improving nutrition in hospital food

Issue 85 June 2013

NHDmag.com

improving nutrition in hospital food Diane Spalding & Andrew Wilson p22

Nutritional influences on gut health Alison Burton-Shepherd Queens Nurse, Nurse Tutor ‘Gut health’ is a term that is increasingly used in medical literature and in the food industry. . . . p7

eating out intense sweeteners gluten-free guide lactose intolerance older adult immunity

dieteticJOBS • NHD Clinical • new research • Subscription offer ISSN 1756-9567 (Online)

from the editor

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

I wasn’t planning on visiting the hospital where I worked for 38 years, but fate works in strange ways. Having her first ‘lesson’ on the tennis court playing alongside her husband, whilst making a valiant attempt to return the ball, my wife fell and broke her wrist. The net result, excuse the pun, was a visit to A&E and the predictable four-hour wait. You can read a lot when you know you have the time and this was such an opportunity. We/I also then decided to take a few more books on our forthcoming two-week holiday North of the Border as the plaster cast was to be on for six weeks. A week after the break, excuse the pun again, we returned to the hospital for a new cast and I decided to seek out my old department and surprise anyone who might remember me from when I left almost two years ago. As I neared the end of the long walk down the hospital corridor, I was confronted not by the office

Contributors

door but a brick wall! Yikes, I’m glad I got out in time. I retreated back to the plaster room, finding out later that the dietitians were now located ‘on a ward somewhere’. Going back is never going to be the same. Tomorrow morning we set off on our adventure and I’m sharing with you two books that I’m looking forward to reading whilst island-hopping from Mull to Skye. The first is Gulp by Mary Roach. This is a journey down the digestive tract which from my first glimpse looks fascinating and funny, encountering gastroenterologist Dr Terdman, the flatus specialist J. Fardy and the excrementalist Dr. Crapo. My second read is Big Brother by Lionel Shriver which is a fictionalised account of coping with her obese brother. It is a thin man versus fat man tale which I am assured leaves no reader neutral. You can take the dietitian out of the hospital but you can’t take dietetics out of the dietitian.

Contents

Writer; Nutrition & Dietetics

5 News Product/industry news

Chris Rudd

7 Gut health

Ursula Arens

Dietetic Advisor, Sheffield PCT Medicines Management Team

Dr Anita MacDonald

Consultant Dietitian in IMD, Birmingham Children’s Hospital

Dr Amelia Lake

Lecturer in Knowledge Exchange in Public Health, Centre for Public Policy & Health, Durham University

10 Eating out in Islington 12 Intense sweeteners 15 Older adult immunity 16 Gluten-free guide 19 Gluten sensitivity

21 NHD Clinical: 26 Lactose intolerance

22 Cover Story

Dr Carrie Ruxton Freelance Dietitian

Kate Harrod-Wild

Specialist Paediatric Dietitian, Betsi Cadwaladr University Health Board

Alison Burton-Shepherd

Queens Nurse, Nurse Tutor, Department of Adult Nursing Florence Nightingale School of Nursing and Midwifery

Katie Kennedy MNutr RD Dietitian

Diane Spalding

Improving nutrition in hospital food 29 Dietetics in Nepal 30 dieteticJOBS / events & courses

Facilities Dietetic Adviser, Leeds Teaching Hospitals NHS Trust

Andrew Wilson

Senior Facilities Manager (Patient Catering), Leeds Teaching Hospitals NHS Trust

Sarah Dornan

Registered Dietitian, Nottingham University Hospitals NHS Trust

Dr Charlotte Neville

Research Fellow, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast

4

NHDmag.com June 2013 - Issue 85

28 Web watch

Photos: istockphoto.com unless otherwise stated Editor Neil Donnelly RD FBDA Features editor Ursula Arens RD NHD Clinical editor Chris Rudd RD Design Heather Dewhurst Sales Richard Mair [email protected] Publisher Geoff Weate Publishing Assistant Lisa Jackson

Address Suite 1 Freshfield Hall, The Square, Lewes Road, Forest Row, East Sussex RH18 5ES Phone 0845 450 2125 (local call rate) Skype NHDmag Fax 0870 762 3713 Email [email protected] www.NHDmag.com www.dieteticJOBS.co.uk

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

news

product / industry news D3 or D2: which vitamin is best?

Dr Carrie Ruxton PhD, RD Freelance Dietitian

Public health guidelines at present don’t differentiate between vitamin D2 and D3, yet these seem to offer distinct metabolic differences. A new randomised controlled trial conducted in New Zealand tested the impact on serum vitamin D (25(OH) D) levels of taking either: 25μg (1,000IU) vitamin D2, or the same dose of D3 versus a placebo. Supplements were taken at the end of the summer and throughout the winter months (25 weeks in total). By the end of the study, those taking vitamin D2 had significantly lower serum 25(OH)D3 levels, compared with the group supplemented with vitamin D3. The results suggest that vitamin D3 was more effective at raising serum levels than D2. These are important findings which should be considered before the new UK dietary guidelines are developed. In addition, health professionals recommending supplements to patients should select products containing vitamin D3. For information see: Logan VF et al (2012). British Journal of Nutrition Vol. 109: pg 1082-8.

Celery and calorie-burning

It is well known that obesity prevalence is rising and new innovative strategies are needed to support weight management. Now, new research indicates that eating celery could be one way forward. Following an overnight fast, 15 healthy females had their resting metabolic rate measured using indirect calorimetry. Volunteers then ate 100g celery (16 kcal) and diet-induced thermogenesis (energy used when digesting foods) was measured regularly for 180 minutes. From the consumption of a 16 kcal (100g) stick of celery, energy expenditure was calculated to be 13.76 kcal. These findings show that diet induced thermogenesis of 100g of celery was 86 percent of the total energy intake (you use up nearly what you eat!). These findings indicate that with its high fibre and water content, celery seems to be a good snack and should be included within weight loss diets. For information see: Clegg ME et al (2013). Proceedings of the Nutrition Society Vol. 71, Issue OCE3 - Winter Meeting abstract.

Hungry shoppers buy more calories

Dr Carrie Ruxton is a freelance dietitian who writes regularly for academic and media publications. A contributor to TV and radio, Carrie works on a wide range of projects relating to product development, claims, PR and research. Her specialist areas are child nutrition, obesity and functional foods. www.nutritioncommunications.com

We are often advised to avoid shopping when hungry. This theory has now been explored in a research trial. In one part of the study, 68 participants were asked not to eat for five hours before performing shopping tasks in a controlled environment. In another part of the experiment, food purchases of 82 subjects were logged at different times of day when they were most likely to be feeling full or hungry. In the laboratory study, subjects opted for more high-calorie products after fasting. The field study showed that shoppers bought less low-calorie foods when they were hungrier (between 4pm and 7pm). Overall, these findings suggest that even short-term food deprivation may encourage the purchasing of less healthy food and beverage choices. For information see: Tal A. et al (2013). JAMA Internal Medicine, early view http://media.jamanetwork.com/ news-item/short-term-food-deprivation-appears-linkedto-high-calorie-food-options/

Our range has grown - new Fortini 1.0 Multi Fibre

Nutricia is happy to announce the launch of Fortini 1.0 Multi Fibre, a new 1.0kcal/ml oral nutritional supplement for children. Fortini Multi Fibre 1.0 is the newest member of the Fortini family, developed for children who need an oral nutritional supplement but have lower energy requirements. New Fortini 1.0 Multi Fibre is nutritionally complete and available in four flavours; Vanilla, Strawberry, Banana and Chocolate and will complement Nutricia’s existing Fortini range. Fortini 1.0 Multi Fibre is ACBS approved for children as a sole source of nutrition from one to six years of age or 8.020kg in body weight and comes in a 200ml bottle. Each bottle provides 200kcal, 4.8g protein and 3.0g fibre. Fortini 1.0 Multi Fibre will be available to order from 1st June 2013. If you would like a free sample or a visit from your Nutricia Paediatric Representative, please call us on 01225 751098 or email [email protected].

