Issue 109 November 2015NHDmag.com

paediatric food allergy

Pete TurnerNutritional Support DietitianRoyal Liverpool University Hospital

Parenteral nutrition on the intensive Care unit . . . p24

ISSN 1756-9567 (Online)

dieteticJOBS • web waTcH • New ReSeaRcH

Miriam Tarkin p13

weighT ManageMenT

dysphagia in care hoMes

MycoproTein benefiTs

keTogenic dieT & alzheiMer’s

www.dieteticJoBs.co.uk

since 2009

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.

REFERENCES: 1. Sampson HA et al. J Pediatr 1991;118(4):520-525. 2. Data on file. Abbott Laboratories Ltd., 2013 (Similac Alimentum case studies). 3. Borschel MW and Baggs GE. T O Nutr J 2015;9:1-4. 4. Koo WWK et al. J Am Coll Nutr 2006;25(2):117-122.

Date of preparation: July 2015RXANI150117

NHD_SimilacAlimentum_DPS.indd 1 24/10/2015 15:44

1,2

3

4

SIMILAC ALIMENTUM. FOR BIG LITTLE MOMENTS.

THIS IS HUGE

NHD_SimilacAlimentum_DPS.indd 2 24/10/2015 15:43

NHDmag.com November 2015 - Issue 1094

chris rudd, Dietetic advisorneil donnelly, Fellow of the bDaUrsula arens, writer, Nutrition & Dieteticsdr carrie ruxton, Freelance Dietitiandr emma derbyshire, Nutritionist, Health writeremma coates, Senior Paediatric Dietitianalison holloway, Specialist community DietitianMiriam Tarkin, Specialist Paediatric allergy Dietitianrosan Meyer, Paediatric Research Dietitiancarina Venter, allergy Specialist Dietitiankelly fortune, Nutritionist pete Turner, Nutritional Support DietitianMajella o’keeffe, Registered DietitianTim finnigan, Research and Development Directorpunita Mistry, Registered Dietitianrachel smith, Dietetic Support worker

gillian white,Dietitiancharlotte Jennifer-louise routen, Nutritionist/Dietetics assistant

6 News latest industry and product updates

8 Weight management The integration of dietetics and cbT

19 Clinical nutrition in care homes Managing dysphagia

24 Critical care on the ICU parenteral nutrition

drink scores

33 Sustainable protein sources The benefits of mycoprotein

38 Dementia and nutrition ketogenic diet and alzheimer’s disease

41 Subscribe to NHD magazine it’s easy online

42 Book review The Vitamin complex

44 Web watch online resources and updates

46 dieteticJOBS latest career opportunities

47 Events and courses Upcoming dates for your diary

48 A day in the life of . . . . . . a dietetic support worker

50 Thefinalhelping The last word from neil donnelly

13coVer Storypaediatric food allergy

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 richard@networkhealthgroup.co.uk

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 info@networkhealthgroup.co.uk 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 info@networkhealthgroup.co.uk and include daytime contact phone number for verification purposes. Unless previously agreed all unsolicited contributions will not receive payment if published. all paid and unpaid submissions may be edited for space, taste and style reasons.

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30 Hydration

NHDmag.com November 2015 - Issue 109 5

from the editor

chris rudd nhd editor

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

Welcome to the penultimate NHD before christmas with a variety of articles for you, plus resources and updates, including Web watch which aims to keep you up to date with some of the relevant topics close to our work.

Earlier in October, NHS England pub-lished Commissioning Excellent Nutri-tion and Hydration 2015-2018, which supports and guides commissioners in developing strategies to help prioritise excellent nutrition and hydration care in acute services and the community. It seems to be a practical guide, not only for commissioners, but also for the pro-viders of the services that will hope-fully encourage proactive dialogue and ultimatelyachievethebenefitsofgoodnutritional and hydration care and re-duce the consequences of malnutrition. If you have not seen this guidance yet, may I suggest you search it out! I feel thatthisoffershopeandcertainlyarolefor dietitians. Let me now tempt you with our ar-ticles. Patients with dysphagia will need tohaveatexturemodifieddietandflu-ids may need to be of a particular con-sistency. Kelly Fortune tells us of the multifactorial aspects of providing safe food for this patient group in Managing dysphagia in care homes. For some patients it may not be possible to access the gut or focus on enteral nutrition. Parenteral nu-trition on the intensive care unit (ICU) by Pete Turner takes us on a journey cov-ering when to use and start parenteral nutrition on the ICU, estimating require-ments and what ‘ingredients’ make up the parenteral nutrition recipe. Punita Mistry provides an interesting account of Ketogenic diet and Alzheimer’s disease and concludes that more research into this may provide valuable answers. From the difficulties encountered withour ageing population to paediatric di-

etetics, as our cover story by Miriam Tarkin observes that ‘the field of paediatric foodallergy continues to grow in these excitingtimes’. Miriam asks the question, What’snew in paediatric food allergy? And provides information on offering the most appropriate nutritional care and advice atthe right time, whether it is breastfeeding, when to use particular infant formulas , weaning foods or full diet. The National Institute for Health and Care Excellence supports the use of the low FODMAP diet in IBS man-agement. Good compliance to the low FODMAP diet hinges on the compre-hensive patient education given. Shouldthis education be on a one to one basis ordelivered within a group session? In NHD Extra for our subscribers, Majella O'Keeffe reveals more in Group education and the low FODMAP diet. Experiences in practice written by AlisonHolloway, informs us of a case study aboutthe practical integration of dietetics andcognitive behavioural therapy in weightmanagement. Want to know about sustainableprotein sources? Then look no further than this issue of NHD! Emma Derbyshireprovides us with the nutritional profileof mycoprotein, along with reviews of evidence in relation to its potential health and environmental benefits. Finally, after reading our articles and if you don’t like the idea of Christmas shopping, how about you sit down and write an article for next year’s NHD? We would like to hear from you…

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

www.nutritional-insight.co.ukhello@nutritional-insight.co.uk

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

NHDmag.com November 2015 - Issue 1096

news

L e u k o c y t e (white blood cell) telomere length is a useful indica-tor of biologi- cal ageing, with

shorter telomeres signifying faster ageing. Now, new work has looked at how certain dietarypatternscouldaffectthis. Dietary data using a semi-quanti-tative food frequency questionnaire was collected from a Korean sample of 1958 adults. Leukocytes telomere

length was measured 10 years later on. Prudent (healthier) diets, i.e. those rich in legumes, nuts, fruits and dairy produce, were positively associated with longer telomere length in this co-hort study. Theseareinterestingfindings,indi-cating that our past diets may catch up with us, possibly contributing to ad-vanced biological ageing in our middle or older years. For more information, see: Lee JY et al (2015). European Journal of Clinical Nu-trition. Vol 69 pg 1048-52.

dairy to reduce Body fat leVelS?A growing body of studies has looked at links between calcium

and dairy consumption in relation to body weight and composition. Now, a new meta-analysis has collected the evi-dence in this area. Data from 41 studies (20 using cal-cium supplements) was analysed. Cal-cium intakes were around 900mg per day higher in the supplement groups. In the dairy group, calcium intake was around 1300mg per day. Overall, neither calcium supplemen-tation nor dairy consumption led to re-ductions in body weight or fat. Further sub-analysis, however, showed that in the presence of energy restriction, dairy con-sumptionledtosignificantreductionsinbodyfat,butdidnotaffectbodyweight. These are interesting findings indi-cating that dairy consumption (ideally around three servings daily) could lead to short-term reductions in fat loss when eat-en as part of a weight management diet. For more information, see: Booth AO et al (2015). British Journal of Nutrition. Vol 114 Issue 07 pg 1013-25.

pre-pregNaNcy oBeSity aNd StillBirtH riSkRising body weights amongst women of childbearing age are a growing con-cern. Now, a new case-control study has looked at associations between body mass index before pregnancy and the risk of stillbirths. Data was analysed from 1829 sin-gleton pregnancies from women living in Pittsburgh, US. The rate of stillbirth among lean, overweight, obese and severely obese women was 7.7, 10.6, 13.9, and 17.3 per 1000 live-born and stillborn infants, respectively, indicat-ing that risk increased proportionally with body weight. Scientists further identified thatplacental diseases, hypertension, fetal anomalies and umbilical cord abnor-malities were closely related to still-birth amongst women with obesity and severe obesity. In summary, while there are mul-tiple mechanisms underpinning a still birth, overweight and obese women should be aware that they may be at risk of health and medical complica-tions that increase the risk of still-births. For more information, see: Bodnar LM et al (2015). American Journal of Clinical Nutrition. Vol 102 no 4 pg 858-64.

paSt dietS take a toll oN telomereS.

NHDmag.com November 2015 - Issue 109 7

news prodUcT / indUsTry news

lateSt oN metaBolic SyNdrome

Metabolic syndrome (MetS) is a cluster of risk factors preced- ing the develop-ment of Type 2 diabetes, heart disease and stroke. Screening for MetS is, therefore, an im-portant indicator of future health. As the potential health benefits of thePalaeolithic diet (a diet resembling our ancient ancestors) has attracted much attention recently, one new meta-analysis has looked at this in relation to components of MetS. The new study published in the American Journal of Clinical Nutrition pooled data from four randomised controlled trials (RCTs) with a sample size of 159. Scientists concluded that Paleolithic diets led to short-term improvements in waist circumference, triglyceride levels, systolic and diastolic blood pressure, fasting blood sugar and HDL cholesterol, when compared with control diets. These findings imply that Paleolithic diets could go some way towards improving components of MetS. Further health benefits of Paleolithic nutrition are now worthy of investigation, along with additional RCTs that can feed into updated meta-analysis papers. Otherworkhaslookedintowhetherdifferentprotein sources, i.e. animal versus plant, could affect adults with MetS. Overweight adults(n=62) with MetS ate a healthy diet for two weeks at baseline and were then randomised to eat: 1) plant protein (18%; 2/3s plant sources), 2) animal protein (18%; 2/3s animal sources) or 3) animal protein (27%; 2/3s animal sources). All groups experienced similar weight loss benefitsandreductionsinMetScharacteristics.These findings imply that either plant oranimal protein could improve MetS profiles,althoughfindingsinthisstudywerealongsideheart-healthy, weight loss diets. For more information, see: Manheimer EW et al (2015). American Journal of Clinical Nutrition. Vol 102 no 4 pg 922-3 and Hill AM et al (2015). American Journal of Clinical Nutrition. Vol 102 no 4 pg 757-70.

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NHDmag.com

NUTRITIONAL BENEFITS

OF YOGHURT

Helen Kingett

Bariatric Dietitian

INTENSIVE WEIGHT CONTROL

PROGRAMME . . . p20

WEB WATCH NEW RESEARCH

Carrie Ruxton and Frankie Phillips p25

ELDERLY CARE HOME NUTRITION

PEG FEEDING: CASE STUDY

FALTERING GROWTH

CANCER CARE NUTRITION

Issue 105 June 2015

NHDmag.com

ENTERAL FEEDING FOLLOWING STROKE

Dimple ThakrarPrescribing Support DietitianBolton CCG

DO DIETITIANS NEED TO BE SIP FEED PRESCRIBERS? . . . p18

WEB WATCH NEW RESEARCH

Marion Ireland and Shubha Moses p9MILK ALTERNATIVESMALNUTRITIONCHILDHOOD OBESITYFOLLOW-ON FORMULAS

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NHDmag.com November 2015 - Issue 1098

I have been a dietitian for over 20 years and in that time, I have seen many changes in practice. One of the biggest has been the move away from a medical model of care, to using increasingly advanced counselling and motivational skills. I was fortunate enough to study for a year with Sheffield HallamUniversity on a foundation level 6 Cognitive Behavioural Therapy (CBT) course. The basis of CBT is looking at the interaction between thoughts, feelings, physical symptoms and behaviours, already an integral part of the dietetic role. Once I had completed this course, a job became available as a CBT Weight Management Dietitian for thenewSheffieldWeighAheadservice,which was a tier 3 weight management service. As this was a new service, there were opportunities to create novel ways of working. Supervision was available with the team psychologist to support the development of my CBT work. We agreed early on which patients would come to me and which to psychology, although there was overlap and transfer between us. My client group was primarily made up of those with a history of eating disorders or disordered eating, complex food behaviours and beliefs, emotional connections and emotionally driven behaviours around food and weight, needing dietary support alongside behavioural and emotional work. Although my patients were often sufferingwith depression and anxiety, Idid not see patients for whom this was the primary issue with weight and eating, or whohadothersignificantpsychologicalorpsychiatric disorders, such as personality disorders and psychosis.

What quickly became clear was the complexity of this patient group, many of whom had not received any support that gave consideration to their psychological needs and the origins of their eating behaviours before. As a team, we developed a multidisciplinary assessment which included Gad-71, PHQ-92 and Rosenberg self-esteem scale3 alongside dietary assessment, physical activity assessment and social information. In addition to this, my initial assessment would include a basic formulation of the presenting problem, discussion about the wants and needs of the individual patient, confidentiality and boundary setting. Iwas able to see patients for 45-minute sessions weekly, for up to 10 weeks. A high proportion of patients had sufferedloss,grief,orhadbeenvictimsofcrime or abuse. Supervision and a strong multidisciplinary team were essential in maintaining our own health and perspective in this role. Oneofmyfirstcasesinthisnewrolewas a sharp indicator of things to come. A patient whose obesity began with all their male relatives being murdered in the home. As a result, this patient, as a child, was fed by the mums, aunties and grandparents of the deceased relatives, as a treat and comfort. This had never been disclosed before, so previous healthcare professionals had gone down the route of eat less, exercise more and ‘why are you not complying’? This had served to increase the sense of guilt and failure of this otherwise very successful professional and unsurprisingly led to little success with weight control. There were some common themes and, over time, I developed a way of

exPerienCeS in PrACtiCe

alison hollowayspecialist community dietitian, sheffield Teaching hospitals nhs foundation Trust

Alison has been an nhS dietitian for over 20 years. her primary interest is working with overweight patients with psychological and behavioural eating problems and who are struggling with traditional care.

the practical integration of dietetics and cognitive behavioural therapy in weight management

weighT ManageMenT

for article references please email info@network healthgroup.co.uk or click here . . .

