Issue 105 June 2015NHDmag.com

EntEral fEEding following strokE

Dimple ThakrarPrescribing Support DietitianBolton CCG

Do Dietitians neeD to be sip feeD prescribers? . . . p18

ISSN 1756-9567 (Online)

dieteticJOBS • weB waTCH • New reSearCH

Marion Ireland and Shubha Moses p9

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Reference: 1. Burks W et al. J Pediatr 2008;153:266–271. †This study was conducted with Nutramigen AA without MCT oil.IMPORTANT NOTICE: Breast milk is the best nutrition for babies. The decision to discontinue breastfeeding may be diffi cult to reverse and the introduction of partial bottle-feeding may reduce breast milk supply. 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. © 2015 Mead Johnson & Company, LLC. All rights reserved. This material is for healthcare professionals only.

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from the editor

chris rudd nhd editor

Chris rudd’s career in continuous dietetic service has spanned 35 years. She is now working part time with the Sheffield PCt medicines management team, as a dietetic Advisor.

welcome to issue 105 which offers a selection of articles for you to read whilst you are taking a break from dietitians week (8-12 June).

Editor Chris rudd rDfeatures Editor Ursula arens rDdesign Heather Dewhurstsales richard Mair richard@networkhealthgroup.co.ukPublisher Geoff weatePublishing assistant Lisa Jackson

address Suite 1 Freshfield Hall, The Square, Lewes road, Forest row, east Sussex rH18 5eSPhone 0845 450 2125 (local call rate)fax 0870 762 3713 Email info@networkhealthgroup.co.uk www.nHdmag.com

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Jacqui Lowden takes us through the ‘W’ approach to Follow-on formula milks and leads us to a very interesting conclusion. New parents must get so confused and influenced about what to do with their infants! Ursula Arens almost ‘walks us down the milk isle in the supermarket’ to inform us of milk alternatives ‘The white stuff’. ‘Mock milks’ originate from many plant sources and Ursula’s article tells us more. Both these articles really do look at what milk is best! Appropriate prescribing of ONS has been the topic of interest for some while; however, there are many times when ONS are not used appropriately. Malnu-trition and its consequences, nutritional screening, problem solving, care plan-ning focusing on the food first approach, reviews and monitoring, along with staff training, audits, cost effectiveness, who should prescribe and when, are linked key themes. Dimple Thakrar tells us about the Sip feed project in Bolton and asks us, ‘Do dietitians need to be sip feed pre-scribers?’ Emma Coates takes on another aspect of ONS in Oral nutritional support: Worth every penny? Emma includes the contributing factors in malnutrition and covers the range and cost of ONS. The theme of malnutrition continues with members of the BAPEN Quality Group, Anne Holdoway, Ailsa Broth-

erton and Dr Mike Stroud telling us of the BAPEN Nutritional Care Tool. This is a new measurement tool to support the delivery of improvements in nutri-tional screening, nutritional care pro-cesses, outcomes and the patient experi-ence. A date for your diary is the week commencing the 29 June 2015. Why? This will be the first scheduled national screening week using this new tool. I do hope that you will be willing, able and free to take part in this week. It is estimated that from six to 60 percent of patients show signs of mal-nutrition following a stroke. Marion Ire-land and Shubha Moses’ article, Enteral feeding following stroke covers nutritional screening, assessment and requirements and types of nutritional support that can be offered, as well as the process leading to the discharge planning. Have you been trained HENRY style and work within the field of childhood obesity? If so, Rachael Brandreth’s article on The care pathway for weight management of children across Cornwall will be of inter-est and you will be informed of the LEAF programme. Rachael invites you to get involved, so read on to find the details. Diet swap sounds fascinating. It in-volves 20 rural Africans and 20 Ameri-cans. Ursula Arens reveals the details and concludes, ‘maize with amaze!’

NHDmag.com June 2015 - Issue 105 3

chris ruddDietetic advisor

neil donnellyFellow of the BDa

ursula Arenswriter, Nutrition & Dietetics

dr carrie ruxtonFreelance Dietitian

dr emma derbyshireNutritionist, Health writer

emma coatesSenior Paediatric Dietitian

Jacqui lowdenPaediatric Dietitian

Marion IrelandSpecialist Dietitian, Stroke rehabilitation

Shubha MosesSpecialist Dietitian, Stroke rehabilitation

dimple thakrarPrescribing Support Dietitian, Bolton CCG

Anne holdoway Consultant Dietitian, BDa and BaPeN

Mike StroudPresident of BaPeN

Ailsa brothertonChair of the Quality and Safety Committee, BaPeN

rachael brandrethPaediatric Dietitian

6 News

14 Milk alternatives

18 Sip feeds: dietetic prescribing

23 Follow-on formulas

27 BAPEN Nutritional Care Tool

33 Oral nutritional support

38 Childhood obesity in Cornwall

41 Gut health: research

44 Web watch

45 dieteticJOBS

46 Events and courses

47 The final helping

9CoVEr storYEnteral feeding following stroke

editorial Panel

contents

NHDmag.com June 2015 - Issue 1054

Important notice Cow & Gate Nutriprem Protein Supplement is a food for special medical purposes for the dietary management of extremely low birthweight infants who require additional protein. It should only be used under medical supervision, after full consideration of the feeding options available including breastfeeding. For enteral use only.

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dr emma derbyshire is a freelance nutritionist and former senior academic. her interests include pregnancy and public health.

NHDmag.com June 2015 - Issue 1056

newS

MorE good nEws aBout EggsEggs are a simple and easy way of getting protein and essential micronutrients into the diet. Given this, along with their possible satiety and weight management benefits, it is thought that people with Type 2 diabetes (T2D) could benefit from eating these. New research has now looked into this. In this randomised controlled trial, researchers recruited overweight or obese people with either prediabetes or Type 2 diabetes (n=140). Each participant was then randomly allocated high-egg (two eggs daily for six days or the week) or low-egg diet (<two eggs per week) for six weeks. Markers of metabolic health were measured in both groups. Results showed that there were no statistically significant differences in total cholesterol, low-density lipoprotein, trig-lycerides, or glycaemic control between the groups. However, the high-egg group did report feeling less hungry and hav-ing felt fuller after eating breakfast when compared with the low-egg group. These are interesting findings which imply that high-egg diets could be in-cluded safely as part of T2D dietary man-agement. These may also have the added benefit of helping to stave off hunger. For more information see: Fuller N et al (2015) The American Journal of Clini-cal Nutrition Vol 101 (4) pg705-13.

MorE fruit and VEg BEnEfitsWe are all aware that eating fruit and veg is good for us. Previous research has shown that eating fruit and veg offers a number of important health benefits, particularly in relation to coronary heart disease (CHD), although there have been some inconsistencies. The authors of this meta-analysis reviewed historic studies to establish whether increased fruit and veg con-sumption led to a reduction in CHD. This research identified and analysed 23 studies using a total of 937,665 people and 18,047 patients with CHD. Results showed that increasing fruit and veg intake can lead to significant re-ductions in CHD risk in Western popu-lations but not in Asian populations. In Western populations the risk of CHD was reduced by 12 percent, providing around 477g a day fruit and veg were consumed, by 16 percent if 300g a day of fruit was consumed and by 18 percent if 400g veg a day was eaten. Further research is now necessary to equate this into relevant portion sizes and to further investigate the effect of fruit and veg consumption on coronary heart disease in Asian populations. For more information see: Gan Y et al (2015) International Journal of Cardi-ology Vol 183 (0) pg129-137.

Falls in older people can lead to trauma, hospitalisation, loss of independence and institutionalisation. Existing research into vitamin D status and the likelihood of falls in older people has been inconclusive. In this study, the authors systemati-cally reviewed previously published work and conducted a meta-analysis to find out whether vitamin D blood serum levels were linked to falls in older people. The review identified 18 good quality observational studies. Participant numbers ranging from 80 to 2,957 and age ranges be-tween 63 and 84 years.

Results showed that blood serum 25(OH)D levels, a marker of vitamin D status was lower in fallers compared to nonfallers (i.e. tending to be <20ng mL-1). The risk of falls was also low-er amongst those with higher serum 25(OH)D levels. The authors concluded that these find-ings might help to identify groups that would benefit from taking a vitamin D supplement. For more information see: Annweil-er C and Beauchet O (2015) Journal of Internal Medicine Vol 277 (1) pg16-44.

latEst on VitaMin d

NHDmag.com June 2015 - Issue 105 7

newS Product / InduStry newS

nEw rEsEarCH on nuts and HEaltHEating nuts is known to have beneficial ef-fects on heart health and is thought to re-duce the risk of car-diovascular disease. Two new studies have looked into fur-

ther potential health benefits that might be as-sociated with eating nuts. A new meta-analysis has looked at whether eat-ing nuts could be associated with decreased mor-tality. The review identified 15 prospective studies and included a total of 354,933 participants. Results showed that eating just one serving of nuts per day was found to decrease the risk of all-cause mortality by four percent and CVD mortality by 27 percent. Nut consumption was also associated with a reduced risk of cancer deaths when data from the highest and lower intakes groups were compared. The authors concluded that nut consumption lowers the risk of death from CVD, although fur-ther research is needed to confirm these findings. A second paper has looked at nut consump-tion in relation to stroke risk in a German popu-lation, forming part of the European Prospective Investigation into the Cancer and Nutrition Pots-dam Study. The study took place over 8.3 years (n=26,285), with details on nut consumption being collected at baseline using a semi-quantitative food fre-quency questionnaire. Results showed that the average nut intake was 0.82g per day. While an increased risk of stroke was noted in participants who never ate nuts, no other associations were found. Overall, findings looking into nut consump-tion and health are somewhat mixed. Lack of findings may be attributed to the epidemiologyi-cal nature of these studies. More RCTs are need-ed in order to reach firmer conclusions. For more information see: Grosso G et al (2015) The American Journal of Clinical Nutri-tion Vol 101 (4) p783-793 and di Giuseppe R et al (2015) The European Journal of Clinical Nutri-tion Vol. 69 (4) pg431-435.

wEaning MEtHods and satiEtYWeaning can be a difficult time with plenty of confu-sion over which method to use and what foods to pro-vide. Now, new research has looked into how different approaches can affect satiety.

A sample of 298 mums completed a question-naire when their baby was aged six to 12 months and 18 to 24 months providing information about weaning style, timing of solid foods, child eating style and reported weight. If was found that infants fed using the baby-led approach were significantly more responsive to satiety and less likely to be overweight when com-pared to those weaned using standard approaches. These are interesting findings, but addition-al studies are now needed in the form of ran-domised trials. For more information see: Brown A and Lee MD (2015) Pediatr Obes, 10(1), pg57-66.

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MAlnutrItIon followIng StrokeEstimates vary from six to 60 percent of patients showing signs of malnutrition following stroke, variance depending on the criteria used to identify malnutri-tion (2). It is well recognised that malnu-trition is an independent risk factor for increased morbidity, poorer outcomes and mortality after a stroke (3-6). The risk of malnutrition in stroke pa-tients varies, but it is recognised that nu-tritional status can worsen during admis-sion and that undernutrition following admission is associated with increased case fatality and poor functional status at six months (7). It is important to assess beyond swallowing problems and poor intake and look thoroughly at the me-chanics of ‘plate to mouth’ and the entire meal process, to ensure that the impact of any residual deficits is minimised.

nutrItIonAl ScreenIngScreening of all patients should ideally be carried out within 48 hours of admis-sion to hospital (8) and repeated regularly throughout the episode of care. It should also direct referral to a dietitian for assess-ment and management of nutritional risk. Malnutrition occurs in approximately 15 percent of all patients admitted to hos-pital, increasing to approximately 30 per-cent within the first week. It carries with it a strong association with poorer functional outcome and slower rate of recovery (9). In addition, SIGN 78 (10) recom-mends that a nutritional screening tool for use in stroke patients should focus on the effects of stroke on nutritional status, e.g. presence of dysphagia and ability to eat, rather than solely focusing on pre-existing nutritional status.

nutrItIonAl ASSeSSMent And requIreMentSIt is unclear to what extent hyperme-tabolism and hypercatabolism occur post-stroke, with estimations for the increase in metabolic rate following stroke ranging from 10 percent up to 50 percent, (11) depending on the severity and clinical consequences of the stroke, and clinical judgement is required when estimating the increase in resting energy expenditure. Catabolic effects vary according to the individual, but usually persist for the first few weeks, then begin to resolve in the following weeks and months. Nutritional assessment and estimation of requirements commonly are based on predictive equations such as Henry (2005) (12).