Latest on omega-3s

Two original communications on omega-3s from the Nutrition Society Scottish Section Meeting have been published. The first was a longitudinal study that has investigated whether maternal intakes of linoleic acid (LA), arachidonic acid (AA), alpha-linolenic acid (ALA), eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) correlated with child growth. As part of the Seychelles Child Development and Nutrition Study Cohort, blood samples were taken from 1,474 pregnant women at 28 weeks gestation. In the offspring, various measures of child growth, including gestational age, weight and length were assessed at birth and at 20 months of age. Regression analysis showed that maternal blood levels of LA and total n-6 fatty acids significantly predicted birth weight, while maternal LA, DHA, total n-3 and total n-6 significantly predicted child height and weight at 20 months of age. The authors suggested that specific fatty acids had a beneficial impact on foetal and infant growth. At the other end of the age spectrum, a double-blind randomised placebo-controlled study on 13 elderly females. Participants received either 4.0g fish oil (containing 1.7g EPA and 0.4g DHA) or 4.0g control oil (olive oil) daily for 12 weeks. Participants also carried out resistance training twice a week for this period. Follow-up measurements looked at blood lipid levels and muscle strength. The authors concluded that fish oil supplements could benefit older women by helping to combat age-related muscle loss and target insulin resistance. See Mulhern MS et al (2013). Proceedings of the Nutrition Society, Volume 72: E100; and Kamolrat T et al (2013). Proceedings of the Nutrition Society, Volume 72: E97. NHDmag.com June 2013 - Issue 85

5

news Does calcium benefit health?

Findings from epidemiological studies linking calcium intake to stroke risk have been inconclusive. Now, a new meta-analysis has pooled the evidence from recent studies. Using PubMed and EMBASE, 11 prospective studies were found which examined how calcium intake from dietary sources related to the risk of stroke (a total of 9,095 stroke cases). Data analyses suggested that moderate calcium intakes were associated with a lower risk of stroke (calcium intakes 90% compliance1 – your rst choice high protein2 ONS. Kcal Protein g

300 18 125 Fibreg ml 0

www.nutriciaONS.co.uk

Per bottle References: 1. Nutricia, UK Community Trial, Data on le, 2011 (n=16). 2. Regulations (EC) No. 1924/2006, 2006. European Parliament & of the Council of 20 December 2006 on nutrition & health claims made on foods. Ofcial Journal of the European Union, L404. Nutricia Ltd, White Horse Business Park,Trowbridge, Wiltshire, BA14 0XQ. Tel: 01225 751098.

®

Compact Protein

intense sweeteners

The role of intense sweeteners in the diet Artificial sweeteners, also called low calorie sweeteners, are often seen as a modern ingredient but have, in fact, been used as an alternative to sugar since the discovery of saccharin in 1879. Of the two main types, bulk and intense, the latter have received the most attention from consumer groups and media, particularly in view of the recent European consultation on aspartame. This article will examine the role of intense sweeteners in the diet and consider safety aspects. Dr Carrie Ruxton PhD, RD Freelance Dietitian

Dr Carrie Ruxton is a freelance dietitian who writes regularly for academic and media publications. A contributor to TV and radio, Carrie works on a wide range of projects relating to product development, claims, PR and research. Her specialist areas are child nutrition, obesity and functional foods. www.nutritioncommunications.com

12

Definition Intense sweeteners are food ingredients which offer a more intense sweetness than sucrose. Examples include saccharin, acesulfame-K and aspartame, which are 200 times sweeter than sucrose, and sucralose and neotame which are 600 to 7,000 times sweeter. The calorie content of these varies from zero to four calories per gram, although few kilocalories are delivered in practice as only tiny amounts are needed. Intense sweeteners are typically found in lowcalorie drinks, reduced sugar desserts, dairy products, conserves, confectionery and medicines. However, certain types, e.g. sucralose, saccharin, aspartame and acesulfame K, are also available as table top sweeteners. A recent addition is stevia, which is manufactured from the South American herb, Stevia rebaudiana, making it the first intense sweetener to qualify for a ‘natural’ claim. Stevia owes its sweet taste to two glycoside compounds, called stevioside and rebaudioside, which are 250 to 300 times sweeter than sucrose, as well as being heat- and pH-stable and non-fermentable. While stevia was given approval in Europe in 2011, it already had a long history of use in other countries, such as Paraguay, Brazil and Japan. Safety A glance at lay or pressure group websites may give the impression that sweeteners are dangerous unregulated chemicals, but the truth is somewhat different. Sweeteners, and indeed other food additives, are tightly controlled at EU level based on advice from the European Food Safety Authority (EFSA). The process begins with an application for approval, for which detailed studies are required on technical aspects, safety, likely consumption patterns and contribution to the food chain. Once a sweetener is approved, it is given an ‘E number’ within the range E900-999 which indicates that it is safe for human consumption. Given consumer beliefs, it is worth noting that even natural substances, such as vitamin C, lycopene and vitamin E, have E numbers. Part of the approval process involves the setting of an Acceptable Daily Intake (ADI) which represents the maximum amount of sweetener that can be safely consumed daily over a lifetime. The ADI is expressed in mg per kg of body weight per day and is calculated first by establishing the level at which there are no adverse effects based on human studies. This level, called the NOEL or No Observed Effects Level, is then divided by 100 to create the ADI. Thus, the ADI is a very conservative estimate of the safe intake of a sweetener over a lifetime. An overview is given in Table 1.


