nhd magazine aug/sept 2015

Issue 107 August/September 2015NHDmag.com

Vitamin D in Pregnancy

Anna FitzGibbonPrescribing Support Dietitian

Malnutrition and the elderly. . . p17

ISSN 1756-9567 (Print)

dieteticJOBS • web wAtcH • New reSeArcH

Cordelia Woodward p13

preterm nutrition

dysphagia produCt update

CommuniCations in dietetiCs

nutrition and Chylothorax

www.dieteticJoBS.co.uk

Since 2009

http://www.nhdmag.com/


http://www.nhdmag.com/dieteticjobs.html


Date of preparation: 02/15 Still #1 when it comes to choice and flavour range

Fortisip Compact also has the widest range of fl avours, from banana to forest fruit, which may aid patient compliance.1

Reference 1. Hubbard GP et al. Clin Nutr 2012:31;293–312.

Only Nutricia offers the widest range of compact nutrition, including Fibre and Protein

Here’s to choice

7700 Complete Nutrition Ad Resize_223x160_AW.indd 1 25/03/2015 15:04

NHDmag.com August/September 2015 - Issue 107 3

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.

in recent weeks, you may have noticed how much media coverage there has been around dental disease in children, along with reports on obesity, diabetes and their impact on the nHS. Within recent days, the Scientific advisory committee on nutrition (Sacn) published Carbohydrate and Health Report, which included a recommendation to slash sugar intake and offered the opportunity to increase fibre content in the diet.

An initiative of a £15m three-year pi-lot project in England will see up to 250 pharmacists being recruited to GP practices to provide direct patient care and help ease the workload for the GPs. Might this also be an opportunity for di-etitians? Prescribing Support Dietitians are not new and have been involved in the effective and appropriate prescrib-ing of ONS, gluten-free items and other nutrition related items; however, we may be able to do more! Anna FitzGibbon tells us about the role of A Prescribing Support Dietitian for care homes. Anna works with the Inte-grated Response Team and her role fo-cuses on the prevention of malnutrition, the early identification of those at risk and reducing complications. The role also aims to ensure the appropriate use of oral nutritional supplements. Find out more about this in her article. Keeping with a prescribing theme, I welcome Alison Smith back to give us an informative Dysphagia product update. Not only does Alison’s article describes the different types of thickeners it also provides some costings. ‘The key aims of nutritional man-agement for a patient with Chylothorax are to reduce the volume of the chyle leak and to allow closure of it, to pre-vent malnutrition, and to replenish flu-ids and electrolytes that are lost.’ Shona

Scott’s article Nutritional management of chylothorax patients covers the role of a low long-chain triglyceride oral diet, as well as enteral and parenteral options for providing nutritional support in Chylothorax. Some of you may be interested in preterm nutrition and in this issue NHD, Kate Harrod-Wild shares with us the key features of the Nutrition guide-lines on the neonatal unit. In a good summer with sunshine, many are able to ‘top up’ their vitamin D! Pregnant women are considered to be at risk of low vitamin D status, and the current advice is that all pregnant women take a supplement of 10 micro-grams of vitamin D everyday through-out pregnancy and breastfeeding. Cord-elia Woodward tells us more in our Cover Story, Vitamin D in Pregnancy. I firmly believe that excellent com-munication skills are key skills that all healthcare professionals should have. I encourage you to read what Kirsten Whitehead has to say about Communica-tion skills for dietetians. Let us know what your thoughts are on this. I hope that you all enjoy your NHD summer read. You will now have a slightly longer gap before you receive Issue 108, so you may want to think about reading the above SACN report to fill that gap!


NHDmag.com August/September 2015 - Issue 1074

Chris rudd, Dietetic Advisor

neil donnelly, Fellow of the bDA

ursula arens, writer, Nutrition & Dietetics

dr Carrie ruxton, Freelance Dietitian

dr emma derbyshire, Nutritionist, Health writer

emma Coates, Senior Paediatric Dietitian

dr Kirsten Whitehead, Assistant Professor in Dietetics

Cordelia Woodward, Freelance Dietitian

anna Fitzgibbon, Prescribing Support Dietitian

Kate harrod-Wild, Specialist Paediatric Dietitian

shona scott, cardiothoracic Dietitian

alison smith, Prescribing Support Dietitian

Claire riley, Dietitian

6 News latest industry and product updates

9 Communications in dietetics Where are we going?

17 Malnutrition and the elderly prescribing support dietitians

25 Preterm nutrition nutrition guidelines on the neonatal unit

31 Chylothorax nutritional management of patients

36 Web watch online resources and updates

38 Dysphagia product update Considerations and costings

45 A day in the life of . . . a dietitian down under

47 dieteticJOBS latest career opportunities

49 Events and courses upcoming dates for your diary

50 Subscribe to NHD Magazine it’s easy online

51 The final helping the last word from neil donnelly

13cOVer StOryVitamin D in pregnancy

editorial panel

Contents

editor chris rudd rDPublishing Director Julieanne Murray Publishing editor Lisa JacksonPublishing assistant Katie Dawson Design Heather Dewhurstadvertisement Sales richard Mair Tel 01342 824073 [email protected]

address Suite 1 Freshfield Hall, the Square, Lewes road, Forest row,east Sussex rH18 5eSPhone 0845 450 2125 (local call rate) Fax 0844 774 7514email [email protected] www.nHDmag.com www.dieteticJOBS.co.uk

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

@nHDmagazine

www.nHDmag.com

www.dieteticJOBS.co.uk



http://www.nhdmag.com/ourshop/cat_520243-NHD-subscriptions.html

https://twitter.com/nhdmagazine

mailto:[email protected]


Coming soon: Nutramigen with LGG A new combination of Nutramigen LIPIL with a probiotic

The addition of LGG to Nutramigen LIPIL accelerates the acquisition of oral tolerance in infants with cow’s milk allergy (CMA)1‡

Shortened CMA management could lead to potential cost savings1‡

Clinically proven to effectively manage CMA symptoms2,3

The only eHF clinically proven to accelerate time to tolerance1

Find out more at www.nutramigen.co.uk

A solution for all your CMA needs

NU

TRAMIGEN PURAM

INO

PR

EGESTIMIL LIPIL

NUT

RAMIGEN LIPIL 1 NUT

RAMIGEN LIPIL 2

Dairy doesn't need to be out of reach for long†

PREPARATION INSTRUCTIONSPREPPREPARARA

With LGG®

†79% of infants are tolerant to cow’s milk after 12 months using Nutramigen with LGG.1 ‡vs an eHF based on casein, rice hydrolysate, soy and amino acid formulas. eHF, extensively hydrolysed formula. LGG® (Lactobacillus rhamnosus GG) is a registered trademark of Valio Ltd, Finland.

References: 1. Canani RB et al. J Pediatr 2013;163:771–777. 2. Baldassarre ME et al. J Pediatr 2010;156:397–401. 3. Nermes M et al. Clin Exp Allergy 2010;41:370–77.

IMPORTANT NOTICE: Breast milk is the best nutrition for babies. The decision to discontinue breastfeeding may be difficult 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. EU15.549/07–15.

LGGWith L ®

Comingsoon

8210 NUTR LGG_Pre_launch_223x160mm.indd 1 20/07/2015 12:54

www.nutramigen.co.uk

dr emma derbyshire phd rnutr (public health)nutritional insight ltd

[email protected]

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


neWs

Iodine is important for pregnancy as it helps make thyroid hormones needed for growth, metabolism and babies’ brain development. Now, new work has measured the iodine status of pregnant mums in the UK. The SPRINT (Selenium in PReg-nancy INTervention) trials recruited a sample of 230 women and took spot-urine samples at weeks 12, 20 and 35 of pregnancy. The iodine-to-creatine ratio (a measure of iodine deficiency) was also measured. Mean iodine concentration from all time points was 56.8μg/L and the iodine-to-creatinine ratio was 116μg/g, indicat-

ing that women were mildly to moderately io-dine deficient in each trimes-ter. Only 3.0% of women took prenatal supple-ments contain-ing iodine. On the whole, these findings indi-cate that this group of pregnant women were mildly to moderately iodine defi-cient at all trimesters, which is concern-ing. More studies in other populations are now needed.

The number of women developing dia-betes in pregnancy is on the rise. While conventional treatments are one option, emerging evidence suggests a possible role for magnesium supplements. Seventy pregnant women with diabetes were randomly allocated to take: 250mg magnesium oxide or a placebo for six weeks. Fasting blood samples were taken at baseline and at the end of the intervention. Results showed that fasting plasma glucose levels and serum insulin lev-els were significantly lower (P ≤ 0.001)

amongst women who took the magne-sium, compared with the placebo by the end of the study. Overall, the findings from this trial indicate a possible role for magnesium in the management of gestational dia-betes. More work is now needed to bet-ter understand how magnesium exerts its actions. For more information, see: Bath SC et al (2015). American Journal of Clinical Nu-trition Vol 101 no 6, pg. 1180-7 and Asemi Z et al (2015). American Journal of Clinical Nutrition Vol 102 no 1, pg. 222-29.

There is height-ened awareness about vitamin D deficiency. As this may also come hand in hand with diseases that in-

volve inflammatory processes, it seems likely that anaemia could also follow. New work has looked into this. A large cross-sectional study of 638 healthy American adults measured vita-

min D (25(OH)D) status and anaemia in-cidence. Results found that black Ameri-cans with serum 25(OH)D) levels less than <50nmol/l had an increased likeli-hood of anaemia with inflammation. Taken together, these results indicate that individuals with darker skin, poor vitamin D status and inflammation are at greatest risk of having anaemia. For more information, see Smith EM et al (2015). British Journal of Nutrition Vol 113, Issue 11, pg 1732-40.

Vitamin D anD anaemia link?

lateSt On Pregnancy micrOnutrientS: neW Data On iODine StatuS

magneSium & geStatiOnal DiaBeteS


http://www.nutritional-insight.co.uk/


neWs produCt / industry neWs

PrOgreSS On PrOteinProtein has been hot on the agenda at conferenc-es this year. This seems to be down to the grow-ing body of evidence linking its consumption to satiety and weight management benefits. Now, some new papers add to this further. One of the main verdicts from the Protein Summit 2.0 Conference, published in the Ameri-can Journal of Clinical Nutrition, was that protein dietary guidelines might need to be revisited. The current Recommended Daily Allowance (RDA) for protein is 0.8 grams per kg. How-ever, a growing body of evidence indicates that amounts around twice this could help to pro-mote a healthy body weight, preserve lean body mass and functional ability with age. Another article looking at the benefits of higher protein diets also concluded that about 1.2 and 1.6g protein per kg a day in the form of 25-30 grams of protein per meal led to improvements in appetite, body weight and cardio-metabolic health. These are interesting findings, implying that a revisit of guidelines and the composition of our diets may be needed.

Vitamin D anD DePreSSiOn linkAs there are vitamin D receptors in the brain, it makes sense that there could be links with brain function and mood. Now, a new Dutch study has looked at this. Amongst a large sample of 2839 adults aged ≥65 years, vitamin D (25(OH)D) status was mea-sured and depression measured using a validat-ed scale. Genes affecting vitamin-D status were also studied. Results showed that individuals with a high-er vitamin D status, i.e. in the second, third or fourth quartiles, had a 22%, 21% and 18% lower score of depressive symptoms compared with those with lower vitamin D status, i.e. in the first quartile. These are interesting findings, indicating that low vitamin D status could contribute to depres-sion. Genetic make-up did not affect vitamin D status in this study. Further studies, including randomised trials are now needed. For more information, see Brouwer-Brolsma EM et al (2015). European Journal of Nutrition [Epub ahead of print].

mOnOgen - nutritiOnally cOmPlete

neStlé nutritiOn inStitute Satellite SymPOSium at BSaci SePtemBer 2015

Are you interest-ed in increasing the awareness of Cows’ Milk Al-lergy (CMA)?If so please visit us on Stand 20 at the British Society

for Allergy and Clinical Immunology (BSACI) Meet-ing, Telford, 4-6 September. We will be sponsoring a satellite symposium on CMA. Topics include:• “Cows’ Milk Protein Allergy: Improving Stan-

dards of Care in Paediatric Practice”• “What do we know about lactose?”• “Introducing the new Cows’ Milk Symptom

Score (CoMiSS)”For more details please contact your local represen-tative. For information on our Allergy product port-folio please visit: www.nestlehealthscience.co.uk

To book your company’s product news for

the October 2015 issue of NHD Magazine

call 0845 450 2125 (local rate)

Monogen is a nutritionally complete, low fat, pow-dered feed low in LCT and high in MCT. Monogen is intended for use in the dietary management of defects of long-chain fatty acid oxidation and may also be suitable for infants and children requiring a very low fat diet such as seen in Chylothorax, Intestinal Lymphangi-ectasia and Hyperlipoproteinaemia Type I. Next generation Monogen contains essential fatty ac-ids and is supplemented with DHA.Visit http://nutricia.co.uk/products/view/fat-ty_acid_oxidation_disorders/monogen

www.nestlehealthscience.co.uk


http://nutricia.co.uk/products

Practical advice for healthcare professionals from

The most complete

preterm range

availablepreterm range

available For the dietary management of extremely low birthweight infants

Designed specifi cally to help meet increased protein requirements, as recommended by ESPGHAN, for infants <1,000g1

Adaptable dose to help meet the needs of each extremely low birthweight infant

For use in combination with fortified breastmilkor preterm formulaDeveloped to help meet protein requirements for extremely low birthweight infants

50 x 1g sachets

HOSPITAL USEmust be used under medical supervisionHOSPITAL USEmust be used under medical supervision 98945-1

nutripremprotein supplement

for the dietary management of extremely lowbirthweight infants who require additional protein

Important noticeCow & 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.

Reference1. Agostoni C et al. Enteral nutrient supply for preterm infants: Commentary from the European Society for Paediatric Gastroenterology, Hepatology and Nutrition Committee on Nutrition. J Pediatr Gastroenterol Nutr 2010;50(1):85-91.

AN INNOVATIONIN PRET��MNUTRI��O�THE FIRST AND ONLY PROTEIN SUPPLEMENT

FOR USE WITH FORTIFIED BREAST MILK

OR PRETERM FORMULA

NowAvailable

CG Supplement Network Health Dietitian Digest 223x160.indd 1 06/07/2015 09:45

http://www.in-practice.co.uk/?mode=login


The expected capabilities of a gradu-ate dietitian in relation to communica-tion skills are clearly described2, 3. This includes being an effective communi-cator, active listening, establishing rap-port with patients, demonstrating com-passion, empathy and understanding. These capabilities are comparable to expectations for healthcare profession-als more generally4, 5, 6 and training of healthcare professionals in communi-cations skills to deliver patient-centred care and to support behaviour change is consistently recommended7, 8. Sadly, some healthcare professionals lack skills in communication-related areas, such as demonstrating compassion, offering reassurance and involving patients in care decisions9. To support the NHS in the future, the need for patient-centred care, working with patients and carers to set and achieve healthcare goals by engaging, empowering and listening to the views of patients and carers has been strongly re-emphasised10. The same key messages are consistently being deliv-ered, i.e. good communication skills are important in patient care, a patient-cen-tred approach is required and effective training for those working in healthcare is recommended.

What impaCt do CommuniCation sKills have on dietetiC praCtiCe?In dietetics there is a developing evi-dence base that supports the positive effects of good communication skills.