MAnAgeMent of dySPhAgIA followIng Stroke: Dysphagia, is a common and clini-cally significant complication follow-ing stroke (6) which can result in as-piration. The presence of aspiration is associated with an increased risk of developing an aspiration pneumonia and other broncho-pulmonary infec-tions (3). Both NICE 2004 and SIGN 78 recom-mend that, following acute stroke, all pa-tients should be screened for dysphagia by an appropriately trained healthcare professional before being given food, drink or medication. NICE 2008 (14) recommends that, if the admission screen indicates a swal-lowing problem, then a specialist as-sessment should take place within 72 hours of admission.

enterAl feeding following Stroke

Marion IrelandSpecialist dietitian, Stroke rehabilitation, nhS lothian & nhS forth valley

Both marion and Shubha have a longstanding interest in all aspects of neuro-rehabilitation and have worked in the field for over10 years.

stroke is a major cause of morbidity and mortality in the uk and the third major cause of death accounting for 11% (1). Most people survive a first stroke, but are often left with significant morbidity and/or physical or cognitive deficits.

cover Story

Shubha MosesSpecialist dietitian, Stroke rehabilitation, nhS lothian & nhS forth valley

Effective management of dysphagia is of key importance following stroke, in order to prevent undernutrition and dehydration from occurring, as far as possible. This must involve multidisciplinary working and good communication between in-volved practitioners. Once a full assessment of dysphagia by a speech and language therapist has taken place, the appropriate route of feeding can be identified, making it more attainable to meet nutri-tion and hydration requirements. The route of feeding initially is often a combi-nation of oral and enteral feeding, and the man-agement of each transition through the different stages of this spectrum is a crucial part of effec-tive dysphagia management.

enterAl nutrItIonNutritional intervention following stroke can of-ten involve enteral feeding in patients who are unable to meet their requirements safely or con-sistently via oral diet and fluids, and for some pa-tients, oral intake is contraindicated completely. Contraindications to enteral nutrition are pa-tient refusal, patients with a non-functioning GI tract and where it is inappropriate to feed for eth-ical reasons (16). Enteral feeding in stroke tends to focus on nasogastric and gastrostomy feeding, both of which are used in patients unable to meet their requirements, or who are at risk of disease-related malnutrition.

ethIcAl conSIderAtIonS In enterAlly fed PAtIentSThe complexities of enteral feeding and insertion of enteral feeding tubes should lead us to con-centrate more closely on the decision to feed in the first instance and the ethical considerations surrounding the initiation of feeding in stroke patients as an intervention. However, particu-larly in this patient group, this is a complex and multifactorial decision, as many of the func-tional measures that are initially impaired can improve, but at very different rates in each indi-vidual, thus making it hard to predict how each patient will progress Each patient’s capacity to contribute to this decision needs to be assessed and, if not deemed able to consent, then addi-tional measures should be put in place regarding consent and capacity to do so. Enteral nutrition is regarded as an aspect of

medical treatment and it is recommended that in cases where the benefits of nutrition support are uncertain, a ‘time-limited’ trial should be under-taken (14) Whilst it is important to avoid nutrition-al status deteriorating in the acute phase of stroke, the decision to feed severely disabled patients, with little prospect of neurological recovery is difficult, and all aspects of survival need to be taken into ac-count. This needs to be a medical decision and any previously expressed wishes, e.g. living will or ad-vanced directive, should be adhered to.

hydrAtIonFluid intake in stroke patients is of key impor-tance and may need to be supplemented if un-able to be met orally, most commonly by subcu-taneous or intravenous fluids in the acute phase of treatment. Once an alternative feeding route is established, most likely nasogastric tube in the acute phase, this can serve a dual purpose of providing nutrition and hydration and should be the route of choice for meeting an individu-al’s requirements until oral intake of food and fluids improves. Many factors can make risk of dehydration in stroke patients more likely, such as decreased sense of thirst, fear of incontinence, inadequate intake of thickened fluids required to meet re-quirements, inability to self-feed and commu-nication difficulties, e.g. difficulties in express-ing thirst or need for a drink to carers. Again, with good observation of patients at ward level, coupled with robust assessment measures, these risks can be managed, thus decreasing the likeli-hood of dehydration occurring.

nASogAStrIc (ng) feedIngTube placement involves a fine-bore NG tube being inserted trans-nasally into the stomach. The tubes are usually between 8.0-10mm French Gauge, made from polyurethane, PVC or silicone. NG feeding is ideal in the acute setting, for pa-tients who require short-term feeding, identified as less than four weeks (17). It can be used longer term if other options such as gastrostomy feeding are contraindicated or not appropriate (18). The position of the tube should be confirmed by aspiration of stomach contents and checking that the pH of aspirate is <5.5, indicating gastric contents, as per the National Patient Safety Agen-

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cy Guidelines from 2005 (19). The position of a NG tube should be confirmed before each use by aspiration of stomach contents, and radiological confirmation should only be used when there is ongoing difficulty in obtaining aspirate, or con-cern regarding the tube position that cannot be otherwise resolved. Consent should be obtained for placement of all feeding tubes, and this can prove difficult in stroke patients (and in other neurological condi-tions) as there may be cognitive impairment and significant communication difficulties, along with confusion and poor understanding, particularly immediately post stroke. Medical staff usually take responsibility for obtaining consent for pro-cedures that are considered invasive, or identi-fying when patients do not have the capacity to consent, and putting alternative arrangements for procedures to take place, such as per the guidance for consent and capacity from the British Medical Association in England and Wales, or the Adults with Incapacity Act in Scotland. Results from the FOOD Trial indicated that early enteral feeding, clarified as within seven days, may reduce mortality and that dysphagic stroke patients should be offered enteral feed-ing via nasogastric tube within the first few days of admission. However, it also identified worse quality of life in patients who are allocated early tube feeding, concluding that early feeding may keep patients alive, but in a severely disabled state when they would otherwise have died (20). The RCP Stroke Guidelines go a step further, in-dicating that patients should be fed within the first 24 hours, based on the recommendations of the FOOD Trial and the observed reduction in mortality, with further consultation with patient representatives regarding the timing of initiation of feeding for maximum benefit.

nASAl brIdle (nb) tube retAInIng devIceSNasal bridles are enteral feeding tube retain-ing devices that are increasing in use in patients who repeatedly displace nasogastric tubes, e.g. in patients who are confused following stroke. The use of NB loop has been shown to have few complications and minimal discomfort for the patients, and in one prospective study, showed a reduction in 30-day gastrostomy mortality, in part due to better selection of patients for gas-

trostomy, and also that bridle loops allowed patients an average 10 days of nutrition prior to either recovery or gastrostomy placement. (21) The NICE Guideline for management of acute stroke (14) endorses the consideration of using nasal bridle tubes in stroke patients who are un-able to tolerate a NG tube.

gAStroStoMy feedIngGastrostomy feeding is generally used for patients who require longer-term nutritional support, usu-ally identified as more than four weeks (14). Gas-trostomy tubes are placed directly into the stomach, either endoscopically, surgically, or radiologically, and each patient should be fully assessed prior to placement to ensure that there are no contraindi-cations to placement, e.g. previous abdominal sur-gery, and that placement is appropriate. Previously, a number of studies comparing nasogastric to gastrostomy feeding showed that there was better success in the administration of feed, less interruption to feeding regimen and lower risk of aspiration with gastrostomy feed-ing. As a result, patients were more consistently hydrated and fed and nutritional status improved and, with it, many of the functional measures as-sociated with poor nutrition, such as increased frequency of infection, increased risk of pressure areas, depression, loss of muscle mass, etc. However, the FOOD Trial (20) found that there were no clinically significant benefits of gastrostomy feeding compared to nasogastric feeding and also found a reduction in poor out-comes with NG feeding. The recommendation from this was to use NG feeding initially for the first two to three weeks post stroke, unless there was a clear practical reason to use gastrostomy. An additional finding of interest was that the gastrostomy group had a higher rate of pressure sores, which raised the possibility that these pa-tients may move less or be nursed differently. Poor outcome following gastrostomy inser-tion, as concluded by the FOOD Trial, must con-sider that patient selection is a factor, as those requiring gastrostomy are patients with poor nu-tritional intake and status and the poorest prog-nosis. This links in with the finding that, although early enteral feeding is recommended and does not cause any harm, this can keep patients alive but in a severely disabled state where they would

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NHDmag.com June 2015 - Issue 105 13

enterAl feedIng followIng Stroke

otherwise have died, i.e. survival itself does not equate to survival with good outcome. The commonly used terminology of Percu-taneous Endoscopic Gastrostomy (PEG) and Radiologically Inserted Gastrostomy (RIG) refer to the methods of placement, not type of tube. Tubes are more commonly identified as Balloon-Retained and Non-Balloon Retained, and the type of tube and method of placement vary de-pending on the individual, and which method is most suitable. Surgical gastrostomy can be placed in patients who have failed to tolerate both PEG and RIG procedures. There are various potential complications of gastrostomy tube insertion ranging from minor complications such as cellulitis and localised skin infection, to more major complications such as in-fectious peritonitis or buried bumper syndrome.

MedIcAtIon AdMInIStrAtIonAdministration of medications is often necessary in stroke patients, due to dysphagia or Nil by Mouth status. Careful guidance should be sought regarding method and timing of administration,

along with any drug-nutrient interactions with feed products (22, 23). Administering each medi-cation separately and flushing the feeding tube with 10mls water in between each medication is considered to be good practice.

guIdAnce on MonItorIngMonitoring of patients on enteral feeding should be multidisciplinary, depending on the health-care professionals involved in that individual’s care. Anthropometric and biochemical mark-ers are essential and useful, along with clinical judgement regarding the medical stability of the patient (24, 25)

dISchArge PlAnnIngIt is essential that good practice is established in terms of coordination of discharge from hospital for patients on enteral feeding. Training and sup-port for patients, carers and relatives on all aspects of feeding and ongoing tube care is critical, and it is essential that it is delivered in a timely fashion, with information provided in the most suitable medium for each patient and their carers.

references:1 British Heart Foundation. Coronary Heart Disease Statistics. BHF 20042 Foley NC, Martin re, Salter KL, Teasell rw. a review of the relationship between dysphagia and malnutrition following stroke. J rehabil Med 2009; 41:

707-7133 Dennis M. Poor nutritional status on admission predicts poor outcomes after stroke. Stroke 2003; 34:1450-14564 Davis JP, wong aa, Schluter PJ, Henderson rD, O’Sullivan JD and read SJ. Impact of pre-morbid undernutrition on outcome in stroke patients. Stroke

2004; 35: 1930-19345 Martineau J, Bauer JD, Isenring ea, Cohen S. Malnutrition determined by the patient-generated subjective global assessment is associated with poor

outcomes in acute stroke patients. Clinical Nutrition 2005; 24(6):pp. 1073-10776 Yoo SH, Kim JS, Kwon SU, Yun SC, Koh JY and Kang Dw. Undernutrition as a predictor of poor clinical outcomes in acute ischemic stroke patients. archives

of Neurology 2008; 65: 39-437 Dennis et al. FOOD Trial Collaboration: routine oral nutritional supplementation for stroke patients in hospital: a multicentre randomised controlled trial. Lancet

2005. 365:p755-7638 Nursing & Midwifery Practice Development Unit. Nutrition: assessment and referral in the care of adults in hospital - best practice statement. NMPDU 20029 royal College of Physicians. National Clinical Guidelines for Stroke. rCP 200410 Scottish Intercollegiate Guidelines Network. Clinical Guideline 78. Management of patients with stroke: Identification and management of dysphagia.

SIGN 200411 Finestone et al. Measuring longitudinally the metabolic demands of stroke patients: resting energy expenditure is not elevated. Stroke 2003. 34: p2502-50712 Henry CJ. Basal metabolic rate studies in humans: measurement and development of new equations. Public Health Nutr 2005; 8(7a):1133-115213 Perry L, Love CP. Screening for dysphagia and aspiration in acute stroke: a systematic review. Dysphagia 2001. 16(1), 7-1814 National Institute for Health & Clinical excellence. Stroke - Diagnosis and initial management of acute stroke and transient ischaemic attack. Clinical Guideline

68. 200815 National Institute for Health and Clinical excellence. Nutrition Support in adults. Clinical Guideline 32. NICe 200616 Lennard-Jones Je. ethical and legal aspects of Clinical Hydration and Nutritional Support. a report for the British association for Parenteral and enteral

Nutrition. BaPeN 200017 Manual of Dietetic Practice (4th edition) Blackwell Publishing Ltd 200718 Mcatear Ca (ed). Current perspectives on enteral nutrition in adults. BaPeN working party report. BaPeN 199919 National Patient Safety agency. Patient Safety alert: reducing the harm caused by misplaced nasogastric feeding tubes. 200520 Dennis et al. FOOD Trial Collaboration. effect of timing and method of enteral tube feeding for dysphagic stroke patients: a multicentre randomised controlled

trial. Lancet 2005. 365, 764-77221 Johnston rD et al. Outcome of patients fed via a nasogastric tube retained with a bridle loop: Do bridle loops reduce the requirement for percutaneous

endoscopic Gastrostomy insertion and 30-day mortality? Proc Nutr Soc 2008. 67 (OCe) e11622 white r and Bradnam V (2011). Handbook of Drug administration via enteral Feeding Tubes. 2nd edition. Pharmaceutical Press23 Smyth J (2012). The NewT Guidelines for the administration of medication to patients with enteral feeding tubes or swallowing difficulties. 2nd edition24 Todorovic and Mickelwright (2011). PeNG - a pocket guide to Clinical Nutrition, 4th edition25 aSPeN enteral Nutrition Practice recommendations, JPeN (2009); originally published online

NHDmag.com June 2015 - Issue 10514

They are only given valuable shop floor space because they are bought in such huge quantities, of course. Valentine’s Day brings roses and presentation con-fectionary; July brings English strawber-ries with offers of ‘free’ cream and the end-of-October brings pumpkins which are needed to scare small children and are unlikely to be eaten, despite their nutritional excellence. An interesting feature of the last few years is the expan-sion of shelf space given to an increas-ing variety of other milks*. Not meaning infant formula. Not meaning other mammalian milks such as goat or buffalo, although the latter are also increasingly on offer. Not mean-ing modified cows’ milk (lactose-free) or ‘different’ cows’ milk, such as a2™ milk. Rather, milk-type plant-sourced liquids that can be used instead of cows’ milk to moisten breakfast cereals or counter the astringency of teas or coffees. The dairy-alternative market has grown strongly in the last few years in both volumes and varieties of products on offer, so confirmed the market research organisation Mintel in June 2014. In the two years to the end of 2013, the volume sales of cows’ milk alternatives (CMAs) rose by more than 150 percent in the UK: from 36 million litres, to 92 million litres. The lactose-free cows’ milk market, of which there is only one monopoly prod-uct (Lactofree made by the Danish dairy company Arla), reached volumes of 17 million litres in 2013, so less than one fifth of the volume of the plant-sourced milks. This is perhaps an indication that other factors are driving this trend beyond just the real or perceived diag-

nosis of lactose intolerance. The Mintel survey reported that 18 percent of the 1,500 UK consumers asked, claimed to have drunk soya milk or other plant-based milk and five percent had drunk lactose-free cows’ milk in the previous week. Data from another market research organisation, Kantar Worldpanel (4), re-ported volume sales of soya milk in the year to January 2015 at 79 million litres, although they note a four percent de-cline in the year; also, to put the figure into context, this is less than two per-cent of the volume of cows’ milk sales in the same period. However, soya milk sales battle against the fact that they are a more expensive product at 95 pence per litre and rising, against the cost of cows’ milk of 59 pence per litre and fall-ing. Also, the soya milk market is now a more mature part of the CMA sector and there has been an increase in the vari-ety of other plant milks available in this period. Easily available choices now in-clude products based on rice, almonds, oats, coconut and hazelnuts. Less-easily available choices such as seed milks (hemp or flax/linseed) or sweet chestnut or cashew drinks also exist. Not to men-tion all the other permutations that face the consumer in relation to white-liquid choices: products that are chilled or long life, original or unsweetened, organic or fortified, vanilla or chocolate flavoured, smooth or foamy. Also launched in the UK, but now withdrawn, was a statin-fortified soya milk for those with con-cerns over high blood cholesterol. At the Food Matters Live confer-ence held in London in November 2014,

the white Stuff…

supermarket shelf space can sometimes tell you as much as more sophisticated research tools on what is selling (or rather on what we are buying). Christmas means towers of tubs of wrapped chocolates more than man-high.