In reality, consumer intakes of sweeteners fall below the ADI, even in those groups with a high consumption, e.g. people with diabetes or children/teenagers. Two reviews considered intakes of four commonlyconsumed sweeteners in several European populations (1, 2). Intakes amongst adults were no higher than 29 percent ADI for acesulfame K, 14 percent ADI for aspartame, 11 percent ADI for saccharin and 51 percent ADI for cyclamate. In diabetic populations, the ADI for cyclamate was exceeded (114 percent), but intakes of the other three sweeteners were still 20 to 46 percent ADI and, thus, well within safe limits. Another report (3), surveyed 1,110 UK children aged one and a half to four and a half years, concluding that intakes of sweeteners were unlikely to exceed the ADI for aspartame, acesulfame K and saccharin, but did exceed the ADI for cyclamate which is used nowadays in few products. Even after approval, the regulatory system continues to monitor the safety of food ingredients. A good example is aspartame which was reviewed by EFSA in 2005-6, 2010 and 2013. The most recent EFSA report (4) concluded that the ADI should remain at 40mg/kg body weight as intakes of aspartame within this limit would be unlikely to cause a problem for any population including pregnant women and children. The only exception is people with the genetic condition, phenylketonuria, who need to avoid aspartame as they do not have the correct enzyme to break down an amino acid, called phenylalanine, which is present in aspartame. The EFSA report also commented that intakes of aspartame in general remain below the ADI. The Food Standards Agency is another organisation that keeps sweeteners under review, most recently by conducting a double-blind trial on people who have reported sensitivity to aspartame (5). The results will be available later this year. Evidence for benefit There are four main reasons for recommending products containing intense sweeteners. The first is sugar reduction which is relevant as average intakes of added sugars remain above Dietary Reference Values, particularly in children. Switching from a sugar-containing soft drink to a diet version could remove 15g to 35g of sugar from the diet, which is up to 40 percent of a child’s sugar GDA. A second reason is diabetes control since products containing sweeteners add variety into the diet without the additional glycaemic load from sugar. Thirdly, dental health can be supported by a switch to foods and drinks containing sweeteners because oral

intense sweeteners Table 1: Overview of common intense sweeteners

Name

Estimated sweetness compared with sucrose

Saccharin E954 Acesulfame-K E950

EU approval date

ADI (per kg body weight)

300 times

June 1995

5.0mg

150-200 times

March 2000

9.0mg

Cyclamate E952

30 times

March 2000

7.0mg

Sucralose E955

600 times

September 2000

15mg

Aspartame E951

200 times

December 2002

40mg

Stevia

400 times

November 2011

4.0mg

bacteria cannot ferment intense or bulk sweeteners. Finally, weight management is a relevant target for advice about sweeteners as several studies have reported a reduction in energy intakes when sugar-containing products are substituted for diet versions. One review (6) noted a 10 percent reduction in mean energy intake, as well as modest body weight reductions, when aspartame replaced sucrose in foods and drinks. An acute crossover trial (7) in lean and obese adults reported a ~300kcal reduction in daily energy intakes when stevia or aspartame preloads were given compared with sucrose preloads. This does not mean that sweeteners are inhibiting appetite per se as the effects on energy intake probably relate to the switch from a caloric sweetener to one which is virtually calorie-free. Indeed, some attempts have been made to demonstrate that sweeteners stimulate hunger, but no consistent effects on gut hormones or appetite were found (8, 9). In practice, sweeteners may assist weight management because they help to maintain dietary palatability. This is important since control of appetite and body weight is facilitated when we obtain pleasure from eating food (10). However, as compensation varies between individuals, and is often

incomplete, intense sweeteners work best when part of an energy-restricted diet. A new angle is the potential for using sweeteners to help prevent obesity. A prospective trial was carried out in US primary schools (12) where normal, healthy-weight children were offered either 250ml daily of sugar-containing or artificially-sweetened drinks. After 18 months of follow up, children given the diet drinks had gained significantly less weight than children in the sugary drinks group (6.4kg vs 7.4kg respectively). Further work is needed to confirm these results, but there may be implications for early obesity interventions. Conclusions Products containing intense sweeteners are growing in popularity and appear to offer health benefits, particularly for weight management. Current intakes of most sweeteners fall below Acceptable Daily Intakes, which are kept under review by European expert bodies. Health professionals can continue to reassure patients of the safety of sweeteners and suggest how best they may be incorporated into a healthy diet.

References 1 Huvaere K et al (2012). Dietary intake of artificial sweeteners by the Belgian population. Food Addit Contam 29, 54-65 2 Renwick A (2006). The intake of intense sweeteners - an update review. Food Addit Contam 23, 327-338 3 Food Standards Agency (2003). Diary survey of the intake of intense sweeteners by young children from soft drinks (Number 36/03) www.food.gov.uk/science/research/ surveillance/fsis2003/fsis-200336softdrink 4 European Food Safety Authority (2013). DRAFT Scientific Opinion on the re-evaluation of aspartame (E 951) as a food additive www.efsa.europa.eu/en/consultations/call/130108. pdf 5 Food Standards Agency (2010). Determining reactions to aspartame in subjects who have reported symptoms in the past compared to controls: a pilot double blind crossover study www.food.gov.uk/science/research/foodcomponentsresearch/riskassessment/t01programme/t01projlist/t01054/ 6 De La Hunty A et al (2006). A review of the effectiveness of aspartame in helping with weight control. Nutrition Bulletin 31: 115-128 7 Anton SD et al (2010). Effects of stevia, aspartame, and sucrose on food intake, satiety and postprandial glucose and insulin levels. Appetite 55, 37-43 8 Maersk M et al (2012). Satiety scores and satiety hormone response after sucrose-sweetened soft drink compared with isocaloric semi-skimmed milk and with non-caloric soft drink: a controlled trial. Eur J Clin Nutr 66, 523-9 9 Steinert RE et al (2011). Effects of carbohydrate sugars and artificial sweeteners on appetite and the secretion of gastrointestinal satiety peptides. Br J Nutr 105, 1320-8 10 Bellisle F et al (2012). Sweetness, satiation and satiety. J Nutr 142, 1149S-54S 11 Mattes RD and Popkin BM (2009). Nonnutritive sweetener consumption in humans: effects on appetite and food intake and their putative mechanisms. Am J Clin Nutr 89, 1-14 12 de Ruyter JC et al (2012). A trial of sugar-free or sugar-sweetened beverages and body weight in children. N Engl J Med 367, 1397-406

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IMPROVING NUTRITION IN HOSPITAL FOOD Diane Spalding & Andrew Wilson p22

NUTRITIONAL INFLUENCES ON GUT HEALTH Alison Burton-Shepherd Queens Nurse, Nurse Tutor ‘Gut health’ is a term that is increasingly used in medical literature and in the food industry. . . . p7

EATING OUT INTENSE SWEETENERS GLUTEN-FREE GUIDE

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older adult immunity

Improving older adult immunity: Can eating fruit and veg help? Ageing has been associated with physiological, social and economic changes that can often lead to a compromised nutritional status. Deterioration in the immune system (1) and increased risk of infection (2) are also common characteristics of ageing that can adversely affect nutritional status (3,4). Furthermore, it has been reported that older populations have low intakes of fruit and vegetables (5,6).

Dr Charlotte Neville Research Fellow School of Medicine Dentistry and Biomedical Sciences Queen’s University Belfast

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

Dr Charlotte Neville was trial manager of the Ageing and Dietary Intervention Trial (ADIT). She is currently a Research Fellow in the Nutrition and Metabolism research group within the Centre for Public Health, Queen’s University Belfast. Charlotte’s work primarily involves analysing and developing nutrition related research studies which focus on health and disease outcomes, including obesity, CVD, bone health and cognitive health.

