients seen (n=17) required onward referral to a gastroenterologist. • The total number of IBS referrals to the dietitians increased by 142% from 2016-2017. 30
• The number of referrals received from gastro consultants into the dietetic-led IBS service has increased by 103% since 2016, demonstrating that the consultants see the value of the dietetic input. • In 12 months (2017-2018) the dietetic-led IBS service has saved 161 new consultant appointments. • The service has proven to be cost effective and one that reduces pressure in secondary care by freeing up consultant time. THE FUTURE
Moving forward, the option of utilising dietitians as non-medical prescribers may further remove the need for consultant time, by allowing dietitians to manage those patients who are referred onto secondary care and who require more medical management of their condition. There are a number of medications that may be used with IBS patients, including antispasmodic agents, laxatives, linaclotide, loperamide, tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs).1 If the pathway were to introduce a non-medical prescribing dietitian, both skill sets of dietary management and medication can be utilised to optimise patient symptoms without the need for referring onto secondary care. In addition to this, the use of virtual clinics may further improve wait times and capacity, by capturing a large number of patients at one time. In January 2017, Somerset Partnership NHS Trust trialled the use of IBS group webinars to help capture more of their patients, as they found many were getting lost to follow up as a result of low-FODMAP group sessions. Their conclusions showed positive results for using the webinars, with 82% of patients finding that their confidence in managing their IBS had increased after attending the webinar and 100% of patients stating they would recommend the webinar to a friend.9 The use of webinars within dietetic services has the potential to cost-save for the NHS, as printing/room costs are eliminated. They are also able to reach a vast number of patients at one time, providing patients with the tools to manage their symptoms independently and, therefore, preventing referrals into secondary care. Something to consider in not only IBS pathways, but all applicable services within the NHS.
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This material is for healthcare professionals only.
DO MORE THAN JUST MANAGE COW’S MILK ALLERGY: HELP GIVE HER THE ABILITY TO ENJOY MILK SOONER1† ONLY‡ NUTRAMIGEN WITH LGG® CAN
TRANSFORMING THE LIVES OF BABIES WITH COW’S MILK ALLERGY
† ‡
Versus an eHCF without LGG® or formulas based on soy or amino acids. The only cow’s milk-based formula.
Reference: 1. Canani RB et al. J Pediatr 2013;163:771–777. Nutramigen with LGG® is a food for special medical purposes for the dietary management of cow’s milk allergy and must be used under medical supervision. Nutramigen with LGG® is not recommended for premature and immunocompromised infants unless directed and supervised by a healthcare professional. IMPORTANT NOTICE: Breastfeeding is best for babies. The decision to discontinue breastfeeding may be difficult to reverse and the introduction of partial bottle-feeding may reduce breast milk supply. The financial benefits of breastfeeding should be considered before bottle-feeding is initiated. Failure to follow preparation instructions carefully may be harmful to your baby’s health. Parents should always be advised by an independent healthcare professional regarding infant feeding. Products of Mead Johnson must be used under medical supervision. *Trademark of Mead Johnson & Company, LLC. © 2018 Mead Johnson & Company, LLC. All rights reserved. LGG® and the LGG® logo are registered trademarks of Valio Ltd, Finland. Date of preparation: September 2018 UK/NUT/18/0060i
NUTRITION MANAGEMENT
THE LOW-FODMAP DIET FOR CROHN’S DISEASE This article will look into current research in the area of the low-FODMAP diet and its effect on functional gut symptoms. Priya Tew Freelance Dietitian and Specialist in Eating Disorders 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
32
Crohn’s disease is an autoimmune condition that can affect anywhere along the gastrointestinal tract, with ulceration and an unpredictable relapsing remitting course. Symptoms commonly include abdominal pain, bloody diarrhoea, fatigue, loss of appetite and weight loss. FODMAPs are short-chain carbohydrates that are poorly absorbed in the small intestine, then passed to the colon; the process of fermentation by the colonic microflora leads to an osmotic effect. This draws fluid into the lumen and causes an increase in gas production, resulting in abdominal pain, bloating, flatulence and diarrhoea in some individuals. There is strong evidence for the use of the low-FODMAP diet for IBS management and, now, it also appears to decrease functional gut symptoms in IBD. People with IBD are three times more likely to have IBS-style symptoms than the normal population.1 A small scale study on 52 patients with Crohn’s and 20 with ulcerative colitis found that one in two patients responded well to a low-FODMAP diet (improvement of at least 5/10 in symptoms) for abdominal pain, bloating, wind and diarrhoea.2 A UK study on 180 patients with IBS or IBD given low-FODMAP advice via a dietetic/nutrition-led clinic, found normal stools improved by 66% in the IBD group. A higher adherence was associated with a longer duration of symptom improvement. Foods most often not reintroduced were wheat and onion (fructans) and dairy.3 It was concluded that the low-FODMAP diet seems to decrease functional gut symptoms in IBD. Another study on 88 people looked at symptoms and stool, finding a
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significant improvement on the lowFODMAP diet in symptoms and stool consistency.4 IS ONE FODMAP OF MORE CONCERN THAN ANOTHER?
A series of three-day fermentable carbohydrate challenges of fructans, galacto-oligosaccharides (GOS) and sorbitol were compared to glucose placebo on 32 patients with quiescent IBD. 12 of the patients had Crohn’s disease. Although a small scale study with limitations, it was found that fructans at high doses exacerbated symptoms.5 Another study6 shows that patients with active Crohn’s disease consume lower quantities of fructans and oligofructose than their inactive counterparts and healthy controls. This case control study used a food frequency questionnaire comparing 98 people with active Crohn’s disease, 99 with inactive Crohn’s disease and 106 healthy controls. A lower fructan intake was found in those with active Crohn’s disease compared to the other two groups. More research is needed to look into the impact of lower intakes of prebiotic fructans on gut microbiota. ACTIVE VS INACTIVE CROHN’S
Crohn’s disease can be intermittent with periods of remission and activity. Even in remission there can be some functional gut symptoms that persist. These symptoms can be similar to IBS symptoms and up to 40% of those with Crohn’s can suffer.7 A very small study on eight people in Australia suggested that the lowFODMAP diet may be more useful in periods when the disease is inactive. Patients were fed either a low-FODMAP
This material is for healthcare professionals only.
DO MORE THAN JUST MANAGE COW’S MILK ALLERGY: HELP GIVE HER THE ABILITY TO PROTECT HERSELF FROM FUTURE ALLERGIC MANIFESTATIONS1† ONLY NUTRAMIGEN WITH LGG® CAN
TRANSFORMING THE LIVES OF BABIES WITH COW’S MILK ALLERGY
†
Versus Nutramigen without LGG®.