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workingthatseemedtofitthisgroupofpatients.Where is the evidence base? Well, there is a vast amount of evidence for CBT as a therapy, working withchangeandspecificallytoobesityandeatingdisorders; the key text that I began with was ‘The Cognitive Behavioural Treatment of Obesity’.4 Integral to this approach is building rapport. Obvious, I know, but this is a patient group with an often skewed view of health professionals, including dietitians. They bring with them a range of sometimes terrible experiences of how others have treated them because of their obesity. My experience at this point is of patients presenting with very closed body language (arms crossed is common), fear, tears and, in one memorable case, a ‘witness’! I learnt early on that time to draw out and listen to the patient’s own story of their weight and eating difficultieswasakeypartoftrulyunderstandingnot only what was happening, but what had been tried before and how distressing this was for the patient as an individual. Active listening, gentle encouragement and non-judgemental verbal and non-verbal language were key. I never cease to be amazedbyjusthowmuchpeoplewillconfideinan initial appointment, to a complete stranger, if given the opportunity. A poker face was essential; this patient group are highly attuned to negative verbal and non-verbal cues in professionals. While listening,Iwouldmakenotes,ofteninasimplifiedfive areas template.5 A small cohort may be too scared at this point to tell their story, or even make any eye contact. If this is the case, I revert back to gentle open questioning. I ask patients to complete a journal, starting with their own goals and aspirations: weight, lifestyle or otherwise. I find it helpful to addthoughts and feelings, triggers or purges as appropriate to each individual. A common style I will use, especially with binge eating, compulsive eating or secretive eating, is to ask patients to record only what they feel is excess eating, so not ordinary planned meals, snacks or drinks; but binges, extra snacks and nibbles, extra portions and so on. This approach has proved very helpful in identifying those who feel that they binge, but in fact do not

and in quantifying the amount and types of binge episodes. It is not unusual for patients to return for follow-up, having spotted trends in their own diaries and started to make changes after seeing the‘extra’eatingclearlyforthefirsttime. Using the diary and assessment, I discuss and agree next steps with each patient individually. The types of changes we work on have common themes. Emotional eating, binge eating, habitual overeating, eating to please others, secret eating, eating as self-harm or, commonly, a combination. We usually agree a number of areas for change and then begin with those that the patient feels will be the easiest to manage. This can take some negotiation, as often patients will want to start with themostdifficultproblemfirst,orindeedchangeeverything at once. Some have no idea where to start, as the prospect is simply too overwhelming. Often the starting point is uncomplicated habits such as a biscuit with a cup of tea or chocolate out of the machine at work. We aim to build a sense of hopeandself-efficacyatthisstage. Dietitians will be familiar with many of the treatment methods used. The use of distraction and alternative food choices, which can be just as valid with this group as any others, some further methods used include thought stopping, harm reduction, mindful eating, urge surfing, self-soothing andHelicopter view/perspective. The resource website www.getselfhelp.co.uk is invaluable in this work.5

Case Study

A typical case was that of a 54-year-old lady who had gained weight through three pregnancies, tried Slimming World and Weight Watchers in the past, losing 1-2 stones and then regaining. At initial assessment she had a BMI of 41.77kg/m2, Rosenberg score 12, fruit and vegetable intake two/day and zero physical activity. This lady described a history of repeated bullying in her life from neglect in childhood through to domestic abuse in a previous relationship.Weidentifiedduringassessmentthatthis had led to low self-esteem and depression and

NHDmag.com November 2015 - Issue 10910

weighT ManageMenT

Active listening, gentle encouragement and non-judgemental verbal and non-verbal language were key.

this had impacted on her weight through a pattern of emotional eating and occasional binges. Previous attendance at commercial groups had increased her guilt and further reduced her self-esteem, as she felt unable to disclose her secretive emotional eating behaviour. Dietary assessment showed that she had started to reduce her portions, takeaways and eating out. She ate regular meals with low fat and low sugar choices. During binges and emotional eating she would eat large amounts of cake, biscuits and chocolate. She was knowledgeable about healthy eating and weight loss. Goals of treatment were agreed as improved understanding of the triggers for emotional eating and links with self-esteem, increased physical activity and weight maintenance. We began with psycho education about managing emotional eating, breathing techniques for anxiety and normalising responses to stress and distress. She completed an eating and emotions diary which we used to explore the triggers for emotional eating. We worked together to devise individualised strategies for difficult situations. Physical activitywas encouraged and reviewed. At times during treatment, she was bothered by negative thoughts about herself and feeling ‘pressure’ to lose weight. We explored thinking about health in broader terms, moving the focus from weight alone, including positive self-esteem and mood. This approach led to increases in physical activity and reduction in emotional eating responses. This lady gained a much greater understanding of her use of food to manage emotions. She was abletoreflectandfeltmuchcalmerandlesscriticalofherselfduringdifficultfamilystressesandwassubsequently less likely to turn to food binges. Weight loss was modest, -1.5kg; however, she had significant increase in self-esteem, fruit andvegetable intake and physical activity. Rosenberg 25 (+13), fruit and vegetables 5 (+3), physical activity 200 minutes per week (+200). This lady was initially apprehensive about how we could help her, having focused on diet alone in the past. She was able to share her feelings about her low self-esteem and be open about her real problems with food. The sessions allowed us to get to the origins of her weight gain and the difficultiesthatshehadinaddressingthem,ratherthan straightforward education which she neither

needednorwanted.Increasedconfidenceinherselfthen led to her being able to initiate physical activity andmanagesomeverydifficulttimesathome. It is crucial that we identify those patients for whom there are more complex underlying causes for the maintenance of their obesity. In this way, we have the potential to be able to create longer-term change.This case illustrated the benefits ofnotneglecting thewiderdefinitionsofhealth, inthis case, as in many; overall physical and mental health was improved in advance of weight loss. Integral to this approach is looking holistically atalltheaspectthataffectaperson’schoicesaroundfood and this often requires discussion and referral on, for example, for relationship counselling, stress management, mental health services, exercise on referral, alcohol and drugs services. I am clear that this is a lifelong process of managing overeating, much like any other chronic health condition. Ideally, ongoing support would be available as with other chronic syndromes. My experience is that most people are not ‘cured’, but thattheycanmovethedifficultieswithfoodtoaless prominent position in their lives. One of the key points I learnt from my experiences, was the value of having the CBT skills alongside extensive dietetic experience. This combination meant that I could adjust dietary treatments, at times moving away from standard practice, to allow a reduction in anxiety, guilt and failure by the patient. This gave me an advantage over our psychologists in managing treatment plans, especially for patients with conditions such as diabetes. An example would be negotiating an increase in oral hypoglycaemic agents with a patient’s GP to control their diabetes whilst they work on the psychological elements of their eating. Focusing away from low sugar, managed carbohydrate for a binge eater with diabetes, whilst they establish a regular eating pattern and physical activity. This approach does require a great deal of communication with other professionals, as, often, patients who I would be working with would leave enthused and feeling more in control, only for that empowerment to be crushed by a well-meaning professional reverting to standardised advice. The underlying philosophy of my work remains that: given the right approach, most people are honestabouttheireatingdifficulties:anyprogressin any area of health, is valuable.

NHDmag.com November 2015 - Issue 109 11

weighT ManageMenT

For the dietary management of mild to moderate cows’ milk allergy

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Making life taste good!

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• Contains lactose which significantly increases the absorption of calcium and improves palatability2,3

• Hypoallergenic for better tolerance - the most extensively hydrolysed formula in the UK4

• 100% extensively hydrolysed whey protein source facilitates faster gastric emptying5,6 and provides a more palatable option compared to casein based eHF3,4

NHDmag.com November 2015 - Issue 109 13

There is now a large body of evidence to guide us on how vitamin and mineral supplementation and other dietary factors, such as pre- and probiotics, given during the pre- and postnatal period,can influenceoutcomesofallergicdisease.2 The addition of nutritional components to hypoallergenic formulas for both prevention of allergies and the induction of tolerance, have also been explored.Thiscanoftenbeaminefieldfor healthcare professionals and, as such, this article provides an update on the current recommendations and emerging research on nutrition and allergy in paediatrics to guide clinical practice.

allergy preVenTion: cUrrenT gUidelines Duetothesignificantimpactthatfoodallergy can have on quality of life, mor-bidity and the financial implicationsfrom consultations and treatments, there has been great interest in the pri-mary prevention of food allergy. It is thought that cows’ milk protein allergy (CMPA) alone has a cost of £25 billion to the NHS3 and is the leading cause of fatalities from food allergy in the UK.4

In 2014, following a systematic review, the European Academy of Allergy and Clinical Immunology (EAACI) published an evidence-based guideline to provide advice on

preventing food allergy, particularly for those at high risk of developing allergic disease.1 The recommendations are summarised in Table 1. Exclusive breastfeeding is recommended for all infants aged four to six months. If breastfeeding is insufficient or notpossible, it is recommended that infants at high risk are given a hypoallergenic formula.1 These recommendations are supported by the Cochrane review on dietary prevention of allergic disease and food hypersensitivity in children.5 The EAACI guideline also states that there is no need to avoid introducing complementary foods beyond four months. With the exception of peanut (following the publication of the EAACIguidelines),thereisinsufficientevidence to provide recommendation about either withholding or encourag-ing exposure to potentially allergenic foods after four months once weaning has commenced, even if there is a family history of atopy.1 The EAACI guidelines are also in accordance with the American Academy of Paediatrics recommendations on the effects ofearly nutritional interventions on the development of atopic disease.6

eaTing habiTs and The deVelopMenT of allergy and feeding behaVioUrHealthy eating has been shown to reduce food allergy in infancy. In

Miriam Tarkinspecialist paediatric allergy dietitian and dietetic lead

miriam works at the Whittington hospital in critical care and paediatrics and has been working on developing the Paediatric Allergy Service there over the past five years. She is the Secretary for the food Allergy and intolerance Group of the BdA.

co-authors: rosan Meyer and carina Venterrosan meyer, Principal Paediatric research dietitian, Great ormond Street hospital and research and education manager of the food Allergy and intolerance Specialist Group of the BdA

Carina Venter, Allergy Specialist dietitian, nihr Post doctorate research fellow, University of Portsmouth and Chair of the BdA’s food Allergy and intolerance Specialist Group

coVer sTory

WhAt’S neW in PAediAtriC food AllerGy?

over the last decade, a number of changes have been introduced to clinical practice guidelines and committee recommendations in the management of food allergy in children. most recently, these changes have been in relation to the primary prevention of allergy.1

a recently published birth cohort study led by Grimshaw et al, it was shown that infants whose diets included high levels of fruits, veg-etables and home-prepared foods, were less likely to have a food allergy by the age of two years compared to those with unhealthy diets.7 This study highlights the importance of giving healthy eating advice to all families during con-sultations, including those with children at high risk of developing food allergies. Another study published last month by Maslin et al, showed that young children consuming an exclusion diet for CMPA had higherscoresforfeedingdifficulties,fussyeatingand were slower to eat at mealtimes than those consuming an unrestricted diet up to 10 years after outgrowing their CMA.8 It is, therefore, important for children with CMPA to see a dietitian following diagnosis, to provide targeted guidance on weaning, including advice on texture, increasing variety and feeding behaviour.9 Children with CMPA should also be challenged as early as possible to assess tolerance

NHDmag.com November 2015 - Issue 10914

paediaTric food allergy

recommendations for all infants:• Nospecialdietduringpregnancyorthe

lactating mother• Excusivebreastfeedingforfourtosixmonths• Introductionofcomplementaryfoodsafter

the age of four months according to normal standard weaning practices and nutrition recommendations,forallchildrenirrespectiveof atopic heredity.

further recommendations for high-risk infants:• Ifsupplementalfeedingisneededduringthe

firstfourmonths,anapprovedhypoallergenicformula is recommended.

Table 1: summary of recommendations for primary preventionoffoodallergyfromEAACIfoodallergyprimarypreventionguideline1

and progression of outgrowing their allergy, in ordertopreventfeedingdifficultieslateron.

hypoallergenic forMUlasAHydrolysedformulasforallergypreventionHypoallergenic formulas may also have a role in the prevention of allergy. The 10-year

figure 1: Map guideline flow chart13

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German Infant Nutritional Intervention (GINI) study showed that intervention with partially hydrolysed whey and extensively hydrolysed casein formula in non-breastfed infants with a family history of allergy, led to a reduction in allergy disease, particularly atopic eczema/dermatitis lasting up to 10 years of age.10 Two systematic reviews and three randomised con-trol trials reviewed by EAACI in 2014, show evidence to suggest that extensively hydrolysed whey or extensively hydrolysed casein formula alsohaveaprotectiveeffectinhighriskformulafed infants.11

b hydrolysed formulas for management of cMpaAn important role for dietitians is to provide support and education to other health pro-fessionals and General Practitioner’s on the hypoallergenic formula available and appro-priate prescribing, particularly due to the eco-nomic burden that prescriptions of these for-mulas can present.2 Guidelines, such as those from the British Society of Allergy and Clinical Immunology and Milk Allergy in Paediatrics (MAP) (see Figure 1), can prove very helpful in the decision making for managing CMPA in both the breastfed and formula-fed infant.12,13

The range of hypoallergenic prescription for-mulas and commercially available cows’ milk substitutes that are accessible in the UK contin-ues to increase. The prescription milks availa-ble in the UK are detailed in Table 2. In the last few years we have had the addition of Exten-sively Hydrolysed Formulas (EHFs): Althera (Nestle) and Similac Alimentum (Abbott) and Alfamino, an amino acid formula (AAF) from Nestle. There was also a recent name change from Nutramigen AA to Nutramigen Purami-no (Mead Johnson).

nUTsPeanut allergy is an increasingly global health problem, which affects between 1.0 and 3.0%of children in westernised countries.14 There is now evidence to support early rather than de-layed peanut introduction during the period of complementary food introduction in infants. In the Learning Early About Peanut Allergy (LEAP) study performed at the Evelina children’s hos-pital, it was shown that consumption of peanut protein in high-risk infants (such as those with more severe eczema and egg allergy) can pre-vent peanut allergy.14 This study showed an 80% reduction in prevalence of peanut allergy in the

NHDmag.com November 2015 - Issue 109 15

paediaTric food allergy

feed name manufacturer protein Source lactose content

extensively hydrolysed formulas

althera sMa hydrolysed whey

contains lactoseaptamil pepti 1Milupa

hydrolysed wheyaptamil pepti 2

cow and gate pepti-Junior cow and gate contains residual lactoseinfatrini peptisorb nutricia

nutramigen 1 lipil Mead Johnson

hydrolysed casein lactose freenutramigen 2 lipil

pregestimil lipil

similac alimentum abbott

amino acid formulas

alfamino sMa

amino acids lactose free

neocate lcp

nutriciaNeocateActive

NeocateAdvance

nutramigen puramino Mead Johnson

Table2:ExtensivelyhydrolysedandaminoacidformulasavailableonprescriptionintheUK

peanut protein consumption group (3.2%) com-pared to the avoidance group (17.2%).14

Following the results of the LEAP study, a consensus document on early peanut introduction and the prevention of peanut allergy in high-risk infants, was published by the World Allergy Organisation (WAO).15 Based on existing guidelines and LEAP trial data, this document provides guidance to assist the clinical decision making of healthcare providers regarding early peanut introduction. The guidance from this document advises that infants with early-onset atopic disease, such as severe eczema, or egg allergy in the first four to six months of life,might benefit from evaluation by an allergistor a physician trained in the management of allergic diseases. It states that clinicians can perform hospital peanut challenges for those with evidence of positive peanut skin tests to determine whether they are clinically reactive before home introduction is initiated.15

Further studies are required to identify the optimal age for introduction of other allergen-ic foods into the diet of high-risk of allergy or already allergic children, to look for ways to improve practice and prevent food allergy. We eagerly await the results of the UK Enquiring About Tolerance study (EAT) (www.eatstudy.co.uk), which is designed to test the hypothesis that repeated exposure to potentially allergenic foods(specificallywheat,sesame,fish,eggsandnut) through consumption at an early age, helps prevent food allergies in childhood.

pre-/probioTic debaTeThere is increasing evidence that disturbances in the gut microbial composition play a role in the pathophysiology of immune mediated disorders, such as food allergy.16 The concept that increasing prevalence of allergic disease has resulted from a lack of microbial stimuli during infancy and early childhood, is known

as the hygiene hypothesis.16 As such, there is great interest in understanding the role that pre- and probiotics might play in the prevention and treatment of allergy. Probiotics are live bacteria that colonise the gastrointestinal bacteria and provide a health benefit to thehost.17 Many studies have been performed on a variety of different probioticstrains on diverse paediatric at risk popula-tions. Conflicting results have been found,which has made it difficult for guidelines tobe formulated on their routine use for both prevention and allergy disease modification.Thesedifferentfindingsmayberelatedtotheoverall composition and nutrient content of the diet. However, preliminary evidence shows that Lactobacillus rhamnosus GG (LGG) may accelerate development of oral tolerance in cows’ milk allergic infants.18 Probiotics dur-ing pregnancy have also been associated with a reduced risk of eczema in high-risk infants.19 Despite thisresearch, there is insufficientevi-dence at present to support a recommendation for the use of probiotics for the prevention or treatment of food allergy in routine practice and further research is required. Prebiotics are non-digestible food com-ponents that selectively stimulate the growth or activity of ‘healthy’ bacteria in the colon.20 There is some evidence that prebiotics (com-monly oligosaccharides) added to infant feeds may prevent eczema and asthma in infants. However, a Cochrane review performed in 2013 indicated potential concern about the reliability of some of the prebiotic studies.20 As with pro-biotics, it is also early days before routine use can be recommend for prebiotics for the preven-tion of allergy and further research is required before they are recommend in routine practice. It is also important to determine which of the prebiotic and probiotic strains are suitable and for which patient population.1

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paediaTric food allergy

There is increasing evidence that disturbances in the gut microbial composition play a role in the pathophysiology of immune mediated disorders, such as food allergy.