An increase in fruit and vegetable intake may potentially benefit older populations because of their initially low intake of fruit and vegetables and their altered immune status. Indeed, several of the micronutrients associated with fruit and vegetable rich diets, such as carotenoids, flavonoids and vitamin C, have been shown to improve immune function (7,8). On the basis of the evidence, a UK based study published in the December 2012 issue of The American Journal of Clinical Nutrition (9), has examined whether increasing fruit and vegetable intake can improve the immunity of older adults. Methods In a randomised controlled trial (The Ageing and Dietary Intervention Trial (ADIT)), 83 healthy volunteers aged 65 to 85 years with low fruit and vegetable intakes (≤2 portions/day) were asked to increase their fruit and vegetable consumption to the recommended five portions/day, or to follow their normal diet (therefore consuming ≤2 portions/day) for 16 weeks. A portion was as defined by the Food Standards Agency, i.e. an 80g serving (e.g. one apple, orange or banana, three heaped tablespoons of vegetables, or 150ml fruit juice). Throughout the 16-week period, compliance was monitored using diet histories and fasting blood samples were taken to assess micronutrient status. All of the participants received extensive personal dietetic advice and nutritional counselling to encourage incorporation of the fruit and vegetables into their diet without, for example, compromising energy intake, and in line with their physical capabilities. Compliance was also encouraged by provision of menu suggestions and recipes. Participants were allowed a free choice of fruit and vegetables for consumption during the study but were encouraged to consume as wide a variety of fruit and vegetables as possible. In order to assess immune function, each participant was administered a Tetanus and Pneumovax vaccine at week 12. Antibody response to the vaccination was then tested by assessing clinically relevant immune function endpoints (i.e. specific antibody binding to Tetanus Toxoid and Pneumococcal capsular polysaccharides) at the start and end of the intervention. Ethical approval for the study was obtained from the Office for Research Ethics Committees Northern Ireland (ORECNI). Results Eighty-two participants completed the 16-week intervention. The usual baseline fruit and vegetable intake of the participants was 1.4 portions/day (SD 0.6). The analysis of the diet histories showed that change in daily fruit and vegetable consumption was significantly different between the two groups throughout the 16 weeks, with those in the five

portions/day group consistently showing a larger increase in fruit and vegetable intake compared to those in the two portions/day group (at week 16 the mean increase in the number of portions was 0.4 portions in the two portions/ day group and 4.6 portions in the five portions/day group). This was also reflected in greater changes in vitamin C, zeaxanthin, β-cryptoxanthin and lycopene in the five portions/day group compared to the two portions/day group. Participants consuming the five portions of fruit and vegetables per day also showed greater increase in antibody binding to Pneumococcal capsular polysaccharide compared to those consuming two portions per day. No significant differences were observed between the two groups in relation to change in antibody binding to Tetanus Toxoid. Discussion and conclusion This study has shown, for the first time that consuming five portions of fruit and vegetables per day improves antibody response to the Pneumovax II vaccination in older adults. This increased response was particularly evident in individuals who had never received the Pneumovax II vaccination before. Although the mechanism behind the greater response to the pneumococcal vaccination is unclear, our results would suggest that the increase in fruit and vegetable intake in some way augmented the T-cell antibody pathway of antigen presentation, therefore resulting in greater immune response. This observation should potentially be of great interest and relevance to vaccination programmes. Given that the immune systems of older adults are less effective than that of younger individuals and are characterised by increased incidences of chronic diseases and susceptibility to infection, the findings of this study may be of particular importance (10, 11). Response to vaccination was chosen as our primary outcome measure as it is a purposeful test of immune response. It is also a meaningful marker, as pneumococcal immunisation of older people is part of the vaccination programme in the UK. However, the clinical and public health relevance of changes in these markers has yet to be fully established. In conclusion, this study has shown that increased fruit and vegetable intake improves antibody response to the Pneumovax II vaccination in older people, thus linking an achievable dietary goal with potentially enhance immunity. This is an encouraging endorsement of the ‘5-a-day’ message. For more information see: Gibson et al (2012). American Journal of Clinical Nutrition 96: pg 1,429-36 or contact: Dr Jayne Woodside ([email protected]) or Dr Charlotte Neville ([email protected]), Centre for Public Health, Queen’s University Belfast. NHDmag.com June 2013 - Issue 85

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gluten-free guide

Gluten-free guide Gluten-free products are a vital resource for people who have gluten intolerance or coeliac disease. The following guide provides a useful reference for resources, foods, events and support contacts for both healthcare professionals and for coeliac sufferers. During Gut Feeling Week in May, Coeliac UK, the national charity for people with coeliac disease, supported the need for gluten-free foods to remain on prescription, following the release of results of a survey by the British Specialist Nutrition Association (BSNA). The BSNA, the trade association for manufacturers of specialist nutritional products, asked 1,000 patients with coeliac disease for their views on gluten-free prescriptions. The survey posed questions about the access and availability of gluten-free foods and asked about individuals’ attitudes towards gluten-free food on prescription. Results released highlighted the importance for people with coeliac disease to have access to gluten-free food on prescription and suggested that those who have had their prescriptions cut or stopped altogether found managing their gluten-free diets to be more challenging as a result. Full results of the survey can be found on the BSNA website. Sarah Sleet, Chief Executive of Coeliac UK said, “Following a gluten-free diet enables patients to live a full and healthy life. However, to do so, it is crucial that they are able to access basic gluten-free foods, such as bread, flour and pasta, which are the staples in all our diets. The BSNA’s sur-

Wellfoods Good enough to eat

vey suggests that cuts to gluten-free prescriptions in some areas are causing difficulties for patients. The results mirror previous research carried out by Coeliac UK and others, showing that if your income is low or you are unable reach the large supermarkets, being able to access gluten-free staples such as breads and flours is very difficult. Prescriptions play a vital role in ensuring vulnerable patients are not disadvantaged.” Coeliac disease is an autoimmune condition caused by intolerance to gluten. One in 100 people in the UK have coeliac disease for which there is no cure and the only treatment is strict adherence to a lifelong gluten-free diet which is a medical treatment. Gluten is a protein found in wheat, barley and rye. Left untreated coeliac disease can lead to serious health complications at greater cost to the NHS. Coeliac UK’s Gut Feeling Week, aims to reach the estimated half a million people with coeliac disease who have not yet received a formal diagnosis and empower them to strive for diagnosis. Coeliac UK is assessing the impact of restrictions on gluten-free prescribing, where both the number of units and the types of staple gluten-free foods have been restricted.