One of the key areas is with the demon-stration of empathy, that is, the desire to understand the patient’s experience and to demonstrate that understanding to the patient11. Demonstrating empathy in dietetic consultations has been shown to improve patient satisfaction12, 13, 14. Good-child et al found that the more empathetic the dietitians’ response to emotional cues was, the more satisfied patients were. Greater patient satisfaction is important as it is more likely that highly satisfied patients will maintain appointments and adhere to the dietary recommendations that have been made, which is essential if dietetic practice is going to be effective14. Empathy has also been shown to lead to higher levels of agreement about the decisions made within a consultation12,

15 and to more extensive dietary changes being implemented16. However, there is little evidence as yet to suggest that this leads to improved clinical outcomes16. Several studies have elicited the views of dietitians and their patients on what was desirable within consultations17,

18, 19. Although these studies were completed in different countries; the UK18, Australia17 and Israel19 and there may be different cultural views, the conclusions were very similar. Patients stated that they want to be treated as individuals17, to be listened to17, to have a rapport with the dietitian17, 18. They wanted a positive partnership17 and for the dietitian to be patient-centred18 and empathic19. Although the clinical skills of

CommuniCAtion SkillS for dietitiAnS: where Are we uP to And where Are we going?

dr Kirsten Whiteheadassistant professor in dietetics, university of nottingham

kirsten whitehead worked in the nhS for over 20 years, moving into dietetic education in 2001. kirsten teaches communication skills and undertakes research in this important subject area for dietitians.

there are few dietitians who do not agree that good communication skills are at the heart of dietetic practice1,but what exactly is meant by ‘good communication skills’ and how do we know if we have got them or not? this article will discuss some of the recent relevant policy and published literature in this subject area and aims to provide some suggestions for how we could further develop these skills as a profession.

CommuniCation sKills in dietetiCs

For article references please visit info@networkhealth group.co.uk


the dietitian were considered important, patients also valued active engagement, sharing and open communication18 and the appropriate personal presentation of the dietitian17, 18, i.e. smart but not too formal. The ability of dietitians to be flexible in their communication approach was important as some patients prefer a more practitioner-led and some a more patient-led consultation18, 19. In contrast, patients were less likely to attend follow-up consultations when the dietitian lacked a patient-centred approach, lacked empathy, did not individualise advice or focused on information giving19. This reinforces the need for good communication skills for effective practice. One area where there is clear evidence of a need for improvement is in relation to shared decision making. In a Canadian study, Vaillancourt et al used a validated tool to assess dietitians’ consulta-tions and found an overall mean score of 29 (±8.0%) (range 0% [no patient involvement in the decision] to 100% [high patient involvement]) which sug-gests that dietitians were not involving patients in the diet-related decision making process20.

developing CommuniCation sKills post-registrationThe dietetic workforce includes people who trained in a variety of Higher Education Insti-tutes (HEIs) with differing methods of teaching and learning. The pre-registration training of di-etitians is constantly developing and those who trained many years ago will have had a different pre-registration education experience to those who trained more recently. Several studies have demonstrated that dietitians would like more training in communication skills post-registration and that their pre-registration training focused more on knowledge than communication skills1,

14, 21, 22, 23. There is an assumption that experience leads to skill development, but little evidence to support this. In the UK, there is little to guide dietitians on how to develop their communication skills, or what they should be aiming for. In the USA, the Academy of Nutrition and Dietetics has re-cently produced a series of documents for a va-riety of specialist areas of dietetics which define the skills required at three different levels of prac-tice: competent, proficient and expert24. A compe-tent practitioner is recently qualified, a proficient

practitioner is generally three or more years post-registration and an expert practitioner is recogn-ised within the professional as having reached the highest level of knowledge and skill. This gives dietitians a very explicit guide to what they need to do to progress in a specific clinical area, and communication skills are included as one of the six domains of professional practice within this24. Similarly, a study undertaken to describe what is meant by advanced or expert practice concluded that advanced practice tasks are patient-centred and include the use of advanced interviewing, education and counselling strategies25. How do dietitians develop from competent to proficient and expert levels in relation to their communication skills? There are many opportu-nities for Continuous Professional Development (CPD) in communication skills available and some are dietetic specific. Whitehead et al (2009) found that the majority of dietitians responding to a survey (n=906, 79.6%) had undertaken CPD and were very positive about its effect on their work practice, but many were keen to develop their skills further, in particular, in advanced skills such as motivational interviewing and cognitive behavioural strategies1. Evidence from medicine and nursing suggests that communication skills can be enhanced by training; however, there are concerns about the difficulties of transfer of train-ing into practice26, 27 which was also a concern of dietitians1.

hoW do We measure sKills?One of the challenges with skill development is having an objective way of assessing skills. How do we know if attending training actually leads to positive changes in practice? Most studies have explored dietitians’ perceptions of their skills, or patients’ views of the dietitian’s skills, rather than any objective measure. For this reason, Whitehead et al (2014) developed and validated an assess-ment tool, DIET-COMMS, which is designed for the assessment of communication skills within di-etetic patient consultations28. The tool was tested using videoed consultations with simulated pa-tients, with students at various levels of training and qualified dietitians. DIET-COMMS is a sim-ple form covering one side of A4 which consists of 20 items which cover the content of a dietetic consultation and the communication skills within




that. Each item can be scored with 0 (not done or not achieved), 1 (partly achieved or attempted), or 2 (fully achieved). DIET-COMMS has been com-prehensively tested and it has been found to have face validity, content validity, construct validity, predictive validity, intra-rater reliability and mod-erate inter-rater reliability. As with any assessment tool, there is a need for those using it to be familiar with it and to be able to assess in a consistent manner. For this reason a training package is being developed to support its use in both student training and for CPD. The training package will be open ac-cess via a web page, so no cost will be incurred for users and they will be able to return to the package as often as they wish. The package in-cludes video-recorded mock consultations to a variety of standards. These were undertaken in out-patient clinics, a ward setting and a home setting. There are service user views on the con-sultations to aid understanding on how the pa-tient might feel or react in those situations and also an expert view on how each consultation would be scored on DIET-COMMS. There are downloadable resources to support teaching and learning. For example, feedback sheets on each of the 20 items on DIET-COMMS are de-signed to support individuals to identify what they could do differently to improve that specif-ic item. Guidance sheets have been developed, for example, on how to set up peer assessment in the workplace and on giving constructive feedback. The DIET-COMMS training package will be launched in 2015.

the Way ForWardThere appears to be a willingness and desire with-in many dietitians1 to undertake CPD in relation to their communication skills post-registration. The DIET-COMMS training package may support this, but there are other questions to consider.

How good are dietitians as a profession at the moment? Some may consider that there is no need for improvement, as dietitians are all good at communicating already. The reality is that we really don’t know the answer to this question as the research has not been complet-ed; however, many studies suggest that there is room for improvement1, 18, 19 and consider-able variation has been demonstrated28.

Should UK dietitians develop a framework for skills required for competent, proficient and expert levels in relation to communication skills, as has been completed in the USA24?Would such a tool be helpful and would it ensure that this aspect of professional prac-tice would be considered more formally?Should peer observation or peer assessment in the workplace be undertaken routinely? There is evidence that this is occurring in some departments already1, but concerns have been raised that some dietitians would find this threatening and that it would not be accept-able28. However, this already happens with some other healthcare professionals regularly, such as doctors.Is it time for a more consistent approach to dietetic pre-registration training? This al-ready happens in UK medical schools where a national group develops guidance and tools to support the HEIs29.Is there a need for a BDA Specialist Group on communication skills? It is a subject relevant to all, but may provide support and guidance for those who want to develop their skills.

There are many unanswered questions and a lot of potential for research which can take the dietetic profession forward. Developments in this area could help dietitians to consistently deliver the high quality, patient-centred, effective services that we are capable of and which are required to meet professional standards and current guid-ance. What part can you play?




®- here t help y nd ywith PKU ever he way.

y repr ve t ay t m rPKU pr ney.

www n

Tel: 0151 709 9020 Email: [email protected] Web: www.vitaflo.co.uk

A Nestlé Health Science Company® Reg. trademarks of Société des Produits Nestlé S.A

www.vitaflo.co.uk

tel:


Cordelia Woodward Bsc rdFreelance dietitian

Cordelia is a freelance dietitian and owner of www.cwdietetics.co.uk. She has worked previously for nhS trusts as a special-ist dietitian and has keen interests in pregnancy, dia-betes, weight loss and cardiovascular disease.

Pregnant women are considered to be at risk of low vitamin D levels amongst other subgroups4. there is a close link between a mother’s vitamin D level during pregnancy and a new born baby’s vitamin D status5. the mother needs to ensure adequate stores for herself and her baby.

Adequate stores of vitamin D in pregnan-cy can help prevent rickets in babies and in infancy (especially for exclusively breast-fed babies)1. Although we may think of rickets as a problem from the past, there is concern that it is re-emerging in children

VitAmin d in PregnAnCy

Cover story

Figure 1: adapted from (3). 25(oh)d - 25-hydroxy vitamin d; this is used to assess vitamin d status, 1,25(oh)2d - 1 25-dihydroxy vitamin d - this is the active form of vitamin d.

sunlightultraviolet B

sKin7-dehydrocholesterol

previtamin d3

vitamin d3

Circulationvitamin d2 and d3

(from diet or supplements)

liver

2h(oh)d

Circulation

Kidney

1,25(oh)2d

in the UK6. In addition, al-though not conclusive, some studies have shown vitamin D deficiency may be associ-ated with an increased risk of gestational diabetes, pre-eclampsia, low birth weight and caesarean section7.

vitamin d: BaCKgroundVitamin D is a fat soluble vitamin which plays several important roles within the body. One of its key roles is to help absorb calcium and phosphate and, in doing so, it helps to keep our bones strong and healthy. Whilst we get some vitamin D from dietary sources, we make most of it through the ac-tion of sunlight on our skin through a series of reactions (Figure 1). Plasma 25(OH)D (also known as 25-hydroxy vitamin D) concentration is used to assess vitamin D status1. In the UK, we can


www.cwdietetics.co.uk.


only make vitamin D between April and October (the sunlight is only at the correct wavelength in the summer months) and the latest National Diet and Nutrition Survey (NDNS) highlighted that the UK population has lower levels during the winter months2. During winter months the body’s stores of vitamin D from the summer and dietary sources are needed to maintain adequate vitamin D status.

requirementsIn 1991, the Committee on Medical Aspects of Food and Nutrition Policy (COMA) set a Refer-ence Nutrient Intake (RNI) of 10 micrograms of vitamin D per day for all pregnant and breast-feeding women (COMA, 1991)8. The Scientific Advisory Committee on Nutrition (SACN) re-iterated the above recommendation in 2007 in their update of vitamin D1. This is in contrast to most children and adults, for which there is ac-tually no RNI set, as it is assumed they will get enough vitamin D from sunlight exposure5. This is, however, currently being reviewed by SACN.

supplementationThe NICE guidelines advise that UK healthcare professionals should recommend a vitamin D supplement of 10 micrograms for all pregnant and breastfeeding mothers9. This is also sup-ported by the Royal College of Obstetricians and Gynaecologists7. All pregnant women should be informed about the importance of vitamin D supplementation at their first appointment with their healthcare professional5. Some women are at greater risk of vitamin D deficiency, including those with darker skin and women with limited exposure to sunlight and so extra care must be taken to ensure that these women are taking a daily vitamin D supplement9.

Whilst the advice for vitamin D supplemen-tation is not new, evidence suggests that it is not necessarily being implemented as well as intend-ed. To highlight this, the Infant Feeding Survey10 suggested that the majority of women do not take vitamin D supplements during pregnancy. Vitamin D supplements can be obtained from a pharmacy, a supermarket, or on prescription. They are also included in ‘Healthy Start vita-mins’ (eligible for some women) and ‘pregnan-cy multivitamins.’ Although most commercial multivitamins are likely to contain vitamin D, these are best avoided in pregnancy due to their vitamin A content (which can harm the unborn baby). Vegan pregnant women should ensure that their vitamin D supplement is not from an animal origin by checking the label.

Where to get Healthy Start vitamins from:• Health clinics• Children’s Centres• Sure Start Centres• Outreach programmes• GP surgeries

Food sourCes

Sunlight is the main source of vitamin D and food sources are limited. For most people, diet only provides 10-20% of total vitamin D intake with 80-90% coming from cutaneous synthesis following sunlight exposure11. The main sourc-es are shown in Table 2. Cooking methods can impact the vitamin D content of a food; for ex-ample, baking fish has no effect, whereas fry-


vitamin d

The NICE guidelines advise that

UK healthcare professionals should

recommend a vitamin D supplement

of 10 micrograms for all pregnant and

breastfeeding mothers


ing fish reduces the content by 50%12. Whilst oily fish is a good source of vitamin D, it must be noted that pregnant women are advised by the government to limit oily fish to twice per week due to pollutants in the fish. The advice is also to limit tuna to no more than four cans per week (or no more than two tuna steaks per

week) due to the mercury content. Moreover, eggs, another source of vitamin D, need to be thoroughly cooked to prevent the risk of salmo-nella. Cod liver oil (5μg vitamin D per capsule) and liver (1.1μg/100g) should also be avoided completely during pregnancy due to their high vitamin A content13. High street food retailer Marks & Spencer have recently added vitamin D to their bread and bread rolls, with a minimum of 0.75 micrograms per 100g. It will be interesting to see if other food retailers do likewise.

Can too muCh vitamin d Be harmFul?In the UK, the Expert Group on Vitamins and Minerals reports that taking 25 micrograms or less a day of vitamin D supplements is unlikely to cause any harm14. Our body does not make too much vitamin D through sunlight; however, individuals need to be aware of sun safety and should cover up/protect skin if they are out for long periods4.

assessing vitamin d adequaCyThere is much debate regarding the appropri-ate cut-off values for optimal vitamin D status15; however, the National Osteoporosis Society, in a document entitled Vitamin D and Bone Health: A Practical Clinical Guideline for Patient Manage-ment, in 201316 proposed the following thresh-olds for bone health with regard to assessing vitamin D status (using 25-hydroxy vitamin D as a marker):• Less than 30nmol/litre - deficient• Between 30-50nmol/litre - may be inadequate

in some people• Greater than 50nmol/litre - sufficient for almost

the whole population


vitamin d

Vitamin D (μg) Per 100g

salmon, fresh, wild 8.60

salmon, fresh, farmed 4.70

Canned salmon, pink, drained

1.60

smoked salmon 8.90

tuna, raw 3.20

tuna, canned 1.10

pilchards, canned in tomato sauce

14.00

mackerel, raw 8.00

sardines, canned in oil, drained

3.60

eggs, whole, raw 3.20

eggs, yolk, raw 12.80

eggs, white, raw nil

Beef, mince, raw 0.70

Fortified breakfast cereals 3.00-8.4

Fortified fromage frais 1.25

Fortified yoghurt 4.00

Fortified fat spreads 5.00-7.5

Fortified dairy free milk alternative drinks

0.75-0.8

table 2: sources of vitamin d in the diet (data obtained from dietplan7, Forestfield software). μg - micrograms

Whilst oily fish is a good source of

vitamin D, it must be noted that

pregnant women are advised by the

government to limit oily fish to twice per

week due to pollutants in the fish.



NICE guidelines5, on the other hand, define defi-cient as less than 25nmol/litre.

sCreening pregnant WomenCurrently, it is not routine for women to be screened for vitamin D deficiency in pregnancy because there is no data to support this in terms of health benefits or cost effectiveness7.