NHDmag.com November 2015 - Issue 109 17

ViTaMins and MineralsOther nutritional components have been investigatedtoassesstheireffectontheimmunesystem. These include vitamin D, vitamin E, zinc and folate. The potential link between allergic disease and vitamin D emerged when it was identified that higher rates of allergic diseasewere observed in higher latitudes, where vitamin D deficiency is more common.21 A number of recent studies have examined the link between vitamin D and eczema. In several observational studies, lower serum vitamin D levels were associated with increased risk of eczema and skin barrier dysfunction in children.22,23 An association has also been found between low serum vitamin D levels and the diagnosis of asthma in children.24 The Department of Health (DoH) currently recommends vitamin D supplementation for: (a) all pregnant and breastfeeding women and (b) infants and young children aged sixmonths to five yearsshould have vitamin D supplementation.25 The DoH states that the infants who are formula fed do not need supplementation until they are receiving less than 500mls of formula.25

Several studies have examined dietary intake of vitamin E intake during pregnancy.25 A reduction in childhood wheeze has been associated with both maternal vitamin E and zinc intake.26,27 Therewere no significantresults found for asthma, eczema or food allergy with maternal vitamin E intake.25 Maternal intake of folate supplements during pregnancy may influence childhood immunephenotypes via epigenetic mechanisms.28 Folic acid supplementation is recommended for all pregnant women to reduce the risk of congenital malformation. Current National Institute of Clinical Excellence (NICE) guidance recommends that health professionals advise all women who may become pregnant to take 400 micrograms daily before pregnancy and

throughoutthefirst12weeks,eveniftheyarealreadyeatingfoodsfortifiedwithfolicacidorrich in folate.29Therehasbeensomeconflictingevidence about folic acid in late pregnancy, with a possible increase in childhood asthma.30 Further research is required and there is no change in recommendation for the supplementation of folic acid in pregnancy.

in sUMMaryA significant amount of interest and researchsurrounds the prevention and treatment of allergy. Guidelines now exist for the primary prevention of food allergy. Exclusive breastfeeding continues to be strongly recommended. If breastfeeding is insufficientor not possible, an approved hypoallergenic formula is recommended for high-risk infants. In terms of the management of CMA, the number of EHF and AA formulas available in the UK continues to increase and it is important that we follow existing guidelines and educate other health professionals on these in order to ensure appropriate prescribing. Irrespective of atopic family history, normal standard weaning practice and nutrition recommendations remain unchanged for now for the introduction of complementary foods after the age of four months and delayed introduction of allergenic foods is not recommended. As we now know that there is an association between healthy eating and outcome of food allergy, it is important for health professionals to deliver healthy eating advice. In recent years, there have been great strides forward in the management of food allergy in paediatrics, making the role ofthedietitianincreasinglyessential.Thefieldof paediatric food allergy continues to grow in these exciting times.

paediaTric food allergy

for article references please email info@networkhealthgroup.co.uk or click here . . .

Maternal intake of folate supplements during pregnancy may influence

childhood immune phenotypes via epigenetic mechanisms.

Verbatim patient quote, Fresenius Kabi data on file

– Thick & Easy™ Clear Acceptability Study Report Sept 2014

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References: 1. Fresenius Kabi data on file – Thick & Easy™ Clear – Acceptability Study Report Sept 2014.® Thick & Easy is a registered trademark of Hormel Health Labs. Fresenius Kabi Ltd is an authorised user. © Fresenius Kabi Ltd. October 2015 Date of preparation: October 2015 Job code: EN01141

Thick & Easy™ Clear is a gum-based drinks thickener that retains the natural appearance, taste and texture of fluids,1 and also ensures a consistent thickness over time.

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NHDmag.com November 2015 - Issue 109 19

Theclinicaltermfordifficultyswallow-ing and chewing food, dysphagia, occurs as a result of either nerve or structural damage which interferes with the safe movement of food and fluidfrom the mouth to the stomach. Signs of dysphagia include difficult, painfulchewing or swallowing, dribbling or food spillage from lips and a sensation that food is stuck in the throat or chest, as well as a dry mouth, heartburn and changes in eating habits. Caused by a wide range of conditions, from strokes to degenerative illnesses such as dementia, dysphagia can have serious consequences. For example, if aresidentsufferingwithchewingandswallowing difficulties is served foodwith an inappropriate texture for their particular stage of dysphagia, there is a riskofaspiration-wherefoodorfluidis accidentally ‘breathed in’, potentially leading to aspiration pneumonia - and choking. There is also the emotional and psychological impact of not being able to eat normally.

risk of MalnUTriTionMore than one million people over the aged of 65 are either malnourished or at risk of malnutrition.1 In fact, 41% of new residents are malnourished when entering a care home2 and, for those with dysphagia, ensuring that they get the nutritional intake they need to improve and maintain their health and wellbeing, can be particularly challenging.

kelly fortunenutritionist, at apetito

Kelly works for apetito, a provider of meals to care homes across the country.

Between 50 and 75% of care home residents are thought to have dysphagia, which means that catering to residents with chewing and swallowing difficulties is a challenge that most homes face on a daily basis.

clinical nUTriTion

mAnAGinG dySPhAGiA in CAre homeS

Not only can eating become a very tiring process, the threat of the serious consequences described above can make mealtimes a fearful experience. Furthermore, for residents with dys-phagia as a complication of dementia, the confusion and memory problems thatarisecanhaveasignificantimpacton appetite levels and their overall dining experience. Traditionally, dysphagia sufferershave been offered liquidised food,which can be unappetising and lacking in distinctive flavours. As water isusually added as part of the liquidising process, this dilutes both taste and nutrients, without contributing calories, vitamins or minerals. Each of these factors can contribute to an increased risk of becoming undernourished, which is why it is especially important to screen residents with dysphagia for malnutrition - both on admission to a home and on an ongoing basis. There are a number of screening tools available, but BAPEN’s ‘MUST’ tool is well recognised by the industry and is simple to use. As well as screening all residents for malnutrition,thefirststepincateringtoresidents with dysphagia is for them to

STAYING STRONG MEANS I CAN STILL PICK UP MY GRANDSON.NEW Ensure Plus Advance. It helps provide the nutritional support they need to get back to what they love.

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NHDmag.com November 2015 - Issue 109 21

clinical nUTriTion

be assessed by a speech and language therapist, who can diagnose which stage of the condition they have reached.

gUidelines for TexTUre-Modified dieTsResidents with chewing and swallowing difficultieswhorequireatexture-modifieddiet,must be served food that is safe for them to eat, which is determined by the stage of dysphagia they are experiencing. Recognising the difficulties faced inpreparing texture-modified food, theNationalPatient Safety Agency created the Dysphagia Diet Food Texture Descriptors. These were

published in 2011 and replace previous versions that were developed by the British Dietetic Association and the Royal College of Speech and Language Therapists. Each Descriptor includes examples of how particular types of food should be prepared in order to be suitable for a resident at that stage of a texture-modified diet. This ranges fromCategory B, which can be described as a thin purée and is for those with more severe forms of dysphagia, to Category E. Described as ‘fork mashable’, food within Category E is for those in theearly stagesofdysphagiaor in thefinalstages of returning to a ‘normal’ diet.

food must be soft, tender and moist

requires some chewing

Piecesofsofttendermeatmustbeservednobiggerthan15mms

no skin, bone or gristle

no sticky foods, e.g. cheese chunks, marshmallows

Checkbeforeservingthatnohardpieces,crustorskinhaveformedduringcooking/heating/standing

Table 1: category e - ‘fork Mashable dysphagia diet’

requires little chewing

Hasbeenmashedupwithaforkbeforeserving

Usuallyrequiresaverythick,smooth(non-pouring)sauce,gravyorcustard

Shouldhavenohard,tough,chewy,fibrous,stringy,dry,crispy,crunchyorcrumblybits

Shouldhavenoskin,boneorgristle

Meat must be finely minced - pieces approximately 2.0mms.

Table 2: category d - ‘pre-Mashed dysphagia diet’

cannot be poured

smooth throughout, requires no chewing

is moist

holds its shape on a plate or when scooped

can be eaten with a fork because it does not drop through the prongs

no garnish

Table 3: category c - ‘Thick purée dysphagia diet’

can be poured

does not hold its shape on a plate or when scooped

requires no chewing

cannot be eaten with a fork because it slowly drops through the prongs

The texture is not sticky in the mouth

Therearenoloosefluidsthathaveseparatedoff

Table 4: category b - ‘Thin purée dysphagia diet’

As a very minimum, the Care Quality Commission requires all care settings to offer Category C and E meals to residents.As dysphagia is a journey that changes, it is very important that input from a speech and language therapist is sought on a regular basis to ensure that residents are given a diet that is fully appropriate for their stage. Tables 1, 2, 3 and 4 outline a few examples of what is required by each category. It is also important to note that, as the texture of food may change during the cooking/cooling process, consistency should be checked just prior to serving to make sure the dish is still fully compliant with the descriptors. For full details of the Descriptors click here . . . Fluids and medications may also need to be thickenedfordysphagiasufferers,butitisvitalto make sure care homes seek the advice of a speech and language therapist.

The righT appearanceNot only should texture-modified food meetthe guidelines outlined by the Descriptors, the appearance of food is an important consideration, especially for residents with dementia who may become easily confused about what they are being served. Ideally, meals should be visually appealing and resemble the foods they are supposedto.Whilethiscanbedifficultforcarehomes to achieve in-house, there are specialist food products available that include moulded options that look just like the food served to other residents.

sUpporT aT MealTiMesWhere needed, residents with dysphagia should be offered help to adopt the correct postureto encourage safe and comfortable digestion. Similarly, any help needed with eating and drinking should be available throughout the day.

Setting the scene for comfortable dining is of course important for all care home residents, but is particularly vital for those with dysphagia, so noise and interruptions should be kept to a minimum during mealtimes. Attractively set tables will help create a setting conducive to the enjoyment of food, but ‘fussy’ decorative touches can prove distracting - especially for residents prone to confusion, such as those with dementia - so presentation should be kept uncluttered. To minimise any isolation, dysphagia sufferersmayexperienceatmealtimes, texture-modified meals should complement the menuoptions available to all residents.

sUMMaryAs dysphagia is a common side effect ofconditions that typically impact more greatly on elderlypeople(suchasthosewhohavesufferedastroke, have dementia and Parkinson’s), catering to residents with chewing and swallowing difficulties is an ongoing challenge for carehomes. Working with specialist providers of texture-modified meals is a useful means ofserving residents options that closely resemble the dishes available to others, but regardless of whether dishes are prepared in-house or through an external supplier, adherence to the Descriptorsmeanshomescanbeconfidentthatresidents with dysphagia are served meals that are safe for them to eat. As well monitoring for signs of under-nourishment among all residents, dietitians should work closely with speech and language therapists, care home managers and caterers to ensure that residents with dysphagia continue to be served the most appropriate and safe texture suitable for their chewing and swallowing abilities, as well as food that is appealing and enjoyable to eat.

NHDmag.com November 2015 - Issue 10922

clinical nUTriTion

References1 The Malnutrition Task Force www.malnutritiontaskforce.org.uk/about2 baPeN: Nutrition Screening Survey in the UK and Republic of Ireland in 2011

Where needed, residents with dysphagia should be offered help to adopt the correct posture to encourage safe and comfortable digestion.

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372 – Category C Thick Puréed Chicken & Gravy

NHDmag.com November 2015 - Issue 10924

Recent studies have, however, suggested that this should not be the case and when given in appropriate amounts, at the right time, through the right access device, it is assafeandbeneficialasenteralnutrition.Indeed, withholding it during prolonged failed attempts to establish enteral nutrition may result in increased mortality in malnourished patents. In 1998, Heyland published a meta-analysis of studies of PN in ICU and surgical patients.1 This compared standard therapy-iv dextrose and oral diet vs PN and reached the conclusion that PN should not be used on the ICU as it was associated with increased septic morbidity. Subsequent papers suggested that enteral nutrition (EN) was safer than PN2 and guidelines promoted the use of EN3 leading to a negative attitude towards PN. It is possible to explain the negative findings of the Heyland meta-analysis,as many of the studies included were carried out in the 1980s and 1990s when hyperalimentation was common and huge energy and nitrogen loads were given to metabolically stressed patients, possibly without the stringent line care that is often employed today. It is well accepted that most of the complications of PN, including hyperglycaemia, hyperlipidaemia, azotaemia and liver dysfunction, are due to overfeeding.4 In particular, hyperglycaemia in the days before intensive insulin therapy5 could be responsible for the poor outcomes and increased sepsis.6 Furthermore, the firstgeneration lipids used in many of the studies were high in pro-inflammatoryomega-6 fatty acids.