Gluten-free resources and information BDA Gastroenterology Special Interest Group (GSG), bda.uk.com, 0121 200 8080, [email protected]. British Society of Gastroenterology, bsg.org.uk, 020 7935 3150, [email protected] Coeliac UK, coeliac.co.uk, 0845 305 2060 Celiac Disease and GF diet Information (USA), celiac.com Celiac Disease Awareness Campaign (USA), celiac.nih.gov, 1-800-891-5389, [email protected] Celiac Disease Meetup Groups (USA), celiacdisease.meetup.com Celiac Handbook (USA), celiachandbook.com, [email protected] CORE - fighting gut and liver disease, corecharity.org.uk, 020 7486 0341, [email protected] DS-gluten free, dsglutenfree.co.uk, 0800 954 1981, [email protected]

Gluten free loaves, rolls,

Glutafin, glutafin.co.uk, 0800 988 2470, [email protected] Juvela – supporting healthcare professionals, juvela.co.uk/hcp, 0800 783 1992, [email protected]

burger buns,pizzas

Nutrition Society, nutritionsociety.org, 020 7602 0228, [email protected]

and flour . . . Wellfoods

Patient UK, patient.co.uk

Towngate, Mapplewell, Barnsley S75 6AS [email protected] Tel: 01226 381 712

www.wellfoods.co.uk 16

Dr Schar Institute, drschaer-institute.com, 0800 988 8470, [email protected]


Primary Care Society of GB, pcsg.org.uk, 0207 836 0088, [email protected] Sure Foods Living, surefoodsliving.com, 415-785-4980, [email protected] The Celiac Site (USA), theceliacsite.com Uni of Chicago Celiac Disease Centre, cureceliacdisease.org, 773-702-7593

gluten-free guide Supplier Abel & Cole Limited Against The Grain Almondy

Website abelandcole.co.uk againstthegrainfoods.com almondy.co.uk

Phone 0845 262 6262 01688 302 223 020 7795 8148

Contact [email protected] [email protected] [email protected]

Baked To Taste

bakedtotaste.co.uk

01404 47904

[email protected]

Beanie’s Health Foods Blue Lotus cakes Bounce Brookfarm

beanieswholefoods.co.uk bluelotuscakes.co.uk bouncefoods.com brookfarm.com.au

0114 268 1662 0116 299 8122 0845 838 2579 0061 (02) 6620 9500

[email protected] [email protected] [email protected] [email protected]

Clearspring

clearspring.co.uk

020 8749 1781

[email protected]

Clives Pies Community Foods Ltd Dr Schar Droppa & Droppa

clivespies.co.uk communityfoods.co.uk drschaer.com/en/ droppaanddroppa.com

01364 642 279 020 8208 2966 01925 865100 01237 420 417

[email protected] [email protected] [email protected] [email protected]

Drossa Limited

drossa.co.uk

020 3393 0859

[email protected]

DS-gluten free

dsglutenfree.co.uk

0800 954 1981

[email protected]

Eco Green Store Ethical Superstore

ecogreenstore.co.uk ethicalsuperstore.com

0844 351 0211 0845 009 9016

[email protected]. [email protected]

Fayre Field Food Tec

fayrefieldfoodtec.com

01270 530 750

[email protected]

Feel Free

feelfreeforglutenfree.co.uk

08081 290 261

[email protected]

General Dietary

generaldietary.com

0203 044 2933

[email protected]

Genius Gluten Free

geniusglutenfree.com

0845 874 4000

[email protected]

Glebe Farm

glebe-flour.co.uk

01487 773 282

[email protected]

Glutafin

glutafin.co.uk

0800 988 2470

[email protected]

Gluten Free Foods Ltd

glutenfree-foods.co.uk

020 8953 4444

[email protected]

Gluten Free Direct

glutenfree-direct.co.uk

01757 289 200

[email protected]

Gluten Free Kitchen

glutenfreefood.info

01969 622222

[email protected]

Glu-2-Go

glu2go.co.uk

01324 717 273

[email protected]

Goodness Direct

goodnessdirect.co.uk

0871 871 6611

[email protected]

Granovita

granovita.co.uk

01933 273 717

[email protected]

Green’s Beers Hale and Hearty Harmony Foodstore Heinz Deliciously Gluten Free Honey Buns Hunter’s Puddings

glutenfreebeers.co.uk halenhearty.co.uk harmonyfoodstore.co.uk heinz.co.uk honeybuns.co.uk hunterspuddings.co.uk

0161 456 4226 020 3405 3134 07788 205322 0800 528 5757 01963 23597 01539 733 454

[email protected] [email protected] [email protected] via online form [email protected] [email protected]

Juvela

juvela.co.uk

0800 783 1992

[email protected]

Kallo Foods Kealth Foods Livwell Lovemore Free From Foods Meridian Foods Morley’s of Swanland Mrs Crimble’s Munchy Seeds Nairn’s Natural Grocery

kallofoods.com kealthfoods.com livwell.eu lovemore-freefromfoods.com meridianfoods.co.uk glutenfreebutcher.co.uk mrscrimbles.com munchyseeds.co.uk nairns-oatcakes.com naturalgrocery.co.uk

0845 602 1519 0845 082 2350 0845 120 0038 01685 815 072 01962 761 935 01482 634 225 01256 393460 01728 833 004 0131 620 7000 01242 572 323

[email protected] [email protected] [email protected] [email protected] [email protected] [email protected]. [email protected] [email protected] [email protected] [email protected]

Naturally Good Food

naturallygoodfood.co.uk

01455 556878

[email protected]

Nick Stafford’s Hambleton Ales PGR Health Foods: Rizopia pasta Plamil Proceli Pure (Kerry Foods)

hambletonales.co.uk

01765 640 108

[email protected]

Ready meals and desserts: dysphagia, allergy, vegan, home delivery Breads, cakes, prescriptions Bread, cakes, biscuits, savouries. Sauces, pestos, jams, spreads, juice concentrates Sausages, pies, savouries, specialities Biscuits, ricecakes, mixes, sweet and savoury snacks Seeds, seed mixes, snack bars Oatcakes, muesli, porridge Amaranth, muesli, spaghetti Wholefoods, bakery, breakfast, pasta, sauces, spreads, condiments, savouries, sweets, ready meals Beers and ales

pgrhealthfoods.co.uk

01992 581 715

[email protected]

Rizopia pasta

plamilfoods.co.uk proceli.com puredairyfree.co.uk

01303 850 588 0034 93 788 36 00 0800 028 4499

[email protected] [email protected] [email protected]

Real Food Direct

realfooddirect.co.uk

0844 247 7777

[email protected]

Roley’s

roleys.com

0031 33 463 0165

[email protected]

Sally’s Sizzling Sausage Co

sallyssizzlers.com

020 7213 9474

[email protected]

Sauces of Choice

saucesofchoice.co.uk

01335 630 003

[email protected]

Simply Free

simply-free.co.uk

01582 840502

[email protected]

The Village Bakery Melmerby

[email protected] [email protected]

Gluten-free, wheat-free bakery

Wellfoods

village-bakery.com 01768 898 437 newburnbakehouse.com/pharma01773 515034 cy-ordering wellfoods.co.uk 01226 381 712

Chocolate, mayonnaise Breads, rolls, buns, muffins, cookies, croissants, pasta Dairy-free butter spread Sauces, mixes, biscuits, crackers, crispbreads, cakes, puddings, flour, pasta Cakes, breakfast, cookies, bread, flour Sausages, bacon, meatballs, gammon, burgers, barbecue range, Continental meats Chutneys, sauces Brands, mixes, flour, stuffing, pasta, crackers, condiments, gravy, spreads, snacks Cakes, snack bars, brownies

[email protected]

Wiltshire Farm Foods

wiltshirefarmfoods.com

0800 773 773

[email protected]

Windmill Organics

windmillorganics.com

0208 547 2775

[email protected]

Loaves, rolls, buns, flour, pizza, prescriptions Ready meals inc breakfasts, desserts and pureed meals, home delivery Amisa, Biona, Biofair brands and miscellaneous