Current intaKe/status - ndnsResults from the NDNS 2014 reported evidence of an increased risk of vitamin D deficiency in all age/sex groups. Almost one fifth of UK adults were found to have a low vitamin D status (in this case, defined as less than 25nmol/litre)2. Whilst not at a national level, several studies have demonstrated that pregnant women have low vitamin D status1. For example, a study by Brough et al (2010) found that 70% of women in their first trimester from a diverse ethnic group in London had 25-hydroxy vitamin D below 50nmol/litre (insufficiency)15.

In addition, a study on 160 women in South Wales found that 50% of women had levels be-low 20nmol/litre (deficiency) on their first ante-natal visit17.

summaryIn summary, vitamin D plays an important role in the body, helping to absorb calcium and keep our bones strong and healthy. In pregnancy, having adequate vitamin D can help prevent rickets in babies as well as having other potential benefits. Pregnant women are considered to be at risk of low vitamin D status, as highlighted in sev-eral studies, and the current advice is that all pregnant women take a supplement of 10 micro-grams of vitamin D everyday throughout preg-nancy and breastfeeding. Dietitians have a role to play in educating patients about the importance and reasoning be-hind such supplementation advice and helping to ensure that it is being implemented.

references1 Scientific Advisory committee on Nutrition (2007). Update on Vitamin D. London: tSO. Available at: www.gov.uk/government/uploads/system/uploads/

attachment_data/file/339349/SAcN_Update_on_Vitamin_D_2007.pdf [accessed: 18/06/2015]2 bates b et al (2014). National Diet and Nutrition Survey. results from years 1-4 (combined) of the rolling Programme (2008/2009 - 2011/12), London: Public

Health england3 Zhang and Naughton (2010). Vitamin D in health and disease: current perspectives. Nutrition Journal 9:654 National Health Service (2015). Vitamin D. Available at: www.nhs.uk/conditions/vitamins-minerals/Pages/Vitamin-D.aspx [accessed 17/06/2015]5 National Institute of clinical excellence (2014). Vitamin D increasing supplement use among at risk groups. Available at: www.nice.org.uk/guidance/ph56/

resources/guidance-vitamind-increasing-supplement-use-among-atrisk-groups-pdf [accessed: 26/04/2015]6 Pearce SHS & cheetham tD (2010). Diagnosis and management of vitamin D deficiency. british Medical Journal; 340:14201477 royal college of Obstetricians and Gynaecologists (2014). Vitamin D in Pregnancy. Available at www.rcog.org.uk/globalassets/documents/guidelines/

scientific-impact-papers/vitamin_d_sip43_june14.pdf [accessed 17/06/2015]8 committee on Medical Aspects of Food Policy (1991). report on Health and Social Subjects 41 Dietary reference Values (DrVs) for Food energy and

Nutrients for the UK, report of the Panel on DrVs of the committee on Medical Aspects of Food Policy. the Stationary Office. London9 National Institute of clinical excellence (2008). Antenatal care. Available at: www.nice.org.uk/guidance/cg62/resources/guidance-antenatal-care-pdf

[accessed: 18/06/2015]10 bolling K et al (2007). Infant Feeding Survey 2005. the Information centre11 Food and Health Innovation Service (2012). Fish as a dietary source of healthy long chain n-3 polyunsaturated fatty acids (Lc n-3 PUFA) and vitamin D.

Available at: www.abdn.ac.uk/rowett/documents/fish_final_june_2012.pdf [accessed: 18/06/2015]12 chen tc et al (2007). Factors that influence the cutaneous synthesis and dietary sources of vitamin D. Arch biochem biophys; 460:213-713 National Health Service (2015). Foods to avoid during pregnancy. Available at: www.nhs.uk/conditions/pregnancy-and-baby/pages/foods-to-avoid-pregnant.

aspx#close [accessed: 18/06/2015]14 Foods Standards Agency (2003). Safe Upper Levels for Vitamins and Minerals, Available at: http://cot.food.gov.uk/sites/default/files/vitmin2003.pdf [accessed:

18/06/2015]15 brough L et al (2010). effect of multiple-micronutrient supplementation on maternal nutrient status, infant birth weight and gestational age at birth in a low-

income, multi-ethnic population. the british Journal of Nutrition 104(3): 437-4516 National Osteoporosis Society (2013). Vitamin D and bone Health: A Practical clinical Guideline for Patient Management. Available at: www.nos.org.uk/

document.doc?id=1352 [accessed 17/06/2015]17 Datta S et al (2002). Vitamin D deficiency in pregnant women from a non-european ethnic minority population - an interventional study. bJOG 109, 905-908

Whilst not at a national level, several studies

have demonstrated that pregnant women have

low vitamin D status.

http://cot.food.gov.uk/sites/default/

www.gov.uk/government/uploads/system/uploads/

www.nhs.uk/conditions/vitamins-minerals/Pages/Vitamin-D.aspx

www.nice.org.uk/guidance/ph56/

www.rcog.org.uk/globalassets/documents/guidelines/

www.nice.org.uk/guidance/cg62/resources/guidance-antenatal-care-pdf

www.abdn.ac.uk/rowett/documents/

www.nhs.uk/conditions/pregnancy-and-baby/pages/foods-to-avoid-pregnant.

www.nos.org.uk/



malnutrition and the elderly

In 2013, I was offered the role of PSD for care homes, working within the Inte-grated Response Team (IRT) that covers care homes for adults in the northern part of West Sussex. The IRT is made up of nurses, a pharmacist and a dietitian. It is com-missioned by Crawley, Horsham and Mid-Sussex Clinical Commissioning Groups (CCGs) to work with those care homes identified as needing support by members of the IRT steering group. The group includes representatives from the CCGs, adult safeguarding team, West Sussex County Council and local GPs. The IRT works in collaboration with care homes to improve awareness of community services and to empower staff through training and education in order to provide consistent evidence-based care. This leads to a reduction of inappropriate and unnecessary 999 calls, A&E attendances and hospital admis-sions. We also provide general support to all care homes in the area through our care home forums, newsletters and roll-ing training programme.

summary oF the dietetiC roleThe Prescribing Support Dietitian role within the IRT aims to raise the standard of nutritional care provided within care homes through advice, training and sup-port to all staff involved in food and fluid provision. The role focuses on the preven-tion of malnutrition, the early identification of those at risk and reducing complications. The role also aims to ensure the appropri-ate use of oral nutritional supplements.

Liaison with other healthcare pro-fessionals and teams that support care homes guarantees consistent evidence-based messages around the common nutritional concerns and nutritional management of individuals at risk of malnutrition in care homes. For ex-ample, involvement in the care home champion meetings for community nurses and presenting at tissue viability nursing team meetings.

BaCKgroundIt is known that malnutrition and de-hydration in care homes can lead to in-creased risk of hospitalisation, readmis-sion and long term ill health1. The British Association for Parenter-al and Enteral Nutrition (BAPEN) found that over 37% of residents admitted to care homes were either malnourished or at risk1. This highlights the need for excellent nutritional care. However, the Dignity and Nutrition report from CQC showed that one in six homes did not meet the standard set for nutritional care (outcome 5)1. This role provides opportunity to engage with a wide range of stakehold-ers linked to care homes with the aim of raising the awareness of the importance of recognising malnutrition early, pre-venting its development and treating the condition appropriately. The emphasis has been around im-proving nutritional care in care homes, increasing knowledge and confidence in adopting a food first approach for resi-dents who are at risk of malnutrition.

A PreSCribing SuPPort dietitiAn for CAre homeS

anna Fitzgibbon prescribing support dietitian, Care homes integrated response team

Anna fitzgibbon is a Prescribing Support dietitian for care homes, employed by first Community health and Care. Anna has worked as a dietitian for 15 years, mainly in prescribing support roles. her main interests (aside from prescribing support) are nutrition in older people and dementia care.

Prescribing Support Dietitians (PSD) have generally been employed to ensure the clinical and cost-effective prescribing of oral nutritional supplements (OnS) in the community, with the management of nutrition support patients. this role continues to grow to include a variety of settings and focus has extended to gluten-free products, infant formulas and thickeners.



I THOUGHT I’D HAVE TO ASK MY SON FOR HELP. STAYING STRONG MEANS HE CAN ASK ME.NEW Ensure Plus Advance. It helps provide the nutritional support they need to get back to what they love.

Visit abbottnutrition.co.uk to find out more.Date of preparation: September 2014 RXANI140256e

Ensure Plus Advance

NH

D E

nsur

e P

lus

Adv

ance

Ad_

GA

RD

EN

ER

_FP

34178 Ensure Plus Advance NHD FP_v1_Gardener_AW.indd 1 17/12/2014 15:20



Improving residents’ nutritional status through food is the most appropriate way to manage the risk of malnutrition and the associated compli-cations of this. Malnutrition brings the associ-ated costs of an increased number of GP visits, more prescriptions, slower healing, reduced immunity and longer hospital stays which is estimated to cost the UK economy £13 billion per year2. Oral nutritional supplements (ONS) are a common treatment for malnutrition and can be inappropriately prescribed. ONS are often initi-ated before food fortification and dietary coun-selling has been trialled, frequently with no as-sessment or goals of treatment. Food should be a first line treatment3, 4, although lack of knowl-edge, historical use and inconsistent messages promote care home staff to regard ONS as the ‘magic bullet’ to treat malnutrition. By supporting care homes to provide bal-anced nutritious menus, providing education on the timely identification and management of malnutrition and to raise awareness of the ap-propriate use of oral nutritional supplements, (i.e. use of ONS only if meeting Advisory Com-mittee for Borderline Substances (ACBS) cri-teria after dietary measures have been unsuc-cessful in achieving goals of treatment), there is a reduction in the number of oral nutritional supplements needed. This approach offers sig-nificant cost savings and cost avoidance to the Clinical Commissioning Group(s).

The IRT Prescribing Support Dietitian:• reduces inappropriate pre-

scribing of oral nutritional supplements through educa-tion, training and clinical as-sessments;

• empowers carers to support a residents’ return to a bal-anced food intake, reducing the need for inappropriate ONS;

• empowers carers to use Food First throughout their home, thereby reducing requests for ONS prescriptions;

• improves nutritional care as described above, which can:

- reduce admissions - reduce readmissions - reduce hospital stay- improve quality of life and promote independent living - reduce long-term dependence on ONS- maximise food intake facilitating long- term recovery and nutritional health2, 5.

Key Components oF the psd For Care homes roledietetic assessments and reviewsAll residents in the care home who receive a pre-scription for an oral nutritional supplement are assessed and then reviewed (with GP and, if pos-sible, resident consent) by the IRT dietitian. Exclusions:• Those under the care of another dietitian. In

this case, contact is made to inform them of IRT intervention and dietetic aims around ONS and Food First.

• Those individuals with enteral feeding tubes in situ.

59 residents were reviewed in eight care homes over a nine-month period (see Chart 1).• 32 residents (54%) assessed did not require

further prescription for oral nutritional sup-plements after dietetic advice, so a request to the GP was made to stop prescriptions.

Chart 1: resulting change in ons prescription following dietetic intervention


• 11 residents (19%) had their prescription mod-ified; reduced or product change or increased.

• 16 residents (27%) had no changes made to their prescription:- Some patients were end of life or had ad-

vanced dementia, so it would have been challenging and distressing to discontinue the prescriptions. Unfortunately prescrip-tions are often commenced in these groups with good intentions, but inappropriately. Perhaps to be seen to be providing nutri-tional support or due to challenging be-haviour and repeated food refusal.

- Some residents did meet ACBS criteria and required ONS to support their nutritional status (such as those with COPD, Parkin-son’s and oesophageal stricture). However, education was needed to ensure that Food First was implemented as well as ONS in order to gain the greatest benefit.

There is strong evidence to confirm that the majority (78%) of prescribing is inappropriate based on findings of:• 19 residents having MUST scores of 0 (i.e.

healthy weight and no significant weight loss).• 42 residents on ONS not meeting the ACBS

criteria for prescription.• 13 residents prescribed only one dose daily.• Food First advice consistently not being fully

implemented.

Findings show that due to the complexities of resident’s clinical condition, family, resident and car-er expectations, cultural reliance and lack of knowl-edge that ONS is consistently used inappropriately. For example; A pudding style supplement was be-ing used as dessert rather than using the menu op-tions available. This was costing the CCG £3.92 per day (two items); a fortified pudding would provide greater calories (fortified mousse provides 308Kcal compared with between 170-200Kcal by standard pudding style ONS) and costs the care home ~£0.38. Ceasing ONS is therefore a challenging process. Dietetic expertise is required to assess resi-dents that may not require ONS, but due to a variety of factors should continue with their pre-scriptions. Where possible, more cost effective products are recommended, hence the reason that 54% of residents prescribed ONS had the

recommendation to stop, not the 78% found to be receiving prescriptions inappropriately. This is where the importance of effective training on the identification and management of malnutri-tion, particularly around prevention, is vital. This role ensures engagement with the key stakehold-ers to promote and cascade the preventative and Food First messages, resulting in better nour-ished residents and fewer requests for ONS.

trainingIn-house training around identifying and man-aging malnutrition is provided to those homes identified to the IRT. This is tailored to include case studies and documentation relevant to the home and the staff attending. The majority of staff trained are carers (i.e. not registered nurses). All training is designed to deliver simple take-home messages that can easily be imple-mented in a care home, e.g. the use of fortified milk for all residents. Evaluation is consistently positive with 98% of attendees rating the train-ing as very good or excellent. A generic nutrition training session is deliv-ered on our rolling training programme. Com-mon concerns encountered during the team’s work have prompted the development of work-shops including bladder and bowel (nutritional management of constipation), dysphagia man-agement and ‘MUST’. The importance of good nutrition and Food First messages are included in all the training delivered by the IRT.

resourcesListed below are the resources that have been developed to support care home staff to deliver excellent nutritional care:• Nutritional Care:• Food First advice to promote weight• Nourishing drink recipes• Managing Constipation• Using oral nutritional supplements• Diabetes Mellitus and diet• Overview of meals (catering advice)• Core actions and minimum standards for nu-

trition and hydration• MUST record sheet and actions• Malnutrition assessment• Dignity at mealtimes (advice when assisting individuals to eat and drink)




Key performance indicatorsThe dietetic role has three main KPIs attached against which the role is measured and evaluated.

Kpi 1: reduce usage of ons by 50%• On average 18% of residents across the eight

homes (all nursing) were prescribed ONS.• Across the eight homes the number of ONS

(as items) was reduced by 77%.

• This represents a 59% reduction in spend ONS products.

Kpi 2: 80% of target care homes are using a validated malnutrition screening tool:• 100% of focus homes are using MUST at the

end of IRT intervention.• An audit was carried out by the team to assess

nutrition screening, accuracy of the result,



graph 1 shows the reduction in ons usage following dietetic intervention in the irt focus homes

graph 2: total savings on ons across 8 irt focus homes

Lower savings achieved in Care Home 3 due to a large number of residents transferred from another home with complex needs and a heavy reliance on ONS. It is very difficult to reduce or cease ONS in end of life or in residents that have become dependent on ONS.


Contact your local Vitaflo® representative today to find out more about the new look to Pro-Cal shot.

Same great product Improved new look!

Available in Strawberry, Neutral & Banana flavours

NE

W PRESENTATION

120mlbottle

A Nestlé Health Science Company®Reg. Trademark of Société des Produits Nestlé S.A.

NHD0815BJuly 2015

Nutritional Helpline: +44 (0)151 702 4937 Web: www.vitafloweb.com follow us @ProCalNews

Pro-Cal shot is a Food for Special Medical Purposes.

www.vita?oweb.com

https://twitter.com/procalnews?lang=en

documentation of results and actions if the resident is identified at risk. This local audit highlighted frequent screening, but often scores were inaccurate with little or no evidence of action in the nutrition care plan6.