More recent studies have shown that PN may actually be safer than EN in patients with questionable gut function7,8

and a 2005 meta-analysis found improved survival with PN in patients who could not be successfully fed enterally within 24 hours of ICU admission.9 In fact, this EN has almost certainly been dispelled by the CALORIES trial published last year.10 In this large scale trial carried out in 33 ICUs across the UK, 2388 patients were randomised to early EN or PN. There were no differences in outcomes,including infection rates and 30-day mortality between the two modes of feeding. Another particularly interesting findingwasthataround50%ofpatientsinboth groups failed to meet their estimated energy target of 25kcal/kg, with the mean energy intake for each being around 20kcal/kg. This can lead us to the conclusion that if you avoid overfeeding, especially in the early stages of critical illness, the outcomes are the same for EN and PN.

when To Use pnAlthough modern PN is safe, the general consensus from expert groups is that enteralnutritionshouldbeusedasthefirstline of feeding because of its protective effectonthegutbarrieranditsfavourableinfluenceonthegutassociatedlymphoidtissue (GALT) and immune function.11 It is an often overlooked fact that around 70-80% of an adult’s immunological tissue is situated in the gut12 and the theoretical benefits of keeping it healthy shouldnot be ignored. EN should, therefore, be used where possible and PN employed

PArenterAl nUtrition on the intenSiVe CAre Unit (iCU)

pete Turnernutritional support dietitian, royal LiverpoolUniversityhospital

Pete turner is a nutritional Support dietitian at the royal liverpool University hospital specialising in critical care, parenteral nutrition and intestinal failure. he is also Chair of the committee responsible for organising the BAPen Annual Conference.

parenteral Nutrition (pN) has had a bad reputation on the intensive care unit with its use often being reserved for patients with complete gut failure. enteral nutrition is seen as the gold standard for nutritional support and lack of success in establishing it is often seen as a failure by the icu team.

criTical care

NHDmag.com November 2015 - Issue 109 25

quickly in patients with gut failure, including bowel obstruction, ischaemic bowel, short bowel syndrome and certain types of gastrointestinal leaksandfistulae.However,manypatientsontheICUdonotfitclearlyintothesecategoriesandhowquickly to start PN in patients with questionable gut function or poor tolerance of EN is a subject for debate.

when To sTarT pnHow early to start PN became particularly controversial when a study by Casaer13 recommended withholding PN for up to eight days in critically ill adults. In the ‘Early Parenteral Nutrition to supplement insufficient enteralnutrition in Intensive Care Patients’ (EPaNIC) study, 4640 ICU patients were fed as much enterally as possible and then randomised to early initiation of parenteral nutrition (day 2) or late (day 8) to meet a calculated energy target. The late initiation group showed improved outcomes with less infections, less cholestasis, fewer days of mechanical ventilation and renal replacement therapy, as well as a relative increase of 6.3% in the likelihood of being discharged from ICU alive. However, in this study, patients who were largely not malnourished were fed to a very high energy intake of up to 36kcal/kg/day in the early stages of their critical illness. Furthermore, patients who were most likely to benefit fromPN,suchas thosewithBMI<17kg/m2 or those with short bowel syndrome, were actually excluded from the study. Many patients had diagnoses such as cardiac surgery suggesting that they could have been enterally fed if a more aggressive approach to their EN had been used. Indeed, the study protocol reveals that a very low gastric residual volume (GRV) threshold of 250mls wasusedtodefinetolerancetoenteralfeed,whichiscontrary to the recommendations of ASPEN11 who suggest EN should not be withheld for anything less than a GRV of 500mls. The EPaNIC study simply serves to reinforce our conclusions from previous studies: that feeding excessive amounts of PN to patients with a functioning gut who are not malnourished in the early stages of critical illness is associated with poor outcomes. In contrast, a Swiss study14, that carefully introduced PN at day 4 where EN was clearly not tolerated due to gut dysfunction, showed

improved outcomes. In a randomised study of 305 patients, indirect calorimetry was used to determine an energy target and PN initiated to supplement EN in achieving energy balance, alongside the maintenance of tight glycaemic control. Careful use of combined EN and PN without excessive energy provision to patients with gut dysfunction resulted in fewer infections, more antibiotic free days and shorter duration of mechanical ventilation. Braunschweig2 found that it was the particularlymalnourishedpatientswhobenefitedfrom use of PN. Even the aforementioned 1998 Heyland3 study supports its use in malnourished surgical patients. Thus, the evidence clearly supports cautious early introduction of PN on ICU, especially in malnourished patients with an element of gut dysfunction. Indeed, spending an excessive amount of time unsuccessfully trying to establish EN in this group of patients may be associated with increased mortality.2,8,9 ESPEN15 certainly supports this view, recommending that PN should be introduced after 48 hours of arrival on ICU if EN cannot be established.

esTiMaTing reqUireMenTsThree previously mentioned major studies10,13,14 havemoreorlessconfirmedthatexcessiveenergyprovision in the early stages of critical illness is harmful. Failure to meet energy targets later has also been associated with poor outcomes.14,16,17

The ESPEN18 recommendation of 20-25kcal may give as good a starting point as any initially, although the very metabolically stressed or those at high risk of refeeding syndrome may

*Independent, head-to-head taste testing for PaediaSure, PaediaSure Plus, PaediaSure Fibre, PaediaSure Plus Fibre and PaediaSure Peptide vs. Fortini or Frebini Energy or Peptamen Junior Powder

REFERENCES: 1. Huynh DTT et al. J Hum Nut Diet. DOI 10.111/jhn.12306 Published online 25th March 2015. 2. Data on file. Abbott Laboratories Ltd., 2007 (PaediaSure Plus & PaediaSure Plus Fibre taste testing). 3. Data on file. Abbott Laboratories Ltd., 2013 (PaediaSure Fibre taste testing). 4. Data on file. Abbott Laboratories Ltd., 2013 (PaediaSure & PaediaSure Peptide vs. Peptamen Junior Powder).

Date of preparation: July 2015RXANI150120

NHD_PaedPeptideMeena_DPS.indd 1 23/09/2015 13:42:10

When a child is sick and malnourished, you just want to see them well again. PaediaSure’s full range of nutritional products supports them through the rough patch, and helps them get back to doing what kids do best.

FEELING THE EFFECTS OF MEENA’S RECOVERY

• Oral nutritional supplements have been shown to increase total energy intake and improve nutritional status in at-risk children1

• PaediaSure offers a comprehensive range of products and styles to meet the needs of your patients

• Children love the great taste*2-4

THE PAEDIASURE RANGE. HELPING KIDS BE KIDS AGAIN.

NHD_PaedPeptideMeena_DPS.indd 2 23/09/2015 13:42:15

*Independent, head-to-head taste testing for PaediaSure, PaediaSure Plus, PaediaSure Fibre, PaediaSure Plus Fibre and PaediaSure Peptide vs. Fortini or Frebini Energy or Peptamen Junior Powder

REFERENCES: 1. Huynh DTT et al. J Hum Nut Diet. DOI 10.111/jhn.12306 Published online 25th March 2015. 2. Data on file. Abbott Laboratories Ltd., 2007 (PaediaSure Plus & PaediaSure Plus Fibre taste testing). 3. Data on file. Abbott Laboratories Ltd., 2013 (PaediaSure Fibre taste testing). 4. Data on file. Abbott Laboratories Ltd., 2013 (PaediaSure & PaediaSure Peptide vs. Peptamen Junior Powder).

Date of preparation: July 2015RXANI150120

NHD_PaedPeptideMeena_DPS.indd 1 23/09/2015 13:42:10

When a child is sick and malnourished, you just want to see them well again. PaediaSure’s full range of nutritional products supports them through the rough patch, and helps them get back to doing what kids do best.

FEELING THE EFFECTS OF MEENA’S RECOVERY

• Oral nutritional supplements have been shown to increase total energy intake and improve nutritional status in at-risk children1

• PaediaSure offers a comprehensive range of products and styles to meet the needs of your patients

• Children love the great taste*2-4

THE PAEDIASURE RANGE. HELPING KIDS BE KIDS AGAIN.

NHD_PaedPeptideMeena_DPS.indd 2 23/09/2015 13:42:15

need to start lower at around 10kcal/kg on day 1 as per the recommendations of NICE.19 Using kcal/kg is probably acceptable in many patients; however, it can under- and over-estimate at the extremes of BMI20and is theoreticallyflawedatthe extremes of age as you would be giving the same amount of energy to a 70kg 80-year-old female as to a 70kg 21-year-old male athlete, although their body composition is likely to be entirely different.Here, predictive formulae forbasal metabolic rate (BMR) plus around 10-20%, have a theoretical advantage, with the Henry equation best representing the UK population. Use of an obesity adjusted weight for those with a BMI >30kg/m2 has been demonstrated to allow estimation of requirements closer to measured energy expenditure.21

SomedietitiansprefertheuseofICUspecificformulae such as the Penn-State equation; however, a recent study of 5672 patients found that there were no differences in mortality ortime to ICU discharge alive for use of kcal/kg and complex equations, including Ireton-Jones, Mifflin-St Joel, Schofield and Harris-Bennedict.22 It is important to realise that all predictive formulae just give an estimation of needs, especially when taking into account the difficultyinobtaininganaccuratedryweighttouse in them - most ICU patients are considerably oedematous following fluid resuscitation.Whichever method you decide is best for your patient group, regard this as just a starting point and monitor carefully for signs of overfeeding, such as hyperglycaemia and hyperlipidaemia, with appropriate modification of your energyprescription accordingly. Also be aware that patients require more when they are recovering, with ESPEN recommending an increase to 25-30kcal in the anabolic (recovery) phase.18

Nitrogen (N) requirements are possibly one of the most controversial aspects of ICU nutritional support, with some authors suggesting that higher intakes are favourable23, especially in maintaining lean mass. However, a recent secondary finding of a large multicentre study24 was that the patients who received the most protein in the first week lost the most muscle mass, especially the more metabolically stressed. It would appear that very catabolic or immobile subjects are unable

to utilise high protein loads24,25,26 especially to synthesise skeletal muscle and, therefore, it seems logical that nitrogen provision follows the same pattern as energy, with less being required at first and more in recovery. Consider following the recommendations of NICE19 and giving <0.16gN/kg in first fewdays and increasing to > 0.24gN in the anabolic phase. Signs that a patient is entering an anabolic phase include a drop in inflammatory markers such as C-reactive protein, resolving oedema, reduced hyperglycaemia and insulin requirements, plus the return of appetite and mobility. In addition, Bernstein suggested that a 40mg rise in weekly serial prealbumin levels indicates the switch to anabolism27.

opTiMUM coMposiTion of pnIt is very important to consider the type of lipid used for ICU PN. It is almost certainly not optimal to use first generation lipidscomposed exclusively of soy bean oil, as these have long been associated with cholestasis, contain hepatotoxic phytosterols28 and are rich in omega-6 fatty acids which are the precursors of arachidonic acid and pro-inflammatoryeicosanoids. Using second generation lipids where some of the soy bean oil is replaced with olive oil or coconut oil which is high medium chain triglycerides may have theoretical advantages; however, the third generation lipids containing anti-inflammatory omega-3fatty acids from fish oil have been associatedwith improved outcomes on the ICU.29

Glutamine is a conditionally essential amino acid, with increased requirements in the critically ill. Parenteral supplementation of 0.3-0.5 g/kg has been shown to be safe and is associated with reduced septic morbidity, mortality and length of stay.30,31 Its use became extremely controversial following the REDOX32 trial and subsequent Canadian guidelines advising against giving it to critically ill adults.33 However, the REDOX trial has been criticised for giving a median dose of 0.78g/kg which is way in excess of that previously considered safe. In addition, both the enteral and parenteral routes were used in patients with a functioning receiving enteral nutrition. There is very little evidence to support the use of enteral glutamine, possibly because the GALT can synthesise glutamine from amino acids

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criTical care

NHDmag.com November 2015 - Issue 109 29

criTical care

derived from the gut lumen. However, the use of parenteral glutamine should be considered in long-term ICU patients who are exclusively parenterally fed. Wischmeyer31 urged caution in septic patients, or those with multiple organ dysfunction syndrome (MODS); however, this recommendation was largely based on the excessive dose used in the REDOX trial. Previously, it was concluded that smaller doses of parenteral glutamine are likely to bebeneficialintheseconditions.34

Modern parenteral nutrition is safe to use on the ICU and may be associated with

improved outcomes including survival. It should be considered for all patients who cannot be established on EN within 48 hours of admission to the ICU, especially those who are malnourished. Avoid excess provision of energy and nitrogen in the initial stages and increase in recovery. PN can be used to supplement EN to ensure requirements aremetwhileconferringthebenefitsofENthegut.Thirdgenerationlipidscontainingfishoilshouldbe strongly considered and those exclusively on PNforprolongedperiodswillmostlikelybenefitfrom glutamine supplementation.

References1 Heyland DK, MacDonald S, Keefe L et al (1998). Total parenteral nutrition in the critically ill patient: a meta-analysis JaMa16; 280(23): 2013-92 braunschweig cL, Levy P, Sheean PM, wang X. enteral compared with parenteral nutrition: a meta-analysis. am J clin Nutr 2001, 74(4), 534-423 Heyland DK, Dhaliwal R, Drover Jw, Gramlich L, Dodek P. canadian critical care clinical Practice Guidelines committee. canadian clinical practice guidelines

for nutrition support in mechanically ventilated, critically ill adult patients. JPeN J Parenter enteral Nutr. 2003 Sep-Oct; 27(5): 355-734 Klein c, Stanek G, wiles c. Overfeeding macronutrients to critically ill adults: metabolic complications. J am Diet assoc 1998, 98(7): 795-8065 Van den berghe G, wouters P, weekers F, Verwaest c, bruyninckx F, Schetz M, Vlasselaers D, Ferdinande P, Lauwers P, bouillon R. Intensive insulin therapy

in critically ill patients. N engl J Med 2001 Nov 8; 345(19): 1359-676 Umpierrez Ge, Isaacs SD, bazargan N, You X, Thaler LM, Kitabchi ae (2002). Hyperglycemia: an independent marker of in-hospital mortality in patients with

undiagnosed diabetes. J clin endocrinol Metab 87, 978-9827 Griffiths RD. Is parenteral nutrition really that risky in the intensive care unit? curr Opin clin Nutr Metab care 2004; 7: 175-1818 woodcock NP, Zeigler D, buckley P, Mitchell cJ, MacFie J. enteral versus parenteral nutrition: a pragmatic study. Nutrition 2001, 7(1), 1-129 Simpson F and Doig G. Parenteral vs enteral nutrition in the critically ill patient: a meta-analysis of trials using the intention to treat principle. Intensive care Med

2005, 31(1): 12-23. epub 2004 Dec 910 Harvey S et al. Trial of the route of early nutritional support in critically ill adults. N engl J Med 2014; 371: 1673-168411 Mcclave S, Martindale R, Vanek V et al (2009). Society of critical care Medicine (SccM) and american Society for Parenteral and enteral Nutrition (aSPeN)

Guidelines for the Provision and assessment of Nutrition Support Therapy in the adult critically Ill Patient: Journal of Parenteral and enteral Nutrition Vol 33 No 3 277-316

12 Furness Jb, Kunze wa, clerc N. Nutrient tasting and signaling mechanisms in the gut. II. The intestine as a sensory organ: neural, endocrine and immune responses. am J Physiol. 1999 Nov; 277(5 Pt 1): G922-8

13 casaer M et al. early versus late parenteral nutrition in critically ill adults. N engl J Med 2011; 365: 506-51714 Heidegger cP et al. Optimisation of energy provision with supplemental parenteral nutrition in critically ill patients: a randomised controlled clinical trial. Lancet.