MIlk AlternAtIveS

ursula Arens writer; nutrition & dietetics

Ursula has spent most of her career in industry as a company nutritionist for a food retailer and a pharmaceutical company. She was also a nutrition scientist at the British Nutrition Foundation for seven years. Ursula helps guide the NHD features agenda as well as contributing features and reviews.

NHDmag.com June 2015 - Issue 105 15

MIlk AlternAtIveS

Richard Hall, from the drink industry research agency Zenith International, reviewed consumer demand for dairy-free and lactose-free products. Lactose intolerance was the normal condition in adulthood globally; the Caucasian populations in and from Europe were the exception. But there had been a strong increase in awareness of lactose intolerance and, although, diagnosis was often unreliable, it introduced the motivation for people to seek alternative products. There was currently a greater variety of plant-based prod-ucts available in the US and developments that he predicted for the UK market were range ex-tensions to other dairy products such as creams and yoghurts, blends of plant sources such as different nuts, or products using sugar alterna-tives such as stevia.

Plant milks can be made from:

Soya

coconut

cereal - rice, oats, barley

nuts - almonds, hazelnuts, cashews

Seeds - hemp, linseed

Sweet chestnuts

why Are uk conSuMerS goIng for Mock MIlkS? More than one quarter of the 1,500 consumers questioned by Mintel (2) agreed that plant-based milk was generally healthier than cows’ milk and eight percent reported more specifically that drinking cows’ milk caused them digestive problems and feeling bloated. There were also concerns over environmental and welfare as-pects of cows’ milk consumption. A surprisingly large number of UK consumers were doubtful of the purity of cows’ milk: nearly 60 percent of the sample (and 70 percent of the under-25s) claimed distrust. There are many nutritional differences be-tween cows’ milk and plant-sourced milks. Prod-ucts that are marketed as organic may not be fortified, but many of the other plant milks have additions of vitamins B2 and B12 and calcium to match levels found naturally in cows’ milk. Many products also have additions of vitamin D at levels that are very much higher than the trace

levels and seasonably variable amounts naturally present in cows’ milk. Energy contents of cows’ milk and plant milks are similar, but macronutri-ent profiles differ: plant milks are always lower in saturated fats (with the exception of coconut), and are sometimes lower in proteins. They may, however, contain modest amounts of fibre. Other than nutrient differences, some plant milks also promote health benefits due to the presence of other compounds such as beta-glucan in oat milk or isoflavones in soya milk. For healthy adults, fortified plant milks offer a tasty and nutritious alternative to cows’ milk. But these drinks are unsuitable for infants and as a main drink in young children under three years of age**. There are some concerns that per-ceptions of the healthiness and naturalness of plant milks may lead to a too-early inclusion of these products into the diets of very young chil-dren. A study on the inappropriate premature and extended use of plant milks in infants in France (1) documented hypoalbuminemia, hy-pocalcaemia and impaired growth in infants fed plant milks. The researchers cautioned that the energy and protein content of these milks were not adequate for feeding infants and called for statutory measures to improve parental educa-tion on this issue. The US consumer is also increasingly con-sidering non-dairy milks, which now command nearly 10 percent of the category sales and boast gains of nearly 95 percent in the five years pe-riod to 2014 (and retail sales at US $2,000 mil-

NHDmag.com June 2015 - Issue 10516

MIlk AlternAtIveS

lion). In a Mintel survey (3), US consumers were asked what milks they had consumed in the last three-month period. Responses were that 71 percent had consumed cows’ milk, but plant milks were also a surprisingly frequent choice: almond milk (30 percent), soy milk (23 percent), rice milk (14 percent) and about 10 percent each for seed milks, oat milks and ca-shew milks. The primary reason given by US consumers for drinking non-dairy milk was the belief that it was generally more nutritious. Ad-ditionally, consumers enjoyed the taste of these products and believed them to be a good source of protein. Specific reasons given for choices of non-dairy milks were also lactose sensitiv-ity or other intolerance to dairy products, and concerns about the use of growth hormones in dairy milk (rBST and/or rBGH - the use of bovine somatotropin to increase milk yield and bovine growth hormone to increase muscle is permitted and declared as safe in the US, but is not permitted in the UK or any other EU country). Another report on US consumer atti-tudes supports the strong growth of non-dairy milks (5). But there are winners and losers in the

year to 2014: in decline are soya and rice milk, whereas there is strong growth for coconut and especially almond milk. The dairy industry has not been shy in countering anti-cow claims by plant milk en-thusiasts. Cows’ milk is generally higher in protein than some plant milks and possible muscle-building benefits from the higher leu-cine levels in whey protein are of great interest to the sports and body sculpture communities. Further, the naturalness of milk is emphasised: no fortification or ‘additives’ are needed to embellish this food. While the cow must plead guilty to being a very major contributor to greenhouse gas emissions, environmental fin-ger-pointing has suddenly hit the halo held by almond milk: claims that one gallon of water is needed to produce one almond in the parched, über-dry West Coast of the US has caused dis-cerning Californian consumers further confu-sion over which is the best milk. Consumers can ask the questions, journalists and tweeters can debate the issues and sciency-di-etitians can, as ever, offer pragmatic answers to this and other questions of what-is-best food choice.

* The term ‘milk’ is protected, and defined by the eU milk marketing standards as, ‘produce of milking one or more farmed animals’. Companies producing plant-sourced mock-milks are careful not to use the term ‘milk’ on product labelling, and the use of the word in this article is just lazy-writer-itis: it does not imply disregard for eU definitions or dairy interests.

** alpro have launched a ‘soya +1’ drink that has been developed ‘especially for little ones’. In comparison to the alpro original soya drink, the +1 product contains more energy and fat and carbohydrate (from maltodextrin), but slightly less sugars and fibre. The +1 product also contains iron and iodine and twice the levels of vitamin D. It is not suitable as a replacement for breast milk or infant formula under the age of one year.

references1 Le Louer B, Lemale J, Garvette K, Orzechowski C, Chalvon a, Girardet JP, Tounain P (2014) Severe nutritional deficiencies in young infants with

inappropriate plant milk consumption. arch Pediatr 21, 5, 483-82 Mintel report (June, 2014) UK: Dairy drinks, milk and cream3 Mintel report (april 2015) US: Dairy and non-dairy milk: spotlight on non-dairy4 www.dairyco.org.uk (13.2.15) quoting statistics from Kantar worldpanel5 Nutrition Business Journal (NBJ) 2015. Special Diet report; infographic ‘nuts for non-dairy’

NH-eNews plus NHD eArticle with CPDThe UK’s only weekly enewsletter for dietitians and nutritionists. To register please visit

NHDmag.com

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NHDmag.com June 2015 - Issue 10518

Malnutrition can be defined as: ‘a state of nutrition in which a deficiency or ex-cess (or imbalance) of energy, protein and other nutrients causes measurable adverse effects on tissue/body form (body shape, size and composition) and function and clinical outcome’ (1). The cost of disease-related malnutri-tion is in excess of £13 billion per year, of which ~93 percent live in the community (2). Tackling malnutrition can improve nutritional status, clinical outcomes and reduce healthcare use (2). The National Institute for Health and Clinical Excel-lence (NICE CG32) has shown that sub-stantial cost savings can result from iden-tifying and treating malnutrition, CG32 is ranked third in the top clinical guide-lines shown to produce savings (3). Sip feeds are often used to treat mal-nutrition; however, they should only be considered when diet alone has proved to be, or clearly will be, insufficient to sus-tain or improve oral intake (4). Sip feeds are also referred to as oral nutritional sup-plements (ONS).It has been documented that ONS are often prescribed without involvement of a dietitian and with no at-tempt to improve oral intake by conven-tional dietary methods (4).

the ProJect PurPoSeOver the last two years there has been a significant rise in spend on ONS in Bol-ton. In 2011/12 the amount spent was in the region of £1.4m and in 2012/13 it was £1.5m (sourced from 5). This repre-sents an average growth of nine percent year on year to Bolton Clinical Commis-sioning Group (CCG). The purpose of this project was to establish the current prescribing prac-tices of sip feeds within Bolton CCG to

ensure the NHS commitment to provid-ing best value for taxpayers money and the most effective, fair and sustainable use of finite resources (6). The prescrib-ing of ONS has a significant impact on local prescribing budgets which are often prescribed inappropriately due to of lack of dietetic assessment (4). In order to identify if the CCG was spend-ing inappropriately on ONS, a Medicine Optimisation Dietitian (MOD) was em-ployed with the aims discussed below.

ProJect AIMS• Identify and evaluate current inap-

propriate ONS prescribing within the CCG for adults in Bolton Com-munity, who are not under the care of a dietitian.

• Audit the presence of nutritional screening by GPs or in care homes prior to prescribing ONS.

• Stop and reduce inappropriate pre-scribing by investing in dietetic sup-port.

• Support GPs with screening, assess-ing and treating malnutrition ap-propriately.

• Develop guidance on nutritional screening and prescribing of ONS for adults in Bolton community.

• Educate prescribers of ONS on ap-propriate prescribing and the prin-ciples of ‘food first’

Food first, being defined as ‘using everyday foods to increase protein and/or energy density of the diet, including drinks’, is often achieved through adding high fat/carbohydrate/protein foods/drinks to the diet in food and/or drinks. It is not intended to achieve nutritional completeness for micronutrients.

do dietitiAnS need to Be SiP feed PreSCriBerS?

dimple thakrarPrescribing Support dietitian, bolton clinical commissioning group (ccg)

dimple works with Bolton gPs and onS prescribers to advise and provide training on appropriate onS prescribing and food first. She is also a member of the BdA Prescribing Support dietitians, neurosciences Specialist, freelance dietitians groups and a BdA media spokesperson.

looking at the sip feed Project in Bolton

SIP feedS: dIetetIc PreScrIbIng

NHDmag.com June 2015 - Issue 105 19

PIlot ProJect delIveryAll patients who met the project criteria (see below) were assessed by the dietitian. Those who did not attend were assessed by telephone consultation. Ap-propriate nutritional care plans were agreed with all patients, including advice on ONS. Individual GP practice data was collated and then summarised for the seven practices detailed in Figure 1.

ProJect IncluSIon crIterIA• Over 18 years old• Currently being prescribed a ONS and not

under the supervision of a dietitian• Not enterally tube fed• Not on palliative care register• Not diagnosed with an eating disorder

The cost saving/avoidance has been calculated from the sum of the cost of the ONS discontinued and is only indicative of that moment in time and will be referred to as cost saving in this article.

reSultSTotal number of patients seen: 117 (see Fig. 1).

concluSIon• 88 percent of the sip feeds being prescribed were

inappropriate at the time of dietetic review.• The cost of the inappropriate prescribing cal-

culated though cost avoidance was in the re-gion off £156,000/annum.

• Over half of the spending on ONS prescribing could be saved with appropriate prescribing.

• Though this was not collated, there was little evidence of nutritional screening, assess-ment, or monitoring of patients on ONS from the documentation.

Anecdotal evidence suggests that the reasons for the inappropriate ONS prescribing were of-ten due to:• unclear written or verbal communication as to

clinical reasoning for starting and stopping ONS;• GPs lack of knowledge/confidence with food

first and criteria for use of ONS;• lack of patient monitoring on ONS;• high volume of requests for ONS from care

homes without establishing adequate food first techniques;

• lack of dietetic involvement when ONS are commenced;

• GPs welcomed the input from the dietitian and acknowledged the above.

recoMMendAtIonS• To extend the project for the whole of the Bol-

ton population.• The need for GP and staff Training GP on:

1. appropriate sip feed prescribing2. food first

• To collect data on nutritional screening and ONS initial prescribing source.