• MUST training is now provided as part of the bespoke training delivered in focus homes and is included on the rolling train-ing programme.

Kpi 3: reduce prevalence of malnutrition by 5.0% (from baseline assessment):• National data suggests between 32-42% of

older adults in care homes are malnour-ished7.

• This is reliant on care homes screening ac-curately, which has been found not to be the case locally.

• Therefore, baseline data collection includes nutrition screening on 50% of residents un-dertaken by the team to ensure accuracy of data.

• Current data suggests prevalence in line with national reporting.

• Care homes have this repeated at the three- to six-month review.

• Data collected for one care home at the six-month review point suggested a decrease in the prevalence of malnutrition in the region of 6.0% from baseline assessment.

Cost avoidanCeDietetic intervention can reduce prevalence of malnutrition and dehydration, which in turn could prevent falls, UTIs, constipation, pro-mote wound healing and prevent the initia-tion of ONS 5. All of these factors have a significant im-pact on cost both in terms of quality of life and finance. This cost avoidance is difficult to measure. The possible exception would be avoid-ance of ONS prescriptions; however, because only those individuals already prescribed ONS are seen, the cost avoidance linked to im-proved nutrition and thus preventing requests for ONS is difficult to estimate. It is likely that as a result of the education, training and resource that is put into the focus

homes and messages cascaded via the IRT news-letter and through forums and rolling training, that many residents who would have started on ONS did not, because the Food First message had been implemented and those at risk identi-fied earlier, thus preventing deterioration. As part of this role, liaison with the CCG’s GPs, medicines management team and other teams, such as tissue viability nurses, admission avoidance and community nursing also pro-vides opportunity to further promote the Food First message. All nurses within IRT are aware of and promote the Food First message.

Future areas oF WorK• Reduce laxative prescriptions: Laxative use

is widespread in care homes. There is some evidence demonstrating a reduction in laxative use by introducing fruit smoothies onto the care home menu8.

• Reducing inappropriate use of thicken-ers (e.g. Nutilis, Thick and Easy, Thicken-Up): Observations suggest an over use of thickening agents, often after a ‘coughing episode’. This can in fact negatively impact on the hydration status of residents by re-ducing fluid intake causing dehydration9 and which, in turn, can contribute to falls, delayed wound healing, reduced cognitive function and quality of life. This inappro-priate use is again at a cost to the CCG. Training and resources targeting this will aim to positively impact on the malnutri-tion and dehydration commonly seen in residents with dysphagia.

ConClusionA Prescribing Support Dietitian for care homes is proving to be an effective and high qual-ity intervention for improving the nutritional care of residents in care homes and reducing inappropriate prescribing of oral nutritional supplements. The role is far reaching through liaison with other community based teams, GPs and medicines management to promote ‘Food First’. Without the dietetic role, malnutrition in care homes would continue to be under recognised, under treated and inappropriate prescribing of ONS would continue.






Working with care homeschallenges encountered in raising awareness of malnutrition and its management• Theassumptionthattheelderlydoloseweightandthisisnormal.Thishasbeenfoundelsewhere10.• Poorcommunicationbetweenstaff-carestaffdonotroutinelyreadcareplansandarenotencouragedtoinform

the plan10. Care staff often know their residents in great detail, but this is not reflected in the documentation.• Poorcareplanningwithgenericstatementssuchas‘toprovideMrXwithabalancedandvarieddiet’;nodetailas

to what this means to them or how to deliver this.• Foodandfluidchartsthatarepoorlycompleted,therefore,potentiallysuggestingthatresidentshavenotbeen

offered food or drink at certain times of the day. often staff are not clear as to why a resident is on a food and fluid chart and the charts are never evaluated, further impacting on their completion11.

• MUSTisatickboxexercise-itoftenseemsnottomatterwhattheMUSTscoreis;thereisnodifferencereflectedinthecareplansandMUSTissimplysomethingthat‘CQCexpecttosee’6.

• Lackofawarenessabouthowtomanage‘challengingbehaviour’inpeoplewithdementia.Oftenthismeansresidents are malnourished and may be prescribed ons for the sake of doing something.

• 80%ofpeoplelivingincarehomeshavedementiaormemoryproblems12. some care home staff may not understand how to communicate with or manage those with dementia13.

• Residentsatendoflifeareprescribedoralnutritionalsupplementsbecausetheresidentisnoteatingand/orforthe sake of doing something.

Our solutions• Assumptionsand‘mythbusting’aroundweightloss,‘normal’weightforolderpersonsanduseofONSisalways

included in nutrition training and all related training.• TheimportanceofgooddocumentationisthreadthroughallIRTtrainingandaworkshop(includescareplanning,

food and fluid charts and screening tools) specific to this topic is now included on the teams rolling training programme.

• Basicinformationandawarenessraisingarounddementiaisdiscussedduringtraining,resourcesprovidedandcare homes are signposted to the specialist dementia care teams in the area.

key points to remember when working with care homesgeneral• Itmaybeobvious,butremembertoworkwiththecarehomeandconsiderwhatisimportanttothem,whatthe

barriers are and what can they change and implement.• Considerwhoyourstakeholdersare.Itmaybeobvioustoengagewiththemanagerandcateringstaff,butthere

may be a member of staff who has a particular interest, works daily and could be your nutrition champion. other membersofstaffsoon‘rolemodel’andyoursuggestionsbecomepartofthedailyroutine.

• Donotassumethatyouradvice‘toprovidehomemadefortifiedmilkshakes’willbecarriedout.Bespecific-maybe ask the chef about their ideas, where they can source dried milk powder/egg white powder from, suggest specific amounts to add to different food and drinks. discuss how this can be implemented, when and by whom?

training• Staffwillalwaysbenefitfromtrainingevenifitisarefresher,areminderonMUSTandthebenefitsofdetailed

personalised care plans and good documentation.• KeepyourkeymessagesSMART-provideonlyafewspecifickeymessages;youmaybeabletobuildupon

these if you visit the home regularly. if someone doesn’t understand, it is likely not to be done.• Usethecarehomesowndocumentationforexamplesifpossible,e.g.theirfoodandfluidcharts.Also,trytouse

some of the residents as case studies - this relates the training to the home and helps staff engage.• Addinsomeinformationaboutmanagingsomeofthebehavioursassociatedwithdementia,suchasdistracted

from eating or wanting to walk/restless at mealtimes. the Caroline Walker trust has published an excellent resource whichcansupportyouwiththis.‘EatingWell:supportingolderpeopleandolderpeoplewithdementia’14.

• Severalshort‘bite-sized’trainingsessionsmaybebettertodeliverkeymessagestostaffthantryingtodeliveronethree-hour session. always encourage the manager and catering staff to attend.

• Makeanytrainingveryinteractive.AllthetrainingIRTdeliversalmost100%ofattendeesstatethattheirfavouritepart is the discussion, games or practicals.

• Onesizedoesnotfitall-focusontheareasthatcanbeimprovedinthatparticularhome,evenifitisjustonething.• Donotgetfrustrated!Sometimesthecarehomeisnotinthe‘rightplace’-itmaybeabetteruseofyourtimeto

postpone intervention until the new manager is in place, for example.



Where standardised feeding regimes have been introduced, NEC rates have reduced and NEC has been virtually eliminated in some centres1. As a result, neonatal net-works have worked to develop enteral feeding guidelines to use across their net-works, the most well-known of which is the East of England Network guideline2. The Welsh Neonatal Network - which I work within - has recently finished an enteral feeding guideline for our preterm infants, which is based on this guideline. This launched in October 2014 at the Wales Neonatal Network Audit Day and Wales Health Boards are now working on implementation. A key factor is own-ership and some of the lessons we have learned are the following:1. It is helpful to have a well-respected

consultant to champion the guidelines.2. The support of the Network is key.3. Involvement from the multidisci-

plinary team makes implementation more successful.

4. A clear process for implementation is needed from management down-wards. We:a. made presentations at different

forums from the Network Au-dit Day to a Dietetic Managers’ meeting;

b. developed and piloted a path-way on two units;

c. held a champions’ study day where we presented the process used to produce the guideline, the guideline itself, a version of the pathway and led a discus-sion on implementation.

The Guidelines are to be used in their original form across the Network, but health boards are adapting the path-way to fit local circumstances. Some of the key features of the guideline are dis-cussed below.

nutritional requirementsThe nutritional requirements of preterm infants are higher than for infants born at term and the reasons are multifactorial:• Low nutritional reserves/stores.• Immature organ systems - leading

to increased work of breathing and reduced digestion and absorption of nutrients, for instance.

• Increased risk of infection (due to immature immune system).

Care on the neonatal unit is designed to minimise the impact of these deficits; for instance, ventilation supports imma-ture lungs where necessary and babies are nursed in incubators or hot cots to minimise the heat loss from immature skin. However, comparison of nutri-tional requirements (see Table 1), dem-onstrates that, despite these measures, nutritional requirements are significant-ly higher in preterm infants relative to size, with additional difficulties in meet-ing these requirements. Embleton et al6 established that pre-term infants accrue an inevitable protein deficit that is strongly correlated with post-natal growth retardation on the neonatal unit. Poor growth velocity in preterm ne-onates has been related to risk of cerebral palsy, subnormal mental development

nutrition guidelineS on the neonAtAl unit

Kate harrod-Wildspecialist paediatric dietitian, Betsi Cadwaladr university health Board

kate harrod-wild is a Paediatric dietitian with almost 25 years’ experience of working with children in acute and community settings. kate has also written and spoken extensively on child nutrition.

there has been an increased emphasis on standardised feeding regimes in neonatal units in recent years. although there is still much research needed on optimal feeding regimes, standardised feeding regimes have been found to reduce rates of necrotising enterocolitis (nec), a potentially devastating complication of prematurity which can lead to gut necrosis, gut resections and even death.

preterm nutrition


Some babies are crying out for Similac AlimentumIt’s got proven acceptability,1 and because 93% of the peptides are <1,000 Daltons in size, it’s got hypoallergenicity all wrapped up too.2 So if a baby has an allergy to cow’s milk, don’t compromise, choose Similac Alimentum.

For more information, visit abbottnutrition.co.uk

References1. Data on �le. Abbott Laboratories Ltd., 2013 (AK94: Tolerance and compliance of infants fed an extensively hydrolysed infant formula). 2. Sampson HA et al. J Pediatr 1991;118(4):520-525. Date of preparation March 2014 RXANI140054.

Important notice: Breastfeeding is best for babies, and is recommended for as long as possible during infancy. Similac Alimentum is a Food for Special Medical Purposes and should be used under the supervision of a healthcare professional.

32925

32925 Similac Alimentum 223x320 DPS Arthur NHD Ad v2a-AW.indd All Pages 14/03/2014 17:29

index and neurodevelopmental impairment7. Neu-rological examination performed at 5.4 years by a neurologist blinded to perinatal outcome, found cognitive deficits were associated with intrauter-ine growth retardation (measured as weight at birth), poor neonatal weight gain and lower post-discharge head circumference8. Improved protein and energy intakes in just the first week were asso-ciated with improved neurodevelopmental scores at 18 months9. Time taken to stabilise respiratory status, delays in starting and increasing parenteral and enteral feeds and episodes of sepsis leading to feeds being stopped, all contribute to deficits in nutritional status for preterm babies while on neo-natal units. Most infants under <1500g will not tolerate full nutritional requirements enterally from day 1 and will need parenteral nutrition; this too will take several days to meet the infant’s full nutritional requirements. The immaturity of the preterm gut means that enteral feeds need to be advanced cautiously. However, it is important that enteral feeds are introduced as early as possible to prevent gut atrophy, leading to an increased risk of infection via the gut. However, advancing enteral feeds too fast risks NEC.

Therefore, trophic feeding (up to 24mls/kg/d) is increasingly standard practice on neonatal units; giving small amounts of feed enterally to keep the gut patent while building up parenteral feeds, until the infant is stable enough to increase enteral feeds. A recent large prospective study10 found that early introduction of enteral feeds in growth-restricted preterm infants, results in earlier achievement of full enteral feeding and does not appear to increase the risk of NEC. However, concerns regarding the risk of NEC mean that any change in practice around early feeding is likely to be viewed very conservatively. A new large multi-centred trial in the UK and Ireland undertaken by SIFT group (Speed Increasing Feeds Trial) aims to recruit 2500 very preterm or VLBW infants to compare advancement of feeds at either 30ml/kg/day or 18ml/kg/day. This trial will recruit infants who are fed either human or formula milk. Initial results are awaited.

Breast milKUse of breast milk has been well recognised to decrease the risk of NEC. Prospective, longitudi-nal nutritional studies in preterm infants started in the 1980s11, evaluating the influence of early dietary practices on clinical and neurodevel-opmental outcomes. In these early studies, any breast milk (MEBM or donor breast milk (DBM)) was shown to reduce the incidence of NEC by up to tenfold12. The protective effects of breast milk have been correlated with its anti-inflammatory com-ponents (IL-10), growth factors (EGF), erythro-poietin, lysozymes and immunoglobulins, as well as pre- and probiotics which favourably affect gut microflora13. Mothers should be given all necessary support to start expressing breast milk within a few hours of birth and encouraged to express at least eight times a day including at night. Techniques, such as ‘hands-on’ pump expression, can help to maximise volumes and suitably trained midwives and neonatal nurses should provide ongoing support to ensure vol-umes are maintained and breasts are emptied so that the calorie rich hind milk is expressed. Breast milk from the mothers of preterm infants is known to be higher in protein than the milk of term infants, helping to provide the necessary ex-tra protein intake (Table 2); although, after the first



few weeks, protein levels start to fall towards term levels. Where MEBM is not available, donor breast milk is thought to be helpful in reducing the risk of NEC in high risk infants (<28 weeks; <1000g; IUGR). However, this milk is often drip milk - so called because it drips from one breast while the baby feeds from the other. As a result, donor breast milk can be much lower in calories and pro-tein than standard breast milk, which has adverse consequences for growth. More recently, preterm donor milk has become available from some milk banks, which should be used whenever possible. In addition, some breast milk banks are making nutritional analyses of their donor milk available, which makes it easier to assess the nutritional ad-equacy of the milk that is being provided. As a result of the desire to use breast milk to minimise the risk of NEC and also maximise cognitive outcome, breast milk fortifiers (BMF) have been developed, which add calories, pro-tein and vitamins to breast milk, while enabling the full volume of breast milk to be given (see Table 2). Cochrane14 found evidence of improved short-term weight gain, linear growth and head growth with the use of BMF and no evidence of increased risk of NEC. Nevertheless, care should be taken with addition of breast milk fortifier to minimise any risk of NEC. BLISS recommends that breast milk fortifier is used in infants <1500g at birth and <34 weeks once they are on full feeds and serum urea is <4.0mmols/l and falling15. This is because there is a correlation between serum urea and protein content of milk16.

estaBlishing FeedsEnteral feeding will usually be established using orogastric or nastogastric tubes. Oral feeding starts to develop from 32 weeks; however, because of immature suck-swallow-breathe, most infants will not be able to breast or bottle feed totally until somewhere between 35 and 40 weeks gestation. Some units will send infants home while still tube fed, or on oxygen or both; policies differ locally depending on the services and support available to families in the community.