2013 Feb 2; 381(9864): 385-9315 Pierre Singer, Mette M berger, Greet Van den berghe, Gianni biolo, Philip calder, alastair Forbes, Richard Griffitths, Georg Kreyman, Xavier Leverve, claude

Pichard. eSPeN Guidelines on Parenteral Nutrition: Intensive care. clinical Nutrition 28 (2009) 387-40016 Villet S, chiolero RL, bollmann MD, Revelly JP, cayeux RN Mc, Delarue J, berger MM. Negative impact of hypocaloric feeding and energy balance on clinical

outcome in IcU patients. clin Nutr.2005, 24(4): 502-917 Strang R, Turner P, Shenkin a, Mogk M, welters I. Nutrition and Trace elements in Intensive care Unit acquired weakness. clinical Nutrition Supplements Vol

5 Supp 2 2010, 208-20918 Kreymann KG, beger MM, Deutz Ne, Hiesmayr M, Jolliet P, Kazandjiev G, Nitenberg G, van den berghe G, wernerman J, ebner c, Hartl w, Heymann c,

Spies c. eSPeN Guidelines on enteral Nutrition: Intensive care. clin Nutr 2006, 25(2): 210-2319 NIce 2006 clinical Guideline 32: Nutrition Support in adults20 ava M Port and caroline apovian: Metabolic support of the obese intensive care unit patient: a current perspective. curr Opin clin Nutr Metab care 2010,

13(2): 184-19121 cutts Me, Dowdy RP, ellersieck MR, edes Te. Predicting energy needs in ventilator-dependent critically ill patients: effect of adjusting weight for edema or

adiposity. am J clin Nutr 1997, 66(5): 1250-622 compher c, Nicolo M, chittams J et al. clinical Outcomes in critically Ill Patients associated with the Use of complex vs weight-Only Predictive energy

equations. JPeN J Parenter enteral Nutr 201423 Michele Nicolo, Daren K Heyland, MSc, Jesse chittams, Therese Sammarco, charlene compher. clinical Outcomes Related to Protein Delivery in a critically

Ill Population: a Multicenter, Multinational Observation Study. JPeN J Parenter enteral Nutr 2015 apr 21. pii: 0148607115583675. [epub ahead of print]24 Puthucheary Za, Rawal J, McPhail M, connolly b, Ratnayake G, chan P, Hopkinson NS, Phadke R, Dew T, Sidhu PS, Velloso c, Seymour J, agley cc, Selby

a, Limb M, edwards LM, Smith K, Rowlerson a, Rennie MJ, Moxham J, Harridge SD, Hart N, Montgomery He. acute Skeletal Muscle wasting in critical Illness. JaMa. 2013 Oct 16; 310(15): 1591-600

25 biolo G, agostini F, Simunic b et al (2008). Positive energy balance is associated with accelerated muscle atrophy and increased erythrocyte glutathione turnover during 5 wk of bed rest. am J clin Nutr 88, 950-8

26 Glover eI, Phillips SM, Oates bR, Tang Je, Tarnopolsky Ma, Selby a, Smith K, Rennie MJ. Immobilization induces anabolic resistance in human myofibrillar protein synthesis with low and high dose amino acid infusion. J Physiol 2008 Dec 15;586 (Pt 24): 6049-61

27 bernstein L, bachman T, Meguid M. Prealbumin in Nutritional care consensus Group. Measurement of visceral protein status in assessing protein and energy malnutrition: standard of care. Nutrition 1995, 11: 169-71

28 Zi-wei Xu and You-Sheng Li. Pathogenesis and treatment of parenteral nutrition-associated liver disease. Hepatobiliary Pancreat Dis Int 2012, Vol 11: 58629 edmunds ce, brody Ra, Parrott JS, Stankorb SM, Heyland DK. The effects of Different IV Fat emulsions on clinical Outcomes in critically Ill Patients. crit

care Med 2014 Vol 42 No 5 1169-117730 Novak et al. Glutamine supplementation in serious illness: a systematic review. crit care Med 2002, 30, 2022-202931 Paul e wischmeyer, Rupinder Dhaliwal, Michele Mccall, Thomas R Ziegler and Daren K Heyland. Parenteral glutamine supplementation in critical illness: a

systematic review. critical care 2014, 18: R7632 Heyland D, Muscedere J, wischmeyer Pe, cook D, Jones G, albert M, elke G, berger MM, Day aG for the canadian critical care Trials Group. a

Randomized Trial of Glutamine and antioxidants in critically Ill Patients. N engl J Med 2013; 368: 1487-9533 Heyland D et al. canadian clinical Practice Guidelines. www.criticalcarenutrition.com/docs/cPGs%202015/4.1c%202015.pdf34 weitzel LR, wischmeyer Pe. Glutamine in critical illness: the time has come, the time is now. care clin 2010 Jul; 26(3): 515-25

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The current love of spread-sheeted information, and computer-cracked health scoring tabs and apps, fits inwith the growth of self-monitoring appliances. Perhaps being able to self-score and self-monitor diverse health behaviours, including food and drink consumption, may be the way to self-motivate and self-remedy fitness andwell-being. The only danger being that, as geeky whiz kids develop more com-puter algorithms, health professionals, such as dietitians, may no longer be needed. But of course not! Dietitians have unique insights and skills that no num-ber crunching, bleeping-blinking com-puter could ever match. But there has been some interest in scoring foods and diets, with methods that bring new ways to assess and correlate intakes to disease risk and health outcomes. And numeric scores are what computers (and some people) like best. Kiyah Duffey and Brenda Davyfrom Virginia Technical University developed a way to score the healthi-nessoffluid intakes,published in theJournal of the Academy of Nutrition and Dietetics in July 20151. And the Healthy Beverage Index (HBI) is just the kind of tool so in-demand by soft-ware designers and app developers.

whaT is The hbi and whaT does iT show?Score components relate to both amounts and nutritional quality of

fluids consumed, with highest theo-retical points being 100. Duffey andDavy describe fluid requirements as1.0ml liquid for each kcal consumed and are calculated at 2000ml for typi-cal US adults. Drinking at least these amounts of fluids per day, scores 20,with proportionately lower scores for lower amounts. Energy from fluids isalso a generic factor, with less than 10% of total energy intakes scoring highest points of 20 and more than 15% scoring lowestpointsof0.Thisseemsatightfitwith minor fuzzy factor for major point differences. Then come the individual fluidcomponent scores. Water (either tap or bottled) gains up to 15 points if at least 20% of requirements are consumed in this form, contrasting with 0 points if nofluidisconsumeddirectlyaswater.The next highest scoring component includes sugar-sweetened beverages (SSBs). Of course, in the nutrition liter-ature, this term has come to mean ‘full-fat’ versions of carbonated canned or bottled drinks, but it also includes any sugar containing dilutable squashes andsyrups,fruit-flavoureddrinksandsweetenedteasorcoffees,includingthepopular coffee-shop milk-shake styleversions. Not consuming these items gives 15 points to the score; consuming more than 8.0% of total energy from SSBs brings the point score down to zero. Small 5-point units are gained by not consuming full-fat milk and further 5-point units come from consuming

drinK SCoreS

advising people on a balanced diet is sometimes a complex instruction. people want to know the precise amounts and times of the day of the right foods and drinks for them; anything else just leads to randomness and muddle, and from that, a decline into chaos and anarchy (dietetically speaking).

hydraTion

ReviewbyUrsula arens writer; nutrition & dietetics

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

hydraTion

modest amounts of drinks, including unsweet-enedteaandcoffee,low-fatmilkorsoyamilk,diet drinks, pure fruit juice and alcohol. Exceed-ing modest amounts of these latter items brings the point score back down to zero. If your head is buzzing, it is because this is really informa-tion for a computer programmer, but what are the outcomes of this beverage scoring system?

oUTcoMes

day 1 day 2

black tea, 750ml black tea, 750ml

coffee plus soya milk, 300ml green tea, 250ml

red wine, 350ml coffee plus soya milk, 300ml

black tea, 250ml orange juice, 100ml

Total fluids: 1650ml Total fluids: 1400ml

hbi score: 55 hbi score: 77

Table 1: Ursula’s two-day score

NHDmag.com November 2015 - Issue 109 31

DuffeyandDavymodeldifferentbeveragedia-ries. A healthy one scoring the top 100 points, in-cludes 1500ml from tap or bottled water, 750ml (threemugs)fromblackcoffeeorgreentea,250mlfrom skimmed milk and even includes a small (150ml) glass of red wine. From this selection, morethan2600mloffluidsareconsumed,pro-viding nearly 200kcals. The contrast is the ‘typi-cal’ American beverage diary. Water provides only 250ml of fluid intakes. An equal amountcomes fromblack coffee.Mostfluid consumedcomes from sodas, both standard and diet ver-sions, and an additional 250ml comes from va-nilla latte. This beverage diary provides 1700ml of totalfluidsperdayandan energy intakeofnearly 500kcals. The HBI score for the typical American beverage diary is 56 points. The average HBI score of US adults was assessed from National Health and Nutrition ExaminationSurvey(NHANES)five-yeardatacollected to 2010. Analysis from more than 16 thousand intake diaries produced a score of 63, slightly higher that the modelled typical beverage intake score of 56. Individuals with the highest HBI scores were those consuming most of their fluid intakes aswater.While in-takes of water were variable, the range of scores for intakes of SSBs and energy from beverages was even more variable (more than a 10-point

range), suggesting that these were the most challenging themes in trying to increase HBI scores in the US population. A random two-day score was calculated for the author (see Table 1). Scores were both lower (55) and higher (77) than for the US population score of 63. Total energy requirements were sug-gestedbyDrDuffeytobeamodest1600kcals,sorequirementsfortotalliquidintakesweredefinedas 1600ml daily. The inadequacies of day one were no water intake, excess alcohol and excess energy intakes (due to the half-bottle of red wine). The inadequacies of day two were lesser, but still an indication of the challenge to achieve top scores: nowaterintakeandinadequatetotalfluidscon-sumed: 200ml short of the calculated requirement. While conceding shamefully to being a camel about drinking straight-water and preferring hot beverages for hydration, the HBI score system only allows a maximum score of 85 if water-pure is not consumed (even with lakes of tea). Duffey and Davy further assessed the as-sociation between the HBI and various mak-ers of cardio metabolic risk from the NHANES data. Higher HBI scores (by at least a 10-point difference) were associatedwith better cardiometabolic measures: in normal-weight adults these were lower odds of having a high waist circumference, of hypertension and of having more favourable lipidprofiles. Inmenspecifi-cally, there were also lower odds of having high C-reactiveproteinlevels.DuffeyandDavycon-cede limitations of their methodology, but sug-gest that the data supports some indications of adverse cardio metabolic health outcomes from fluiddeficits.Theyproposerefinementsof theHBI to optimise measured and observed health associations. But, in any case, they advocate for US adults to drink enough tap or bottled water.

NHDmag.com November 2015 - Issue 10932 NHDmag.com November 2015 - Issue 10932

hydraTion

The hydraTion indexAnother indexproposedforscoringfluids, is thehydration index. This has been developed by Dr Stuart Galloway at the Health and Exercise Sci-ence research group at the University of Stirling, and was presented at the 6th European Hydration Institute Meeting held in London this June2. Hy-drationefficiencyoffluidsconsumedrelatestovol-umes over time, of course, but also factors such as energydensityofthefluid,electrolytecontentandthe presence of diuretic agents. In order to develop the hydration index, Dr Galloway investigated the effectsonurineoutputandfluidbalanceofcon-sumingone litreof13differentdrinkscomparedto the reference of still water. More than 70 willing male students participated in the drinking trials and they may have been especially keen on the day thatalitreoflagerwasofferedatbreakfast. Urine outputs over four hours from fasted students were highest from the consumption of a litre of still water, and were similar for cola drinks,teaorcoffee,lager,orangejuiceorsportsdrinks. Urine outputs were lower after intakes of a litre of oral rehydration solutions or of milk. Variationsincaffeinecontentandsugarscontent

belowlevelsof10%hadnoinfluenceonhydra-tion index scores.

whaT To drink for hydraTion?DrGalloway’sdatasupportstheparticularbenefitsof still water, but other typically consumed drinks scored nearly as well, including lager. Lower hydra-tion index scores were demonstrated for milk and drinks with higher (above 10%) sugars content, and perhapsthesechoicesshouldspecificallybeomit-tedfromadviceoneffectivehydrationsources. There are many health and, perhaps, some cog-nitivebenefitsfromconsumingadequateamountsof fluids and, formost peoplemost of the time,typical choices made provide adequate hydration. However, unintended excess energy intakes are ariskifmostfluidsconsumedalsoprovidecalo-ries,andkeepingmostfluidintakesenergy-freeisan important public health message - which runs counter to the many urgent advertising messages communicating that people (young men) seeking vigour need energy drinks. Water cannot be chal-lenged as the pinnacle source of hydration, but many other drinks are nearly as good - and tea re-mainsmypersonalchoiceofwet-stuff.

. . . Your essential resource

NHDmag.com . . .