SIP feedS: dIetetIc PreScrIbIng

subject total no patients total in %

Stopped sip 103 88

reduced sip 1 0.85

changed sip 12 10

Increased sip 1 0.85

Started on sip feeds 0 0

referred to community dietetics 1 0.85

take patient off community dietetic waiting list 2 1.7

no further dietetic intervention needed 54 46

referred back to the gP for monitoring 32 27

referred back to hospital consultant 0 0

Calculated rounded monthly cost savings ~£12,000

Calculated rounded annual savings ~£156,000~53% from total annual spend

figure 1: Summary of data collected and cost savings

NHDmag.com June 2015 - Issue 10520

SIP feedS: dIetetIc PreScrIbIng

MAIn ProJectProject design:The project was extended in the same format for 12 months, to cover the remaining 43 GPs. In ad-dition, Prescribing Guidelines for the appropri-ate use of oral nutritional supplements (ONS) in the community (adults) (PGONS), July 2014, were developed to support GPs and provide food first handouts for patients. Following the patient assessment phase, an individual GP practice training programme was developed for all practice staff. This included:• a Practice Patient Data Summary Report,

aiming to ensure that the training was rel-evant and pertinent to each practice;

• a cost saving and incidence analysis of inap-propriate ONS prescribing presentation;

• a food first interactive game aiming to raise awareness of food first and increase knowl-edge of ONS nutritional contents and appro-priate prescribing;

• guidance on implementing the PGONS;• personalised practice recommendations aim-

ing to provide future guidance;• a simple two-part project evaluation ques-

tionnaire.

reSultS:Forty GP practices were included in the project. Two had no patients that met the criteria and

one practice refused to participate. 154 patients received dietetic review (average age 71 years old). The total cost savings were in the region of £152,000 per annum for the 40 practices; which equates to an average of approximately £1,000/patient/annum. Only one out of 154 showed evidence of ap-propriate screening, i.e. MUST and % weight loss recorded in the GP patient notes. However, it is common practice for care homes to collect MUST scores and body mass index (BMI), but there was no documented evidence of this on request for ONS. There were no differences found in prescrib-ing trends of ONS in care homes compared to patients in their homes. However, there was a greater incidence of under usage of ONS in pa-tients in their own home, i.e. patients not taking their full prescribed dose of ONS. This suggests that patients when unmonitored by trained staff struggle to tolerate the directed dose of ONS as their food intake increases. This highlights the need for close monitoring, while a patient is on ONS to support the weaning off process and re-duce wastage as per the PGONS. The majority of GPs were trained on food first and the PGONS with the exception of three who either declined or were unable to com-plete the training within the project time frame.

figure 2: trend of cost savings in bolton ccg compared to national and greater Manchester

Source: nhS business Services Authority december 2014, Advisor: Jole hannan, clinical effectiveness Pharmacist, bolton ccg

NHDmag.com June 2015 - Issue 105 21

The PGONS was made available to all GPs and hospital prescribers with the aim to reduce fur-ther inappropriate ONS prescribing and pro-mote food first. Figure 2 demonstrates the impact of dietetic intervention (started January 2014) on cost sav-ings compared to Greater Manchester and Na-tional trends. Qualitative data gathered following the prac-tice training was very positive and in summary staff reported the following:• The training to be greatly needed and to be

provided annually.• Very practical and easy to apply to practice.• The Food First Patient leaflets were well received.• Staff felt more confident to use food first as a

first line approach over prescribing ONS.• Appreciated the importance of monitoring

patients regularly.

The limitations of this project are:• True cost savings over time were not collected

due to the short project time, i.e.12 months.• Due to the limited dietetic funding, patients

could not be reviewed and, while detailed in-structions on monitoring and reviewing nutri-tional status was given to the GP and/or practice nurse, clinical outcomes could not be measured.

concluSIonSSpecialist dietetic intervention has been shown to reduce inappropriate spending on ONS in Bolton and achieved the aims of this project. It was evident from GP feedback that the training was a crucial part of the project, which will need to be continued to ensure sustainable and clini-cally safe cost savings. Further dietetic input is needed to continue to support clinically safe, cost savings in ONS prescribing, particularly in assisting prescribers to maintain safe and appro-priate nutritional care, as well as enabling clini-cal outcomes to be measured and reported over a greater period than 12 months.

nutrItIonAl recoMMendAtIonS for gPS And other onS PreScrIberS• Assess nutritional status appropriately and

set nutritional measurable goals.• Treat early signs of malnutrition with food

first if appropriate.• Avoid ONS on repeat prescriptions.• Monitor, review and act upon nutritional

changes.• Stop ONS when nutritional goals have been

achieved.Recommendations for dietitians:• When communicating with GPs state clearly

and concisely when and by whom review and monitoring of nutritional status should be completed.

• Always consider food first as first line ap-proach.

• When first recommending ONS, ensure clear goals are agreed with the patient, carers, staff and prescriber, including how long the patient should expect to remain on ONS.

• Be aware of the cost of ONS in Primary care.• Indicating clearly with dates, where possible,

when ONS should be discontinued.• Promote dietetics by optimising on (ad hoc)

training opportunities with GPs, i.e. in prac-tice meetings or in passing when discussing patients.

future thoughtSIt is clear from this project that those patients on ONS who aren’t under the supervision of a di-etitian need close monitoring to ensure that their nutritional needs are being met appropriately and cost effectively, thus ensuring that the NHS runs efficiently. Is it time to pass ONS prescribing over to di-etitians and use the cost saving demonstrated in this project to invest in dietitians? Let’s use every opportunity to fly the flag for dietetics. We are the nutrition experts!

SIP feedS: dIetetIc PreScrIbIng

references1 www.guidelinesinpractice.co.uk/eguidelinesmains/index/page/5/www.gov.uk/www.dh.gov.uk/about_gip2 Managing adult Malnutrition in the Community. Including a pathway for the appropriate use of oral nutritional supplements (ONS).

www. Malnutrtionpathway.co.uk3 NICe CG324 Manual of Dietetic Practice (2007)5 Health and social Care Information Centre (Dec 2014)6 The NHS Constitution (2013)

1 Contains 1.89g/100kcal of protein, including -lactalbumin, making the protein level and quality closer to that found in breastmilk (1.7g/100kcal). Nommsen LA et al. Am J Clin Nutr 1991; 53: 457–465.

2 Koletzko B et al. Am J Clin Nutr 2009; 89(5):1502S–8S.

3 Price per 100g of infant milk powder: HiPP £1.06, Aptamil £1.11. Price per case of 24 infant milk hospital formula: HiPP £8.36, Aptamil £8.84. Prices correct as at April 2015.

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NHDmag.com June 2015 - Issue 105 23

The Infant Feeding Survey (IFS) 2010 (3) demonstrated that, although the initial breastfeeding rate increased from 76 per-cent in 2005 to 81 percent in 2010, and that mothers are continuing to breastfeed for longer, the proportion following current guidelines on exclusive breastfeeding for the first six months of a baby’s life have remained low since 2005, with only one in a 100 mothers following these guidelines. It is, therefore, essential that continuous improvements are made in infant formu-las (IF) to ensure that the high nutrient re-quirements required by infants are met. The most recent definition describes is as a ‘food intended for use by infants when appropriate complementary feed-ing is introduced and which constitutes the principal liquid element in a progres-sively diversified diet of such infants’ (4). FOFM contains the same ingredients as standard IF, but with higher levels of protein, iron and micronutrients, such as vitamin D. The levels of nutrients are strictly controlled under the European Commission Directive on Infant Formu-lae and Follow-on Formulae. The Co-dex Alimentarius of the United Nations Food and Agriculture Organisation and the WHO also provide guidance on the composition of IF, which is used widely internationally (Codex Alimentarius Committee, 2006). The most recent UK legislation was 2007, with amendments made since. In 2014 the EFSA produced its opinion (5). This will form the basis of new legislation in due course, as there is presently a review of the Codex stan-dard for FOFM, jointly with the WHO and the Food and Agriculture Organisa-tion (FAO), due for completion in July 2016. Issues such as the age range of the

intended population, product definition, compositional requirements, the role of such products in the diet and the need for such a standard will be reviewed.

who uSeS fofM?The IFS (6) has investigated the use of FOFM at different stages. At Stage 2 of the survey (four to 10 weeks old), use was low (nine percent). By Stage 3 (eight to 10 months old), mothers were more likely to be using FOFM (57 percent) as their ba-by’s main source of milk with IF at 35 per-cent. At Stage 3, 69 percent of all mothers had given their baby FOFM. Most moth-ers followed the recommendation of not giving their baby FOFM before the age of six months (16 percent had given FOFM when their baby was four months old, increasing to 50 percent at six months). Mothers from routine and manual oc-cupations and mothers who had never worked were more likely than average to say that they had given their baby FOFM at an earlier age (18 percent and 27 per-cent respectively at four months).

the chArActerIStIcS of fofMIron: The case for FOFM was its potential role in preventing iron deficiency anae-mia. The health problems associated with iron deficiency anaemia have long been recognised, e.g. immune status alteration, adverse effects on morbidity, delayed behavioural and psychomotor develop-ment, below average school achievements and growth retardation (7-12). It was suggested that FOFM is given from six months, when an infant’s stores have become depleted (Domellof et al, 2001) and cannot be replaced by breast milk (being a poor source of iron). How-

follow-on formulA milkS

the world Health organisation (wHo) and the department of Health (dH) both emphasise the benefits of exclusive breastfeeding (1, 2). in the uk, however, few mothers follow policy recommendations.

InfAnt forMulAS

Jacqui lowdenPaediatric dietitian - team leader critical care, therapy & dietetics, rMch

Presently team leader for Critical Care and Burns, Jacqueline previously specialised in gastroenterology and cystic fibrosis. although her career to date has focused on the acute sector, Jacqueline has a great interest in paediatric public health.

for article

references please

email: info@

networkhealth

group.co.uk

ever, randomised controlled trials have not shown any consistent benefit from the additional iron in FOFM compared to IF, after the age of six months (13). There is also evidence that giving extra to those who are already replete in that nutrient could cause long-term damage and have an adverse effect on growth (14). Infants aged six to 12 months, who al-ready had high iron levels, fed an iron fortified for-mula (mean 12.7mg/L) versus a low-iron formula (mean 2.3mg/L), scored lower on every 10-year development outcome (15). Excessive iron intakes may result in a reduced uptake of other trace metals, such as copper and oxidation of lipids, due to the pro-oxidant effects of excess iron (16). Morley et al 1999 (17) found that giving an iron supplemented FOFM to nearly 500 infants and toddlers between the ages of nine to 18 months, had no developmental or growth advantages. The recent EFSA opinion (18) proposes that the minimum content of nutrients in IF and FOFM should be the same apart from iron, sug-gesting that FOFM should have a higher mini-mum target iron content than first IF. If the same formula is to be suitable for the first year of life, then the EFSA recommend that the minimum iron content should be 0.6mg/100kcal. This is based on the assumption that about 70 percent of daily iron (equivalent to 5.7mg iron per day) could be provided by complementary foods, and a minimum content of iron in FOFM of 0.6mg/100kcal is proposed. First IF, however, currently meet this higher level and are there-fore appropriate for the first year. The EFSA also noted that, although some data suggest that iron supplementation in iron-replete infants may lead to impaired growth and development and an in-creased risk of infections, the evidence is limited. Therefore, they have concluded that a maximum iron content in FOFM cannot be recommended. There is some argument, however, that FOFM should be considered for inclusion in anaemia pre-vention programmes, especially those aimed at some of the poorest families in the UK (19), although meat-rich weaning diets and use of commercially prepared baby foods which are iron supplemented, are also discussed as advantageous (8).

Minerals: FOFM contains higher amounts of cal-cium and phosphorous because calcium require-ment increases in the second six months of life.

Infants should begin to consume solid foods at six months and, therefore, additional calcium and phosphorus requirements should be met without difficulty from first IF and food sources (20).

vitamin d: In the UK, all breastfed infants over six months of age, formula-fed babies receiv-ing less than 500ml of formula and all children aged one to five years are recommended to take vitamin drops that contain vitamin D, as a public health policy. However, the uptake of children’s vitamin drops is very poor (3). At Stage 1, only seven percent of babies were receiving vitamin drops, increasing to 14 percent at Stage 3. The more deprived minority groups suffer most from the risk factors for vitamin D defi-ciency. These include darker skin, covering up, prolonged breastfeeding by vitamin D deficient mothers and a lack of usage of fortified formula milk (21). For these groups, there may be some benefit in the usage of fortified FOFM. If children are recommended to have vitamin drops and consume fortified milks, high intakes could be consumed, as vitamin D is a category A nutrient in terms of the risk of over-consumption (22). The ESPGHAN Committee on Nutrition, however, noted that reports on vitamin D intoxica-tion are scarce and that there is no agreement on a vitamin D toxicity threshold (23). Recent inter-vention studies using doses of up to 25μg vitamin D per day (plus the amount ingested via fortified IF) for up to five months after birth, did not dem-onstrate that these intakes are associated with hy-percalcaemia in infants. An upper level of 25μg vitamin D per day has been established by the Eu-ropean Food Safety Authority NDA Panel (18).