disCharge planningAdequate nutritional intake should be assessed as part of thorough discharge planning. For a baby

who has been on breast milk fortifier and is mov-ing on to breastfeeding, they need to be able to take enough milk from the breast to support growth. Since breast milk fortifier is not prescribable in the community, there are limited options available if the infant does not thrive. Some units will supply breast milk fortifier for parents to mix with some expressed breast milk, alternatively families may be advised to add formula powder to breast milk or give top up feeds of post discharge or nutri-ent dense formula. For infants who have been on preterm formula on the unit, they will typically be discharged on a nutrient enriched post discharge formula (NEPDF), which is typically half way in composition between a preterm and standard formula (see Table 2). These also contain higher concentrations of vitamins and minerals to meet the ex-preterm infant’s continuing higher require-ments. If an infant is breast milk fed or has a stan-dard term formula, they will need additional vita-min and iron supplements. If an infant is unable to take sufficient vol-ume of breast milk or a NEPDF to gain weight satisfactorily and is at or close to their due date, a term nutrient dense formula may be used (90-100kcals/100mls; 2.0-2.6g protein/100mls). These are not entirely suitable for preterm in-fants, but may be useful where infants are strug-gling to manage volumes, in conjunction with vitamin and iron supplements. Preterm infants are born at a nutritional disadvantage and the current evidence suggests that current neonatal care is not successful in helping them to overcome those early disadvantages. However, much work is going on to improve this situation in the future. Dietitians are not currently universally members of the neonatal team, despite the role of therapists - including dietitians - clearly being recognised in standards and guidelines for neonatal units in England17, 18, 19, Wales20 and Scotland21. Certainly within the Wales Neonatal Network plans are underway to ensure that these standards are met in the future. The involvement of suitably trained dietitians at clinical and policy level will help to ensure that, in the future, robust, standardised evidence based enteral feeding guidelines will help to ensure that preterm infants receive the best possible nutrition from their first day of postnatal life.


preterm nutrition



preterm nutrition

nutrient term infant3 Preterm infant koletzko 20144

Preterm infant1000g–1800g

eSPgHan 20105

energy (kcal/kg/day) 95-115 110-130 110-135

protein (g/kg/day) 2.0 3.5-4.54.0-4.5 (<1000g)

3.5-4.0 (1000-1800g)

sodium (mmol/kg/day) 1.5 3.0-5.0 3.0-5.0

potassium (mmol/kg/day) 3.4 1.9-5.0 2.0-3.5

Calcium (mmol/kg/day) 3.8 3.0-5.0 3.0-3.5

phosphate (mmol/kg/day) 2.1 1.9-4.5 1.9-2.9

table 1: nutritional requirements of preterm infants vs term infants

table 2: nutritional content of milks and fortifiers

energy (kcals/100mls) Protein (g/100mls)

preterm breast milk 70 1.8

preterm breast milk - >2 weeks postpartum

70 1.3

term breast milk 69 1.3

term breast milk + BmF 85 - 86 2.3-2.5

C&g nutriprem 1 80 2.6

sma gold prem 1 82 2.2

C&g nutriprem 2 75 2.0

sma gold prem 2 73 1.9

C&g hydrolysed nutriprem 80 2.6

references1 Patole SK and de Klerk N (2005). Impact of standardised feeding regimens on incidence of neonatal necrotising enterocolitis: a systematic review and meta-analysis

of observational studies. Arch Dis child Fetal Neonatal ed, 90, pp. F147-1512 east of england Neonatal Network (2012). enteral feeding on the neonatal unit. www.networks.nhs.uk/nhs-networks/southern-west-midlands-newborn-network/

guidelines-1/copy_of_guidelines/feeding-and-nutrition/Attachment%2010%20SwMNN%20enteral%20feeding%20jan%202012.pdf/view?searchterm=enteral%20feeding%20neonatal

3 DH (1991). Dietary reference Values: report on Health and Social Subject No 41. London: HMSO4 Koletzko b et al. eds (2014): Nutritional care of Preterm Infants: Scientific basis and Practical Guidelines. world rev Nutr Diet. basel, Karger. 110, 297-299 (DOI; 10.

1159/000360195)5 Agostoni c et al (2010). enteral Nutrient Supply for Preterm Infants: commentary from the european Society for Paediatric Gastroenterology, Hepatology, and

Nutrition committee on Nutrition. JPGN 50: 85-96 embleton Ne, Pang N, cooke rJ (2001). Postnatal malnutrition and growth retardation: an inevitable consequence of current recommendations in preterm infants?

Pediatrics (online) 107, 270-737 ehrenkranz rA, Dusick AM, Vohr br et al (2006). Growth in the neonatal intensive care unit influences neurodevelopmental and growth outcomes of extremely low

birth weight infants. Pediatrics (online) 117, 1253-618 Franz Ar, Pohlandt F, bode H et al (2009). Intrauterine, early neonatal and post-discharge growth and neurodevelopmental outcome at 5.4 years in extremely

preterm infants after intensive neonatal nutritional support. Pediatrics 123, e101-e1099 Stephens be, walden rV, Gargus rA et al (2009). First week protein and energy intakes are associated with 18-month developmental outcomes in extremely low

birth weight infants. Pediatrics 23, 1337-4310 Leaf A et al (2012). early or delayed enteral feeding for preterm growth-restricted infants: a randomised trial. Pediatrics. 2012 May;129(5): e1260-811 Lucas A, Gore SM, cole tJ et al (1984). Multi-centre trial on feeding low birthweight infants: effect of diet on early growth. Arch Dis child (online) 59, 722-3012 Lucas A, cole t (1991). breast milk and necrotising enterocolitis. Lancet 336, 1519-152313 Schnabl KL, Van Aerde, Je, thomas Abr, clandinin Mt (2008). Necrotising enterocolitis; a multifactorial disease with no cure. world J Gastroenterology (online) 14,

2142-216114 Kuschel cA, Harding Je (2004). Multicomponent fortified human milk for promoting growth in preterm infants. cochrane Database of Systematic reviews, Issue 1.

Art. No. cD000343. Available from http://dx.doi.org/ 10.1002/14651858.cD000343.pub15 King c and bell S (2010). Discussion paper on the use of breast milk fortifiers in the feeding of preterm infants. bliss briefings. bLISS www.bliss.org.uk/wpcontent/

uploads/2012/07/bliss_briefings_webV2.pdf16 Polberger SK, Axelsson Ie, räihä Nc (1990). Urinary and serum urea as indicators of protein metabolism in very low birthweight infants fed varying human milk

protein intakes. Acta Paediatr Scan 79, 737-4217 DH (2009). toolkit for high quality neonatal services18 bAPM (2010). Service Standards for Neonatal Services (3rd edition)19 NIce (2010). QS4 - Specialist Neonatal care Quality Standard20 NHS wales (2013). All wales Neonatal Standards (2nd edition)21 Scotland Neonatal Advisory Group (2013). Neonatal care in Scotland: a quality framework

http://dx.doi.org/

www.networks.nhs.uk/nhs-networks/southern-west-midlands-newborn-network/

www.bliss.org.uk/wpcontent/



Its aetiology can be traumatic or non-trau-matic. Traumatic causes, which are most common, include cardiothoracic surgery, head and neck surgery and radiation, while non-traumatic causes can be cardiac failure, sarcoidosis, benign tumours, amyloidosis and congenital duct abnormalities2. The incidence of a chyle leak after surgery is ap-proximately 1.0-4.0%3 and 0.2-1.0% specifi-cally following cardiothoracic surgery4. There is scope for large amounts of fluid to rapidly accumulate in the pleural cavity as approximately 2.4L of chyle is transported through the lymphatic system every day2. Chyle is an odourless, alkaline fluid, 70% of which is absorbed dietary fat, mainly triglycerides4. In the fasting state, chyle will normally be clear but will have a milky appearance after a fatty meal. Equal-ly, a person’s overall intake of fat, intestinal absorption and degree of physical activity5 will affect the fat content of chyle, but it generally ranges from 5.0-30g/litre4 or, in relation to body weight, will be between 10

nutritionAl mAnAgement of ChylothorAx PAtientS

shona scottCardiothoracic dietitian,royal Brompton & harefield nhs Foundation trust

Shona Scott works as a Cardiothoracic dietitian at the royal brompton & harefield nhS foundation trust. in her job she treats patients with a variety of cardiac conditions and chronic lung conditions such as Chronic obstructive Pulmonary disease. She regularly sees patients with chylothorax following cardiac surgery.

chyle passes from the intestinal lymphatics to the cisterna chili and then through the thoracic duct from which it will ultimately enter the venous system1. chylothorax results in accumulation of lymphatic fluid or chyle in the pleural space following leakage from the thoracic duct.

Chylothorax

table 14: a detailed biochemical breakdown of chyle.

Calories 200kcal/l

lipids 5-30g/l

protein 20-30g/l

lymphocytes 400-6800/mm

erythrocytes 50-600/mm

sodium 104-108mmol/l

potassium 3.8-5.0mmol/l

Chloride 85-130mmol/l

Calcium 3.4-6.0mmol/l

phosphate 0.8-4.2mmol/l

and >100ml/kg. Chyle has 200kcal/L and a protein content of 20-30g/L6, although some studies state that this can be as high as 60g/L5. In addition, chyle contains lympho-cytes, the majority of which are t-lympho-cytes, fat-soluble vitamins, electrolytes and enzymes. Table 1 shows a more detailed biochemical breakdown of chyle.

presentationGenerally, chylothorax is asymptomatic until large volumes of fluid accumulate and the se-verity of the symptoms will be related to the rate at which the fluid accumulates and the amount of fluid in the pleural cavity1. Trau-matic chylothorax normally develops within two to 10 days post injury1. The symptoms are typical of those seen with a pleural effu-sion and include dyspnea, coughing, chest discomfort and tachycardia7. More serious consequences of chylotho-rax and the most pertinent for this article are malnutrition due to the loss of protein, fats and fat-soluble vitamins4 and dehydra-tion, hyponatraemia and hypocalcaemia due to the loss of electrolytes2. The loss of lymphocytes can lead to immunosuppres-sion and increase the risk of infection, while the loss of large volumes of fluid can also cause hypovolaemia5.

diagnosisChylothorax is usually diagnosed by analysing the composition of the pleural fluid or chest drain. A triglyceride level of >110mg/dl is diagnostic of a chyle leak1, 2 and a level <50mg/dl rules out a diagnosis of chylothorax unless the patient has been fasting or is malnourished, in which case lipoprotein lipase analysis can be used4.



www.nutricia.co.uk

Monogen is a nutritionally complete*, low fat, powdered feed, for the dietary management of the following conditions:

Long chain fatty acid oxidation defects (LCFAOD)

Chylothorax

Lymphangiectasia

Lipoprotein lipase deficiency

Now

containing essential

fatty acids and LCPs***

High MCT and

Low LCT**

THE NEXTGENERATIONMONOGEN

COMING SOON...

*Suitable for use as a sole source of nutrition for infants and as a supplementary feed for children over 1 year of age and adults**100ml standard dilution (16.8g powder + 90ml water) provides: 74.6kcal; 2.2g total fat of whichLCT 16% and MCT 84% ***Linoleic acid 151mg; Alpha-linolenic acid 28.6mg; and LCPUFAs: DHA 10.1mg; AA 10.1mg

www.nutricia.co.uk

www.nutricia.co.uk

Monogen is a nutritionally complete*, low fat, powdered feed, for the dietary management of the following conditions:

Long chain fatty acid oxidation defects (LCFAOD)

Chylothorax

Lymphangiectasia

Lipoprotein lipase deficiency

Now

containing essential

fatty acids and LCPs***

High MCT and

Low LCT**

THE NEXTGENERATIONMONOGEN

COMING SOON...

*Suitable for use as a sole source of nutrition for infants and as a supplementary feed for children over 1 year of age and adults**100ml standard dilution (16.8g powder + 90ml water) provides: 74.6kcal; 2.2g total fat of whichLCT 16% and MCT 84% ***Linoleic acid 151mg; Alpha-linolenic acid 28.6mg; and LCPUFAs: DHA 10.1mg; AA 10.1mg

A chylothorax may exist even if the fluid is not milky and the fluid may be bloody in appearance. In non-traumatic cases, a CT abdomen and thorax should be performed to rule out malignancy2.

treatmentConsensus guidelines for the treatment of chylotho-rax are lacking 4, 7, but treatment can be conserva-tive or surgical. Varying criteria are given as indi-cations for surgery with some citing a chyle output >1000ml/day4 and others citing drain volumes that are >1.5l/24hrs or >1.0l/day over five days2, 5, or if there is persistent leakage of chyle for >two weeks2. Nutritional and metabolic complications arising from a chyle leak are also indications for surgery4. A more detailed treatment pathway can be seen below2. Conservative management includes placing the patient on a diet low in long-chain triglycerides (LCTs), whether orally or enterally, or placing the pa-tient on a Nil by Mouth regime and using parenteral nutrition. Somatostatin is also used in some circum-stances and has been used successfully in neonates4. It inhibits gastric, pancreatic and intestinal secretions, which helps to reduce chyle production1.

The key aims of nutritional management are to reduce the volume of the chyle leak (a chest drain will be in place to monitor these amounts) and to allow closure of it, to prevent malnutrition, and to replen-ish fluids and electrolytes that are lost4. As LCTs com-prise almost 70% of chyle4, chest drain volumes can be reduced by minimising the amount of LCT in the diet. This can be done orally or enterally using a spe-cialised enteral feed. Generally, if this is not successful in reducing the volume of chyle leak, then the pa-tient will be commenced on total parenteral nutrition (TPN)4, 5. A review carried out by Smoke and Delegge3 did not find adequate evidence to suggest one nutri-tional approach was better than another, but of course it is beneficial if more invasive, risky forms of nutri-tion such as TPN can be avoided. Initiation of a low LCT diet and the use of MCT fat in its place resolves 50% of congenital and traumatic chylothoraces8. This variable success is attributable to the fact that any oral or enteral feeding will contribute to chyle flow and because LCTs derived from the intestine come from endogenous and exogenous sources1. Prior to starting nutritional management of a chy-lothorax, it is important to note the patient’s baseline


Chylothorax

Figure 1: recommended treatment pathway for chylothorax

www.nutricia.co.uk


weight and biochemistry (serum electrolytes, lym-phocyte count, albumin and total protein)2 so that their nutritional status can be monitored during ther-apy. Those following an oral low LCT diet will have to eat larger volumes of food to meet their energy and protein requirements; consequently, those who are already nutritionally compromised and struggling to eat may be better off using enteral feeds rather than trying to follow the diet orally. Another approach is to supplement an oral diet with juice-based oral nutri-tional supplements, which provide valuable calories, protein and vitamins without any fat. Other fat-free or low-fat sources of protein include fat-free yoghurt and cottage cheese, fat-free or skimmed milk, egg whites and protein powders4. Some patients may require their diet to be supplemented with fat-soluble vitamins or a multivitamin and mineral supplement4.When calculating protein requirements of these patients, one should account for protein losses through the chyle leak as it contains 20-30g/L.

loW lCt dietAlthough there are no consensus guidelines, in prac-tise, patients following a low LCT diet with no more than 10g of LCT daily for six weeks, will see reduc-tions in chyle output. A previous review by McCray and Parrish9 found that dietary management is be-ing carried out for periods ranging from one week to 24. Talwar and Lee report that two weeks is often the limit for resolution by conservative management1. A major obstacle in the success of this diet is pa-tient confusion about what foods can be eaten and in what amounts. Therefore, patients should be given detailed diet sheets so that they are aware of hidden sources of LCT, the amounts of LCT in average por-tions of commonly consumed foods (fat exchange list) and foods that are free of LCT. Recipe ideas are also a useful way of improving adherence to the diet as patients can easily become bored due to the lack of palatability of lower fat foods. The Tables below show the foods that can be eaten freely on a low LCT diet, plus a typical day on a low LCT diet. It is virtually impossible to remove all fat from the diet, even vegetables such as broccoli contain 0.8g of LCT in 100g; however, patients are unlikely to be eating these foods in such large volumes that they will exceed the 10g/day threshold. It is more impor-tant that patients are made aware that they need to avoid foods that are rich in fat such as full-fat dairy products, red and processed meats, oily fish, most

biscuits, cakes, puddings creamy sauces and cereals such as muesli and nut containing breads. As fat is such an important contributor of ener-gy in the diet, these patients will need to substitute LCT with medium-chain triglycerides (MCTs). As MCTs are directly absorbed into the portal system bypassing the intestinal lymphatic system, they will provide crucial calories without contributing to chyle volumes. MCT is available as oils or in oral or enteral supplements and provides 8.3kcal/g4. MCT oil is not palatable for most patients but can work well if used in cooking or in baking. It should not be heated to a very high temperature as it has a low flash point so can burn easily. Generally, doses of 50-100mls or 385-765kcal worth of MCT oil across the day are well tolerated, but some patients will complain of abdominal pain, bloating or diarrhoea if given more4. There are several commercial MCT oils available, but they can be expensive and not all patients will be prescribed it by their GP if follow-ing the diet in the community.

enteral FeedsSpecialised enteral formulas can work well to resolve a chylothorax if a patient is unable to eat sufficient amounts orally or is not adhering well to a low LCT oral diet. In addition to being MCT based, some of these formulas are also elemental. It is important to be aware that these formulas will contain varying amounts of LCT; therefore, the total intake should be calculated when planning a regimen. When deciding on an enteral nutrition regimen McCray and Parrish4 suggest that:• enteral nutrition may be useful if chyle output is

<1000ml/day;• a low-fat semi-elemental formula may be effec-

tive if output is less than 500ml/day;• an elemental formula may be required if output is

greater than 500ml/day.These recommendations are based on the literature and clinical experience4.

parenteral nutritionIn unresponsive cases of chylothorax, or when nutri-ents are being lost rapidly into the pleural space, TPN is indicated5. Reports find that patients with a drain output of >1000ml while NBM will likely require TPN4. As lipids containing TPN do not enter the lym-phatic system they will not contribute to chyle pro-duction and can be used safely.