NHDmag.com November 2015 - Issue 109 33

Mycoprotein, the ingredient common to all QuornTM products, is a vegetarian protein produced inside fermenters by adding oxygen, nitrogen, glucose and mineralstoafilamentousfungusknownas Fusarium venenatum.1LordRankfirstidentifiedthisrarebutimportantfungusin theearly1960swhenlookingtofinda micro-organism that could convert car-bohydrate into proteins. This was during a time when there were concerns that population growth could lead to global food shortages and widespread famine.2 Now, more than five decades later,it seems that similar concerns are re-emerging. There is renewed interest in sustainable protein sources due to rising demands for meat, fuelled by accelerations in population growth.3 In fact, demands for animal-based protein are estimated to rise by 72% between 2013 and 2050, which raises new concerns about the sustainability and environmental impacts of this.4 This article develops the knowledge about the nutritional profile of myco-protein, reviews evidence in relation to itspotentialhealthbenefits andbringsin wider environmental perspectives.

nUTriTional profileAs shown in Table 1, when compared to other protein sources, mycoprotein is particularly low in energy, total and saturated fatwhilebeinghigh infibre.Thefibrefoundinmycoproteinistypi-cally one-third chitin (poly n-acetyl glu-cosamine) and two-thirds β-glucan (as1,3 and 1,6).5

Fromahealthstance,forchitinfibre,

there is growing interest in its anti- oxidant, antihypertensive, anti-inflam-matory, anticoagulant, antimicrobial, anticancer and antidiabetic properties.6 β-glucan,however,isthoughttoplayarole in the regulation of appetite control, with its low glycaemic index and actions ongutflorabeingpossiblemechanismsbehind this.7

With regard to the quality and digest-ibility of mycoprotein, the Protein Di-gestibility-Corrected Amino Acid Score (PDCAAS) is a measure of this. This has been reported to be 0.99 for mycopro-tein, which is higher than values previ-ously reported for soybean protein, beef, kidneys beans and lentils.8,9 Mycoprotein also contains all nine essential amino ac-ids required by adults.10

Putting this into the context of Euro-pean Commission nutrition claims, myco-protein is: 1) ‘low in fat’, i.e. contains no more than 3.0 grams of fat per 100 grams of solids; 2) ‘low in saturated fat’, i.e. does not contain more than 1.5 grams of saturat-ed fatty acids per 100 grams of solids and 3) ‘high infibre’, i.e. containsat least6.0gramsofAssociationofOfficialAnalyticalChemists(AOAC)fibreper100grams.11

Mycoprotein also provides a spectrum of vitamins and minerals. Again, applying European Commission nutrient claims, mycoprotein falls under the category of being ‘high’ in zinc, phosphorous, man-ganese, copper, selenium and chromium and a ‘source’ of riboflavin.12,13 It is also low in sodium, containing 2.0 milligrams of sodium per 100 grams; equivalent to 0.005 grams of salt.

myCoProtein: nUtritionAl, heAlth And enVironmentAl BenefitS

dr emma derbyshire phd rnutrindependent consultant (public health)

dr emma derbyshire is a nutrition Consultant who writes regularly for academic and media publications. her specialist areas are public health nutrition and functional foods.

there has been growing interest in the need to utilise alternative protein sources, given that world populations are expanding, yet there is limited space for sustainable agricultural production. Based on these changes, this article discusses the nutritional, health and environmental properties of mycoprotein, taking latest issues into context.

sUsTainable proTein soUrces

Tim finnigan phd

dr tim finnigan is director of research and development at marlow foods

MycoproTein and healThAs shown in Table 2, a growing number of English-languagepapers,identifiedthroughMedline(PubMed) have been published looking at the potential healthbenefitsofconsumingmycoprotein. Several have looked at the effects of myco-protein consumption in relation to energy intake and satiety. For example, Bottin and colleagues (2012) looked at the dose of mycoprotein needed toinducesatietyeffectsamongst35healthyover-weight adults.14 After a period of fasting, the in-gestionof32gramsmycoproteinledtosignificantreductions in energy intake and increased feelings of fullness during an ad libitum lunch served at the end of the day.14

Similarly, work by Williamson et al (2006) and Turnbull et al (1993) found that the ingestion of mycoprotein preloads led to lower food intakes lat-er in the day, when compared to eating chicken.15,16 Oneplausiblemechanismcouldbethehighfibre

contentofmycoprotein,withtheviscosityoffibrein particular being thought to aid early signalling and enhanced feelings of satiation.17

With regard to blood lipid levels, Ruxton & McMillan (2010) conducted a six-week interven-tion trial on healthy free-living adults.13 It was found that, amongst subjects with higher baseline blood cholesterol levels, the ingestion of 88 grams of wet weight mycoprotein daily (dry weight equivalent to 21 grams QuornTM)ledtosignificantreductions in total cholesterol levels.13

Similarly, earlier work found that mycopro-teinconsumptionledtosignificantreductionsintotal and LDL cholesterol18 and improvements in high-density lipoprotein, when mycoprotein was eaten instead of meat amongst individuals with slightly elevated cholesterol levels at baseline19, as well as general reductions in serum cholesterol levels.20Similarfindingshavealsobeenreportedelsewhere by Japanese scientists.21,22,23

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sUsTainable proTein soUrces

mycoproteina (wet) red meatb,c chickenb,d tofub,e rNi12

energy (kcals) 85 176 148 76 na

protein (g) 14 20 21.2 8.08 na

carbohydrate (g) 1.2 0 0 1.88 na

fat (g) 1.4 ‘low in’ 10.0 6.32 4.78 na

of which saturates (g) 0.3 ‘low in’ 3.9 1.57 0.69 na

fibre (aoac) (g) 6.1 ‘high in’ 0 0 0.3 na

Vit B1 (mg) 0.01 0.04 0.15 0.08 1.1

Vit B2 (mg) 0.23 ‘source’ 0.15 0.21 ‘source’ 0.05 1.4

Vit B3 (mg) 0.35 5.07 ‘high in’ 7.48 high in’ 0.20 16

Vit B6 (mg) 0.13 0.37 ‘source’ 0.44 ‘source’ 0.05 1.5

Vit B9 (µg) 10 6 7 15 200

calcium (mg) 42.5 12 10 350e ‘high in’ 800

chromium (µg) 15 ‘high in’ -- -- -- 40

copper (mg) 0.5 ‘high in’ 0.07 0.09 0.19 ‘source’ 1.0

iron (mg) 0.5 2.24 ‘source’ 1.09 5.36 high in’ 14

magnesium (mg) 45 20 24 30 375

manganese (mg) 6 ‘high in’ 0.001 0.02 0.61 ‘high in’ 2.0

phosphorus (mg) 260 ‘high in’ 184 ‘source’ 209 ‘source’ 97 700

potassium (mg) 100 321 ‘source’ 251 121 2000

Selenium (µg) 20 ‘high in’ 16.6 ‘high in’ 15.7 ‘source’ 8.9 ‘source’ 55

Zinc (mg) 9 ‘high in’ 4.79 1.40 0.80 10

Sodium (mg) 2.0 66 79 7 na

Table 1: nutrient density of mycoprotein compared to other protein sources (per 100g)

Key: aData provided by Marlow foods (wet weight); bData extracted from the USDa database (for raw produce); cValues for beef; 90% lean; dValues for stewing meat; eRegular, prepared with calcium sulfate; (--) indicates no data; Na not applicable; RNI Reference Nutrient Intake. Values in bold meet european commission (2008) nutrient claim guidelines.

Other work has looked at markers of glycae-mic control. For example, Bottin and colleagues (2011) found that mycoprotein, when eaten as a soup containing 30 gramsmycoprotein, signifi-cantly improved post-prandial insulin resistance compared to whey protein amongst a sample of 10 healthy overweight adults.24 Similar findings

were also found by Turnbull & Ward (1995), when milkshakes containing mycoprotein were provid-ed to a sample of normal healthy adults.25 While these results seem to indicate that mycoprotein shows promise as part of the dietary management of diabetes, randomised trials are now needed in clinical populations.

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sUsTainable proTein soUrces

publication Study population Health outcome Study methods main findings

Bottin et al (2012)14

n=35 healthy overweightadults

energy intake measured

randomised laboratory study (sevenoccasions)

higher intakes of Myp i.e. 32g portions sig. ↓ ei and ↑ feelings of fullness (P=0.06)

Bottin et al (2011)24

n=10 healthy overweightadults glucose control

randomised laboratory study (two occasions)

Insulinlevelssig.↓ 15, 30 & 45 minutes after eating 30g Myp. Myp sig.improvedPPIRcomparedwithwhey protein (P=0.0165)

ruxton & mcmillan (2010)13

n=21 healthy, free-livingadultsand n=10 controls

Cholesterollevels

ate: 1) mycoprotein daily as quornTM or 2) normal habitual diet for six weeks

amongst subjects with higher baselinecholesterollevels,totalcholesterollevelssig.↓ after eating Myp daily

Williamson et al (2006)15 n=42overweightF Eatingbehaviour

and hunger

Three-day controlled laboratory study

Myp had satiating properties thatpersistedforseveralhoursafter eating a meal

turnbull & Ward (1995)25

n=19 healthy weight subjects

glucose and insulinlevels

Two single-meal studies with crossover

glycaemia was sig. reduced 60minsaftereatingMYPvs.control. insulinaemia ↓ after 30 mins and 60 mins after eating MYPvscontrol.

Burley et al (1993)

n=18 healthy subjects

appetite and satiety feeding trial

after eating a lunch containing MYP(11gfibre)eveningEIatan ad libitum test meal sig. ↓ by18%vscontrol

turnbull et al (1993)16

n=13 female non smokers

energy intake and appetite

Two three-day study periods

ei ↓ sig. by 24% on the day of the study and by 16.5% the next dayaftereatingMYPvscontrol

turnbull et al (1992)18

n=21overweightstaff and students with slightly raised cholesterollevels

Bloodlipidlevels eight-week interventionstudy

after eating 26.9g Myp (from cookies) total cholesterol ↓ by 0.95mmol/l in the Myp and 0.46 mmol/l in the control gp. ldl ↓ by 0.84mmol/l in the Myp and 0.34 mmol/l in the control. differences were statistically significant

turnbull et al (1990)19

n=17 staff & students with slightly raised cholesterollevels

Bloodlipidlevels Three-week metabolic study

after eating Myp instead of meat plasma cholesterol ↓ by 13%. ldl ↓ by 9% in the Myp gp and ↑ by 12% in the control. hdl ↑ by 12% in the Myp gp and↓ by 11% in the control. differences were statistically significant.

udall et al (1984)20 n=100 subjects blood serum

constituentsTwo double-blind crossoverstudies

after 30 days there was a ↓ in serum cholesterol when 20g F. graminearium was eaten as cookies

Table 2: Mycoprotein and health studies

Key: eI energy intake; gp group; HDL High-density lipoprotein; MYP mycoprotein; LDL low-density lipoprotein; PPIR Post-prandial insulin resistance;

↓ reduced, ↑ increased.

enVironMenTalFeeding the world’s growing population will require a vast expansion in agricultural production by 2050.26 For example, whilst the world population was around 2.5 billion in 1950, this is projected to reach around 9.5 billion by 2050.27 Subsequently, one of the greatest challenges we face is feeding nine to 10 billion people while reducing the environmental impacts of this, i.e. greenhouse gas emissions, biodiversity loss and loss of ecosystem. Climate change is also predicted to make the situation worse, further threatening the amount of land available for rearing livestock.28

Innovative protein sources, such as mycopro-tein based QuornTMofferonesolution,potentiallyimproving food security, as less land is needed to produce similar amounts of protein and energy.26 The consumption of vegetarian proteins has in-creased over the years due to rising concerns about animal welfare29, alongside animal diseases, eco-nomic changes, for religious (halal) reasons and now due to the global shortage of animal protein.30

discUssionIt can be seen that mycoprotein is a valuable food ingredient, providing high-quality protein while beinglowintotalandsaturatedfatandhighinfibre(chitinandβ-glucan).5 Recent work has also shown that vegetarian and meat protein both appear to haveapositive influenceonappetite control andweightloss,influencingguthormoneprofilesinasimilar way.31

There has also been a general tendency to see mycoprotein first and foremost as a vegetarianfood. However, changing demands for differentsources of protein and the growing body of evidencesupportingitshealthbenefits,nowmeanthat more people are turning to mycoprotein for different reasons.Therehasalsobeena tendencyfor the micronutrient profile of mycoprotein tobe overlooked, yet it is an important source of zinc, phosphorous, manganese, copper, selenium, chromiumandriboflavin. Including mycoprotein with the weekly diet may also help to keep meat intakes in check. For example, the UK Scientific Advisory Commit-tee on Nutrition (SACN) advises that up to 500 grams of cooked red meat (approximately 70 grams daily) can be eaten daily, which falls in line with colon cancer prevention advice.32 While

most people do not exceed these guidelines, malesmaybenefitfromsubstitution,asevidencefrom the UK National Diet and Nutrition Survey indicates that this population group has some of the highest meat intakes.33 For example, mean consumption has been reported to be 85g daily for males aged 19 to 64 years.33

Taken together, dietitians and health practi-tioners can play an important role in ensuring that their patients are aware of mycoprotein. As seen in the studies reviewed, mycoprotein has the potential to play a role in weight or diabetes management programmes, as well as helping to support a healthy lipidprofileandsubsequenthearthealth.The next stage is for randomised controlled trials to be undertaken in healthcare settings.

conclUsionsIn conclusion, mycoprotein should be recognised as more than a food option for vegetarians. This article has shown that mycoprotein provides good quality protein without being high in total or saturated fat. Itisalsohighinfibrewhichisparticularlyimpor-tant given that SACN (2015) guidelines have shifted fibrerecommendationsforthoseaged16yearsandoverupto30gramsofAOACfibredaily.34

Mycoprotein also has the potential to improve thenutritionalprofileofpatients’diets,alongwithcertain health outcomes. Research, in relation to satietybenefits, looksparticularlypromisingand,on thewhole,makes sense given the high fibre-content of mycoprotein. Next, randomised trials in clinical settings are needed. Finally, innovative protein sources such as mycoprotein, appear to be one way forward given rising concerns about feeding the expand-ing world’s population. Given that QuornTM has been on the market since 1985, it already has a longstanding reputation of being safe. The next stages are to communicate the nutritional, health and environmental benefits of mycoprotein topatients and the lay public.

AcknowledgementThis work was supported by Marlow Foods Ltd, Stokesley UK. The content of the paper has been written independently.

NHDmag.com November 2015 - Issue 10936

sUsTainable proTein soUrces

for article references please email info@networkhealthgroup.co.uk or click here . . .

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NHDmag.com November 2015 - Issue 10938

Dietisthoughttohaveaneffectontheprogression of symptoms and function. In recent years, there has been growing interest in using the ketogenic diet for Alzheimer’s disease. This article reports on recent research in this area and discusses the evidence for implementing the ketogenic diet in this patient group. It is believed that one in six people over the age of 80 have dementia and is estimated that only 59% of people living with dementia in England have a formal diagnosis. Alzheimer’s disease is themostcommonformandaffects62%of those with a diagnosis of dementia.2 With an ageing population and increased awareness of dementia, more people are being diagnosed than in the past. It is important to try to obtain a diagnosis for dementia in order to rule out other possible causes of any symptoms. It allows an explanation for any changes to behaviour and is also important so that any possible treatment and support for individuals and their families or carers can be accessed. Since 2010, the UK government has committed to increasing research funding into dementia.3 However, a recent study concluded that even though this has improved, funding for research into dementia is still disproportionately low against disease burden compared to other diseases such as cancer and coronary heart disease (CHD). Dementia has the highest social care system cost of £10.2 billion per year compared to cancer and CHD. Despite this, in 2012, for every £10 in health and social care cost of disease, cancer received £1.08 in research funding, CHD received £0.65,

compared to dementia which received only £0.08.4 Given disease burden, it is important for research to be carried out in this area. As a degenerative disease, if there are potential methods of reducing the rate of disease progression, then these should be investigated.

whaT is a keTogenic dieT?A ketogenic diet is a diet which results in ketone bodies being produced as a result of the body having to use fat as an energy source instead of carbohydrate. The exact composition of this diet can vary, but it is generally based on a high fat, low carbohydrate and adequate protein intake. The classical ketogenic diet uses a 4:1 ratio in calorie intake of fat to carbohydrate.5 Variations, or less restrictive versions of this, include the modified Atkins diet,medium chain triglyceride diet and low glycaemic index treatment.6 In normal energy metabolism, the brain uses glucose as a primary energy source. However, a high fat and low carbohydrate intake results in fat being broken down in the liver to fatty acids and ketone bodies. This also happens during prolonged periods of starvation or fasting, when alternative energy sources are needed. The ketone bodies can then be used instead of glucose by the brain.7 It has been found that once ketone bodies reach a concentration of 4.0mmol/L, they are used as an energy source by the central nervous system.8

The ketogenic diet has shown to be effective in treating refractoryepilepsyand has been used in this area for many years.5 Although it appears that the ketogenic diet is beneficial in seizure

KetoGeniC diet And Alzheimer’S diSeASe

punita Mistryhcpc registered dietitian, royal Wolverhamptonnhs Trust

Punita’s current role includes medicines management work, home enteral tube feeding and acute oncology. She is a member of the BdA group nAGe and Prescribing Support dietitians Group.

dementia can be described as a progressive syndrome caused by a variety of brain illnesses that affect memory, thinking, behaviour and the ability to perform everyday activities.1

deMenTia and nUTriTion

control, there are potential weaknesses; 30% of participants reported short-term gastrointestinal-relatedadverseeffectsandcompliancewiththediet was poor, with only 10% remaining on the diet for three to six years.5

eVidence for keTogenic dieT in alzheiMer’s diseaseResearch into the use of the ketogenic diet for neurodegenerative conditions, including Parkinson’s disease and motor neurone disease, is growing. Unfortunately, there is little evidence for the use of a ketogenic diet for Alzheimer’s disease, particularly in human trials. Current evidence is based on animal studies, but this appears to be conflicting. Studies usingAlzheimer’s disease in mice that were fed a ketogenic diet have shown improvements in motor function9 and a reduction in β-amyloidlevels (which form the plaques associated with Alzheimer’s disease).10 In canines, however, effectswerelimitedtotheparietallobeonly.11

Although there is little evidence of the benefitsoftheclassicalketogenicdietinhumans,a less restrictive form of the ketogenic diet, such asthemodifiedAtkinsdietwhichwouldcontainhigher amounts of carbohydrate and protein intake compared to the classical ketogenic diet, could be a more realistic strategy to use and could improvecompliance.Using themodifiedAtkins diet has been shown to be effective forchildren with epilepsy12 and so it could be as equally effective as the classical ketogenic dietfor Alzheimer’s disease.