Protein: Formula protein content is another ma-jor component that has been extensively studied, especially as current formulations of FOFM have led to higher protein intake. IF contains approxi-mately eight to 12 percent energy from protein, whilst breast milk contains approximately five to six percent energy from protein (24). This higher content in formulas was intended to compensate for the lower protein quality. The potential for chronic disease risk attrib-uted to rapid postpartum gain is increasingly be-ing recognised and so the ideal degree of ‘catch-up growth’ has become controversial. Healthy

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InfAnt forMulAS

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InfAnt forMulAS

term infants, when randomised to receive a higher protein formula, displayed higher weight gain velocity, Wt for age Z score, Wt for Length Z score and BMI-Z, but no differences in Length for age Z score by six months compared with controls (25, 26). These trends implied a larger fat mass accrual in the high-protein group, a find-ing that persisted until study termination at two years of age (27). Trabulsi et al (28) investigated the effect on infant growth of an IF with a protein content of 1.9g/100kcal compared with an infant formula with a protein content of 2.2g/100kcal. There were no statistically significant differences between the two groups with respect to weight gain, length gain and head circumference at the end of the study at four months of age. Previous recommendations by the Early Nu-trition Academy is that formula high in milk pro-tein should be avoided for infants. Recommenda-tions for the protein content of FOFM used from six months to one year suggest that the protein content should not exceed 2.5g protein/100kcal or about 10 percent of the energy content (29). The EFSA recommends that a minimum protein intake of 1.8g/100kcal from FOFM based on intact milk protein is sufficient to ensure adequate growth and development. However, there is no scientific data which allows the establishment of precise cut-off val-ues for the maximum protein content in FOFM.

role of fofM durIng weAnIngProtein needs are met by breast or formula milk protein, but at the time of weaning, the most suit-able protein-to-energy ratio in a milk or formula will depend on the protein-to-energy ratio of the weaning foods available. This will obviously vary, on what is offered and what is available. The protein-to-energy ratio of weaning food in many developed countries is high, reaching 2.5g/100kcal after correction for protein qual-ity (30). Thus, a very-high-protein milk is not needed to achieve satisfactory intakes. However, even modest displacement of breast milk or stan-dard formula milk by low-protein complemen-tary foods can result in inadequate total protein intake. In many developing countries, the only weaning food is maize or rice, which has a low protein-to-energy ratio. When the protein con-centration of the weaning food drops below that of milk, i.e. when it is <1.0g/100kcal (such as for

cassava), it is impossible to meet total protein needs. The alternative approach to meeting pro-tein needs in situations where complementary foods contain no or low amounts of protein, is to use a FOFM, containing more protein (31).

concluSIonThe growth and development of infants fed FOFM need to be similar to those infants who continue to be breastfed while complementary food is in-troduced. IF consumed during the first year of life can continue to be used by young children. The recent EFSA panel has concluded that it is not nec-essary to propose specific compositional criteria for formula consumed after one year of age. Presently, there is no evidence to support the use of FOFM in infants receiving complementa-ry foods containing adequate protein, carbohy-drate, fat and iron (32). The Scientific Advisory Committee on Nutrition (33), stated that: ‘There is no published evidence that the use of any fol-low-on formula offers any nutritional or health advantage over the use of whey-based infant for-mula among infants artificially fed.’ In 2013, the WHO reiterated its position (34), that FOFM is not necessary and is unsuitable as a replacement for breast milk after six months. For this reason, FOFM is not included in the UK Healthy Start Scheme. There may be nutritional and health advantag-es to continuing formula milk intake into the sec-ond year for those infants considered at high risk of iron deficiency due to poor diet or other difficulties, such as fussy/faddy eating. It is advised, however, that first formula remains the milk of choice during the first year if babies are not breastfed (32). From a nutritional point of view, it maybe that FOFM is best considered in relation to the introduc-tion of complementary food and the toddler diet, rather than breast/bottle feeding. The medical litera-ture now contains mixed findings on their use when included in the introduction of solids for prevention of iron deficiency anaemia in babies over six months of age and in toddlers. With the ‘growth acceleration hypothesis’ suggesting that early and rapid growth during infancy programs the infant metabolic pro-file to be susceptible to obesity and the other compo-nents of metabolic syndrome, a review of the protein content of FOFM is quite timely and will lead manu-facturers to review their formulations.

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In recent years, in collaboration with key stakeholders, including the British Dietetic Association and the Royal Col-lege of Nursing, the BAPEN Malnutri-tion Action Group have undertaken several national nutrition screening weeks (NSWs). Conducted over four years (one per season) in a variety of care settings, the NSWs have generat-ed one of the largest malnutrition data sets in the world. Despite best efforts of many organisations and individu-als to tackle malnutrition, the data illustrates the continuing high preva-lence of malnutrition in the UK, with an estimated three million individuals being malnourished or at risk of mal-nutrition. Failure to treat malnutrition is a costly business. In 2007, the costs as-sociated with malnutrition were esti-mated to be £13 billion; this has risen to approximately £20 billion in 2014. These costs arise from the increased cost of caring for someone with mal-nutrition and the greater utilisation of healthcare resources. The personal cost to individuals and their families is also significant, and are reflected in an increased mortality rate, increased admissions to hospital, increased pres-sure ulcers, falls and infections and an overall decrease in quality of life. Combating malnutrition in the UK continues to present a significant chal-lenge. A shift in mind-set is now need-ed to work together to find innovative solutions and monitor their impact. In this article we introduce the latest data-gathering tool that will enable us to work together towards monitor-ing the provision of nutritional care,

tAcklIng MAlnutrItIon - AchIeveMentS to dAteIn 1992, the King’s Fund published the report: ‘A Positive Approach to Nu-trition as Treatment’. This landmark document became available as a mo-tivated group of nutrition champions established BAPEN. Founded by core groups representing nursing, dietet-ics, doctors, pharmacy and scientific professions, patients and members of industry, BAPEN set in motion a move to raise the profile of nutrition as an integral component of healthcare. In conjunction with the work of BAPEN, the last two decades have seen numerous national, regional and local nutrition initiatives such as ‘protected mealtimes’ and ‘Nutrition Now’ (Roy-al College of Nursing) and the publica-tion of numerous standards, including the NICE guidance CG32, ‘Nutritional support in adults’ (2006) and the NICE quality standards QS24 (2012), which have helped to raise awareness of the prevalence and treatment of malnutri-tion. In addition, both governmental and non-governmental organisations have championed the need for nutri-tional care across care settings, facili-tated by those in practice and those commissioning services. Whilst it is evident that ‘MUST’ has helped to detect malnutrition, malnu-trition rates have changed little in 20 years. Combating malnutrition there-fore remains a significant challenge. Part of the reason for the ongoing issue may be a lack of focus on measuring

introduCing the BAPen nutritionAl CAre tool

Anne holdoway consultant dietitian, chair of Parenteral & enteral nutrition group of the bdA and bAPen council Member

dr Ailsa Brotherton, Anne holdoway, dr mike Stroud on behalf of the BAPen Quality group*.

a new measurement tool to support the delivery of improvements in nutritional screening, nutritional care processes, outcomes and the patient experience.

MAlnutrItIon

Mike StroudPresident of bAPen

Ailsa brothertonchair of the quality and Safety committee, bAPen

evaluate practice and identify areas for improvement.

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MAlnutrItIon

the impact of initiatives in delivering real improvements in nutritional care. Measure-ment to date has largely focused on catering, the quality of food served, rates of nutritional screening and targeted reductions in oral nu-tritional supplement usage. Measurements have however failed to capture in a meaning-ful way and at scale, the quality of nutritional care planned, delivered and the nutritional outcomes achieved.

the rAtIonAle for develoPIng A new MeASureMent toolAmongst senior professionals within BAPEN, it was noted that, whilst the NSWs have il-lustrated improvements in screening rates, smaller scale audits, submitted as abstracts to the Annual BAPEN conferences, suggest that there might be a problem with accuracy of completion of screening tools. In addition, little remained known, collectively, on the pro-vision of nutritional care that followed on from screening. These concerns prompted the multidisci-plinary quality group within BAPEN to focus on a shared interest, which was to develop a new measurement tool to answer key ques-tions that were emerging. Questions included:• How accurate is the screening that is being

undertaken?• What proportions of patients at risk have

a nutritional care plan and are those care plans implemented and acted upon?

• What are the nutritional outcomes follow-ing screening and care planning?

• How good is the patient’s experience of nu-tritional care?

• How do we benchmark nutritional care and what variation exists across the system?

• Which organisations or units are outliers, both positive and negative?

To gather such information in a systemat-ic way on a national basis, the Quality group felt that a measurement tool was essential. This drive reflected recent shifts in the NHS where new measures to track improvement, as opposed to measurement for performance (judgement) or measurement for research, have evolved. We were fortunate to welcome Kate Cheema from the Quality Observatory to the working group. Kate brought knowl-edge of measurement within the wider health-care arena to the group and her involvement helped facilitate the groups’ understanding of measurement, highlighting that measurement to determine improvements could be differen-tiated from measurements for research. Put simply, appropriate measures are es-sential for a team to determine if the changes they are implementing are leading to improve-ments and for measuring the sustainability of improvements. Table 1 below outlines the dif-ference between measurements for research purposes and measurement for process im-provement (IHI).

the PurPoSe of the bAPen nutrItIonAl cAre toolOver many months, through a process of itera-tion and testing amongst users, including more than 80 representatives from nursing and dietet-ics, the new measurement tool, suitably named the BAPEN Nutritional Care Tool, was devel-

Measurement for researchMeasurement for learning and process improvement

Purpose to discover new knowledge to bring new knowledge into daily practice

tests one large “blind” test Many sequential, observable tests

biases control for as many biases as possible Stabilise the biases from test to test

datagather as much data as possible, ‘just in case’

gather ‘just enough’ data to learn and complete another cycle

durationcan take long periods of time to obtain results

‘Small tests of significant changes’ accelerates the rate of improvement

table 1

Source: Institute for health care improvement: www.ihi.org/resources/Pages/howtoImprove/ScienceofImprovementestablishingMeasures.aspx

oped to enable teams to deliver and measure im-provements in nutritional care at a local level. Building on the national nutrition screening weeks’ data collection, the tool utilises quality improvement methodology (i.e. the data is in-tended for improvement purposes, not perfor-mance management or research). The final tool is of succinct design that incorporates:• process measures - prevalence of malnutri-

tion and nutritional care processes;• outcome measures - weight loss (trackable

over time for the duration of admission);• patient experience measures - of the nutri-

tional care received.

Designed by the multi-professional BAPEN Qual-ity and Safety Committee, the tool underwent multiple rounds of testing and development with-in BAPEN’s core groups’ membership. The final rounds of testing involved dietitians and nurses beyond the BAPEN membership. Participants were invited from specialist groups of the BDA such as NAGE; oncology and nursing staff in acute and community care settings and care homes for older people. The patient experience questions were designed and approved by PINNT. Feed-back from more than 80 users was obtained from several WebEx online forums resulting in further refinement of the measurement tool following test-ing in practice. The tool underwent a final round of testing in April and is to be launched at the second Digestive Diseases Federation (DDF 2015) meeting at Excel, London on 22nd to 25th June, where 4,500 delegates are expected to attend from many health-care disciplines. Following launch at the DDF 2015, there will be pro-active rollout of the BAPEN Nu-tritional Care Tool and promotion to encourage adoption and implementation.

benefItS of uSIng the bAPen nutrItIonAl cAre tool In your orgAnISAtIonDr Mike Stroud President of BAPEN commented:“The evidence shows that good nutritional care is one of the most effective treatments avail-able in the NHS, with meta-analyses demon-strating proven benefits from active nutritional support in malnourished patients. As around a third of patients in NHS care are in that group and their higher than average complication and mortality rates can be reduced by a third

or more, the evidence is quite clear: the NHS can make enormous cost savings through im-proved nutritional care in the acute sector.” Many professionals across the length and breadth of the country are currently involved in leading improvements in the delivery of good nutritional care in our organisations. Trust Boards and/or management teams are undoubt-edly asking those leading on the implementation of screening and nutritional care programmes, to provide assurance that the nutritional care subsequently delivered meets existing standards and compares favourably to the care provided in similar organisations. Equally, it is likely that many of us will be required to demonstrate on-going improvements over time. In the absence of a standardised measurement tool, it will be a challenge to demonstrate goals achieved. We, therefore, anticipate the benefits of using the BAPEN Nutritional Care Tool to include:• assessment of the accuracy of the completion

of ‘MUST’ screening across your organisa-tion; using the tool will identify where varia-tion exists for example identify wards who are completing ‘MUST’ accurately and wards who require additional support, e.g. educa-tion and training, to deliver improvements;

• better identification of the prevalence of malnutrition on admission to an organisa-tion and the variation that exists, e.g. be-tween care of the elderly wards and medi-cal/surgical wards;

• assurance of compliance to nutritional care processes and/or identification of where improvements are needed;

• a measure of nutritional outcome; a key in-dicator being the median patients’ weight loss during their admission under your care, taking into account their diagnosis (the tool has been designed to screen out patients for whom tracking weight would not be advisable, e.g. patients with ascites or irreversible severe cachexia);

• a measure of the patient experience - this is a unique question in the new tool as other patient experience measures have tended to focus on food availability and quality.

Many doctors, commissioners, nurses, man-agers still require convincing that good nutri-

NHDmag.com June 2015 - Issue 10530

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tional care makes a difference. Many dietitians work locally to prove that nutritional care does make a difference. As Dr Mike Stroud President of BAPEN concludes, “If this tool becomes wide-ly adopted, it will also answer a lot of questions currently being asked about malnutrition. It will enable prevalence to be tracked on an ongoing basis, removing the need to undertake separate annual surveys, and the tool contains far more information about the nature of the patients. It can, therefore, generate data which will identify not only prevalence in specific patient groups but acceptable benchmarks for acceptable levels of weight loss for specific diseases, operations and the type of ward/unit providing care. We will then know what good looks like and, hence, where improvements are needed. The new tool is really the next logical step to using ‘MUST’ and it will help to deliver the changes that the NHS is looking for in care and the patient experience.” We appreciate that the complexities of deliv-ering good nutritional care make measurement fraught with difficulty, especially around the implementation of care plans. As an example, evi-dence suggests that food record charts are often

poorly completed. Similar difficulties exist in se-lecting appropriate outcome measures given that nutritional status is often affected by many factors other than nutritional intervention, including the presence of underlying disease. However, we be-lieve that beyond advancing the measurement of malnutrition, nutritional care is key to delivering further improvements. The new tool is available to all acute trusts, community hospitals and nursing/residen-tial/care homes that wish to participate in fu-ture screening weeks. Summing up, Rachel Masters, Senior Special-ist Dietitian from the Focus on Undernutrition team County Durham commented, “The scale up of the Malnutrition Measurement Tool has the potential to radicalise nutritional care across the UK. This tool could make the vision ‘let’s be the generation that eliminates unnecessary mal-nutrition’ a reality!” The BAPEN Nutritional Care Tool is being launched at DDF2015. The first national screen-ing week using the new tool is scheduled for September 2015. To register your organisation, please email bapen@bapen.org.uk

Acknowledgements:With thanks to members of the BAPEN Quality and Safety Group, the BAPEN core groups; NNNG and PINNT and members of the BDA who participated in the testing and refinement of the tool.