Chylothorax



Chylothorax

all fruits including fresh, tinned, or frozen (excluding olives and avocado)

all vegetables including those pickled in vinegar

Sugar,honey,goldensyrup,treacle,jam

Jelly, boiled sweets, mints (not butter mints)

Fruit sorbets, water ices, ice lollies, very low-fat frozen yoghurts

meringue, egg white, egg replacer

spices and essences, salt, pepper, vinegar, herbs, tomato ketchup, chutneys, marmite, oxo, Bovril

Fruitjuices,fruitsquash,fizzydrinksandmilkshakesmadewithskimmedmilkandCrushasyruporNesquik

table 2: Foods which can be eaten freely

table 3: example of day’s menu on 10g lCt diet

Breakfast:

1glassoffortified(CHOpowder)orangejuicetoast x 2 with 100g of baked beans and omelette (1 egg white cooked with mCt oil)

lunch:

200mls fat-free soupCooked pasta (90g raw) with 150g tinned tuna in brine, vegetable and tomato sauce (cooked with mCt oil as required)High-energyjelly(fortifiedwithCHOpowder)1 fat-free yoghurt

Dinner:

Fish cakes (60g of white fish, 60g boiled potatoes, 20mls skimmed milk to bind, use egg white and 1 slice of white bread for breadcrumbs) fried in mCt oilmashed potatoes (with skimmed milk) and boiled vegetablesstrawberry milkshake with 200mls of skimmed milk with flavoured powderFruit saladOffer3x200mlbottlesofjuice-basedoralnutritionalsupplementsthroughouttheday

essential Fatty aCidsPatients who follow an oral low LCT diet for more than three or four weeks will require sup-plementation with essential fatty acids (EFA)4. Linoleic acid is the required fatty acid as the body is unable to produce it. Linolenic acid and arachidonic acid can be made from the body if it has a sufficient source of linoleic acids. Daily re-quirements of EFA will be met by providing 2.0 to 4.0% of calories as linoleic acid4. This can be done using a range of easily available oils (wal-nut, wheat germ, sunflower), which can be used as salad dressings or added to foods such as pasta after cooking. If using walnut oil, 1.4tsps would provide four percent of energy for every 1000kcal4. Most enteral formulas will meet EFA requirements if used in specific volumes, as will lipid-containing parenteral nutrition formula-tions. The sedative propofol will also provide a source of EFA, a 150ml infusion would meet the EFA needs of a person who requires 2000kcal per day4.

summaryDespite the fact that dietary manipulation is such an integral part of the conservative management of chylothoraces, there is a distinct lack of evi-dence-based guidelines. The literature on the use of enteral or parenteral nutrition for its manage-ment is largely based on small observational tri-als, small retrospective trials and case reports7. It is important to do a full nutritional assessment of the patient prior to choosing the appropriate regi-men, be it oral, enteral or parenteral or a mix of these. Barriers to adherence to an oral low-fat diet should be alleviated by giving detailed oral and written guidance to patients about those foods that can be eaten freely, the fat content of foods and recipe ideas. Each patient’s need for addition-al supplementation with EFA and a multivitamin and mineral supplement should be considered. A patient’s nutritional plan should be regularly monitored to ensure that it is effective in reduc-ing chyle output and that nutritional status is not being compromised.



WeB WatCh

web wAtCh

Online resources and useful updates.

POOr care FOr OlDer HOSPital PatientS

gP PreScriBing in 2014The House of Commons library has published its latest briefing paper GP Prescribing in 2014: constituency statistics. Prescrip-tion rates for medicines and treatments provide one useful measure of the burden of illness and disease across the country. This paper provides statistics on prescriptions by GP practices in England as a whole and local variation for individual drugs and treatments. In 2014, an aver-age of 18.4 items were prescribed in primary care for each patient registered with a GP practice in England. This amounts to a total of just over one billion items prescribed. The total list price

PHarmaciStS Plan tO eaSe gP WOrklOaDUp to 250 clinical pharmacists are

mental HealtH key FactS aPPThe Royal College of Psychia-

allergy SuFFererS Put at riSk FrOm FaSt FOOD takeaWaySAn undercover investigation

OeSOPHagO-gaStric cancer aWareneSS camPaign: interim reSultSThe National Cancer Intelli-gence Network has published Be Clear on Cancer: oesophago-gastric cancer awareness regional pilot campaign: interim evaluation report. A regional oesophago-gastric cancer awareness cam-paign ran in the North East of England from 10 February to 9 March 2014. This interim report provides available results to date from an evaluation of the effectiveness of the campaign. A full and final evaluation report will be published when the analysis of all metrics is com-plete. Available at www.web.nhs.net with user login.

of these items was £8.6 billion - around £152 per head, with an average cost per item of £8.20. http://researchbriefings.parlia-ment.uk/ResearchBriefing/Su m mary/CBP-7161

Researchers from the London School of Economics (LSE) have published Older people’s experiences of dignity and nutrition during hospi-tal stays: Secondary data analysis us-ing the Adult Inpatient Survey. This report finds that older hospital patients in England face a ‘wide-spread and systematic’ pattern of inadequate care. An estimated one million people in later life are affected by poor or inconsistent standards of dignity or help with eating in hospitals. The report comes from data in the Adult Inpa-tient Survey for 2012-13 to provide a detailed picture of older people’s reported experiences during hospi-tal stays. http://sticerd.lse.ac.uk/dps/case/cr/casereport91.pdf

to be recruited to GP practices to provide direct patient care and help to ease workload. The £15m, three-year pilot project for England will see pharmacists support about one million pa-tients with self-limiting illnesses or long-term conditions. It is part of the GP workforce 10-point plan agreed between the BMA GPs committee, Royal College of GPs, NHS England and Health Education England. http://bma.org.uk/news-views-analysis/news/2015/july/pharmacists-plan-to-ease-gp-workload

by the Royal Society for Public Health has found that just over two thirds of takeaways are not declaring the presence of any of the 14 major allergens used as ingredients in their food. The investigation, which included 10 types of takeaways, found chicken shops to be the worst of-fenders. Legislation introduced in 2014 requires takeaways to be able to declare the presence of any of the 14 major allergens, provide notices in a clear vis-ible format and have a system in place to ensure information can be checked, is accurate and consistent. www.rsph.org.uk/en/policy-and-projects/areas-of-work/allergies.cfm

trists has launched a new app giving access to the College’s mental health information leaflets, videos and podcasts. RCPsych Key Facts App is avail-able from iTunes and Android Play Store. www.rcpsych.ac.uk/healthadvice/atozindex.aspx


http://researchbriefings.parliament.uk/ResearchBriefing/Summary/CBP-7161

http://sticerd.lse.ac.uk/dps/case/cr/casereport91.pdf

http://bma.org.uk/news-views-analysis/news/2015/july/pharmacists-plan-to-ease-gp-workload

https://www.rsph.org.uk/en/policy-and-projects/areas-of-work/allergies.cfm

http://www.rcpsych.ac.uk/healthadvice/atozindex.aspx

https://web.nhs.net/CookieAuth.dll?GetLogon?curl=Z2Fportal&reason=0&formdir=5


WeB WatCh

PrOmOting HealtHy DietS amOng cHilDren anD yOung PeOPle

imPrOVing HealtH anD WellBeing tHrOugH Digital tecHnOlOgieSThe top prize in the People Driven Digital unAwards has been won by an online app which can help save the life of a person experiencing cardiac arrest. The Lifesaver app acts as an interactive crisis simula-tor which uses live-action film to teach the user how to perform CPR and use an automated defibrillator. Further details of all the finalists and the winners for each award category, which includes My COPD, Brush DJ, Timesulin and iPad engage, can be found here: http://mhealthhabitat.co.uk/pdd-award-finalists/

Dementia careThe Alzheimer’s Society has published its fourth annual report Dementia 2015: aiming higher to transform lives. This report looks at the quality of life for people with

PHySical actiVity in cHilDren

management OF irOn DeFiciency anaemia

recOrD Seizure OF cOunterFeit anD unlicenSeD meDicineS anD DeViceS maDe in uk

rare anD leSS cOmmOn cancerSThe National Cancer Intelligence Network in collaboration with Cancer 52 has published Rare and less common cancers: Incidence and Mortality in England, 2010 to 2013. Rare and less common cancers make up just under half of all newly diagnosed can-cers: 47% for 2013 in England for both males and females. As of 2013, there are around 2700 more deaths annually from rare and less common cancers than in 2010. Counts and crude rates are presented for 278 rare and less common cancer sites for incidence figures and 95 sites for mortality figures. The data covers the period 2010 to 2013 and is broken down by year and sex for England. Data relating to many of these sites has not been published routinely before. www.ncin.org.uk/publications/

The BMA has published Food for Thought: promoting healthy diets among children and young people. This report sets out the measures needed to help promote healthier diets among children and young people. It recommends a range of interventions focused on improv-ing attitudes and knowledge; limiting unhealthy cues and ir-responsible retailing practices and creating a healthy food environ-ment. Some of the measures aim to directly protect children and young people, while others are to help parents and carers in making the right choices. http://bma.org.uk/working-for-change/improving-and-protecting-health/food-for-thought

dementia in England and contains the results of the Society’s annual survey of people with dementia and their carers, plus an assess-ment of what is currently in place and needs to be done to improve dementia care and support in England over the next five years. It makes practical recommendations to the new government on the steps that need to be taken to make quality of life better for people with dementia. www.alzheimers.org.uk/site/scripts/documents_info.php?documentID=2888

The Medicines and Healthcare products Regulatory Agency has announced £15.8 million worth of counterfeit and unlicensed medicines and devices that have been seized in the UK as part of a global operation. The seizures, the biggest recorded to date in the UK, include large quantities of illegally supplied and potentially harmful slimming pills, anaemia tablets and narcolepsy tablets. Unlicensed foreign medicines were also found and removed. www.gov.uk/government/news/uk-leads-the-way-with-158-mil-lion-seizure-in-global-operation-targeting-counterfeit-and-unli-censed-medicines-and-devices

Public Health England has published Change4Life Evidence Review: rapid evidence review on the effect of physical activity participa-tion among children aged 5-11 years. This rapid evidence review aims to identify relevant literature on the physiological, psychological, social and behavioural outcomes of physical activity participation among children in that age group, and provide an indication of the strength of the evidence for each outcome. www.gov.uk/govern-ment/publications/change4life-evidence-review-on-physical-activ-ity-in-children

The Royal College of Nursing has published new guidance on iron deficiency and anaemia in adults. This guidance has been published along with other new resources on the topic and is aimed at all nurses, healthcare assistants, midwives and health visitors from all special-ties and backgrounds. www.rcn.org.uk/newsevents/news/article/uk/new-guidance-for-the-manage-ment-of-iron-deficiency-anaemia

http://mhealthhabitat.co.uk/pdd-

www.ncin.org.uk/publications/


http://bma.org.uk/search?query=working-for-change/improving-%20and-protecting-health/food-for-%20thought

http://www.alzheimers.org.uk/site/scripts/download_info.php?fileID=2700

https://www.gov.uk/government/news/uk-leads-the-way-with-158-million-seizure-in-global-operation-targeting-counterfeit-and-unlicensed-medicines-and-devices

https://www.gov.uk/government/publications/change4life-evidence-review-on-physical-activity-in-children

https://www.rcn.org.uk/newsevents/news/article/uk/new-guidance-for-the-management-of-iron-deficiency-anaemia


Many older people who suffer from de-mentia or a number of other conditions, or who have had a stroke continue to live with dysphagia, and an Australian review study found that dysphagia in older adults occurs in:• 13% of free living population• 25% of those in hospital• 60% of those resident in nursing

homes1

Understanding the food and fluid textures required for people with dys-phagia is, therefore, important for any dietitian working with older people. It is also important to have some knowl-edge and understanding of the products currently available, to help achieve both advised texture and an adequate nutri-tional intake. However, evidence of the benefits of texture modification of both fluid and food and the most advanta-geous textures is surprisingly scant2.

thiCKenersPrescribed thickeners are used to thicken fluids to a more viscose consistency than normal, because drinking thicker fluids has long been thought to reduce risk of aspiration for people with dysphagia. A recent systematic review has identified that thickening liquids can reduce risk of aspiration, but thickened fluids can also increase risk of residue remaining in the pharynx after swallowing (Steele et al 2015) which could then be aspi-rated at a later stage. Other studies have suggested use of a ‘free water protocol’ for people with dysphagia who meet

certain criteria, but this is only likely to be appropriate for those who are both mobile and have ‘relatively healthy cog-nitive function’3, 4 which may rule out the majority of older people with dys-phagia. Having said all of this, at least for the time being, thickened fluids re-main a cornerstone of dysphagia man-agement in the UK. Thickeners can also be used to pro-vide consistency in pureed food, pre-venting purees from splitting into solid and liquid once pureed.

starch based thickeners (see Table 1)The majority of thickeners are still made from modified starch which, when mixed with fluid, can have sev-eral less than desirable characteristics. Mouth feel can be ‘granular’ rather than smooth, which can be off-putting for patients, and most starch based thicken-ers also have the disadvantage of being sensitive to amylase (a component of saliva). This can be a significant issue because saliva will be introduced to the thickened drink from the first sip. If, as is common in dysphagic patients, it takes a long time to finish a drink, the action of amylase on the thickener can result in the drink in the glass or cup separating into two or more textures over a period of time, or can result in the action of the thickener being lost altogether5 - both of which may increase risk of aspira-tion. However, the action of amylase on starch-based thickeners is also depen-dent on pH of drinks and Hanson et al6 found that, while amylase broke down

dySPhAgiA ProduCt uPdAte

alison smith rdprescribing support dietitian, Chiltern CCg and aylesbury vale CCg