Warburtons

Main Categories Meals, snacks, sauces, pasta, noodles, sweets Cookies, biscuits Cheescakes and tarts Pasties, pies, sausage rolls, quiches, tarts, cakes, bread, pastry, scones Fry’s Meat replacement products and meals Cakes, brownies and breads Bounce healthy snack bars Macadamia products: muesli, nuts, mixes, snacks, oils Japanese & European foods inc miso, noodles, sauces, pasta, purees, spreads Pies, pasties, rolls, cakes, flapjacks, dips Dried fruits, nuts, seeds, herbs, spices, pulses, cereals, rice producer of gluten-free food: Glutafin and DS-gluten free Artisan bakers: breads, cakes, tarts, muffins, savouries Wide range of products inc biscuits, breads, pizza, pasta, mixes, sauces, pickles, marinades Bread, crackers, snacks, biscuits, pasta and frozen foods including ready meals, pasties, pizzas and Yorkshire puddings Muesli, cakes, cereal, biscuits, flour, pasta, sauces and mixes Tea, coffee, cordials, squash, sauces, rice, pasta, cereal GF bakery, ingredients for the food industry and replacement food products Breads, Christmas, Eastern, Italian, sausages, sweets and savouries Breads, rolls, cookies, snacks, cheeses, communion wafers, pasta, baking products, prescriptions Bakery, frozen pies, pastry Flour, cake mixes, bread mixes, prescriptions, biscuits, cereal, pasta, noodles Breads, rolls, mixes, pasta, biscuits, crackers, prescriptions Biscuits, cookies, bread, cake, cereal, crackers, flour, mixes, pasta, savouries, snacks Frozen foods, sauces, spreads, mixes, cereals, breads, biscuits, snacks, miscellaneous Cakes, puddings, savouries, breads, mixes, pasta, cereals, miscellaneous batter mix, breadcrumbs, sauces, vinegar, gravy Bread, cakes, muffins, cookies, crackers, meusli, pastry, pies, savouries, pasta Granola, juices, snacks, oils, quinoa, oils, condiments, sauces, pate, puree Beers and ales Syrup, pasta, crisps, rice, snacks, mixes Cakes, crumbles Pasta, pasta sauces Flapjacks, cookies, shortbreads, brownies, savoury tarts Chocolate fudge and sticky toffee puddings essential gluten-free foods on prescription, including bread, flour, breakfast cereals, pasta & crackers


17

Leading scientific support for Coeliac Disease and Gluten Sensitivity Support for Healthcare Professionals The Dr Schär Institute is the number one dedicated healthcare professional resource specialising in coeliac disease and gluten sensitivity. Our online and written materials, produced in collaboration with leading experts in the field, provide the latest information and training on the diagnosis and management of gluten related disorders.

Support for patients Dr Schär has two gluten free brands; Glutafin available on prescription, and DS-gluten free in retail. Both brands offer extensive support for patients including free samples, dedicated customer carelines, and helpful online advice for gluten free living. Our brands:

www.drschaer-institute.com Dr. Schär UK Ltd. Station Court, 442 Stockport Road, Warrington, WA4 2GW Telephone support: 0800 988 8470 Email: [email protected]

Register free today www.drschaer-institute.com • In-depth information and compact guidelines • Clinical reference library • CPD training modules • Webinars with leading experts • Patient literature

GLUTEN-free guide

Gluten sensitivity: the emergence of a new disorder Until recently, the term ‘gluten sensitivity’ (GS) was confined to either the scientific literature or the less credible end of the diet industry. Gluten in itself was only ever associated with coeliac disease or wheat allergy and patients showing no clinical indicators of either, but who were selfdiagnosing a potential issue with gluten, were often labelled as fussy eaters and subsequently given no advice to exclude gluten from their diets. Katie Kennedy MNutr RD Dietitian

Confusion among clinicians was also not uncommon and, it seems, not without foundation. GS has a similar presentation to a number of other conditions, most notably coeliac disease, but also irritable bowel syndrome (IBS). With generic gastrointestinal symptoms that include abdominal pain and bloating, diarrhoea, constipation, as well as headache, fatigue, limb numbness and anaemia, general practitioners (GPs) and dietitians report frequently seeing patients with what they believe to be GS, but they are uncertain about how to manage the condition (1). Comparable diagnostic difficulties can also be observed between GS and IBS and the acceptance issues that IBS faced 10 years ago are similarly present with GS; GPs and dietitians knew IBS existed, but were unsure of its origin or treatment. Patients were left either without the appropriate advice, or worse, simply sent on their way.

Symptoms of gluten sensitivity

Symptoms • Bloating • Abdominal discomfort or pain • Constipation and/or diarrhoea

Extra-intestinal symptoms •

Generic malaise, including: o headaches and migraines o fatigue o limb numbness o anaemia

Katie Kennedy has been a Registered Dietitian for the last nine years. During this time she has worked in both community and acute NHS trusts in addition to working as a nutrition consultant within the food industry. Alongside managing her own freelance dietetic consultancy business, Katie is currently employed as a company dietitian for gluten-free food manufacturer Dr Schär UK.

Gluten under the microscope Some experts question the reasons behind the rise in gut issues following the consumption of gluten. A credible rationale has yet to be elucidated, but a number of explanations have been postulated. One hypothesis lies in the evolutionary nature of our diets (2). Only in the past 10 thousand years have we eaten wheat, which in dietary terms is considered relatively recent! Undoubtedly, in evolutionary terms, gluten is a relatively new foodstuff for the human digestive tract and its apparent link to the increase in diagnoses of coeliac disease, which has occurred over the past few decades, is both plausible and difficult to ignore. Gluten itself is a reticular, elastic, porous mass, comprising the main structure in dough; essentially it guarantees elasticity and texture in baked products. Gluten comes from a set of proteins contained in wheat, barley, rye and in various other cereals belonging to the gramineae (grass) family. The group of proteins that make up gluten are known as prolamins, which contain a hard-to-digest amino acid (proline), that in some susceptible individuals can trigger a wide range of reactions. The ingestion of food

containing gluten causes the body (of some) to detect the presence of a foreign element and this sets in motion a series of processes that, in the more severe cases (coeliac disease), can destroy the intestinal mucosa, or, in less severe cases (GS), gives rise to gastrointestinal symptoms. In both cases, after time, the symptoms usually subside upon the adoption of a gluten-free diet. In terms of importance to human health, the amino acids in gluten are not essential, so apart from its usefulness in baking or in the making of flour-based products; gluten can be removed from the diet without initiating any nutritional deficiencies. However, whilst gluten has little nutritional value itself, it is necessary to bear in mind that the foods containing gluten that have to be excluded from the diet in the treatment of gluten-related disorders, can be important sources of various nutrients in the diet e.g. fibre, calcium etc. Nomenclature for GS Clinicians, including GPs, nurses and dietitians, report GS to be a clinical entity that is ever more frequently being observed in their clinics. Patients present with a variety of symptoms, including both gastrointestinal and extraintestinal symptoms. With this in mind, in 2011 a meeting was convened with a panel of global experts in gastroenterology and neurology (3). The meeting discussed the spectrum of gluten-related disorders, including existing conditions such as coeliac disease and wheat allergy, both of which have a clear diagnostic pathway. The experts identified a condition where a reaction to gluten appeared to have happened, but both allergic and autoimmune mechanisms had been ruled out. Alongside the existing conditions, GS was identified - and classified - as an additional gluten-related condition and its pathogenic, clinical and epidemiological properties were discussed (4). The proposed nomenclature and classification of gluten sensitivity - expected to identify many more people globally than for coeliac disease or wheat allergy - paves the way towards developing a clinical diagnostic process for the condition. Recognising GS as an immune-mediated disorder will also help non-coeliacs and non-wheat allergic subjects to identify the cause of their symptoms and take steps to alleviate them. By defining GS as part of the spectrum of gluten-related disorders, a name can be put to the array of symptoms, not to mention the proposed diagnostic algorithm for the condition, which could affect millions of people worldwide. The pathway to diagnosis In practice, for a patient to obtain a diagnosis of GS, they NHDmag.com June 2013 - Issue 85