Reference: 1. Canani RB et al. J Allergy Clin Immunol 2017;139:1906–1913. Nutramigen with LGG® is a food for special medical purposes for the dietary management of cow’s milk allergy and must be used under medical supervision. Nutramigen with LGG® is not recommended for premature and immunocompromised infants unless directed and supervised by a healthcare professional. IMPORTANT NOTICE: Breastfeeding is best for babies. The decision to discontinue breastfeeding may be difficult to reverse and the introduction of partial bottle-feeding may reduce breast milk supply. The financial benefits of breastfeeding should be considered before bottle-feeding is initiated. Failure to follow preparation instructions carefully may be harmful to your baby’s health. Parents should always be advised by an independent healthcare professional regarding infant feeding. Products of Mead Johnson must be used under medical supervision. *Trademark of Mead Johnson & Company, LLC. © 2018 Mead Johnson & Company, LLC. All rights reserved. LGG® and the LGG® logo are registered trademarks of Valio Ltd, Finland. Date of preparation: September 2018 UK/NUT/18/0060i
NUTRITION MANAGEMENT Table 1: Prebiotic foods FODMAP foods that are prebiotics
Low-FODMAP foods that are prebiotics – (portion sizes where indicated limit the foods to low FODMAP)
Wheat/rye breads, couscous, wheat pasta, barley and gnocchi
Chicory leaves (<1 cup), fennel bulb ( ½ cup), green section of leeks and spring onions, beetroot (2 slices or 20g), sweetcorn ( ½ cob), canned lentils ( ½ cup), red cabbage (1 cup)
Jerusalem artichokes, garlic, onion, leeks, asparagus, beetroot, peas, snow peas, and sweetcorn
Banana, rhubarb, kiwifruit, dried cranberries (1 tbsp), pomegranate (½ small or ¼ cup seeds).
Nectarines, peaches, watermelon, persimmons, grapefruit, pomegranate, dried fruit
Oats
Cashews and pistachios Foods containing inulin
diet or a typical Australian diet for three weeks, followed by a three-week washout period before the diets were switched over. The native diet had a prebiotic effect, likely due to the levels of oligosaccharides and polyols. Symptoms of abdominal pain, bloating and flatulence almost doubled on the low-FODMAP diet. This was suggested to be due to the patients being in active Crohn’s.8 Comparing this to a Danish non-blinded RCT, where the 89 people studied had IBS in remission, or IBD with functional gut symptoms, a low-FODMAP diet decreased the functional gut symptoms and increased the quality of life in the IBD group.7 This has been backed up by a study on 127 people, 56 with IBS, 30 with IBD and 41 with coeliac disease. Abdominal symptoms improved after one and three months on the low-FODMAP diet in all subjects and it was suggested that this diet was a valid option in non-active IBD to improve quality of life and social occasions.9 NUTRITIONAL ADEQUACY OF THE FODMAP DIET
Some of the evidence on this topic is unclear and weak, but it can still highlight limitations of using the low-FODMAP diet with this population group. Caution is needed when using a restrictive diet with people who may already be nutritionally compromised. They could be malabsorbing, or consuming foods that they already know need to be avoided.10 The low-FODMAP diet can be a good treatment option if careful attention is paid to the nutritional adequacy of the patient’s diet.11 If it is needed for a long-term approach, then dietary supplements will be required to avoid deficiencies.12 In active states, vitamin B12, folate, B6 and vitamin D can be low.13 34
MICROBIOME
The low-FODMAP diet restricts the intake of many foods that are high in probiotics, therefore, this is not a diet to be on long term as it can impact on the microbiome. These prebiotic food, however, are good for gut health, helping with the growth of beneficial bacteria (see Table 1). This is not limited to Crohn’s, as decreased levels of Bifidobacteria and faecalibacterium prausnitzii have been found in IBS patients on the lowFOMDAP diet, so this is likely to occur in anyone on this diet.7 Encouraging people to consume more prebiotics that are low in FODMAPs may be helpful, as well as keeping the elimination phase to weeks and not months. CONCLUSION
The low-FODMAP diet does appear to have a place in the treatment of Crohn’s disease. It may be more helpful for inactive stages of the disease, but there are limitations to consider. The lowFODMAP diet can impact on the microbiome in the short term, plus there is concern about the nutritional adequacy of this population group, so it can be concluded that the low-FODMAP diet should be used in the short term only. This is exactly how the diet was designed to be used, but many people stay on the restrictive, exclusive phase of the diet. This can be due to fear of their symptoms reappearing, or a lack of support and education from their nutrition team. Encouraging and empowering people to the reintroduction stage is vital for their long-term health. If, for some reason, a patient does need to follow the exclusion stage long term, then supplements are likely to be needed to help the microbiome and to correct nutritional deficiencies.
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PUBLIC HEALTH
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.
HOW SAFE ARE ANIMAL PRODUCTS FROM THE USA? This article focuses on the US practices of washing chicken in chlorine and the use of hormones and antibiotics in the production of meat and dairy products. With Brexit on the horizon, the issue of food security is becoming more prominent. A trade deal between the US and UK is one option that has been discussed. But many are wary of how safe meat, poultry and dairy from the US is, due to the different standards in agriculture and food production. CHLORINE-WASHED CHICKEN
REFERENCES Please visit the Subscriber zone at NHDmag.com
Because of lower animal welfare and hygiene standards in farming in the US, compared with the EU, chickens can be crammed together in small spaces which increases the risk of contamination and disease.1 Therefore, poultry from the US can be washed with chlorine in order to disinfect it before it is sold. According to the European Food Safety Authority (EFSA), the chlorine washing itself does not seem to pose any health risks to humans.2 But there is a precautionary ban on chlorine-washed products in the EU. This is because relying on this method could lead to lower hygiene standards, and the EU emphasises the importance of food quality and safety during all stages of production ‘from farm to fork’.3 If chicken was to be imported from the US, it might not be clear from the packaging whether it has been chlorine washed or not. This is because chlorine washing is deemed to be a process rather than an ingredient, and food production processes are not always listed on food labels. HORMONES USED IN CATTLE FARMING
Steroid growth hormone implants are used in US cattle to increase weight
gain and meat production.4 In 1989, the EU banned meat from the US and Canada which contained artificial growth hormones as a precautionary measure. This sparked the so-called ‘beef war’ between the EU and the US. The EU argued that the risk of hormone residue in meat posed a risk to human health, but continued to allow the use of specific hormones under the supervision of a vet.5 This led to a legal dispute involving the World Trade Organisation in 1997. This was won by the US and Canada on the basis that the risk assessment by the EU was inadequate. Then in 2008, a mixed ruling was given which allowed the EU to continue its ban, whilst allowing the US and Canada to continue their retaliatory trade sanctions on the EU. The most recent review of this topic by EFSA reported that there is not enough data to conclude whether there is a causal relationship between consumption of hormonetreated meat and the development of hormone-dependent cancers such as: breast, endometrial, ovary, testicular and prostate cancer.6 This report also highlighted that there are environmental concerns related to hormone treated meat; such as disturbance to wild fish populations as a result of contamination of rivers near farms with hormone-treated cattle.6 So, there is no strong evidence that hormone-treated meat poses a risk to human health, but there is still some uncertainty about this.