Alison specialises in appropriate prescribing of nutritional products and in appropriate identification and treatment of malnutrition, especially in older people living in the community and in care homes. Alison is a committee member of the bdA older People Specialist group.

this is now the second update of this article (first published in nHD in 2011). Since the last update in 2013, a few new products have become available, but what feels most significant to me is the first advertisement i have ever seen in a national, mainstream magazine for pureed food, suggesting that recognition of the need for modified texture food is growing.

dysphagia




thickener in water very quickly, it did not have the same action when thickener was mixed with orange juice. Starch-based thickeners can take a few min-utes to thicken to the correct texture and it is not uncommon when a drink does not thicken instantly, for patients or carers to add extra thick-ener, thinking that the amount they added ini-tially was insufficient. This can obviously result in the drink becoming significantly thicker than the advised consistency, which can impact on the safety of swallowing2 and is likely to reduce pal-atability, as the thicker a drink is, the less well it tends to be tolerated5, 7. The way that starch-based thickeners work also means that a drink thickened with a starch-based thickener tends to continue to thicken over time, so that even if the correct texture is achieved initially, the drink may become thicker the longer it is left8. Again, as people with dysphagia can take a long time to consume a drink, this is of real concern if intake of thicker drinks can increase risk of residue remaining in the pharynx2.

gum based thickeners (see Table 2)In the last few years, several thickeners con-taining gums, either instead of or in addition to starch, have been launched. There can be some significant advantages to these products in terms of safety and palatability - gums are not broken down by amylase, making them potentially safer products and gum-based thickeners may not cause the same ‘granular’ texture in thickened drinks as starch-based thickeners. The thickening process of gums is also different to that of starch, so that they tend to thicken more quickly and maintain their texture for longer, so that drinks containing gum-based thickeners should not get thicker over time. However, introduction of saliva (and therefore amylase) to a drink thickened with a combination of starch and gums, may still result in the fluid breaking down into a thinner consistency5. It is also important to note that not all gum-based thickeners will thicken drinks immedi-ately, and because gum-based thickeners behave differently to starch-based thickeners, a differ-ent technique may need to be used when add-ing them to drinks. This is particularly pertinent

when considering thickeners prescribed for use in care homes, as without training, staff may be unaware that gum-based thickeners require a different mixing technique. Concerns have been raised regarding the bioavailability of water when gum-based thick-eners are used because, unlike starches, gums tend not to be broken down until they reach the large intestine. A review by Cichero found only two studies which had investigated this con-cern and both found no impact of thickening on bioavailability of water, regardless of the type of thickener used1. Usually, fluid needs to be added to a gum-based thickener and, once mixed, no further thickener can be added. Most scoop sizes for gum-based thickeners will thicken 100ml fluid to stage 1, which is appropriate for drink volumes. However, liquid medications are also likely to need to be thickened and, although the volume per dose tends to be significantly smaller than 100ml, a smaller measure is not currently pro-vided to accommodate this requirement. This means that liquid medications may be given in their unthickened state or, alternatively, thick-ened to a different texture than that advised.

other ConsiderationsMertz Garcia et al8 and Sopade et al9 found that many different factors (including pH, fat and protein content) can influence how thickeners in-teract with different fluids. This means that dif-ferent types of fluid may need different amounts of thickener added in order to achieve the same texture. Thickening fluid can slow its transit through the mouth which, as well as potentially helping to achieve a safe swallow, can also affect how taste is perceived. This means that the person who re-quires thickened fluid may find that drinks they would normally enjoy now taste less pleasant, which of course can put people off drinking ad-equate fluid or using thickener as advised. Several studies have demonstrated that peo-ple with dysphagia frequently fail to consume adequate fluid, and that increased fluid viscosity correlates with lower fluid intake7, 10. It is also interesting to note that when stage 3 flu-ids are taken as small spoonfuls (as may be advised by speech and language therapists), this, together


dysphagia


Nutilis Clear has

been designed to

maintain the original

appearance of drinks,

which may support

compliance and

improved fluid intake.

Transparent resultsMyNutilis.co.uk

The new MyNutilis.co.uk website aims to inspire patients and carers to cook delicious meals with Nutilis Clear.

Visit the website for recipes, news items and videos of Chef Neil making meals that look and taste appealing to patients.

Tin Size (g) FP10 Price*Cost per

Stage 1 drink**No. of Stage 1 drinks** per tin

Nutilis Clear 175 £8.46 £0.15 58

Nutilis Powder 300 £4.92 £0.13 37

Thick & EasyTM 225 £5.06 £0.20 25

Resource ThickenUp® Clear 125 £8.46 £0.16 52

*MIMS, March 2015; **200ml drinks as per manufacturer dosage instructions.

http://mynutilis.co.uk/recipes?gclid=CNiZhLfVkccCFUKWtAod1ogAXQ

http://mynutilis.co.uk/recipes?gclid=CNiZhLfVkccCFUKWtAod1ogAXQ

with the increased oral transit time, means that even those without dysphagia tend to consume 1.2 to 1.3 times less fluid than if the fluid was taken as larger mouthfuls and if the fluid had a shorter oral transit time1. Dehydration can, therefore, be a significant risk for those requiring thickened fluids. Reducing risk of aspiration may reduce the likelihood of chest infections and aspiration pneu-monia and, therefore, reduce or avoid the costs of treating these conditions (prescription of antibiot-ics with or without acute admission). However, it is also important to remember the other poten-tial costs of failing to thicken fluids adequately or palatably. If thickened fluids are unpalatable, patients may choose to drink unthickened fluids or to drink an inadequate volume of thickened fluids, thereby increasing their risk of aspiration and/or dehydration, UTIs and constipation, all of which can result in healthcare costs, as well as reduced quality of life for the patient. Storage of thickeners on wards and within care homes may also needs careful consideration following publication of an NHS Patient Safety Alert11 earlier this year regarding the need to safeguard patients who could be at risk of ingest-ing thickener powder, following the unfortunate death of one patient who did this.

Considerations when requesting or reviewing prescriptionsCost pressures within the NHS continue to be sig-nificant and as health professionals we all need to be mindful of the costs of the products which we may discuss with patients or request GPs to pre-scribe. As in the previous versions of this article, I have included current prescription costs of all the products listed below to aid consideration of cost effectiveness. It is important though to note that, in many acute settings and in some community set-tings too, contracts with nutrition companies may render specific products significantly cheaper than the FP10 (prescription) prices quoted. GPs are likely to need guidance so that they understand the quantity of thickener required to thicken an adequate amount of fluid each day to the recommended consistency. I regularly come across prescription of only one or two tubs of thickener per month due to GPs’ lack of knowl-edge of these products. To thicken the minimum daily fluid requirement of 1600ml12 to stage 1 each day for one month will require four to five tubs of a gum-based thickener and six to nine tubs of a starch-based thickener. In my experience, GPs can be surprised when asked to prescribe an adequate amount of thick-


dysphagia

Product manufacturerthickener

ingredients

cost per tub(£)

Quantity of thickener required

per month to thicken 1600ml fluid per day to

stage 1 (kg)

Prescription cost per month of thickening 1600ml fluid per day to stage 1 (prepared

according to manufacturer’s instructions (13) (Costs from

mims June 2015) (£)

multi-thickabbott

modified maize starch

4.83/250g 1.814 35.05

nutilis powdernutricia


4.92/300g 1.792 – 2.688 29.39 - 44.08

resource thickenup

nestlémodified maize

starch4.55/227g 2.016 40.41

thick and easyFresenius Kabi


5.06/225g 2.016 45.34

thicken aidm & a

pharmachem

modified maize starch maltodextrin

3.71/225g 2.016 33.24

thixo-d originalsutherland


vitaquickvitaflo


7.05/300g 1.500 35.25

table 1: starch based thickeners

5.79/375g 2.24 34.59


ener, but may then realise that their previous inadequate prescribing could have been putting patients at risk. GPs are also likely to need clear advice regard-ing exactly which product is required (and which is not), as the similarity of many of the thickener names (when both starch- and gum-based thick-eners are produced by the same company) may otherwise result in the wrong product being pre-scribed – again, I come across this error in pre-scribing very frequently and care home staff and patients may not notice that the product which is prescribed is not correct. Slõ Drinks, best known for producing pre-thickened drinks, have recently developed thick-

eners specific to types of fluid which tend to be more difficult to thicken safely and palatably - namely alcohol and fizzy drinks. These products are not currently ACBS listed, therefore cannot be prescribed, but are available to purchase.

pre-thiCKened drinKsPre-thickened drinks can be helpful for patients who find it difficult to prepare thickened drinks, for example due to limited manual dexterity or poor eyesight, and there are two products cur-rently on the market, one of which requires the addition of water. The cost of pre-thickened drinks can be an issue, but in some cases, these products may


dysphagia

Product manufacturerthickener

ingredients

cost per tub(£)

Quantity of thickener required

per month to thicken 1600ml fluid per day to

stage 1 (kg)

Prescription cost per month of thickening 1600ml fluid per day to stage 1 (prepared

according to manufacturer’s instructions (13) (Costs from

mims June 2015) (£)

nutilis Clear

nutricia 8.46/175g 0.672 32.49

resource thickenup Clear

thick and easy Clear Fresenius Kabi 8.80/126g 0.627 43.79

thixo-d Cal-Free

table 2: gum based thickeners

Product manufacturerconsistency

availableVolume

nutritional content per

serving

Prescription cost per serving (and cost

per month if 1600ml fluid provided per

day) (mims June 2015) (£)

resource thickened drinks

nestlé‘Syrup’

‘Custard’114ml cup

101-103 kcal (both textures)

0.71(279.02)

slõ drinks slõ drinksstage 1 (cold/hot)stage 2 (cold/hot)

stage 3 (cold)

115ml cup (requires

addition of water)

24-57 kcal30-63 kcal 56-57 kcal

0.30(116.87)

table 3: pre-thickened drinks

tara gum

Dried glucose syrup

8.46/125g 0.537 36.34maltodextrin

xanthan gumnestlé

maltodextrinxanthan gumCarageenan

sutherland xanthan gum 2.57/30g 0.280 23.99


still be a cost-effective choice. Pre-thickened drinks tend not to have the ‘granular’ texture of an added starch-based thickener, which may aid compliance and thereby increase fluid in-take. They should also automatically be the correct texture for the patient, which may help reduce risk of aspiration. Therefore, use of pre-thickened drinks may help to reduce common health risks (dehydration and aspiration) for the patient with dysphagia. Having said that, the texture descriptors are different for each product which can be confus-ing and make choosing the correct consistency more difficult.

pre-thiCKened oral nutritional supplements (ons)How to achieve a consistently thickened ONS has been an issue within all care settings for years, so pre-thickened sip feeds have certainly filled a gap in the market.

There are two companies currently producing pre-thickened ONS in Stage 1 and Stage 2 consis-tencies, and dessert type ONS made by all nutri-tion companies are usually suitable for patients requiring Stage 3 thickened fluids. Pre-thickened ONS do cost more than non-thickened equivalent products, but the cost of the thickener and cost of the consequences of inap-propriately thickened (or unthickened) sip feeds must also be taken into account when looking at the overall cost incurred. For example, Fresubin Thickened costs £2.28 per bottle compared with Fresubin Protein Energy which costs £2.02 per bottle; however, sufficient Thick and Easy or Thick and Easy Clear to thicken the latter to Stage 1 would cost approx 20p. In addition, pre-thick-ened ONS are guaranteed to be the correct texture without any preparation time or issues around consistency which may help reduce risks of both aspiration and malnutrition for the patient with dysphagia.


dysphagia

Product manufacturerconsistency

availableVolume

nutritional content per

serving

Prescription cost per serving

(mims June 2015) (£)

Fresubin thickened

Fresenius Kabi

stage 1stage 2

200ml300kcal

20g protein2.28

nutilis Complete

nutriciastage 1stage 2

125ml306kcal 12g

protein2.21

table 4: thickened ons - stages 1 and 2

Product manufacturer Volumenutritional content

per serving

Prescription cost per serving

(mims June 2015) (£)

ensure plus Crème abbott 125g171kcal

7.1g protein1.88

Forticreme Complete

nutricia 125g200kcal

11.9g protein1.96

nutilis Fruit stage 3 nutricia 150g200kcal

10.5g protein2.36

Fresubin 2kcal Creme

Fresenius Kabi 125g250kcal

12.5g protein1.93

Fresubin yocreme Fresenius Kabi 125g187kcal

9.3g protein1.98

nutricrem nualtra 125g225kcal

12.5g protein1.40

resource dessert energy

nestlé 125g200kcal

6g protein1.59

table 5: ons - stage 3


pureed FoodSeveral companies, including Apetito/Wilt-shire Farm Foods, Oakhouse Foods, Kealth and Simply Puree produce pureed meals for adults with dysphagia and most offer home delivery for individuals and some are also offered by Meals on Wheels services. Thickener is added to most of these pureed foods to maintain texture and if the thick-ener used is starch based, the same concerns regarding maintaining consistency once the food comes into contact with saliva and, there-fore, amylase exist as for drinks. Again if a pa-tient takes a long time to swallow the food or transfers saliva from their mouth to the plated food, this can result in the food splitting into solid and liquid, potentially increasing risk of aspiration. Many of the dishes available are moulded so that their appearance is better than can eas-ily be achieved for food pureed in either a

domestic environment or many care environ-ments. Some of these companies also ensure that the energy and protein content of the meals is high. This is especially important as the nutritional intake of those consuming pu-reed food tends to be lower than that of equiv-alent patients consuming normal food, and patients having pureed food frequently fail to meet their nutritional requirements for either energy or protein14.

ConClusionPrevalence of dysphagia is high in the age-ing population and as the ageing population grows, is likely to become more of an issue in the coming years. Having an understanding of the dysphagia products available will help when advising pa-tients with dysphagia and when working with colleagues, especially speech and language therapists and GPs.


dysphagia

. . . Your essential resource

NHDmag.com . . .




After this, I was lucky enough to get a job in a large teaching hospital in Bris-bane, Queensland. My preferred area is paediatrics, so I worked in every area there was whilst waiting for a paediatric job to come up!

learning the diFFerenCesI currently work in a tertiary children’s hospital in Brisbane, Lady Cilento Chil-dren’s Hospital. Many aspects of my day-to-day job are similar to my time working as a dietitian in Ireland and the UK. However, some things here are vastly different.

KJs

Whist studying for the DAA exams, I realised that Australia uses Kilojoules/Megajoules instead of calories, which is a difficult concept to grasp as a di-etitian trying to do calculations and working in numbers that can go into tens of thousands! Thankfully, now where I work, we talk in calories and I don’t need to divide everything by 4.2 for it to make sense.