19

GLUTEN-free guide Table 1: Nomenclature of gluten-related disorders

References 1 Opinium Research, 21 February 2012 (unpublished) 2 Accomando S and Cataldo F (2004). The global village of coeliac disease. Dig Liv Dis;36:492 8 3 Sapone A et al (2012). Spectrum of gluten-related disorders: consensus on new nomenclature and classification BMC Medicine, 10:13 4 Brown AC (2012). Gluten sensitivity: problems of an emerging condition separate from coeliac disease. Expert Rev Gastroenterol Hepatol.;6(1):43-55 5 Clinic data from Prof A Fasano, Baltimore Clinic, USA 6 www.bsg.org.uk/sections/ small-bowel-nutritionarticles/bsg-guidance-oncoeliac-disease-2010.html 7 Sapone A et al (2011). Divergence of gut permeability and mucosal immune gene expression in two gluten-associated conditions: coeliac disease and gluten sensitivity. BMC Medicine 8 Short Report on the findings of the Second International Expert Meeting on Gluten Sensitivity. 2013. www.drschaerinstitute.com/en/clinicalareas/glutensensitivity/ overview/internationalrecommendations/ 9 Volta U et al (2012). New understanding of gluten sensitivity. Nat Rev Gastroenterol Hepatol; 28:9 (5); 295-9

20

need to provide their GP or dietitian with an accurate description of their symptoms. As discussed, symptoms can include, but are not restricted to, abdominal pain and bloating, diarrhoea, constipation, headache and even fatigue may occur. Limb numbness and anaemia can be other indicators of GS and may or may not be present. It is, therefore, the role of the healthcare professional alone to decide whether the patient is displaying symptoms that may be associated with gluten. In view of the fact that the symptoms of GS share similarities with those of coeliac disease and in some cases wheat allergy, patients needs to undergo a specific set of tests to exclude both conditions before a diagnosis of GS is considered. The sequence of steps for determining GS has been proposed as follows: • Exclude wheat allergy. First of all, it needs to be established whether the patient is allergic to wheat. An allergic response can manifest as a respiratory allergy (which is more frequent in adults), including baker’s asthma and rhinitis; a food allergy (mainly found in children) with gastrointestinal symptoms, urticaria and angioedema, a bronchial obstruction or a worsening condition of atopic dermatitis; contact urticaria. • Exclude coeliac disease. To rule out coeliac disease, the patient undergoes a blood test to detect specific serological markers. Coeliac disease is characterised by certain markers: antibodies to tissue transglutaminase (anti-tTG) and endomysium (EMA). A check for IgA deficiency also needs to be carried out. • Finally, a diagnosis of GS can be considered by the exclusion of gluten from the diet with a resultant cessation of symptoms. Research updates Ongoing research continues to give added credence to the existence of GS. Indeed, GS should now be recognised by clinicians where a gluten reaction has occurred, but both allergic and autoimmune mechanisms have been ruled out. Since identifying and classifying GS, the extent of the condition is now becoming clear. Data from a specialist clinic in the US shows an approximate prevalence of GS of 6.0% (5), compared with 1.0% suffering from coeliac disease (6). It is unknown whether GS is a chronic condition, as is the case with coeliac disease, and certainly its symptoms are generally less severe (6). It can, however, have a significant and deleterious effect on a person’s life. GS is thought to be potentially the most commonly occurring disorder related to gluten with some experts seeing


coeliac disease as just the tip of the gluten-related iceberg. While the occurrence of GS is now increasingly being accepted, its existence remains in question by some health commentators and the media, who attribute gluten avoidance to a lifestyle choice. This misguided assumption has been exacerbated by publicity surrounding the diets adopted by ‘celebrities’ who often legitimise their own gluten avoidance as a way to cut the carbohydrate food group from their diets, frequently as a method to help reduce weight. Alongside the 2011 global consensus meeting, additional research has recently underlined the emergence of GS as a separate condition to coeliac disease (3), which also responds well to a gluten-free diet. The research concludes that the condition - gluten sensitivity - should not only be recognised as a condition but also treated as one. A further meeting of experts from various countries took place in late 2012 to discuss the most recent research in the area of gluten sensitivity and a short meeting report has been produced outlining the findings of this meeting (8). What the experts say Professor David Sanders, Consultant Gastroenterologist at the Royal Hallamshire Hospital and University of Sheffield, comments: “There is a clear gulf of knowledge within the healthcare professional community on the distinction between gluten sensitivity, coeliac disease and wheat allergy - yet gluten sensitivity could affect many more people. Patients who present with gastrointestinal symptoms, but who test negatively for coeliac disease should be automatically considered for gluten sensitivity. Indeed, in most cases, their clinical presentation could be enough to distinguish gluten sensitivity from both wheat allergy and coeliac disease, but testing for and ruling out both conditions, is essential. It is estimated that gluten sensitivity occurs more frequently than coeliac disease, which affects 1.0% of the population. Despite this, only 3.0% of dietitians spontaneously list gluten sensitivity as being the most common disorder associated to gluten; perhaps not surprisingly, the majority cite the more commonly known coeliac disease. Already we see many non-coeliac patients opting for a gluten-free diet and reporting a benefit from it. As the research base continues to grow, we can only hope that gluten sensitivity is acknowledged as a condition, in the same way as similar ailments such as IBS have become accepted and thus it receives the recognition that the experts think it deserves.” Further research is necessary to establish the main clinico-pathological features of gluten sensitivity to allow clinicians to improve their management of the increasing number of patients who are sensitive to gluten (9). That said, exciting research in this area is beginning to support what GS sufferers and some experts have been saying for years, that cutting gluten from the diet of certain individuals can improve their symptoms even if they do not yet have a definitive, clinical diagnosis of coeliac disease.

NHD CLINICAL

C L I N I C A L

principles and patients . . . On 9 May 2013 the Malnutrition Task Force launched ‘Prevention and early intervention of malnutrition in later life – best practice and implementation guide, a local community guide’.

Chris Rudd NHD Clinical 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.