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PUBLIC HEALTH HORMONE USE IN DAIRY PRODUCTION
A growth hormone called recombinant bovine somatotropin (rBST - also called ‘bovine growth hormone’ or BGH) is used to increase milk production in cows.7 The US Department of Agriculture reported in 2014 that only about 14.7% of dairy producers in the US use rBST.7 rBST is banned from use in the EU, Australia, New Zealand, Canada, Japan, Israel and Argentina. The main reason for this, is because good quality studies have linked its use to harming animals - causing lameness, decreased fertility, lactation problems and udder infections.8 However, other studies have contradicted these findings.9 There is also a concern that the increase in udder infections as a result of rBST increases the use of antibiotics and, therefore, the development of antibiotic-resistant bacteria.10,11 But it is less clear as to what extent these antibiotics have a direct effect on human health. The food and drug association (FDA) in the US report that pasteurised milk (regular and organic) is tested for antibiotic residue to ensure that it does not contain dangerous amounts of antibiotics before this reaches the shops.12 Milk used to make products like butter and cheese does not have to undergo this testing, but most of these products do meet this standard.13 There is a theory that consuming rBSTtreated dairy increases the risk of cancer, as it contains higher levels of insulin-like growth factor 1 (IGF-1).14 rBST is not active in humans and is destroyed in the digestive system, but IGF-1 found in dairy is not destroyed by pasteurisation.15 IGF-1 is, however, destroyed in the production of infant formula, due to the use of specific heat treatment technology.16 Despite the theory of a cancer link, studies have found that consuming IGF-1 in dairy has no significant effect on humans.17 This may be because the level of IGF-1 in milk is much lower than the level which is already present in our digestive juices.17 But IGF-1 levels have been found to increase slightly after milk consumption; a randomised trial from the US found that regular milk drinking was associated with 10% higher IGF-1 levels.18 36
As this study only involved rBST treated dairy, it is unclear as to whether this was related to milk in general, or specifically related to the use of rBST in dairy production. An increase in IGF-1 in the blood may be associated with an increased risk of prostate cancer; but the American Cancer Society report that the evidence is inconclusive about this and that more research is needed.19-20 The increased milk production related to rBST use in cows is beneficial for the environment. For example, it has been found that 8-15% fewer cows are needed to produce the same amount of milk when rBST-treated cows were compared with conventional nonrBST treated cows.7,21 In contrast to this, organic dairy production requires 25% more cows to produce the same amount as conventional dairy production (without using rBST).21 Overall, rBST appears to harm cows, but it is unclear as to whether drinking milk produced using rBST causes harm to human health. Importantly, milk which makes it to the shops is very unlikely to contain antibiotics, due to FDA testing procedures.
ANTIBIOTIC USE IN CATTLE FARMING
Antibiotics are used as part of meat production to treat and prevent diseases from occurring in the animals. Antibiotics can also be given to animals in small doses in order to promote growth. This practice has been banned in the EU since 2006 and was also banned in the US in 2017.22-23 Currently in the US, a Veterinary Feed Directive (VFD), or a prescription, is needed for all medically important antibiotics which are given to animals. However, a recent report found that farms in the US still use roughly five times more antibiotics in animals, compared with the UK.24 When this was categorised by animal, antibiotic use in the US was roughly the following: • twice as high as compared with use in UK pigs; • three times as high compared with use in UK chickens; • five times as high compared with use in UK turkeys; • 9-16 times as high compared with use in UK cattle.
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A recent report found that farms in the US still use roughly five times more antibiotics in animals, compared with the UK. The main concern is that it promotes the development of antibiotic-resistant bacteria. This affects humans, as it leads to increased medical costs, longer hospital stays and a higher risk of death related to ineffective antibiotics.25 In the US, more than 23,000 people die every year as a result of antibiotic-resistant bacteria.26 The largest use of antibiotics globally is related to the production of meat and dairy for human consumption.27 Therefore, the WHO has urged the farming sector to:28 • only give antibiotics to animals under veterinary supervision; • not use antibiotics for growth promotion or to prevent diseases in healthy animals; • vaccinate animals to reduce the need for antibiotics and use alternatives to antibiotics when available; • promote and apply good practices at all steps of production and processing of foods from animal and plant sources; • improve biosecurity on farms and prevent infections through improved hygiene and animal welfare. There is also a risk that antibiotic-resistant bacteria can be passed to humans through the food supply. Ground beef is one of the most common foods which is associated with antibiotic-resistant outbreaks.29 But the risk related to this is very low, because cooking food properly destroys this harmful bacteria.30 The FDA also has strict testing procedures in place to prevent meat products being sold which contain unapproved or unsafe drugs, including antibiotics.31 So, the risk of consuming antibiotics from meat in the US is low. The US is working towards reducing its use of antibiotics in animals.
ORGANIC MEAT AND DAIRY
The USDA ‘100% Organic’ logo can be used on products from the US which have not been made using growth hormones or antibiotics. However, organic and ‘antibiotic-free’ produce can still contain antibiotic-resistant bacteria, but this tends to be in slightly lower levels than in conventional produce. For example, a study from 2015 found that organically produced chicken contained 31% antibiotic-resistance bacteria as compared to conventionally produced chicken which contained 43.6%.32 Poultry and eggs that are labelled as organic by the USDA can be chlorine washed, but these are then rinsed with drinking-standard water afterwards.33 However, as mentioned previously, the chances of ingesting hormones or antibiotics from conventionally produced meat and dairy is already very low due to testing by the FDA. CONCLUSION
There is no good evidence to suggest that consuming chlorine-washed chicken poses a health risk. Similarly, there is no strong evidence that eating meat or dairy products which were produced using growth hormones or antibiotics is unsafe for humans. However, there is some uncertainty about hormone-treated meat. Meat and dairy products are rigorously tested to ensure that they don’t contain traces of unsafe hormones or antibiotics before being sold. But these practices can have negative effects on a larger scale. For example, chlorine-washing chickens may encourage poor hygiene standards earlier in the production process, and the use of rBST hormones can harm cows. Furthermore, the widespread use of antibiotics in meat and dairy production can increase the development of antibiotic-resistant bacteria; which is a serious global issue.