Foods & drinKsI spent many happy hours wander-ing around the supermarkets trying to memorise name of foods and brands (so I can ask my favourite question, “Is it the blue top milk you have?”). After learn-ing the proper names of everything, I then had to go back and try to under-stand all the slang words and abbrevia-tions that people use over here. My first diet history consisted of something like this (see Table 1). As well as understanding the com-plexities of Aboriginal foods and cul-ture, I also had to learn the dietetic lingo; saying ‘serve sizes’ instead of portions and asking about tablespoons and cups instead of grams. WHENBEINgSICKIS‘CROOK’Learning the medical abbreviations felt like I had to learn another language (note: nasojejunal feeds NJ = TPT - trans pyloric tube?!). I am thankfully famil-iar with many of the feeds that we use (i.e. Nestle, Nutricia, Abbott) although the range is much smaller. I find myself lamenting over flavours that we don’t

Claire riley, dietitan (accredited practising dietitian in australia, apd), lady Cilento Children’s hospital

Claire has experience working in ireland, the uk and Australia. She completed research in the united States on obesity and in sports nutrition in the uk. Claire is passionate about working in paediatric dietetics. her dietetic experience spans across adults, paediatrics, community and sports nutrition.

a day in the liFe oF . . .

i have been working as a dietitian in australia for the past three years. i passed the Daa (Dietetics association of australia) exams, which were some of the most stressful and expensive exams i have ever taken in my life!

. . . A dietitiAn down under



have here, but I did quickly learn that it’s not helpful to tell patients, “Well, if you were in the UK, you could get that flavour!”

Formulas and FeedsFormulas and feeds here are discussed in kcal/ml, kcal/30ml, percentages, kJ/ml and in strengths, i.e. ‘1.25%’ strength. This was mind boggling for checking and rechecking my cal-culations and also for educating families. There can be updates sent to us by the feed compa-nies that certain feeds are out of stock or, are in short supplies reaching Australia. I quietly pray that none of my families hear about these shortages and everything comes on time. If not, panic can spread and I get dozens of calls from families demanding to know what’s hap-pening with their deliveries.

CostsCost is significantly different to the UK and Ireland. Patients in Queensland need to pay a subsidised amount for their feeds, consum-ables and deliveries. As a result, I am more considered in my approach to recommending nutritional supplements and feeds to families. Using the golden oldie ‘High Protein High Calorie’ information can be the best advice I give out when financial considerations are involved. This has forced me to think outside of the box and let go of my rigidity with pre-scribing nutritional supplements!

australia’s puBliC health messageAustralia also has a totally different public health nutrition message, which I was ini-tially shocked to discover. Australia follows

the ‘5 & 2’ recommendation for fruit and veg-etables (5 = vegetables, 2 = fruit). There is no UK healthy plate model or food pyramid. All of a sudden, the ‘five-a-day’ motto for fruit and vegetables that I once treasured wasn’t enough. I sometimes think I should be over compensating for all the vegetables I missed out on to make up for this huge deficit. I take my dietetic clinics very seriously here, knowing that some families have driv-en for hours, or have flown their entire fam-ily down for my appointment and left their farms and properties. I am very aware of the difficulties that some families have living remotely, includ-ing their access to food, local healthcare and sometimes even telephone coverage. In these instances, I need to make up feeding plans that cover a wide range of issues. This has been a really challenging learning experi-ence for me as a dietitian, forcing me to think ahead and plan for every eventuality without overwhelming the families. I have found Australian medical teams much more informal than those in Ireland or in the UK. I often see my consultants at work in jeans/shorts and insist on everyone includ-ing families use their first names (and nick-names!) at ward rounds and appointments. Consequently, I’m far more able to ask my sil-ly questions and put forward my suggestions to teams in this relaxed work environment. Overall, moving to Australia and work-ing as a dietitian has been an incredible ex-perience and I would encourage anyone who wants to move here to come. But start study-ing for the exams now!

a day in the liFe oF . . .

the meal What was said What it means

Breakfast rice Bubbles and a milo rice crispies breakfast cereal and a flavoured milk drink

lunch Cheerios, toast with nuttlex, an lCm bar and a popper

small sausages, toast with a brand of butter,abreakfasttypebarandajuicedrink

dinner hot chips, zucchini with rissoles Chips, courgettes, small balls of fried mince

snacks pikelets/lamingtons/ice block/lollies/ small pancakes/a type of cake slice/iced lolly/sweets

table 1



Career

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)

We urgently require dietitians for immediate vacancies

To find out your options call or email

Freephone: 0800 032 0454 [email protected]

• 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

paediatriC dietitian - norFolKA Paediatric Dietitian is required from 10th August for four weeks covering general paediatric outpatient clin-ics and general ward work, seeing children with falter-ing growth, allergies and fussy eating. For this or other

dietetic vacancies with Elite, please contact Hayley on 0800 023 2275, or email your CV and interest to [email protected] www.elitedietitians.com

dietitian senior ii - giBraltar health authority: £28,371 to £37,383 paNow is your opportunity to sample the Mediterranean way of life. Gibraltar, a British dependency on the south-ernmost tip of the Iberian Peninsula is the ideal base for exploring the delights of Southern Spain and the magical North African continent. We are looking for an enthusiastic, experienced and highly motivated Band 6 Dietitian, with a broad-based background in general dietetics. The successful candidate will have a varied caseload including acute (medical /surgical) wards, long stay wards and general outpatient clinics, as well as providing training/edu-cation for nursing staff as required. You would be part of a team of three highly experienced Dietitians who would provide you with clinical supervision and support. The appointment will be on contract terms for a period of 10 months to cover a period of maternity leave. Please contact Ms Katrina Skilton, Senior Dietitian, tel: 00350 20072266 ext 2199 or email: [email protected]. Application Packs are obtainable from the Recruitment Section on ext 2081 or Fax: 00350 20043864 or e-mail: [email protected]. Closing Date: Monday 17th August 2015

Continued . . .


www.pjlocums.co.uk

www.elitedietitians.com






0800 023 [email protected] www.elitedietitians.com

Elite Recruitment are a specialist supplier to private hospitals & commercial companies. We are a preferred supplier to NHS trusts nationwide and are the only agency dedicated

to dietetic recruitment.

Can you afford to miss out on registering with elite? The only recruitment agency to supply solely to the Dietitians industry for commercial and private companies across the UK. Either call or email your interest today and receive our free job alerts.

The Number 1 agencyfor Dietetic Recruitment

JOB OF THE MONTH

ADULT AND PAEDIATRIC DIETITIANS REQUIREDWe are urgently looking for experienced dietitians to cover positions across the whole

of the UK. We have Full and Part Time Posts available in both Acute and Community settings Excellent rates of pay – up to £35.00ph.

Band 6 aCute dietitian - Basildon, essexBand 6 Dietitian required for four days for seven weeks. Stroke and surgery experience required. Ex-cellent Rates offered for the right dietitian. Please call 01277 849 649 or email [email protected] for more information on this role. www.elitedietitians.com

paediatriC dietitian essex - ColChesterThis job entails general paediatric dietetics, including the children’s ward and paeds clinics. Clinics may in-clude general paeds, oncology clinics, CF MDT clinics and home feeds. This role is covering a fixed-term con-tract, so they are looking for a locum to fill the role for at least three to four months while they recruit. There would, therefore, be an option for the role to switch to the fixed-term contract. To be considered, please email [email protected] or call 01277 849 649, or visit www.elitedietitians.com

paediatriC dietitian - three days a WeeK (essex)Starting 12/8/15. This would be someone with paeds experience at Band 6/7. Two days a week in North East

London and one day a week at Romford. Caseload is a mixture of clinics/children’s centre drop-ins/weight management programme. For this or other dietetic va-cancies with Elite, please contact Hayley on 0800 023 2275 or email your CV and interest to [email protected], or visit www.elitedietitians.com

Band 5/6 Community dietitian 2.5 days a WeeK (BerKshire)Starting ASAP to cover an Adult and Paediatric caseload, involving clinic. Likely length of contract will be until March 2016. Excellent rates offered for the right dietitian. Please call 01277 849 649 or email [email protected] for more information on this role. www.elitedietitians.com

paediatriC Community dietitian – BerKshire - asapTwo days a week of Specialist Community Paediatric cover, to work within CYPIT services (children and young people’s integrated therapies) until next sum-mer 2016. For this and other dietetic vacancies with Elite, please contact Hayley on 0800 023 2275 or email your CV and interest to [email protected], or visit-www.elitedietitians.com


Career














speCialist paediatriC dietitian - s englandBand 7 Specialist Paediatric Dietitian with experience of diabetes, carbohydrate counting and insulin pumps for an ongoing post. The role is hospital based in the South of England. Email your CV to [email protected]. Our rates are competitive in the current market; we offer assistance with relocation and hospital accom-modation. We provide you with a current CRB, full occupational health check and can organise your man-datory training. PJ Locums is an NHS Government Pro-curement and LPP framework approved supplier for Allied Health, Health Science personnel and nurses.

Band 7 dietitian - immediate startA busy Central London hospital is looking for a Band 7 Dietitian immediate start. Must have experience in diabe-tes: pumps, dose adjustment, complication clinics. Email your CV to [email protected]. 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 per-sonnel and nurses.


Career

uniVerSity OF nOttingHam - ScHOOl OF BiOScienceS Modules for Dietitians and other Healthcare Professionals• Public Health Nutrition Policy - 19th Nov, 2015• Diabetes 1 & 2 - 14th Jan, 2016For further details please email [email protected], 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

14-16th Aug - International Critical Dietetics Conference Manchester International Conference Centre www.criticaldietetics.org

4th-6th Sep - BSACI Annual meeting The British Society for Allergy and Clinical Immunology Telford International Conference Centre, Telford www.bsaci.org/meetings-and-events/index.htm

9th Sep - BDA Branch CPD Meeting NW England North Wales Branch Lance Dobson Hall, University of Chester Warrington Email: [email protected]

11th Sep - Recipe Analysis: Maximising Accuracy - Nutrition and Wellbeing Course Kings College London. www.susanchurchnutrition.co.uk/recipe-analysis-training/

18th Sep - Recipe Analysis: Maximising Accuracy - Nutrition and Wellbeing course Food Nation, Newcastle-upon-Tyne www.susanchurchnutrition.co.uk/recipe-analysis-training/

28th Sep - Targeted Treatments for Cancers of the Digestive System The Education and Conference Centre, LondonSW3 6JJ www.royalmarsden.nhs.uk/education/

30th Sep - Management of Chronic Kidney Disease Stage 4-5 - BDA Trainer London Road Community Hospital, Derby www.ncore.org.uk

30th Sep - Obesity Management - University of Nottingham School of Biosciences Modules for Dietitians and other Healthcare Professionals www.nottingham.ac.uk/biosciences

To place a job ad in NHD magazine or on

www.dieteticJOBS.co.uk please call 0845 450 2125

(local rate)

dieteticJOBS.co.ukThe UK’s largest dietetic jobsite


www.nottingham.ac.uk/

www.criticaldietetics.org

www.bsaci.org/meetings-and-events/index.htm

www.susanchurchnutrition.co.uk/recipe-analysis-

www.susanchurchnutrition.co.uk/recipe-analysis-

www.royalmarsden.nhs.uk/education/

www.ncore.org.uk

www.nottingham.ac.uk/biosciences





NHD Subscription6 Print anD 10 Digital iSSueS

• Latest dietetic and nutrition news

• Feature articles on public health and community nutrition

• Nutrition research updates from the world’s leading nutrition institutions

• Clinical articles with practical features, case studies, guidelines and more

• Expert columns and comment from the coal face of UK dietetics

• Career section with live jobs, events and courses

Subscribing is easy at www.NHDmag.com

Important notes:1. NHD Magazine is a 10 issue per year frequency (6 print issues and 10 digital issues), combining the months of Dec/Jan and Aug/Sept. 2. Subscription fees are annual and not set per 12 issues. Magazine frequency may be subject to change3. Discounted subscriptions are non-refundable.

ONLINE Visit www.NHDmag.com

CHEQUE Please send cheque made out to NH Publishing Ltd to:

NH Publishing Ltd, Suite 1 Freshfield Hall,

The Square, Forest Row, East Sussex RH18 5ES

PHONE Call 0845 450 2125 with credit card details to hand

How to renewEMAIL info@networkhealthgroup.

co.uk for renewal link or phone above

Issue 107 August/September 2015NHDmag.com

VITAMIN D IN PREGNANCY

Anna FitzGibbonPrescribing Support Dietitian

MALNUTRITION AND THE ELDERLY. . . p17

ISSN 1756-9567 (Print)

WEB WATCH NEW RESEARCH

Cordelia Woodward p13

PRETERM INFANT FEEDING

NUTRITION AND CHYLOTHORAX

DYSPHAGIA PRODUCT UPDATE

COMMUNICATIONS IN DIETETICS


Since 2009

Don’t miss out! Keep your professional development up-to-date with the UK’s favourite nutrition and

dietetic magazine.

Subscribe online at NHDmag.com

www.NHDmag.com

www.NHDmag.com




The reasons for this request was that a small editorial group, including my-self, are due to meet up next week and it would be helpful if the magazine was finished beforehand. Hmm! At this point, after cutting up the aforemen-tioned nectarine into bite size pieces and putting them into the correct small individual personal coloured dishes for my grandchildren, I pondered the possibilities. We had left home at 6am that morn-ing to travel down the M6 for two hours to look after the grandchildren for the day. This we do at least every two weeks. Looking after a three-and-a-half-year-old and a one-and-a-half-year-old for 10 hours (not counting debriefing) while their parents are working, requires at least two grandparents in our experi-ence! However, I could have a quick read of the paper and see if there is anything that catches my attention for my Final Helping column. Something did:

‘Researchers found grandparents overfed their grandchildren, giving them sugary snacks and drinks. Children cared for by their grandparents were twice as likely to be overweight or obese.’

I was then interrupted by my grand-children both demanding another nec-tarine. Job done I returned to the article and found that it had been written by a

Professor at the University of Birming-ham whose research had been conduct-ed on parents of children in China! How interesting. However the thrust of the argument was that conflicting childcare beliefs and practice between grandpar-ents and parents are felt to undermine efforts to promote healthy behaviours in children. Being a grandparent is fun, exciting, trying and sometimes tiring. Grand-parents have a duty of care which goes something like, “Not on my watch”. When confronted by tears or tantrums, or sometimes “just as a treat”, one opts for an escape route. Whether this is a Mini Magnum, a packet of large choco-late buttons or a box of raisins, depends on the severity of the incident and the weather! A walk in the park/garden is always a good start to any grandpar-enting day, the activity somehow melts away any ’prick of conscience’ attrib-uted to the ice cream or chocolate. In closing though, I then looked at a further study by researchers in Social Anthropology at Oxford University and published the previous month in Paedi-atric Obesity. They found that emotional support from grandparents has a pro-tective effect against child obesity, even with the presence of other risk factors. Result. Come on kids, let’s get down to McDonald’s, but don’t tell your mum and dad!

the finAl helPing

it was mid-morning and i was busy extracting the stone from a nectarine for my grandchildren and my mobile ‘pinged’. it was an email from NHD‘s Publishing editor asking if i could get my column into her in the next day or two.

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.


As the UK’s leading provider of nutritionally-balanced frozen ready meals, we’ve built our reputation on delivering good food to people who need it. Our new Nutritious & Delicious range calls on all this expertise to deliver tasty meals that contain less than 400 calories, are low in salt, fat and saturated fat, offer a good source of protein, and contribute to your patient’s 5 a day. With free delivery to the door, it’s perfect for patients in need of a carefully controlled diet at home. You look after the treatment. Let us look after the mealtimes.

A tasty new range of 13 meals, all under 400 calories.

Low on calories, salt and fat. Big on taste.

Introducing Nutritious & Delicious.

674 – Chicken & Spring Vegetable Casserole

wiltshirefarmfoods.com

Try our tasty ranges for FREE or request our brochures by calling

0800 066 3169

http://www.wiltshirefarmfoods.com/frozen-ready-meals/shaped-pureed-meals-ready-meals?gclid=CLzG-PHbkccCFRDKtAodnpkCWA

nhd magazine aug/sept 2015

Documents