*Members of the BAPEN Quality and Safety Group – Dr Ailsa Brotherton, Dr Christine Baldwin, Kate Cheema, Liz Evans, Anne Holdoway, Rachel Masters, Lyn McIntyre, Dr Mike Stroud, Vera Todorovic, Dr Elizabeth Weekes, Carolyn Wheatley, Wendy Ling-Relph, Andrea Cartwright, Dr Nicola Turing and Kathy Wallis

To place a job ad in NHD Magazine or on www.dieteticJOBS.co.uk please call 0845 450 2125

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NHDmag.com June 2015 - Issue 105 33

As malnutrition screening is common-place in most hospitals nowadays, the prescribing of oral nutritional support (ONS) supplements is part of routine pathways to treat the patients identi-fied as ‘at risk’ or malnourished. With 25 to 34 percent of patients who are ad-mitted to hospital being malnourished (2), ONS sip feed usage is frequent and costly. However, not all patients affected by malnutrition are found in hospitals. Statistics show that only two percent of malnourished patients are hospital based. Malnutrition in the community setting is a major task for healthcare professionals to tackle, with 93 percent of malnourished patients living in their own homes, five percent living in care homes and two to three percent living in sheltered accommodation (3). Malnutri-tion in care homes could affect up to one in three residents (4). As a consequence of all of these fig-ures, ONS is a major part of the work we do on a daily basis as dietitians, whether we are working in the acute or commu-nity setting. Malnourished patients can benefit greatly from ONS supplements through the additional energy, protein and micronutrients they provide. There is some evidence to show that ONS may impact on health outcomes for malnourished patients; outcomes such as reduced hospital readmission (5). However, in 2013, the National Insti-tute for Health and Clinical Excellence (NICE) stated that there was limited evidence for the efficacy of using ONS

supplements in some patient groups (6) and more research was needed in this area. NICE did acknowledge that the use of ONS supplements may help to improve energy intake and weight in older adults in the community. The use of such products may also be associated with a cost-effective improvement in quality of life, but there did not appear be to any improvement in mortality or hospital readmission rates when used post discharge. It is not just the elderly who require ONS, we see a huge range of patients across the lifespan who require our expertise to help them to achieve opti-mum nutritional intake when they un-able to reach it through food alone. The contributing factors in malnutrition are variable and often a combination can be observed in the patients we treat, see Table 1 for examples of this. As a limited resource within the NHS, it is impossi-ble for dietetics to manage malnutrition alone. As many of the guidelines pub-lished by NICE recommend, an MDT approach to the overall management of many of these patient groups is best practice. It supports a holistic treatment option where nutrition is given just as much emphasis as medication or other therapies. The ONS sip feed business is worth millions of pounds and companies are keen to expand and tailor their product ranges to meet the needs of our com-plex patient groups. From traditional 1.5kcal/ml sip feeds to the ever-grow-

orAl nutritionAl SuPPort: worth every Penny?

it is well known that malnutrition in the uk is as significant a problem as obesity and it presents huge financial implications for public health spending. it is estimated that disease-related malnutrition costs over £13 billion per year (1). the British association for Parenteral and Enteral nutrition (BaPEn) estimates that over three million people in the uk are malnourished, with 1.3 million of these people being over 65 years of age (2).

onS

emma coatescompany Metabolic dietitian, Mevalia (dr Schar uk)

emma has been a registered dietitian for nine years, with experience of adult and paediatric dietetics. She specialised in clinical paediatrics for six years, working in the nhS. She has recently moved into industry and currently works as metabolic dietitian for dr Schar uk – mevalia low Protein.

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NHDmag.com June 2015 - Issue 105 35

onS

ing range of low volume ONS supplements (usu-ally 2.4kcal/ml sip feeds), it seems that there is something to suit the needs and/or preferences of everyone. However, this comes at a price, with the average cost of a 1.5kcal/ml, 200-220ml milk-shake style sip feed is approximately £1.87*; with the average cost of a low volume (2.4kcal/ml) 125ml ONS sip feed is £1.83 (**). Table 2 shows the cost of this intervention over a range of time scales per patient. Despite the cost of ONS sip feeds, along with the price of MDT intervention, it is recognised that screening for, identifying and treating mal-nutrition is key to reducing the ongoing finan-cial burden malnourished patients create for the NHS. NICE have estimated that £17,800 could be saved for every 100,000 patients if malnutrition is managed effectively (7). When compared with non-malnourished patients, malnourished pa-tients require twice as many healthcare resources (8); therefore, tackling malnutrition is a high pri-ority for the NHS. Over recent years, prescribing pathways for drugs has become commonplace to not only en-sure cost effective prescribing, but to improve patient safety and health outcomes. Such path-ways have transferred well to the prescribing of borderline substances such as specialist infant formulas and ONS sip feeds. Prescribing path-ways provide vital guidance for acute and pri-mary healthcare professionals who will often meet a malnourished patient well before they meet a dietitian. Tying in guidance to support the implementation of nutritional screening is now fairly standard as part of an ONS prescribing pathway. This ensures that the correct patients

Category Example

disease related

cystic fibrosisInflammatory bowel diseasechronic liver diseasecoPd/chronic lung diseaseoncology related diseasechronic kidney diseasecongenital heart disease

Compromised mental health

dementiaAlzheimer’s diseasedepressionSchizophreniaeating disorders

Post surgical

gastrectomybowel resectionhead and neck surgerytransplant patients

trauma burnsSevere injury requiring Itu care

treatment related

chemotherapyradiotherapyPoly pharmacydialysis

neurodisability

cerebral palsyProgressive disorders, e.g. Mnd, muscular dystrophyStroke

other physical factors

Age related - over 65 years of agedysphagiaPressure soresloss of senses, e.g. reduced sight, smell, tastereduced mobility/ability to feed selfPoor dentition

social factors

Isolation/living alonePoor housing/cooking facilitieshomelessnessPoverty/low incomePoor knowledge and skills regarding food and cookingdrug or alcohol misuse/dependency

table 1: examples of the contributing factors in malnutrition

table 2: Average cost of 2-3 x 200-220ml 1.5kcal/ml milkshake style sip feeds per day (***) and average cost of 2-3 x 125ml low volume (2.4kcal/ml) onS sip feeds per day (****) per patient.

(*) based on Abbott ensure Plus milkshake style - £2.02 per 220ml, nutricia fortisip - £2.06 per 200ml, fresubin energy - £1.48 per 200ml, nestle resource - £1.91 per 200ml. (**) based on Abbott ensure compact - £2.02 per 125ml, nutricia fortisip compact - £2.02 per 125ml, nualtra nutriplen - £1.45 per 125ml. (***) based on the average calculated from using (*). (****) based on the average calculated from using (**)

2 x 200-220ml 3 x 200-220ml 2 x 125ml 3 x 125ml

Per day £3.74 £5.61 £3.66 £5.49

Per week £26.18 £39.27 £25.62 £38.43

Per month (30 day supply) £112.20 £168.30 £109.80 £164.70

Per year (365 days’ supply) £1,365.10 £2,047.65 £1,335.90 £2,003.85

Prices taken from - www.evidence.nhs.uk/formulary/bnf/current/a2-borderline-substances/a22-nutritional-supplements-non-disease-specific/a222-nutritional-supplements-5-g-or-more-protein100-ml/a2223-nutritional-supplements-more-than-15-kcalml-and-5-g-or-more-protein100-ml <Accessed 14/05/15> and MIMS december 2014 edition.

are highlighted and the appropriate intervention is initiated. Creating a robust pathway that be-comes a daily process for healthcare profession-als to follow, in theory, also raises awareness of the particular issue in question. However, cor-rect and continued use of this process, as well as further monitoring and appropriate onward referral to dietetics may not be as well managed as it could be, particularly in the community. Di-etetic prescribing management posts have been born from the drive to achieve more streamlined and effective use of ONS. For many years, there has been a huge drive to improve nutritional screening in the acute setting. On admission to hospital, it is often mandatory for patients to undergo an assess-ment using the Malnutrition Universal Screen-ing Tool (‘MUST’). Please visit the BAPEN website for full details of the MUST screening tool and it use: www.bapen.org.uk/screening-for-malnutrition/must/introducing-must. The outcome of the assessment provides indication of the patient’s nutritional status and the in-tervention they require. Food first is often the first line intervention for lower risk patients. This includes a ‘little and often’ approach with high calorie/additional snacks, possibly food fortification, depending on the patient’s needs and preferences. For higher risk patients, ONS sip feeds are recommended, whether it be stan-dard 1.5kcal/ml milkshake style/juice style sip feeds, powder sachet supplements or the increasingly popular, low volume (2.4kcal/ml) sip feeds. Prescribing of these products var-ies greatly between NHS trusts, some may be recommended as ‘first line’ products or others may be restricted due to their higher cost. Some pathways recommend the use of one presenta-

tion of ONS sip feed in the acute setting, e.g. a 1.5kcal/ml milkshake readymade style as the first line product, to then switch to another in the community setting once the patient is dis-charged, e.g. a powder sachet supplement. This may be due to the financial constraints that the dietetic department is facing. Initiating ONS in the community setting may be confusing and/or daunting for some primary healthcare professionals, particularly around the type of ONS sip feed to be prescribed and how frequently these patients should be monitored. The ‘Managing Adult Malnutrition in the Com-munity Guide’ has been developed to support primary healthcare professionals to identify, treat and monitor malnutrition in the commu-nity. More details on this useful resource can be found at http://malnutritionpathway.co.uk/ <accessed 14/05/15>. The guide provides an ONS prescribing pathway as well as care plans for residential/nursing homes staff to follow when caring for a malnourished patient. There are also a number of useful downloadable tools on the website. Given that malnutrition affects many more patients over the age of 65, we are on course to see more of it as the ageing population is grow-ing. Whilst there have been some major improve-ments in the identification of malnourished pa-tients and we have the biggest range of ONS sip feeds available to us now, we are still struggling to significantly improve the nutritional status of many of the malnourished patients we see. There is still much work to be done in both the acute and community setting to upskill and educate the healthcare professionals and care staff who provide the day-to-day support for these vulner-able patients.

NHDmag.com June 2015 - Issue 10536

onS

references:1 elia M and Stratton rJ (2009). Counting the cost of disease-related malnutrition in the UK in 2007 (public expenditure only) in: Combating Malnutrition:

recommendations for action. report from the advisory group on malnutrition, led by BaPeN.2 www.bapen.org.uk/about-malnutrition/introduction-to-malnutrition <accessed 14/05/15> 3 elia M and russell Ca (2009). Combating malnutrition: recommendations for action. report from the advisory group on malnutrition, led by BaPeN4 russell C and elia M (2012). Nutrition Screening Survey in the UK and republic of Ireland in 2011. a report by BaPeN5 Stratton rJ et al (2012). a systematic review and meta-analysis of the effects of the impact of oral nutritional supplements on hospital readmissions.

ageing res rev 2013, 12(4): 884-976 National Institute for Health and Clinical excellence. evidence update 46: Nutrition Support in adults. a summary of selected new evidence relevant

to NICe clinical guideline 32 ‘Nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition’ (2006). London: National Institute for Health and Clinical excellence, 2013. available at: www.evidence.nhs.uk/Search?q=evidence+update+46%3a+Nutrition+Support+in+adults. <accessed 14/05/15>

7 National Institute for Health and Clinical excellence (NICe) (2006). Nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition. Clinical Guideline 32

8 Guest JF et al (2011). Health economic impact of managing patients following a community-based diagnosis of malnutrition in the UK. Clin Nutr; 30(4): 422-249

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NHDmag.com June 2015 - Issue 10538

Q. how do you defIne overweIght And obeSIty In chIldhood?A. Body Mass Index (BMI) is a measure of weight for height. It is the gold stan-dard for assessing weight in children and it should be plotted on gender spe-cific UK charts and the centile should be used for diagnosis and monitoring (1). Clinical cut-offs using these BMI charts:

BMI >91st centile = overweight BMI >98th centile = obese

Over this level there is no consensus in terminology. In our specialist clinics we use the SIGN definitions (2) as follows:

BMI >99.6th centile = severe obesity BMI >+3.5sd = very severe obesity BMI >+4sd = extreme obesity

BMIs should not be used in isolation, but should be a key tool in your clinical as-sessment. Body shape is another consider-ation; however, waist circumference should not be used for diagnosis in children.

Q. IS obeSIty reAlly A ProbleM In chIldhood?A. Yes! Cardiovascular and diabetes risk factors are not uncommon in obese chil-dren and young people. These include increased blood pressure deranged lipid profiles (e.g. cholesterol and triglycerides), enlarged left ventricular mass, hyperg-lycaemia and hyperinsulinaemia. Sleep apnoea and abnormal liver function tests (signs of non-alcoholic fatty liver disease) are other co-morbidities seen. There can also be significant psychological and so-cial consequences. For information about screening for comorbidities see the OSCA statement (3). It is recommended that all

children with a BMI >98th centile should be screened. In practice our GPs under-take much of this screen.

Q. whAt doeS the evIdence SAy About treAtIng chIldhood obeSIty?A. NICE states that dietary guidance should not be given in isolation. Interven-tions should be lifestyle focused, including behaviour change, increased activity and decreased sedentary time (screen time), as well as reduced energy intake. At least one parent should be involved and whole family change should be promoted. Fam-ilies should be encouraged to focus on SMART lifestyle goals (4). The aim of intervention should be to reduce BMI centile. In most overweight children, this will be achieved through weight maintenance or even decreased trajectory of weight gain initially. In more extreme cases, e.g. when a child will never grow into their weight, grad-ual weight loss may be necessary. This should be at a maximum rate of 0.5 to 1.0kg per month and post-puberty.

Q. IS there AnythIng elSe thAt Should be conSIdered?A. Referral to the paediatrician should be considered if there is a suspected under-lying cause, including if a child is obese and short for their age, if they are severely obese before the age of two years, or those with serious medical comorbidities. There are no medications licensed for use in children in the UK. However, Orlistat is sometimes used post puberty in extreme situations, although this is off licence and

the CAre PAthwAy for weight mAnAgement of Children ACroSS CornwAll

rachael brandrethPaediatric dietitian, cornwall’s Paediatric weight Management Service

As co-lead for children for dom uk, rachael campaigns for Junk free Checkouts and sits on the APPg for a fit and healthy Childhood.