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SKILLS & LEARNING
Lucy Aphramor Dietitian and Consultant Lucy Aphramor developed Well Now, a trauma-informed approach to nutrition that teaches compassionate self-care and advances social justice. She is an award-winning dietitian, and performance artist.
CREATING KNOWLEDGE FOR TRANSFORMATION: UNDERSTANDING HEALTHISM IN NUTRITION DISCOURSE In this article, I begin to explore the question: what’s at stake in how we talk about health? Our answers will differ depending on our personal views and values, shaped in turn by our life experience, including our professional education. In particular, in this article, I want to consider the concept of healthism and how it is adopted or repudiated, intentionally or otherwise, by different groups of nutrition professionals. I will consider how health and healthism appear within mainstream dietetics, within the non-diet approach (HAES)5 and in my own Well Now practice, which uses a health justice approach. DEFINING HEALTHISM
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When I talk about healthism, I am referring, in part, to a belief system that sees the pursuit of personal wellbeing as a moral obligation. In this healthist mindset, ‘being healthy’ becomes a civic duty, ranked above everything else, like professional accountability, world peace or being kind.1 The moral dimension of pursuing personal health is taught and transmitted in everyday food talk, from ‘I’ve been good today’ to ‘I know I shouldn’t’. It is strongly evident in public health campaigns that focus on weight conversion and that conflate body size, lifestyle and health. These campaigns construct thin people as healthy - and therefore (sic) morally responsible. In comparison, fat people are constructed as unhealthy, irresponsible citizens whose behaviours and attitudes are to blame for everything from climate change to spiralling healthcare costs. At its core, this healthist, neoliberal ideology conceals and ratifies a morally heinous supremacist mindset. In this case, the supremacist mindset gets enacted through fat stigma and thin supremacy.
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By focusing on lifestyle as a route to health, healthism ignores the fact that early life events, how we get treated by others in our everyday lives and our current circumstances, strongly impact on health via pathways that have nothing to do with what we eat or whether we’re active. For example, because healthism explains hypertension through salt intake, physical activity and weight, it overlooks data on racism and hypertension.2 In this way, healthism amplifies and hides the detrimental metabolic impact of living with racism, and other oppression and involves status syndrome denialism.1 Of course, wellbeing and privilege can also overlap with ‘lifestyle’. Daily yoga practice, being free of addiction and relying on meals made from an organic vegetable box delivery can materially affect our health whatever our social class or life circumstances. But if you’ve got PTSD, live in a polluted neighbourhood, subsist on a zero hours contract, are daily shamed and marginalised, these factors detract from wellbeing even if you can find the time for yoga and have the money, time, impulse, storage capacity, prep and cooking space, equipment, mental bandwidth, physical dexterity and pain-freeness to enjoy home-cooked organic meals. As well as ignoring the corporal experience of power, healthism overlooks how structural injustice impacts health through exposure to traffic, industrial pollution, access to
clean water, nuclear contamination, plastics in the food chain and other environmental factors. In short, healthist practice and discourse denies the direct and indirect roles of power in determining health. We have an epidemic of PRDs (power-related diseases) and healthism secures privilege by calling them NCDs (noncommunicable diseases). Using a healthist ideology means we cause harm. This happens directly as we influence clients within the therapeutic relationship. It happens as the attitudes and perspectives we perpetuate cement the status quo and it happens via the missed opportunity to offer a more caring, socially-awake response to disease. MAINSTREAM DIETETICS AND HEALTHISM
Mainstream dietetic texts do not name healthism and authors reveal uncritical adherence to a healthist ideology throughout their work. It is easy to see that dietetic discourse is premised on the healthist belief that health is primarily derived from correct body/mind management practices, concerning diet, exercise, sleep, mindfulness, smoking, resilience, alcohol, and so on. This view authorises healthisms' moral judgement as the notion of wilful culpability sanctions blame and shame. After all, it would be nonsensical to blame someone for poor health outcomes if this was outside their personal control. Mainstream dietetics is strongly committed to the idea of personal responsibility for health and perpetuates healthist beliefs that embed moral judgement and superiority. Within a healthist ideology it is taken for granted that (1) everyone has the cognitive and financial capacity needed for self-care, and (2) making 'good' lifestyle choices secures health. This ‘make simple changes’ stance is embraced by Public Health England and British and international dietetic organisations. Here, the message is simply eat well and be active to enjoy thinness (sic) and health. Editors of The Manual of Dietetic Practice,3 a core undergraduate text in the UK, reflect an explicitly healthist stance in statements such as: ‘Much of the world’s disease burden results from a few largely preventable risk factors, most of which are related to diet and lifestyle.’ (p 2) ‘Mortality and morbidity from chronic diseases
are greatest in those who are least advantaged, much of it attributable to adverse diet and lifestyle influences.’ (p 4) These statements are not grounded in any conventional scientific reality and exemplify status syndrome denialism. We need only read an introductory book in critical public health4 to see the claims as post-truth disinformation. Instead, we can more accurately state that much of the world’s preventable disease burden results from patriarchy, colonialism and capitalism. Related pathways to ill-health are growing up in a war zone, experiencing racism, sexism and poverty. Yes, clean water and the ability to feed our family and ourselves with dignity matter, but these cannot be described as diet and lifestyle factors. Yes, health inequity is largely preventable: remedy requires a thoughtfully theorised decolonised, traumainformed approach. In a fantasy world where everyone’s lifestyle meets recommended guidelines, we will remain a weight diverse population and health inequalities will persist as long as there is environmental degradation, racism, abuse, fat stigma, thin supremacy, professional unaccountability, and so on. TACKLING HEALTHISM
Advocates of the non-diet approach HAES5 recognise healthism as a social problem that they are committed to addressing by interrogating their own and other’s practice. The phrase ‘health is not a moral obligation’ is a truism used within the HAES community to challenge the core assumptions of healthism that link human worth and health status. I previously situated my work within HAES and have doubtless said it myself. Today I theorise my work as a heath-justice approach, which is distinct from a non-diet approach, and this discussion usefully highlights some differences between the two ideologies. I argue that, instead of dismantling healthism, repeating ‘health is not a moral obligation’ in fact inadvertently secures its hold. This is because the phrase embeds health within a reductionist framework, in other words, it locates health in individuals and lifestyle, and it ignores the role of power relations on health.