NHDmag.com November 2015 - Issue 109 39

To minimise compliance issues, an alternative method of inducing ketosis, by using a ketone monoester alongside normal intake, has been investigated. It was shown to improve cognitive performance and reduce amyloid-β and taudeposition in a mouse Alzheimer’s disease model.13 A study which observed the effect of taking a ketone monoester supplement in one participant with Alzheimer’s disease concluded that using this method is safe, convenient and can be taken regularly as a food supplement with no difficulty. It resulted in the participant with early onset Alzheimer’s disease improving from needing constant supervision to becoming more self-sufficient (within days) and carrying out more complex tasks, such as housework and gardening, by six weeks. He was also able to discuss events that had taken place the previous week.14 During this 20-month study, the participant’s brain MRI was stable. Unfortunately, these effects were limited and he eventually deteriorated and also showed poor wound healing, respiratory infection and an outbreak of fever. Despite his poor outcome, this case study did show that not only did the ketone monoester slow down progression, but it also temporarily reversed some symptoms of Alzheimer’s disease. A stronger evidence base perhaps, including randomised controlled trials, is needed before these results can be generalised.

The ketogenic diet has shown to be effective in treating refractory epilepsy and has been used in this area for many years. Although it appears that the ketogenic diet is beneficial in seizure control, there are potential weaknesses . . .

MechanisM of acTionThe mechanism through which a ketogenic diet improves symptoms of Alzheimer’s disease is unclear; however, it is believed that it provides a neuroprotective effect. It has been shownin animal models (mice) that a ketogenic diet resulted in improved mitochondrial function and less oxidative stress and β-amyloiddeposition compared to those fed a normal feed.10 Cognition and alertness has been shown to improve with patients who are on a ketogenic diet for epilepsy15, which was thought to be due to improvements in seizure control, decreased medication,oranonspecificeffectofthediet. Another study found that attention and social function improved in children with epilepsy.16 Therefore, although there is a lack of evidence for the use of the diet in humans with Alzheimer’s disease, there is evidence which demonstrates an improvement in cognitive function from following the ketogenic diet. The question that arises is whether it would result in a significant improvement in symptoms ofAlzheimer’s disease and at what stage of the disease would the diet need to be implemented in order to have a beneficial effect in slowingdown the rate of progression of disease.

pracTicaliTy of iMpleMenTing a keTogenic dieT in This paTienT groUpAlthough the evidence base for a ketogenic diet in this population is still building, the reality of being able to follow this diet in this patient group is another challenge altogether. Firstly, there is the issue of gaining informed consent to implement thisdiet,whichmaybedifficultdependingonwhat stage of dementia the individual is at. If an individual is confused, or if they are unlikely to remember or understand why their food choices have been restricted, then it may cause them unnecessary distress. A further challenge is the actual implement-ation of the diet. This may vary depending on where the individual is living. For example, it may be easier to implement if the individual is within

a care setting and all meals are being catered for. However, it would require appropriate training forstaffincarehomes.Ifanindividualislivingin their own home and family members are caring for them, then they would require dietetic advice for a ketogenic diet. If an individual was still managing to prepare their own meals, it maybedifficulttoimplementachangeintheirdiet at a time when routine is key. If memory hasbeenaffected,thentryingtoremembernewinformationwillbedifficult. More importantly, we need to question the use of a restrictive diet in a group that may be facing existing nutritional issues. It is common for individuals with Alzheimer’s disease to have a poorappetite,notrecognisehungerorthirst,sufferfromdisease-relatedmalnutrition,havedifficultychewing or swallowing, and, therefore, any restrictions to their food choices could have a further impact on their nutritional status. Maintaining nutritional status is usually a priority in this patient group. When considering malnutrition and the use of energy dense diets for people with dementia, the ketogenic diet would at least coincide with this, as both are based on a high fat intake. It would be important to assess people at an individual level to determine what the nutritional priority and the dietetic aim is and how appropriate the ketogenic diet would be for them. Overall, there is limited evidence for the use of a ketogenic diet for Alzheimer’s disease at present. More importantly, it is restrictive in a patient group that may already be facing nutritional issues. Familiar foods, nutritionally dense foods and maintaining nutritional status should remain the priority for people with Alzheimer’s disease. However, we cannot ignore the potential for the diet to improve quality of life. It would be beneficial for the effects of the ketogenic dietto gain more research funding and it would be interesting to observe the potential future for its use in neurodegenerative disorders.

NHDmag.com November 2015 - Issue 10940

deMenTia and nUTriTion

. . . we need to question the use of a restrictive diet in a group that may be facing existing nutritional issues.

for article references please email info@networkhealthgroup.co.uk or click here . . .

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NHDmag.com November 2015 - Issue 10942

But perhaps you have time to linger and consider further why this is such an excellent book. The hugely annoying factor is just that Catherine Price is not a nutrition professional, but has managed to dig deeper, consider wider, communicate more clearly and conclude more pragmatically than many colleagues who are more learned in this terrain. She is a disciple of Michael Pollen who is well known as a prolific and influential food policycommunicator, but Catherine Price has steered more into the sciency-bit of food debate (the home of dietetics). Catherine discusses the history of vitamins, the economic and policy debates of vitamins, the latest health research on vitamins, the confusions both planted and accidental around vitamins, the industry and consumer pushes and pulls around supplementation and the legislative and political inputs on vitamin use. There is massive interweaving of all of these aspects and all contribute to the high alertness of consumers and industry to these ‘magic bullets’ that promise health and wellbeing, to counter the damages of sedentary lives and convenience-driven food choice. Catherine is always cool and rational in her discussions and yet there is enough pepper and spice in the illustrations she selects, to make this a very exciting read. The topics are all well known to dietitians and yet there

are so many new and astonishing aspects to Catherine’s insights on vitamins, that ahuge‘fortification’ofunderstandingisguaranteed. For a tiny taster of the contents of this book, let’s start at the very beginning: with the letter A. Vitamin A is widely available from many natural and fortified food sources in the UK diet,but deficiency is still a global problemcausing blindness and fatal outcomes from impaired immune responses to diseases such as measles. Night blindness precedes dry-eye and ulceration of the cornea and, yet, even if it never develops to the severe stages, it is a major handicap in societies without the illumination provided by electricity. Seeing children become fully dependent on others after sunset - estimated to affect more than130 million preschool children and it is common enough to be considered a normal part of late pregnancy in some poorercommunities-estimatedtoaffectmore than six million pregnant women annually. Historical descriptions of sailors’ blindness were evidently due to vitamin A deficiency, but were taggedto causes as random as homesickness or humidity or masturbation. Treatments forafflictedsailorswerebizarre,althoughbeing locked in a dark closet, ‘to give the eyes a rest’, was perhaps less painful than other common maritime remedies for ill health.

if you are in a hurry, the conclusion of this review is, a muSt read book for dietitians.

book reView

the VitAmin ComPlexour obsessive quest for nutritional perfection

ReviewbyUrsula arens writer; nutrition & dietetics

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

by caTherine priceoneworld pUblicaTions, 2015isbn 978-1-78074-346-2price: £11.99

Catherine interviewed vitamin A expert Alfred Sommer about his battles to combat deficiencyinIndonesia.Hisinitialsuggestionsto dose vitamin A orally were mocked by WHO experts, who supported the evidence-based strategy of injections. The critics said that children would spit out capsules, and that, ‘patients liked injections’. The strong associations between night blindness and mortality rates led Sommer to consider that it was a late rather than an early indicatorofvitaminAdeficiency,andhisstudyof 26 thousand children published in 1986, demonstrated that giving one vitamin A capsule every six months resulted in the 34% reduction in death rates in deficient children. Catherinedescribes Alfred Sommer as a feisty expletive-filled New Yorker, who can now take ‘I-told-you-so delight’ that vitamin A supplementation programmes are viewed as the single most cost-effectiveinterventioninmodernmedicineandare being funded by UNICEF in more than 70 countries. Shipping pills between and around countries cannot be the solution to vitamin A deficientpopulations (although the DSM-funded Sight and Life vitamin A supplementation programme deserves high praise). Beta-carotene to vitamin A conversion rates have been re-assessed in the last two decades, with dramatic changes for policy. Pure beta-carotene in oil has a conversion rate to vitamin A of about two to three, but assessments for typical American diet rates were increased from six to about 12; Sommer estimates that conversion rates in typical Indonesian diets are lower still at about 24, half those in typical American diets. The lower conversion rates explainedthegreatervitaminAdeficiencyratesobserved in some populations, where theoretical diet calculations predicted adequacy. Newfocusonfood-firststrategieshasledtodevelopmentsofbiofortificationand,specifically,genetic-modification.Thestoryof‘GoldenRice’isfornow,justastory.Theinsertionsofdaffodil

genes into rice that made it a beta-carotene source was announced in 1999 and there was excitement thatthiswasthefirstgeneticallyengineeredcropthatoffereddirectbenefits toconsumers ratherthan only farmers. But there was opposition. A huge amount of golden rice would need to be consumed to meet daily vitamin A requirements, and the involvement of the biotech company Syngenta increased opposition from food activists. Fifteen years later, field test trials ofan even higher carotene variant of golden rice were successful and Syngenta declared ‘free use’ of the product to farmers whose direct annual profits from rice were less than 10,000US dollars. But there is still not a single grain of commercially produced golden rice on the market because of fundamental opposition to the technology. Catherine observes huge hypocrisy and ‘nutritional blindness’ from the well-fed supplement-taking populations of the US in relation to a technology that could contribute dramaticallytoreducingvitaminAdeficiencyinsuffering populations.On this topic, Catherinehas given a “yes” to a strategy that she feels can challenge the500 thousandvitaminA-deficientchildren going blind each year. Many of the descriptions in this book are based on the American marketing and legislative developments of vitamin use. There is a whole sorry chapter on how the Food and Drug Administration (FDA) was humiliated and politically outmanoeuvred in relation to the ‘Dietary Supplement Health and Education Act (DSHEA)’ passed in 1994 - for fear of being thought even more bizarre. I will not reveal that this was my favourite chapter. I could go on and on presenting cherries of detail from this information feast of a book. But rather, I give this a 10/10 rating and urge dietitians to put aside ‘140-character reading’, and read the 380 pages of this book. It is a deeply satisfying masterpiece of nutrition science writing.

NHDmag.com November 2015 - Issue 109 43

book reView

. . . I give this a 10/10 rating and urge dietitians

to put aside ‘140-character reading’, and read

the 380 pages of this book.

NHDmag.com November 2015 - Issue 10944

web waTch

WeB WAtCh

online resources and useful updates.

reSearcH prioritiSatioN: WorkSHop reportS

commiSSioNiNg NutritioN aNd HydratioN care

meaSuriNg cHild deVelopmeNtThe Department of Health has updated its guidance Developing a public health outcome measure for children aged 2 – 2½ using ASQ-3. Originally published in January 2015, this update includes information on how to submit data on the child development indicator to HSCIC and about the introduction of the ASQ Social and

alterNatiVe guide to meNtal HealtH care iN eNglaNd

deNtal carieS aNd oBeSity iN cHildreNPublic Health England has

ageiNg aNd HealtHThe World Health Organisation has published World report on aging and health. This report outlines a framework for action to foster healthy ageing built around the new concept of functional ability.