Being overweight or obese in childhood has become so common that it can be a surprise to parents and even to health professionals. Here, i aim to answers some basic questions about childhood obesity and then go on to describe the model that is used locally across Cornwall.

chIldhood obeSIty

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chIldhood obeSIty

should only, therefore, be used under strict medical supervision. Surgery can be considered post puberty too in very severe obesity (BMI >3.5 SD) with severe comorbidities. It should only be carried out by very specialised multidisciplinary teams. Safeguarding is another consideration. Al-though there is not much guidance on this at the moment, good practice says that it should be considered as neglect if there is a repeated fail-ure to engage. Emotional abuse can sometimes be part of the cause of the child’s obesity and so this should be considered. Viner (5) published a useful guidance paper and, more recently, a pro-posed framework has been set out by Garel (6).

our Model In cornwAllCornwall has a disparate and rural population which had to be a strong consideration when de-signing service delivery. Although it is a popu-lar holiday and second home destination and a wonderful place to live, there is significant socio-economic deprivation in the local popula-tion. The NCMP figures, available from National Obesity Observatory (7), show us that obesity in children is linked to deprivation with levels be-ing twice as high from the lowest to the highest decile and our levels of obesity reflect this. We have two care pathways for overweight and obese children. The first is for babies and toddlers up to the age of two years and the sec-ond is for children and young people aged two to 16 years. The age split is based on the age for which BMI is more widely validated. The path-ways aim to bring together the work of profes-sionals in this area and are hosted on our website (8). This website aims to be the central point of information for both families and professionals. Although it is hosted by the Health Promotion Service, it aims to host information from all ser-vices working in weight management across the lifecycle and across Cornwall. As children’s dietitians, we work in a multi-disciplinary (MDT), multi-agency team to provide weight management advice to families alongside training and clinical supervision to other profes-sionals working in this area. We aim to provide care in a way that is most acceptable to families. When consulted, they said that they would prefer to gain the key messages through professionals whom they are already working with until there

is a greater level of concern. When there is that greater level of concern, we provide a specialist programme called LEAF (Lifestyles, Eating and Activity for Families), which is a level 3 service for the early years (children of six years of age and younger). In the team, we have a paediatri-cian, dietitian and Activity Advisor. We also work in partnership with the local children’s centres which provide the space for our group sessions as well as the crèche that is an important aspect of facilitating engagement. The LEAF programme was locally developed over three years ago as we were unable to find a model of intervention that was appropriate for our target age group. We are HENRY (Health, Exercise & Nutrition in the Really Young) (9) trained and, although it is not designed for level 3, we base many of our principles of interven-tion on the HENRY model. The format of LEAF is a one-to-one initial session, usually at the fam-ily home, where the focus is on motivation to change and their understanding of the referral as well as preparing them for the clinic. The next step is our MDT clinic at the hos-pital, where all three professionals see the fam-ily at the same time. This reduces the number of appointments and the time taken for families, which is an essential part of facilitating engage-ment in a county where they may be travelling for over an hour by car, or much longer if using public transport. Being together for the clinic is also beneficial for the professionals involved, as it allows us to ensure that we have all heard the same information and promotes consistent and manageable care plans. It is at this appointment that families are offered the GOOS (genetics of obesity study) (10). The next stage in the programme is six weeks (spread over two to three months) of small group-based sessions run in local children’s cen-tres. Although it is our gold standard for inter-vention, it is not always possible for families to attend these sessions. If this is the case, we find other ways, such as working one-to-one, but also involving health visitors, school nurses or other professionals already working closely with the families, e.g. family support workers. Once this part of the programme is complete, we see them back in the MDT clinic before discharging to pri-mary care for ongoing monitoring and support.

In some instances, we will continue to work with families for a longer period where they have struggled to engage, but are now more ready. As you might expect in the group sessions, we cover a whole range of healthy lifestyle topics. As the groups are small, it allows us to really help families make the information relevant to them and each week we encourage SMART goals to be set. Although most of the sessions are parent fo-cused delivery, one of the sessions is for the whole family in which we play fun games and do some ‘taste testing’ to see if we can eat a rainbow. If you would like to see other ideas to promote creative healthy snack times, you can follow my ‘Fun with food’ board on Pinterest (11). Our outcomes are based on pre- and post-in-tervention measures, which include BMI z-score, energy from drinks, amount of sleep and level of sedentary behaviours. We use the NOO SEF (the standard evaluation framework from the National Obesity Observatory, now part of Public Health England (7)). However, we found that there is a lack of validated tools for measuring outcomes in this age group and so started using our own drinks dia-ries and lifestyle questions. The drinks diaries seem to suffer less from the reporting bias of food diaries, but the lifestyle questions, including hours of sleep and number of hours of screen time, do. The former is subjective and based on clinical experience, but the latter is based on the relatively recent introduc-tion of accelerometers for the older children in the programme (four years upwards). Something that we are looking to explore further is bio-impedance measures to show changes in body composition. We would like to hear from others working in this area to share experiences and improve our outcome measures. You can get in touch with our team via LEAF.programme@cornwall.nhs.uk Our other client group for one-to-one work is children with a genetic condition called Prader Willi Syndrome. The Prader WiIli Syndrome Association has lots more information on this condition (12). We work with children and young people up to transi-tion to adult services and deliver dietetic interven-tion alongside the paediatric endocrinologist.

whAt cAn you do?Dietitians are very well placed to make a real dif-ference in this relatively new and growing spe-ciality. If you are in a specialist role, can I please

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chIldhood obeSIty

encourage you to get involved with DOM UK (13) so that we can share our knowledge and experi-ence to help progress this relatively new area of dietetics. Even if you are not in a specialist role, or even in a paediatric role, you can still make a dif-ference by getting involved with promoting social change. For example, visit www.junkfreecheck-outs.org to get involved with the joint DOM UK and Children’s Food Campaign movement to see checkouts free from the temptation of junk foods (14). Whether you have children of your own or not, you can promote change and attitudes in your local schools and communities. It is not just about treatment either. An excel-lent example of preventative work is the Food For Life Partnership (FFLP); you can find more details at www.foodforlife.org.uk (15). Many of our lo-cal schools are signed up (for free) to FFLP, which is a highly recommended platform to promote a whole food cycle approach to improving chil-dren’s nutrition. It incorporates growing, cook-ing and good nutrition through resources, lesson plans and ideas for schools, and aims to transform food culture. It has been shown to have a positive impact on both health and education, as well as its effects spreading into the wider community. Go on get involved - you CAN make a real difference!

for article references please email: info@networkhealthgroup.co.uk

examples of ‘fun with food’ at a group session

NHDmag.com June 2015 - Issue 105 41

A year ago, it was a great day for some 20 rural Africans living near the town of Empangeni in Kwa Zulu Natal South Africa. Some American researchers asked (paraphrased), “Would you like to eat an American diet (for free) for two weeks?” The answer could only be an enthusiastic yes, even when the price-to-be-paid, the butt-clenching proce-dure of colonoscopy, was revealed. At the opposite end of the globe, for some 20 African-Americans living in Pitts-burgh Pennsylvania there was perhaps less appeal for the offer of the diet swap experiment; an all-you-can-eat typical African diet, but with perhaps the ben-efit of better health. The study of the diet swap between 20 rural Africans and 20 big-city Ameri-cans for the modest period of two weeks gained much interest in the media when published in April 2015, and mostly be-cause there was astonishment about the speed of change to gut measures. Was a change of diet really such a fast-acting modifier on the colonic environment? It appears so. Lead researcher Professor O’Keefe, from the Department of Medi-cine and the University of Pittsburgh, concluded that the diet swap resulted in remarkable reciprocal changes in both groups in many of the colonic mucosal biomarkers of cancer risk (3). Colon cancer rates are more than 13-fold higher in African Americans com-pared to rural South Africans, and dif-ferences in diet are likely to be the main factor. American diets are high in fat and animal protein and low in fibre and a typical African diet features the inverse. But are the risk factors associated with differences in disease rates, long-term

and cumulative effects from life-long dietary patterns? Or can modifications of diet result in near-instant measurable changes to gut environments? The typical African American diet would be familiar to many British dieti-tians; lots of prepared meat items such as hamburger, hotdogs, ribs or steak mar-ried to lots of refined and fatty starch, such as fries, white pasta or fried potato. Colour on a plate is more likely from ketchup or mustard than fruits or veg-etables. The typical rural South African diet is small embellishments around the central base of phutu/mielie meal (also called pap or very confusingly and per-haps ironically, ‘African salad’) (2). This polenta-like staple may have very small additions of vegetables or fermented milk for flavour, but the only other usual additions to the diet are beans and cabbage/onion/spinach. Fruits may be seasonally available (bananas/pineapple/guava), but these will only be occasional items, along with salad items such a tomatoes. Chicken, meat and sausages are much relished and ap-preciated, but are generally considered expensive foods for special days. After assessment for general good health and absence of exclusion crite-ria, 20 Americans and 20 Africans did a diet swap. The subjects were all middle aged (mean = 55 years) and most were overweight (mean BMIs = 28), although the Africans were shorter and lighter than the Americans. Diet were carefully prepared and measured and intakes observed: amounts consumed were ad libitum, but small additions of juice were added in situations where weight loss was observed in the two-week period.

diet SwAP

a study in swapping the diets of 20 rural africans with the equivalent number of americans for two weeks, led to some surprising results…

gut heAlth: reSeArch

ursula Arens writer; nutrition & dietetics

Ursula has spent most of her career in industry as a company nutritionist for a food retailer and a pharmaceutical company. She was also a nutrition scientist at the British Nutrition Foundation for seven years. Ursula helps guide the NHD features agenda as well as contributing features and reviews.

The overall weight of all foods consumed by the Americans on the swap diet was bulky: it was nearly 2,300g compared to the denser 1,550g consumed by the Africans celebrating US-style cuisine. The Africans enjoyed foods such as sausages and pancakes, or bacon and cereal for breakfast, hamburger with fries or meatballs with spa-ghetti for lunch and steak with noodles or roast beef and potatoes for supper. The Pittsburghers had to get used to consuming a lot of maize-meal based items. Breakfast could be maize por-ridge or corn grits with scrambled egg. Lunch could be maize bread with kale salad or bean soup. Supper could be maize muffins with vegetables or lentils and rice. Because maize meal is bland-tasting, a challenge was for the Americans to consume enough of this food and spice flavourings or artificial sweeteners were permitted additions. Nutrient patterns in the swapped diets were very different. For the African-Americans, there was a reduction in energy intake due to significant reductions in fat. There were strong increases in energy from carbohydrate and fibre intakes increased nearly four-fold. For the Afri-can-Africans, the swapped diets were higher in energy diet to significant increases in intakes of fat and of protein; in fact protein intakes were considerably higher than usual American diets indicating perhaps a carpe diem attitude to the offers of luxury items such as steak and chicken. Fibre intakes in the swap diet for Africans was low; less than one fifth of their usual intakes. Intakes of a particular type of fibre, resistant starch, was calculated to be particularly high in the usual African diet and calculations from carbohydrate malabsorption of mielie meal have suggested that at least 10 percent of this food resists digestion. Data was then collected from colonoscopy undertaken before and after the diet swap. Ini-

tial investigations found normal mucosal scores for four of the Americans (10 of the Africans). Adenomatous polyps were observed in nine of the Americans (none of the Africans). And diver-ticula could be observed in 14 of the Americans (but none of the Africans). Some of the markers of mucosal inflammations were higher in the Af-ricans indicating, perhaps, higher levels of con-tact with parasites; two subjects were positive for schistosoma and one subject was host to a 6.0cm section of tapeworm. There were also profound differences in the baseline microbiota of the two sample groups; Americans were dominated by the genus Bacteroides and the Africans dominated by the genus Prevotella. Professor O’Keefe character-ised the African microbiota as containing more ‘starch degraders, carb fermenters and butyrate producers’ than the resident populations of the American colon. Mucosal proliferative biomarkers of cancer were measured and were found to be significant-ly reduced in the US subjects following the swap diet and significantly increased in the African subjects. Further, protective faecal short chain fatty acids (acetate/ proprionate and butyrate) were increased in the US subjects and conversely reduced in the African subjects. Lastly, there was suppression of secondary bile acid synthesis in the US subjects and increased production in Af-rican subjects. Together, all of the markers in the American subjects after adoption of the rural Af-rican diet are considered as protective in relation to the risk of colon cancer (and the exact reverse in the Africans after the swap to a US diet).

concluSIonSWhat conclusions can be drawn from this very small and very short-term study? Are beneficial effects more due to reductions in fat or in pro-tein, or to massive increases in fibre? Professor O’Keefe considers that the clear and measure-

NHDmag.com June 2015 - Issue 10542

gut heAlth: reSeArch

Energy kcals fat %E CHo %E Protein %E fibre g

uS usual diet 2,393 35 47 15 14

African usual diet 2,353 16 72 11 66

uS swap diet 2,205 16 70 14 55

African swap diet 2,526 52 21 27 12

table 1

NHDmag.com June 2015 - Issue 105 43

gut heAlth: reSeArch

able changes demonstrated in his study are re-markable, and that perhaps the next big food trend will be the ‘butyrogenic’ diet (which is, in fact, almost the inverse of the much discussed FODMAPS diet). Several large epidemiological studies have not been able to confirm associa-tions between fibre intake and the occurrence of bowel cancer, but Professor O’Keefe suggests that there may be a threshold effect of about 50g per day (which is more than twice the current UK dietary target of 24g, and also very much higher that the proposed figure issued by the Scientific Advisory Committee on Nutrition [SACN] of 30g per day). Interestingly, the main contributors of fibre in the usual rural South African diets are not fruits and vegetable, and certainly not any wholegrain breads or cereals, rather the white stodge that is mielie-meal. And

the nutritional feature of this product seems to be the high content of starch tat is resistant to digestion - perhaps up to 18 percent claim Ahmed and colleagues (1). Eat-more-fibre has been a familiar dietary message for at least four decades and there are no obvious interests to challenge this concept. However, the conclusions from this study are that in relation to bowel health, we need a lot more and that white starchy maize can contrib-ute significantly. This study has such a neat and tidy methodology and measured endpoints are so clear, that the small numbers and short dura-tion do not limit the clarity of the conclusions. But the study does contribute muddle to the de-bates that are trying to define the components of fibre which may benefit colonic health. In seems that maize may amaze!

references1 ahmed r, Segel I, Hassan H (2000). Fermentation of dietary starch in humans. american Journal of Gastroenterology, 2000, 95,4,1017-10202 engelbrecht S, de Beer T (2005). african Salad - a portrait of South africans at home. Day One publications, Cape Town3 O’Keefe S, Li JV, Lahti L et al (2015). Fat, fibre and cancer risk in african americans and rural africans. Nature Communications DOI:10.1038/

ncomms7342

Several large epidemiological studies have not been

able to confirm associations between fibre intake

and the occurrence of bowel cancer . . .