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SKILLS & LEARNING A number of expanded versions of the phrase are discussed. Experts in the official HAES organisation, ASDAH,5 note that, ‘Pursuing health is neither a moral imperative nor an individual obligation,’ and continue, ‘Health status should never be used to judge, oppress, or determine the value of an individual.’5 I am in wholehearted agreement with the second part of the phrase. Tying human worth to health status supports supremacist views, stigma and shame. Enacted in individual lives, it can be (simultaneously) a source of profound personal distress and a means of managing our distress. Connected to this, I also believe that no one is morally obligated to pursue 'health behaviour change'. However, the assertion that ‘pursuing health is neither a moral imperative nor an individual obligation’ mistakenly embeds neoliberalism. It does this by framing health, not as socially determined, but as a personal property, and as a function of individual decision-making around eating and body management. Theorising health like this unwittingly closes the door on talking about how power, or rape, or shame, or immigration policy, impact health. Lifestyle is ensconced centre-stage and so seamlessly streamlined with the dominant discourse that there is not the mildest shadow of a question mark to foothold critique. By erasing eco-social determinants of health, it also ignores the way that our individual behaviours impact on others’ health. We are back in a scenario where the role of privilege in assuring health for the privileged and damaging the health of the oppressed is overlooked. ‘Health is not a moral obligation’ paints a world where the decisions we make in our personal and professional lives, in how we build knowledge and talk about health, are free of wider consequence. It functions to reinforce a system of thought that denies the corporal reality of our inter-relationality. Its deep structures are reductionist and body-unaware, they hide trauma. In overlooking the body politic, it denies the role of power relations in shaping our sense of self, our life opportunities and our health outcomes. The fact that we may not intend our actions to have the outcomes 40
they do, does not alter the reality of the actual outcomes. Outside of healthism, health is understood as a function of our circumstances and histories: the dynamic sum of oppression, privilege, trauma, luck, access to clean water, green spaces, community and so on. Well Now is theorised to be body-aware, relational and intentionally political, through which lens 'health' is reappropriated to account for these connections. Now health is not conceptually reducible to self-care, and it is also anything we do that creates a fairer world, such as paying taxes and speaking up against bigotry and misogyny. In this relational mindset, ‘pursuing health’ then involves tackling racism and building a safe and sustainable world. If this isn’t a moral obligation, I’m wondering what is. We need to tackle healthism and the thinking that sustains it in order to work together towards health-justice. At the same time, hearing the idea that our human worth is not decided by our health status can be hugely liberating. Paying attention to praxis and community knowledgecreation6,7 can help us communicate both these truths, ensuring congruence between intent and outcome. CONCLUSION
Many of us, myself included, entered the health professions legally qualified but lacking the skills, training, knowledge and vision that we need to be safe and competent practitioners. I was taught to use a reductionist ideology, one that did not recognise the person-society-planet complex in theorising health. I was trained to be healthist. Just as we can be sexist, racist, sizist, whether or not we intend to be, whether or not we know what the terms mean, or have any interest in understanding what’s at stake, we will be pro-healthist, or anti-healthist even if we’ve never heard the words before. This can be a startling, unwelcome realisation. And also a liberating one. Because every new awareness makes transformation a more meaningful concept. We get to choose. Some of the options we have are to repress the knowledge and opt for oppression as usual, to hand-wringing, or wait to be sent on a course; or to reject complacency, educate ourselves, strategise for justice and speak up.8,9
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PAEDIATRIC COMMUNITY
SOCIAL CARE: DEVELOPING A DIETETIC WORKFORCE FOR THE FUTURE Evelyn Newman Nutrition and dietetics advisor: care homes NHS Highland Award winning dietitian, Evelyn Newman, is well known throughout the profession for her writing, volunteering with the BDA and innovative work. She currently holds a unique role in The Highlands. @evelynnewman17
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In the summer of 2014, NES (NHS Education for Scotland) were looking for someone who might be interested in developing and piloting alternative dietetic placements in social care settings. I immediately responded and set about gathering partners to help me take social care placements forward in Highland. Initial scoping meetings proved very positive and so, the first ever innovative dietetic social care placement in the UK was created, tested and evaluated in October 2014. Further details of all Highland dietetic social care placements are available on the NES website.1 The development of innovative social care dietetic placements2 supports a changing workforce profile for the future and has allowed a greater appreciation and understanding of residents’ lives and their rich histories. It has helped students to understand a social model of care, which is asset based, using co-production methods, putting the resident in control. This is in contrast to the conventional clinical model, which directs care and is dominated by organisational standards, protocols and regimented routines. The success of this innovative, multiagency/professional approach has been widely recognised and promoted across the dietetic profession and beyond.3,4 In 2015, we were delighted to come runners up in the Social Care category of the Advancing Healthcare Awards. We went on to win the BDA’s prestigious Dame Barbara Clayton award in the summer; before finishing the year as runners up in the Innovative Partnership category of the Scottish Dementia Awards.5 I had the pleasure of presenting our work at the Scottish BDA conference (‘Dietitians leading the future of Scotland’s health’) in September 2016. This generated greater interest from other boards and from
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practice education facilitators (PEF) across Scotland, supported by NES. Since then, there has been an increase in the numbers of opportunities for student dietitians to fully experience working and exploring nutritional care in social care settings. In November 2017, NES ran a monthlong social media campaign to promote and encourage the development of social care placements across Scotland. Later that month, I participated in a multi-agency event that focused on supporting PEFs to build capacity and create more Allied Health Profession (AHP) student placements within the wider Scottish care sector. This was followed up in April 2018 with a national conference exploring how Scottish Boards might create capacity for AHP student practice-based learning events (#AHPPrBL). In NHS Highland, we have had the opportunity to test and evaluate A, B, C and masters placements in social care settings. We have shown that peer-assisted learning (PAL) also works well, but the opportunities to deliver this is reliant on having two students on placement at the same time, which rarely happens because of how placements are allocated to each board. We are currently looking for opportunities to have dietetic students alongside nursing and other professions who are also on placement. Evaluations from all participants (staff, students and HEI) have demonstrated that evidence for all
Students demonstrated
good communication and organisational skills by talking with care home staff, kitchen staff,
residents and family
members, to gather the essential information
before making proposals. placement competencies can be easily achieved in these settings. Supervision is arranged within the care setting and therapeutic input is only offered when a community dietitian is present. Examples of work, which students have completed across Highland, Glasgow and Lanarkshire include the following: • Asset mapping for individual care homes to look at what services and facilities are available for the service users within the care home environment and local community. • Quality improvement projects, including a Continence Audit and the importance of hydration for staff. The aim was to encourage staff to measure both input and output. Students in Lanarkshire also wanted to raise awareness of the importance of hydration for both residents and staff by getting them to calculate their own fluid requirements and monitor their intake over a three-day time period. Staff in one Highland care home were shocked to realise that they were only consuming half of their daily requirement. • Reviewing care home menus to ensure that residents were receiving nutritious food and drinks. Students demonstrated good communication and organisational skills by
NHD CPD eArticles
talking with care home staff, kitchen staff, residents and family members, to gather the essential information before making proposals. This allowed social care settings to evidence delivery of national health and care standards.7 • Completing an audit of all MUST scores with the care home nurse; checking accuracy and reporting on variance before jointly agreeing and presenting recommendations for improvements and training to care staff. • In care at home placements, students spoke with service users, documenting the challenges to eating, shopping and cooking. A review of limited food stocks raised concerns for some. Students were subsequently invited, to present their insights of this PAL placement to the senior social work team. In conclusion, social care placements have been positively evaluated and are valued by service users, care staff, students and HEIs. They will only succeed with attention to thorough pre-placement planning and a positive inquiry approach to understanding, delivering and improving nutritional care.