0-5 cHildreN’S puBlic HealtH traNSferThe Local Government Association has published Must knows:

iNflammatory BoWel diSeaSe auditThe Royal College of Physicians has published the fourth inflammatoryboweldisease(IBD)clinical audit report. The report reveals that the majority of patients (80% adult and 77% paediatric) with Crohn’s disease saw an improvement following biological therapies. The purpose of this auditistomeasuretheefficacy,safety and appropriate use of the biologicaltherapiesinfliximaband

Public Health England has publishedfivereportsfromworkshops held to prioritise research needs in dementia, obesity, best start in life and evaluation of public health interventions: www.gov.uk/government/publications/research-prioritisation-workshop-series

Emotional questionnaire. www.gov.uk/government/publications/measuring-child-development-at-age-2-to-25-years

Making these investments will have valuable social and economic returns, both in terms of health and wellbeing of older people and in enabling their ongoing participation in society. www.who.int/mediacentre/news/releases/2015/older-persons-day/en/

The King’s Fund has published an animationillustratingthedifferentmental health services available and howtheyfitinwithotherhealthservices. Whilst demonstrating the range of services available, it also highlights some of the issues that need to be addressed. www.kingsfund.org.uk/audio-video/alternative-guide-mental-health-care-england

NHS England has published Guidance - commissioning excellent nutrition and hydration 2015-2018. This document provides guidance on commissioning and provides examples of approaches that can be adopted locally to improve the nutrition and hydration care of the population in acute services and the community. It also outlines why commissioners should make this issue a priority - how to tackle the problem, how to assess the impact of commissioned services and highlighting the work which is already underway. www.england.nhs.uk/commissioning/nut-hyd/

Children’s public health transfer. It details councils statutory responsibility for commissioning children’s public health services for children aged 0-5 following the transfer of these responsibilities from the NHS on 1 October 2015. This joins up with the much larger transfer of public health functions to local government which included responsibility for 5-19 year olds, which took place on 1 April 2013. www.local.gov.uk/web/guest/publications/-/journal_content/56/10180/7505714/PUBLICATION

published The relationship between dental caries and obesity in children: an evidence summary, exploring whether dental caries and obesity are found in the same individuals and populations. The report reviews and summarises what is currently known and supports the dental public health and obesity teams. www.gov.uk/government/publications/dental-caries-and-obesity-their-relationship-in-children

NHDmag.com November 2015 - Issue 109 45

web waTch

Nao guide to tHe departmeNt of HealtH

Resources from Nice

Nice SHared learNiNg dataBaSe: dietetic-led coeliac SerViceNICE has added ‘A dietetic-led coeliac service incorporating group education’ to its Shared learning database. This example describes Gloucestershire Hospitals NHS Foundation Trust service redesign to increase patient capacity within existing dietetic provision,

Nice guidaNce: coeliac diSeaSe

dieteticJOBS.co.ukThe UK’s largest dietetic jobsitesince 2009

NHDmag.com October 2015 - Issue 108 49

CAREER

We urgently require dietitians for immediate vacancies

To find out your options call or email

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

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

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

We offer inpatient and community UK & NI coverage

Competitive rates

www.pjlocums.co.uk

NUTRITION

To place an ad or discuss your requirements please call

0845 450 2125 (local rate)

• Quarter page to full page

• Premier & Universal placement listings

• NHD website, NH-eNews & NHD Magazine placements

adalimumab, in patients with IBD in the UK. The audit also aims to capture patients’ views on their quality of life at intervals during their treatment. www.rcplondon.ac.uk/press-releases/latest-uk-ibd-audit-report-shows-further-improvement-patients-

Nice guidaNceNICE has published the following guidance: Type 1 diabetes in adults: diagnosis and management. NICE guideline (NG17). www.nice.org.uk/guidance/ng17 Diabetes (Type 1 and Type 2) in children and young people: diagnosis and management. NICE guideline (NG18). www.nice.org.uk/guidance/ng18

whilst also aiming to improve service quality. www.nice.org.uk/sharedlearning/a-dietetic-led-coeliac-service-incorporating- group-education

TheNationalAuditOfficeispublishing a suite of short guides, one for each government department. A short guide to the Department of Health is designed to provide a quick and accessible overview of the Department and focuses on what the Department does, how much it costs and recent and planned changes. www.nao.org.uk/wp-content/uploads/2015/09/A-Short-Guide-to-the-Department-of-Health.pdf

NICE has published guidance Coeliac disease: recognition, assessment and management (NG20). This guideline covers the recognition, assessment and management of coeliac disease in children, young people and adults. It updates and replaces NICE guideline CG86 and includes recommendations on: referral of people with suspected coeliac disease; information and support; advice on dietary management; non-responsive and refractory coeliac disease; and monitoring and review in people with coeliac disease. www.nice.org.uk/guidance/ng20

NHDmag.com November 2015 - Issue 10946

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)

dieTiTian senior ii - gibralTar healTh aUThoriTy - £29,151 To £38,411pa (depending on experience).Now is your opportunity to sample the Mediter-ranean way of life in Gibraltar. 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 out-patient clinics, as well as providing training/educa-tionfornursingstaffasrequired.Youwouldbepartof a team of three highly experienced dietitians who would provide you with clinical supervision and support. The appointment will be on contract terms to cover a period of maternity leave. To discuss any aspects of the post, please contact Ms Katrina Skil-ton, Senior Dietitian on 00350 2007 2266 ext 2199 or email katrina.skilton@gha.gi Application packs can be obtained from the Recruitment Section on 00350 2007 2266 ext 2082, Fax: 00350 2004 3864 or email: kevin.galliford@gha.gi Closing Date: Friday 6th November 2015

paediaTric specialisT dieTiTian, band 7 - londonWe are currently looking for an experienced Paedi-atric Dietitian to cover a full-time (37.5 hours per week) two-month post in London. Extensive expe-rience of working with children within Diabetes and Insulin Pumps. This is a community post cov-ering schools, patients’ homes and hospital clin-ics. Please call Elite Dietitians on 01277 849649, or email: hayley@eliterec.com.

band 5/6 coMMUniTy dieTiTian - norTh wesT englandNorth West England Band 5/6 Community Dieti-tian is required to cover a nutrition support role covering Clinics and Home visits. Applicant must have own transport. Starting as soon as possible, full time until the end of December. Please call 01277 849649, or email hayley@eliterec.com. www.elitedietitians.com

band 6 acUTe dieTiTian - essexBand 6 Dietitian required for an acute post to start as soon as possible. This is a full-time post covering adult wards. Please call 01277 849649, or email hayley@eli-terec.com. Visit www.elitedietitians.com

band 6 acUTe dieTiTian - berkshireBand 6 Dietitian required to cover general acute wards for approximately eight weeks, starting as soon as possible. This is a full-time post, 37.5 hours per week. Please call 01277 849649, or email hayley@eliterec.com. www.elitedietitians.com

band 6 paediaTic acUTe and coMMUniTy dieTiTian - kenTStarting middle of November, this is a two-day post covering both community and acute work. A car is re-quired for this post in order to carry out the commu-nity aspect. Please call 01277 849649, or email hayley@eliterec.com. www.elitedietitians.com

specialisT bariaTric dieTiTian - phoenix healTh, liVerpool - £32,000- £36,000 (+ benefiTs)Contract:37.5hoursperweek,12-monthfixed-termcontract. Phoenix Health is a highly specialised and experienced provider of weight loss surgery found-ed and led by doctors. We are recruiting a Specialist Bariatric Dietitian to join the team at Aintree Hospi-tal in Liverpool, which can include travel to Phoenix Health’s other locations in Chester, London, Man-chester and Belfast. Key duties include: Pre- and post-operative assessment of NHS and private patients, face-to-face, by telephone or by Skype; providing di-etary advice to patients before and after bariatric sur-gery; motivating and supporting patients with behav-iour change for long-term success; working within a multidisciplinaryteam;carryingoutgastricbandfills(training provided); participating in 24/7 on-call hel-pline cover; admin, data collection, audit and analysis as required. Application deadline: 17th Nov 2015 In-terview date: 27th Nov 2015 Start date: 4th Jan 2016. Please email your CV to sally@phoenix-health.co.uk For an informal discussion, please contact Sally on 07585 047 188. www.phoenix-health.co.uk

NHDmag.com November 2015 - Issue 109 47

career

We urgently require dietitians for immediate vacancies

To find out your options call or email

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

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

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

• We offer inpatient and community UK & NI coverage

• Competitive rates

www.pjlocums.co.uk

uNiVerSity of NottiNgHam - ScHool of BioScieNceS Modules for Dietitians and other Healthcare Professionals

•Diabetes 1 & 2 - 14th & 15th Jan 2016•Understanding Behaviour Change -

9th & 10th Feb & 22nd March 2016

For further details please email: lisa.fox@nottingham.ac.uk, tel: 0115 951 6238 or check out the University website at www.nottingham.ac.uk/biosciences and click on short courses then ‘for practising dietitians’.

eVentS And CoUrSeSDiabetes Professional Care 2015 11th-12th Nov London’s Barbican Exhibition Centre www.diabetesprofessionalcare.com

Introduction to Childhood Obesity BDA Trainer 17th Nov London Road Community Hospital, Derby Full details at www.ncore.org.uk

Food Matters Live 17th Nov ExCeL London www.foodmatterslive.com

Partnerships in Clinical Trials 17th-19th Nov Hamburg www.informa-ls.com/event/PCT2015

Healthy eating: What the science says 11th Nov Conway Hall, 25 Red Lion Square, London WC1R 4RL www.eventbrite.co.uk/e/autumn-2015-lecture-series-tickets-18117237144

To promote your upcoming events or courses here please call 0845 450 2125 (local rate)

NHDmag.com November 2015 - Issue 10948

We run regular audits throughout the hospital to ensure that our service is meeting the needs of the Care Quality Commission Regulation 14, including nutritional screening. We support catering developments, set up new supplement orders from the hospital pharmacy for our inpatients and monitor the stock of supplements on our respective wards. Many of our patients are fed via nasogastric tubes or gastrostomies; despite this, we can ensure optimal nutrition at home, school and nursery, and even out and about. We also help the dietitians by liaising with our Home Enteral Feeding team to ensure that correct feed deliveries take place. To extend our knowledge and skills, we also support our Special Feed Unit twice a month. Here we make up specialised feeds in a safe environment, which allows us to become familiar with concentrations and dilutions, and we quickly learn to associate certain feedswithspecificconditions.Ourfeedsare mostly paediatric specific and candiffer in suitability of age-range. Theknowledge I have picked up from my time in the Special Feed Unit has been very useful. My role as a Paediatric Dietetic DSW for the Renal service, is currently funded by the British Kidney Patient’s Association. My remit is to support the two qualified dietitianswho specialisein Renal Disease in this specialist tertiary hospital, which supports all the local hospitals in the South West of England.Due to the nature of Chronic Kidney Disease, I get to see many patients on a regular basis and witness all their ‘ups

and downs’ throughout progression and treatment. Getting to know the children, parents and carers well allows me to gain a better insight when taking diet histories and to offer realisticlow salt and healthy eating advice. Despite living with these conditions, these children are some of the most determined and cheerful little critters I have ever come across and this exudes strength to their parents. In the renal service, we monitor patients’ biochemistry very closely; altering levels might result in feed plans and diets being adjusted accordingly. Haemodialysis can alter these readings, so bloods must be checked both before and after. Haemodialysis usually lasts around three hours and patients can be in two to four times a week! Micronutrients are also checked and vitamin/mineral supplements might be added. I spend time each week pulling patient notes and filling in recent biochemistry,anthropometric information in preparation for meetings and clinics. As kidney disease progresses, a patient’s ability to maintain appropriate biochemical levels deteriorates and so their dietary needs change. These diets can be very complex and the dietitians advise all complex patients. However, I canofferlowsaltadvicewhenaskedbythe dietitian and healthy eating advice to post-transplanted children. As renal diets can be extremely restrictive, after a transplant, getting children to eat a healthy and balanced diet can be extremely challenging; some children may need to redevelop a positive relationship with food or learn eating skills.

. . . A dietetiC SUPPort WorKer:nePhroloGy

rachel smithdietetic support worker, bristol children’s hospital

rachel is a renal dietetic Support Worker at the Bristol Children’s hospital. her goal is to go back to university to study to become a dietitian.

i am one of four dietetic Support Workers (dSWs) at the Bristol royal Hospital for children. i work with the renal team, others work with patients with cystic fibrosis, metabolic diseases, cancer, gastroenterology and Burns.

a day in The life of…

NHDmag.com November 2015 - Issue 109 49

Children with this condition are at risk of growth problems, so this means that we need to closely monitor growth. Part of my role is to regularly plot height, weight (and head circumference for babies) for the dietitians. Through taking diet histories I am able to help patients express their likes and dislikes and I have worked with the dietitians to obtain school menus in order to check that the children are getting as much choice as possible. Most sick children we see need high energy diets alongside restrictions. We often experience difficulties when getting children to trysupplements and I enjoy the challenge of creating different options, such as ‘renal shakes’ to getour patients to try them. We have a resident Play Therapist who is fantastic at supporting us too. My additional tasks can range hugely on a day-to-day basis. Since my start in January this year, I have created an à la carte renal-specificmenu and snacks list for our babies, toddlers and children. I have aided in the organisation and running of a national renal recipe competition, an initiative set out via the Paediatric Renal Interest Nutrition Group to create a recipe book which will hopefully be available to paediatric renal patients by next year. I have also created a Guide to theNutrition andDietetic Service leaflet forWardstaff,outliningwhatweofferasaservice,

how to contactus andfindourguidelinesandinformation and how to obtain specialised feeds (amongst other things). I was lucky enough to lead on organising and running a ‘Salt Awareness Week’ stand alongside the National ‘Salt Awareness Week’ which was aimed at raising awareness of hidden and added salt within foods. As a result of the success of this, I now work with others to create a regular health promotion corner in the outpatient waiting area and have since gone on to organise a similar event on ‘sugar and dental health’. The paediatric DSWs have an abundance of ideas for future projects and I am excited to get stuck in. Alongside my renal specific role, I alsomaintain the department website and create and distribute our monthly newsletter, Nutrition MiniBites,which is sentout to staff toupdatethem on all things nutrition and dietetic! My role as a DSW is a healthy balance of patient contact, sourcing information, creating resources and helping with administration. Our small renal dietetic team supports each other, as well as the whole multidisciplinary team, to optimise the health of our patients on a day-to-day basis. Our team goal is helping our children achieve healthy lives and I am pleased to be a part of this.

a day in The life of . . .

NHDmag.com November 2015 - Issue 10950

Some years ago now, my wife and I left home with our suitcases to embark on a well-earned break in the sun. We were flying from our local airport in Black-pool, only a matter of 10 minutes away from our home, to Alicante in Spain. Blackpool airport, now sadly closed forsuchflights,onlynumberedaroundadozen departures each day, so checking in was relatively quick and trouble free. On this occasion,weweredroppedoffand headed towards the check-in desk. After a few minutes or so, it was our turn to hand over our passports and tickets to the young lady behind the desk and wait for instructions. I duly loaded my case onto the scales and waited for it to bounce along the conveyor belt and dis-appear and then load our second case. “This one’s two kilogrammes over the baggage allowance,” said the young lady. “Oh,” I said, somewhat surprised. “I checked it before we left on our bath-room scales this morning and it was one kilogramme under.” “I think that may have been before I put in the toiletries,” spoke a voice from my side. Well, I didn’t really want to start emptying the contents of our suitcase in front of waiting passengers and also hold them up, so I asked how much the charge for the extra baggage would be. “It’s £6 for each extra kilogramme, so that would be £12 in total.” “I’ll pay that,” I said, glancing sweet-ly sideways. I presented a £20 note. “I’ll just go and get your change,” came the reply, and before I could say anything further, she was walking the length of the airport to the solitary shop. I drew a deep breath. At that point, a woman’s voice from behind me said,

“Good morning Mr Donnelly, not the best way to start your holiday is it?” “Oh hello,” I said, turning around and trying desperately to put a name to afaceandaplace,“Yes,itcanbediffi-cult to pack everything you may need into your hold baggage allowance.” “I don’t think it’s fair really you know,” she continued. “I’ve only seen you twice at the hospital and in that time I’ve lost over 10 pounds in four weeks. You have to pay for the extra fivepoundsorso inyoursuitcase,butthanks to you, the plane is still going tobefivepoundslighterbecauseoftheweight I’ve lost. They should be paying you for using less fuel!” “Well, thank you very much,” I said, “and very well done with your weight loss, keep up the good work.” “The thing is Mr Donnelly,” she continued, “so many people are far too heavy like me and the seats on the plane are so small that we tend to spread out ontothepersonnexttous,soineffect,you normal weight persons get a double whammy!” I barely heard the next words from our wandering desk attendant. “Here’s your change and your boarding card Sir.” “Thank you,” I said and nodded po-litely to both ladies, whilst wondering how the seat allocation system worked and how next to present the idea of a ‘flying fat tax’ to the overweight andobese British Public. Footnote: Professor Dame Sally Davies, theChiefMedicalOfficer andself-styled ‘nation’s doctor’ recently said, “I’ve often wondered why aircraft don’t charge by total weight of the per-son and their luggage”. Hmm! They do in Samoa!

the finAl helPinG

thoughts from almost abroad with Neil donnelly . . .

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.