Issue 104 May 2015NHDmag.com

OPTIMAL DIET FOR BONE HEALTH

Dr Justine ButlerSenior Researcher and Writer Viva!Health

RETHINKING DAIRY . . . p29

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WEB WATCH NEW RESEARCH

Dr Carrie Ruxton p11

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online resources and useful updates.

End of lifE CarENHS Improving Quality has published End of Life Care in Advanced Kidney Disease: A Framework for Implementation. The Framework is about enabling people to achieve high quality end of life care, rather than ‘telling them what to do’. To achieve this, it explores the ‘kidney specific’ issues of end of life care focusing on patients opting for conservative kidney management and those ‘deteriorating despite’ dialysis. The overarching aim is to help people with advanced kidney disease to make informed choices about their needs for supportive and end of life care. www.nhsiq.nhs.uk/resource-search/end-of-life-care-in-advanced-kidney-disease-a-framework-for-implementation.aspx

PatiEnt ExPEriEnCEImproving patient experience is going to be a big challenge for the incoming government, according to Picker Institute Europe. Picker has created an infographic which highlights some of the key patient experience related challenges that need to be addressed going forward, if a person centred approach is to be achieved. www.pickereurope.org/wp-content/uploads/2015/05/GE-infographic-Final.pdf

dEMEntia friEndlY daYs outCare UK has published a new guide Good to Go: a guide to dementia friendly days out aimed at transforming the experiences of

those caring for loved ones living with dementia and providing information to overcome the challenges of getting out and about. This book explains how to plan trips and how to make the most out of every outing. www.careuk.com/care-homes/news/dementia-guide-helps-carers-get-good-to-go

nEw anaEMia lEaflEtA new patient information leaflet on anaemia has been produced by NHS Blood and Transplant. The eight-page booklet, What is anaemia? explains who is most at risk of developing the condition and explains that pregnant women are at a higher risk because the foetus takes essential iron from its mother for its own development. The booklet outlines the symptoms and explains the different types of anaemia, such as the underproduction of red cells, a problem in the bone marrow and excessive bleeding. The leaflet also explains what tests may be run to ascertain whether or not a person is anaemic and the treatments available. www.rcm.org.uk/tags/leaflet

using aPPs in CliniCal PraCtiCEThe Royal College of Physicians has published Using apps in clinical practice. This guidance aims to provide clinicians and medical app developers with important information about the use of apps in clinical practice. www.rcplondon.ac.uk/sites/default/files/apps_guidance_factsheet.pdf

HosPital adMissions for strokE in PEoPlE agEd 40-54 YEarsAn analysis of hospital admission data by the Stroke Association has found that the number of people aged between 40 and 54 admitted to hospital following stroke has increased by 46 percent for men and 30 percent for women in the last 15 years. It is thought that the rise is due to increasing sedentary and unhealthy lifestyle, and changes in hospital admission practice. www.mynewsdesk.com/uk/stroke-association/latest_news/tag/life-after-stroke

alCoHol ConsuMPtion trEndsThe Organisation for Economic Co-operation and Development (OECD) has published Tackling Harmful Alcohol Use Economics and Public Health Policy. The report highlights that harmful drinking is on the rise among young people and women in many OECD countries, partly due to alcohol becoming more available, more affordable and more effectively advertised. In the UK, the report highlights that the levels of alcohol consumption were above the OECD average and had increased during the last 30 years. In 2011, an average of 10.6 litres of pure alcohol per capita was consumed in the United Kingdom, compared with an estimate of 9.5 litres in the OECD. www.oecd.org/health/tackleheavycostofharmfuldrinking.htm

NHDmag.com June 2015 - Issue 105 45

d i e t e t i c J O B S . c o . u k

To place a job ad here and on www.dieteticJOBS.co.uk

please call 0845 450 2125 (local rate)

full-tiME HEaltHCarE diEtitian - iss faCilitY sErViCEs - HEaltHCarESalary up to £35,000 pa (depending on experience). Due to continued business growth, we are expand-ing the operational dietetics team in our Northern division and as such are looking to appoint another Regional Healthcare Dietitian. This is an established and important position in the ISS Dietetics team. ISS Facility Services - Healthcare is a division in the UK of the global ISS Group, providing full facility services to the NHS and private hospitals. The role includes the provision of dietetic support to our Northern contracts, client liaison, training and the development of rel-evant resources for our NHS hospital trusts where we provide a patient catering service. You will liaise with our Client Dietitians in regards to menu planning and will be responsible for computer generated nutritional analysis and diet coding of menus. It is likely that you will also be involved in wider healthcare projects that the team is undertaking. You will be a HCPC registered dietitian with proven experience in contract catering and at least two years’ clinical experience. You will have an office base in the North but you must be willing to travel within the UK and hold a driving licence. For an informal discussion about the post, please contact: Lauren Bowen, Head of Patient Devel-opment, Nutrition & Dietetics, tel: 07787 532701. The closing date for applications is Friday 26th June 2015. Please send a covering letter with a copy of your CV to lauren.bowen@uk.issworld.com www.issworld.com

SPecIAlISt PAedIAtrIc dIetItIAn Band 7 Specialist Paediatric Dietitian with experience of diabetes, carbohydrate counting and insulin pumps for an ongoing post from June. The role is hospital based in the South of England. Email your CV to registration@pjlocums.co.uk. Our rates are competitive in the current market; we offer assistance with relocation and hospital accommodation. We provide you with a current CRB, full occupational health check and can organise your mandatory training. PJ Locums is an NHS Government Procurement and LPP framework approved supplier for Allied Health, Health Science personnel and nurses.

bAnd 6 PAedIAtrIc dIetItIAn - eASt AnglIAWe are currently looking for a Band 6 Dietitian with some paediatric experience. This is an acute post which will last for up to three months and ideally to start as soon as possi-ble. Accommodation available. Excellent rates offered. Call 0800 023 2275 or 01277 849 649. Email: hayley@eliterec.com for more information on this role. www.elitedietitians.com

PAedIAtrIc bAnd 6 dIetItIAn - ASAP - eSSexThis is a part-time position required to cover clinics two days a week. The clinics are held on different days each week so this will suit someone who is not already in post and is flexible on which two days they can work from week to week. This department also requires a dietitian for adult clinics two days a week, so if you are available four days, this may work for you. Please contact Hayley on 0800 023 2275/01277 849 649, or email your CV and interest to hayley@eliterec.com www.elitedietitians.com

PAedIAtrIc bAnd 7 leAd dIAbeteS dIetItIAnFull-time position. West London. (37.5 hours) covering clinics at school sites, patients homes and hospital clinics. Extensive experience of working with children with diabetes and insulin pumps. Starting as soon as possible until the end of August. Please Call 0800 023 2275 or 01277 849 649. Email: hayley@eliterec.com. Please visit our website www.elitedietitians.com for up-to-date jobs.

bAnd 6 renAl dIetItIAnLondon/Surrey borders. Starting end of June covering three acute wards - experience of chronic hemodialysis ben-eficial. 35 hours per week - one to two months. The appli-cant must have strong clinical NHS experience and be able to hit the ground running. Please call Hayley at Elite for further information on 0800 023 2275/01277 849 649. Email: hayley@eliterec.com or visit www.elitedietitians.com

bAnd 5 dIetItIAn - MAncheSter Starting middle of June covering general medical and sur-gical wards. This is a full-time post and will run for one to two months. Excellent rates offered for the right dietitian. Please call 01277 849 649 or email hayley@eliterec.com for more information on this role. www.elitedietitians.com

bAnd 6 - kent - June StArtCovering adult community clinics, this is a full-time post running for two to three months. Car would be ideal but not essential as a hire vehicle can be arranged. To be con-sidered for this role please email Hayley@eliterec.com or call 01277 849 649. www.elitedietitians.com. Please follow us on Twitter @elitedietitians or visit our website www.elitedietitians.com for up-to-date jobs.

bAnd 6 oncology - StAffordShIre - StArt IMMedIAtelyBand 6 Acute Dietitian required to cover oncology wards and nutrition support. Starting as soon as pos-sible and running for two months. Please call 0800 023 2275 or 01277 849 649. Email: hayley@eliterec.com. Please follow us on Twitter @elitedietitians or visit our website www.elitedietitians.com for up-to-date Jobs.

bAnd 6 Acute PAedIAtrIc dIetItIAn - norfolkExperienced Band 6 Dietitian with some paediatric ex-perience required for two to three months. Starting as soon as possible. Accommodation available. Please call Hayley now for more information on the above posi-tion and other excellent roles we have available, 01277 849 649 or 0800 023 2275. Email: hayley@eliterec.com

NHDmag.com June 2015 - Issue 10546

cAreer

uniVErsitY of nottingHaM - sCHool of BiosCiEnCEs Modules for Dietitians and other Healthcare Professionals• Obesity Management Module - 30th September• Gastroenterology Module - 8th OctoberFor further details please email marie.e.coombes@nottingham.ac.uk, tel: 0115 951 6238 or check out the University website at www.nottingham.ac.uk/biosciences and click on short courses then ‘for practising dietitians’.

eventS And CourSeS

10th June - Priorities for improving outcomes in diabetes care: prevention, integration and personalisationThis event is CPD certified Central London www.westminsterforumprojects.co.uk/

12th June - Effective Clinical supervision Master ClassLondon Road Community Hospital, Derby www.ncore.org.uk

23rd to 25th June - iPC2015International Scientific Conference on Probiotics and Prebiotics Budapest, Hungary www.probiotic-conference.net/

We urgently require dietitians for immediate vacancies

To find out your options call or email

Freephone: 0800 032 0454 Registration@pjlocums.co.uk

• PJ Locums is an NHS Buying Solutions framework approved supplier for allied health

• Our aim is to find you the right person and the right job

• We offer inpatient and community UK & NI coverage

• Competitive rates

www.pjlocums.co.uk

NHDmag.com June 2015 - Issue 105 47

Some years ago, 1967 to be precise, I read a book called Energy, Work and Leisure by Dr JVGA Durnin. It was the first of its kind. I still have the original much thumbed-through copy. It covered the energy expendi-ture of adults engaged in a variety of everyday activities, professions and sporting activities, from gardening to bus conducting to squash. I was hooked. Two years later, following my practical dietetic training in Glas-gow, I helped with one of his, (now Professor John Durnin) research studies at the Insti-tute of Physiology at the University of Glasgow for six months. Energy expenditure, body fat con-tent and appetite control became the fundamentals of my career in Dietet-ics and shaped the path I followed. I wouldn’t change a thing. So, back to Wembley. Well, Pres-ton North End (PNE) were in the League One Play-off Final. The win-ners go into the Championship next season, that’s one below the Premier League. Before the match, our well-

respected manager of some two and a half years, Simon Grayson, was quoted as saying, “When I came there was no fitness coach, dietitian or Chief Scout.” How fitting to see our profession so widely recognised at this level of professional sporting activity.

Our group was on the front row near the centre line. The atmosphere and nervous antici-pation was tangi-ble. Ninety minutes plus added time of individual energy expenditure based on a platform of the team supporting them was going to define their season. Suffice it to say that as I now look for-ward to the next

football season in the Championship following a 4-0 victory, I still think back to how my own career started and the joy and pleasure that com-bining energy, work and leisure gives throughout your life. I would, however, like to give my profuse apologies to the sup-porters of Swindon Town for the bias in this article. Now back to the gardening…

the finAl helPing

i love writing this short article every month. it keeps me in touch. it makes me look back. it helps me look forward. it’s personal. it’s now Bank Holiday Monday at 7.30am and i am putting this together following my return from wembley stadium at 2.30am this morning.

neil donnelly

Neil is a Fellow of the BDa and retired Dietetic Services Manager. His main areas of interest are weight management and eating disorders

Energy expenditure,

body fat content and

appetite control became

the fundamentals of my

career in Dietetics and

shaped the path I followed.

I wouldn’t change a thing.

Imagine if there were only 99s

Right patient, right product, right outcomes

Choice is good

Offering a variety of oral nutritional supplements is likely to improve compliance and intake.1 That’s why Nutricia offers a wide range of fl avours and formats, including Forticreme Complete (125 g pot),

a high energy (200 kcal), high protein (11.9 g) dessert-style nutritional supplement.

Forticreme Complete — the little pot packed with a lot of nutrition.

Visit www.nutriciaONS.co.uk/forticremeto request a sample or arrange a visit fromyour local Nutricia Representative.

Reference 1. Nieuwenhuizen WF et al. Clin Nutr 2010;29:160–169.

Date of preparation: 02/15

7484 Forticreme Press Ad_223x160_AW.indd 1 24/03/2015 14:24