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F2F
FACE TO FACE Ursula meets: 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.
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Ursula meets amazing people who influence nutrition policies and practices in the UK. MARGARET ASHWELL President: Association for Nutrition Nutrition Consultant Developer of the Ashwell® Shape Chart and Ashwell® String Test
Actor WC Fields advised fellow thespians never to work with animals or children. Writers should consider the advice never to interview friends or family. Because Margaret is a very dear friend, there is no chance of an unbiased feature and no chance of a cool description of professional achievement. I was lucky to report to her for five years when she was Science Director at the British Nutrition Foundation (BNF): she inspires great loyalty in all those who have worked with her, which is probably because she is such a fierce champion of nutrition underlings. Margaret obtained a First Class Honours degree in Physiology and Biochemistry at the University of Southampton. There was a tiny sixweek nutrition component in the course, which Margaret bluntly declares that she skived entirely. “The irony,” she admits. She was funded to do her PhD at the National Institute of Medical Research (NIMR). She then had to speak very slowly to me, explaining, “It was on mitochondrial biogenesis. Much to everyone’s disappointment, I found that mitochondrial DNA coded for less than 5% of its own proteins. This figure still holds but, goodness, how important those few proteins are for optimal health.” Wanting to write for a wider audience, Margaret took a job at the Consumers’ Association to write their first Which? slimming guide. So
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this was how Margaret first got into nutrition. She had an advisory panel of nutrition experts to consult and scatters the names of many greats: PassmoreGarrow-Durnin-McCance-Howard. Margaret then joined the Medical Research Council (MRC) in Harrow to do research on adipose tissue. None other than Nobel Prize winner Sir Peter Medawar (her previous Director at NIMR) worked there, and he enjoyed chatting to the bright young colleague (mainly about cricket); together they also carried out studies on adipose tissue transplantation. During this time, Margaret became Hon Secretary of the Association for the Study of Obesity (ASO) and also set up the Adipose Tissue Discussion Group (ATDG). Both groups are still active and Margaret laughs that everyone came to ATDG meetings with small ice buckets of tissue samples to share for cross analysis verification. After attending an obesity meeting in New York, and weary of the Ameri-centric discussions, Margaret and Per Bjorntrop from Sweden co-wrote the Constitution of the European Association for the Study of Obesity (EASO - which has now hosted 25 conferences). In 1980, Margaret obtained a highly prized ‘permanent’ post with the MRC Dunn nutrition unit in Cambridge. The arrival of computer tomography in Cambridge allowed Margaret to collaborate with Adrian Dixon on measures to assess the impact of human
central fat distribution on disease. “I remember my disagreement in the 1980s with a suggestion that UK adult obesity statistics could, in future, exceed the then level of 6%. The irony,” again, she admits. In 1986, Margaret surprised everyone, including herself, by accepting the job of Principal of the Good Housekeeping Institute. But while Margaret investigated vacuum cleaner functions and best-red-wine to go with steak, she was still strongly hooked into the world of nutrition. She was Secretary to The Nutrition Society for four years and was appointed onto the Government’s Food Advisory Committee (FAC) for nine years. For this she was made an Officer of the Order of the British Empire (OBE) and says that, “Sitting on the FAC was fairly relaxing. I gave opinions and then others worked hard with follow-ups and actions. So in my case ‘other buggers’ efforts’ was fairly apt.” Margaret admits that she only had to really start learning about nutrients (mainly macronutrients) in 1988 when she became Science Director of the BNF. She was thrown into the complexities of reviews on every nutrient that the roulette wheel of current science debate spun. Of course, this demanding full-time post was not enough for Margaret. She set up the nutrition freelance group, ‘London Nutcases’. And developed the ‘Ashwell® Shape chart’ based on the ability of waist-height ratios to predict heart disease risk. She also wrote the definitive book about the lives of Robert McCance and Elsie Widdowson*, which she describes as the most satisfying achievement of her career. Oh yes, and brought up a young family. I was alarmed at the too-much-on-her-plate: how did she do it? “I just like being busy,” was her shoulder shrugging response to this repeated question. Since 1995, Margaret has been a selfemployed nutrition consultant. In those early
days, she missed being part of a team. So what did she do? She set up the network of professional nutrition consultants (www.sensenutrition.org.uk) known as SENSE. The group now has 60+ members and organises excellent professional update meetings. One of Margaret’s first self-employed projects was as research programme manager for the UK government, evaluating and monitoring research projects in the area of nutrition that she said she knew least about: micronutrients. She went on to be involved in many EU nutrition projects on diverse aspects of cradle-to-grave nutrition; this time as the partner responsible for dissemination. Supporting young researchers and giving them a pull or a push, is what she does best. In 2015, she was elected to be President of the Association for Nutrition (AfN) admitting that this was another steep learning curve needing further knowledge of the regulatory scene and the ability to build bridges with other sciencebased nutrition professions (dietitians!). Just this year, Margaret was delighted to be made an Honorary Doctor of Science by the University of Westminster (she laughs that this is her only degree which actually mentions nutrition). Margaret has had the unfair advantages of being spaniel-enthusiastic and super smart. But her career success has not been without scrapes and I wince when she shows me her bruises and describes some of the punches that hit her. But, she is now stronger than ever. She loves mastering academic challenges, but mostly enjoys casting broadly science information. She pushes younger colleagues to do more than they feel ready for, but always supports them and always throws praise their way. She loves creating new ideas and new networks and the gatherings of colleagues. So many become her friends. As am I.
*McCance and Widdowson; A Scientific Partnership of 60 years British Nutrition Foundation, ed. Margaret Ashwell A very readable description of the lives and careers of M&W, in their own words and the reports of many close colleagues. The book is full of amazing stories of nutrition research from the 1930s onwards and how M&W pulled clarity from confusing and contradictory data.
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A DAY IN THE LIFE OF . . .
AN ADULT CYSTIC FIBROSIS DIETITIAN Vanessa Bara Specialist Dietitian in Adult Cystic Fibrosis, Royal Brompton and Harefield NHS Foundation Trust Vanessa has worked in a variety of areas, including general paediatrics, head and neck cancer surgery, gastroenterology, respiratory and lung cancer. She currently works with adults with cystic fibrosis.
Cystic fibrosis (CF) used to be considered a disease of childhood, with many sufferers dying of malnutrition. In 1965, The Royal Brompton established the first adult CF service in Europe and with more than 600 patients from age 16 years upwards, it remains one of the largest CF centres in Europe. CF is a recessive genetic disorder affecting the transport of salt and water into and out of cells. CF disease ranges from mild to severe and different organs may be more or less affected in different people. Table 1 shows some of the complications of CF. Good nutritional status is key to the wellbeing of people with CF and more effective nutritional care has resulted in gains in survival.1 Better understanding of CF and associated therapeutic advances have continued to improve outcomes: the median age of survival from birth in the UK has increased from 35 years in 20072 to 47 years now.3 As part of a 2.5 whole-timeequivalent CF dietetic team, I work within a MDT alongside specialist
nurses, physiotherapists, psychologists, pharmacists and doctors. The role of the dietitian includes nutrition support (oral and enteral), CF-related diabetes (CFRD), fat soluble vitamins, Pancreatic Enzyme Replacement Therapy (PERT), gastrointestinal symptoms, bone health and, increasingly, weight management. We provide a clinical service to approximately 20 inpatients and participate in the weekly MDT ward round discussion. Each week we attend three clinics (seeing 15-20 patients per clinic), conduct 12 Annual Reviews and respond to 15-20 phone or email enquiries. We also support additional clinics including transition, CFRD and gastrointestinal.
Table 1: Examples of complications in cystic fibrosis Infective lung exacerbations Nasal polyps Sinusitis Pancreatic insufficiency Low levels of fat soluble vitamins Constipation Distal Intestinal Obstruction Syndrome CF-related diabetes Reflux CF liver disease Arthropathy Osteopenia/osteoporosis Infertility issues
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CASE EXAMPLES My day will vary depending on the clinical schedule, but here are some recent cases I have been involved with: CF-related diabetes An inpatient was diagnosed with CFRD when routine monitoring of blood sugar levels revealed consistently elevated results. She had several non-CF comorbidities and a limited range of foods that she could tolerate, many of which were high glycaemic index choices. I provided education sessions for her and her supportive family. She was fearful that she would be unable to manage the significant changes needed, so I focused on reassurance and helping her to develop her confidence. She has since made remarkable progress with following the dietary advice, resulting in good blood glucose control. Nasogastric (NG) feeding Our service looks after approximately 30 patients who use gastrostomy or NG feeding tubes at home. We provide their ongoing dietetic care, but liaise with local dietetic services regarding the funding and provision of feed and equipment. A patient was discharged recently after trialling NG feeding for the final week of his admission. His body mass index (BMI) had been under 20 for about two years. (We aim for a body mass index (BMI) of at least 20kg/m2, with optimal BMI of 22-25kg/m2 in women and 23-25kg/m2 in men.4) We had been discussing the benefits of tube feeding with him for around 18 months, but he had been resistant to the idea. Unfortunately, his weight was on a downward trend, despite drinking ONS and receiving a lot of dietary education. This is a common situation that we encounter every week. During this admission his weight dropped to its lowest level, exacerbated by a loss of appetite during hot weather. To my surprise, his proposed plan to avoid further weight loss was to start overnight NG feeding and so he started that night, gaining nearly 2kg by discharge without any improvement in his oral intake. He is not yet psychologically ready to feed at home, but has said that he will consider it during his next admission. CF and pregnancy At any one time, at least one of our 600 patients is pregnant. A current inpatient in her final trimester has not managed to sustain weight gain for reasons that include nausea, fatigue and missing meals because of her hectic job. Her lung function has dropped significantly too. In hospital and without her busy schedule, she is now eating well and drinking ONS, but has gained only 0.5kg in a week. At our last consultation, I raised the topic of NG feeding as an additional tool to promote weight and functional gain. She is considering this option and we will be working closely with the MDT, including monitoring her weight, exercise tolerance and lung function, before making a joint decision about whether to start feeding or not. Pancreatic enzyme dosing Some patients find it difficult to appropriately dose their PERT and complain of the typical symptoms of malabsorption, including abdominal discomfort and loose, greasy, orange stools. If a verbal consultation doesn’t pinpoint the offending food (the most common cause is a takeaway!), we suggest they send us a diary of food and drink intake, PERT dose and bowel symptoms. On reviewing a recently returned diary, it was obvious that the patient was not adding extra PERT for desserts and that this was most likely responsible for his symptoms. I phoned him and provided more education regarding when and how to change PERT doses, keeping the changes as simple as possible to help him remember them. At follow-up in clinic, the patient’s symptoms had resolved after making the changes and he felt more confident with PERT dosing.
Of course, my days are not all clinical. For example, I am the Secretary of the UK's CF Dietitian's Group. At the Group’s study day in May, I presented the results of a survey I had conducted. I have been
involved in a multidisciplinary Quality Improvement project regarding inpatient care of gastrostomy tubes. Working in the area of adult CF offers up its challenges, but each day is fulfilling.
References 1 Corey M et al. A comparison of survival, growth, and pulmonary function in patients with cystic fibrosis in Boston and Toronto. J Clin Epidemiol 1988; 41(6): 583-91 2 Cystic Fibrosis Trust. UK CF Registry Annual Data Report 2007 3 Cystic Fibrosis Trust. UK Cystic Fibrosis Registry 2017 Annual Data Report 4 Cystic Fibrosis Trust. Nutritional Management of Cystic Fibrosis, 2nd edition, September 2016
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NETWORK HEALTH DIGEST
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BOOK REVIEW
THE OMEGA PRINCIPLE:
SEAFOOD AND THE QUEST FOR A LONG LIFE AND A HEALTHIER PLANET Review by Ursula Arens Writer; Nutrition & Dietetics
PAUL GREENBERG PUBLISHER: PENGUIN PRESS 2018 ISBN: 978-1594206344 HARDBACK £20.81
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.
The book cover to The Omega Principle is vanilla-plain. The title: long-winded and unremarkable. But don’t let cover or title deceive you. This book is firecracker amazing: a beautiful, shimmering text about omega-3s and the bait-ball of complexity around finding fish and eating fish. It pulls together nutritional and Of course, dietitians will love, most environmental aspects of fish con- of all, his discussions of the medical sumption. Was there ever a more aspects of omega-3. He describes the whirling current of hot debate? Paul theories of the role of dietary omega-3s Greenberg loves fish and loves writing: in human evolutionary development. his expert thoughts are as carefully He describes historical records of and beautifully presented as a plate of fish eating. He describes the early sushi. This book gets the Ursula Arens observations of fish and health in the award for best book of 2018 for dietitian diets of Eskimos (Inuits) and Japanese. readers! He describes the early The book contains research strongly sugPaul constantly seven chapters, each a gesting highly CHDseparate theme looking protective effects of scatters polished at one aspect of fish jewels of information diets high in oily fish. eating or fish catching. But somehow, the more so your inner Paul constantly scatters recent intervention voice has to keep polished jewels of trials have produced information so your weaker and more dilute shouting, “Wow inner voice has to keep observations of the so, interesting.” shouting, “Wow – so, potency of omega-3s. interesting.” He is also Greenberg asks for a master of the hairpin turn. He will guidance from a biostatistician. Martina set up a hypothesis and describe some Pavlicova critiques lumping together data: as you are lulled into a false sense of different outcomes: 1% reductions in of comfort, he then pulls out fresh data cardiac deaths are valid benefits from and finishes with a contrary conclusion. fish-eating, but are lost when pulled It is because he is such a skilled writer together with general sudden death and master of the subject, that you and stroke/heart attack data. Also, (the reader) enjoy his theme jumps inflammation-reduction effects of statins and playful spins of the data. Because may mask the smaller and weaker his obvious overall conclusion is that effects of omega-3s. When omega-3s are fish science and fish politics are very put under research spotlights, claimed important but very complex. benefits appear to fade. www.NHDmag.com December 2018/January 2019 - Issue 140
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BOOK REVIEW
The tone of the book becomes bleaker as he investigates global fish stocks . . . He freezes in the Antarctic while observing the scooping up of tons of krill (now banned).
Greenberg concedes some of the omega-3 trial flops, but swims back with the observation that consistent better health outcomes always seem to contain omega-3s; something he describes as the Forrest Gump effect. In the way that the film character Forrest Gump always appears central to various important events in US history, so omega-3s always seem to be the marker for good health in individuals and also more widely in the food chain. Perhaps this short description does not fully reveal the picture he paints, but I found this metaphor as clever and as enjoyable as the Forrest Gump film. His conclusions are that omega-3s are not the hero, but always the ‘good guy’ in human diets. The tone of the book becomes bleaker as he investigates global fish stocks. He goes out with fishermen looking for scarce anchovies in the Mediterranean. He describes the Peruvian industry for anchoveta fishing. He freezes in the Antarctic while observing the scooping up of tons of krill (now banned). He boils in the desert learning about algal omega-3 production. He attends long dry meetings politicking about Menhaden fishing licensing on the north-east coast of the USA. Of course, declines in fish stock are almost yesterday’s news: we have heard 50
it hundreds of times. But Paul peels the layers of the-how and the-why of the crisis and most insightfully gives his thoughts on what should be done. One earnest proposal: the reigning in of the reductionist industry. This refers to fish caught not for direct human consumption, but rather marine product caught for processing into fish oil, animal feed or fertilizer. There is an urgent need to put an economic cost onto environmentally damaging practices, and vacuuming up fish to convert to fertilizer must be decried, especially as slight shifts in current practice (as Paul Greenberg describes) can result in equal outcomes. Paul concludes with pragmatic advice on fish eating and even dishes out a few fishy recipes. The book provides 20 pages of dense referencing for those who want to fact-check his claims. I have especially noted his list of three pending research projects due out in the next year or so, examining omega-3 interventions (the REDUCEIT, STRENGTH and the VITAL studies). The book shows perfect mastery of a technically complex subject, presented in prose as pearlescent as the belly skin of a fresh mackerel. This is one book on my shelf that will never go to the charity shop.
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FESTIVE FARE Louise Robertson Specialist Dietitian
Sarah Howe Specialist Dietitian www. dietitianslife.com 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. Sarah is an experienced NHS Dietitian specialising in the fascinating area of Inherited Metabolic Disorders in adults..
It is crazy to think that Christmas is upon us again. It’s the time of year for lots of indulgence, food, drinks and parties. As dietitians, we are often the butt of Christmas jokes and jibes: “The dietitian won’t be eating dessert - too many calories,” and, “Don’t offer the nutritionist a chocolate, or a slice of Christmas cake, or they will be telling you off.” I can tell you now that this isn’t the case in our
office, especially with the constant supply of goodies in the Metabolic department! With this festive NHD edition, we are here to arm you with some facts and foodie jokes with which to wow your dinner guests, before the jokes are on you!
DID YOU KNOW? 1 Turkey is a relative newcomer to the Christmas table. Prior to the turkey tradition, Christmas fare included roast swan, pheasants and peacocks. A special treat was a roast boar’s head decorated with holly and fruit. 2 During early Victorian times, mince pies used to be made from actual meat! This is thought to date back to Tudor times. However, throughout the 19th century, the traditional mince pie recipe started to develop into the one we know today, with fruit and spices. 3 The tradition of putting tangerines in stockings comes from 12th-century French nuns who left socks full of fruit, nuts and tangerines at the houses of the poor. 4 Christmas trees were first decorated with fruits (mainly apples). Later on, people started using candles to light up their trees and then from c1895, electric lights were used. 5 The average person is thought to eat 6000 calories on Christmas Day! IT’S A CRACKER! 1 Why did the tomato blush? Because it saw the salad dressing!
2 Why don’t eggs tell jokes? Because they would crack each other up! 3 What do you call someone else’s cheese? Nacho cheese!
4 Why did the orange go out with a prune? Because he couldn’t find a date! 5 How do you make an apple turnover? Push it down the hill!
6 Why was the mushroom invited to a party? Because he’s a fun-guy!
7 Have you seen the movie about the Atkins diet? Dude, where’s My Carbs!
8 What are calories? Tiny creatures that live in your closet and sew your clothes a little bit tighter every night!
What about completing a detailed diet history and nutrient analysis for a Christmas Day’s food intake? Now, that would be a fascinating and possibly shocking task!
On behalf of Dietitian’s Life and the whole team at NHD, we wish you all a healthy and happy Christmas and New Year.
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