This guide includes five principles including raising awareness to prevent and treat malnutrition, working together, identifying malnutrition, personalising care, support and treatment and monitoring and evaluating. Can this be ignored when it states lives will be saved and tons of millions of pounds each year will be saved? The striking facts for the commissioners are that the NHS could save £45.5 million per year even after costs of training and screening and if dehydration was tackled across the NHS £950 million could be saved in the UK. It will be interesting to see the outcome of this guidance. Our cover article has taken into account some of the above principles. Diane Spalding and Andrew Wilson work in partnership to improve the nutrition and quality of hospital food and share this with us in Hospital food and nutrition. 2,000 patients are fed each day and the food service has made changes to ensure that there are bespoke menu choices and that local food providers are used. Feast your eyes on what happens in Leeds and see how partnership working and good communication channels helped make that difference.

I like the idea that patients are offered afternoon tea. It was Henry James who stated: ‘There are few hours in life more agreeable than the hour dedicated to the ceremony known as afternoon tea.’ Dietetics at the top of the world! Sarah Durnan shares her experience of visiting Nepal, a small country with a population of 30.5 million and only nine dietitians. Sarah gives an overview of Nepal and focuses on the contrasts of enteral tube feeding in the community in Nottingham and Nepal. I remember the days when enteral feeds were ‘homemade’; in Nepal this seem to be the norm. Lactose intolerance by Kate Harrod-Wild informs us about using the right product at the right time for the right diagnosis and when to reintroduce foods back into the diet. In the centre of this month’s NHD you will find the Gluten-free pull-out guide. It is a useful reference for resources, foods, events and support contacts for both healthcare professionals and for coeliac sufferers. I hope that you enjoy reading this month’s section and maybe you will be enjoying afternoon tea too! NHDmag.com June 2013 - Issue 85

21

NHD CLINICAL - Hospital food and nutrition

Working in partnership to improve nutrition and quality of hospital food Diane Spalding Facilities Dietetic Adviser, Leeds Teaching Hospitals NHS Trust

Andrew Wilson Senior Facilities Manager (Patient Catering), Leeds Teaching Hospitals NHS Trust

Diane Spalding has previously worked as Director of Leicestershire Nutrition and Dietetic Services, the Dietetic Officer at the Department of Health and Head of Nutrition and Dietetics at Harrogate. She has always worked closely with patient catering services and believes this is an important aspect of a dietitian’s role. She currently works as Dietetic Adviser to the facilities team at Leeds Teaching Hospitals NHS Trust. Andrew Wilson has a catering background and has worked in the NHS for his entire career, predominantly in patient catering. He has been involved in many of the changes at Leeds including the development of the Receipt, Assembly and Distribution Unit.

22

As one of the largest NHS Trust’s in the UK, Leeds Teaching Hospitals NHS Trust (LTHT) has the responsibility of feeding around 2,000 patients a day at five different sites across the city. The broad ethnic mix, vast range of clinical services and variety of special dietary needs inevitably means that LTHT is faced with a unique set of challenges where the provision of patient meals is concerned. The process to develop the Patient Catering Strategy by the senior facilities team and patient representative groups at Leeds is described here. Background The Leeds Teaching Hospitals NHS Trust is spread across five sites - Leeds General Infirmary (including the Leeds Children’s Hospital), St James’ University Hospital, Chapel Allerton Hospital, Seacroft Hospital and Wharfedale Hospital. In 2002 the Central RADU was opened as a central hub for a delivered Cook-Freeze system to provide meals to all patients within LTHT. At the RADU all products are ‘picked and packed’ for the wards according to the orders received (as chosen by patients). The products are packed in thermo-containers (insulated boxes) for each ward and delivered to each hospital site twice a day (for lunch and evening meal). The food is then regenerated at ward level prior to service by the Ward Housekeepers to patients. However, the outputs from recent Picker surveys (1) were below expectations. The issue was mainly in relation to the taste of foods provided. To address this, the senior facilities team developed a catering strategy forum resulting in a three-year catering strategy plan. Putting the patient at the centre Until recently, the Trust has taken a fairly conventional approach to catering, using one supplier to fulfil the contract for frozen products who was largely responsible - in consultation with LTHT - for developing menus and meeting nutritional targets for a diverse range of patient requirements. The situation now is radically different from this. A complete reassessment has been made of how LTHT provides patient meals with a view to making nutrition, quality and patient satisfaction the driving force behind all decision making. LTHT has always been aware of the need for patient satisfaction when it comes to meals, but as with most Trusts a prescriptive approach had generally been taken. It was the Trust and the caterer who largely decided the menu. As a main focus in the Patient Catering Strategy it was decided that there needed to be a power shift. This involved five key innovations: 1. Engaging the people of Leeds, to ensure that any future developments were truly patient led, by teaming up with Leeds LINk to form a large


2. 3. 4.

5.

patient catering group which has supported the changes and gained independent feedback from patients over the last two years. Introducing continual competition for the suppliers to keep standards and value at their highest. Shifting the decision making on menu content and style to the patients in a more far-reaching way than ever before. Streamlining the ward ordering process and wastage recording to ensure maximum efficiency, so that any savings from this can be reinvested into the menu. Increasing the sourcing of fresh and locally produced food.

The first step was to restructure the Menus in line with the eating habits of our local population and to ensure maximum efficiencies in ward ordering and wastage control. This was achieved in conjunction with the Leeds LINk group patient representatives, resulting in a move towards a different style of meals incorporating a three-course ‘bistro style’ lunchtime menu and a two-course traditional evening meal. The evening and weekend menu offers themed and traditional menus, e.g. Friday evening ‘Fish & Chips’, Saturday evening ‘Takeaway’ style menu, Sunday traditional roast lunch. Work is currently underway to develop the breakfast menu, which includes hot options. This is affordable due to the efforts made to reduce wastage by limiting the ability for wards to over order meals. The specification and tendering process During 2012 and with the support of the NHS Supply Chain by utilising their existing framework, LTHT was involved in a tendering process for the supply of frozen meals. The outcome was to appoint, not one, but three suppliers to meet a newly formulated set of catering criteria. It was felt that by taking the unusual measure of having more than one supplier this could result in significant quality improvements, supplier competition and greatly increased choice for patients. This has enabled us to choose the best dishes from each supplier.


Development of the menus In order to meet the needs of patients at LTHT, a range of menus are available to give appropriate choice to meet likes/dislikes, cultural and religious needs, personal preferences, as well as the full range of clinical specialities and the provision of therapeutic diets. The needs of both ‘nutritionally well’ patients and those who are ‘nutritionally vulnerable’ have been accommodated by the range of choices on the menu. The majority of patient’s needs are met through the following menus:

No dietary coding

Meal component

Adult core menu Older people’s menu Children’s core menu Snack menu (for adults with a MUST score of 1 or more)

Additional menus: • • • • •

Kosher menu Multicultural menu African Caribbean menu Gluten free (NGCI) menu Renal/low potassium menu

Fat (g)

Salt equiv. (g)

12

1.8

Entree dish alone (protein source vegetarian alternative)

9

1.8

120

4

Entree dish alone (protein source - fish, meat, chicken)

At least 300

12

2.0


At least 300

9

2.0

Potatoes, alternatives and vegetables

At least 100

Desserts (custard accompaniment to be added to this to increase to 5.0g protein and 300kcals)

At least 220

At least 4

Snacks (per snack item)

At least 150

At least 2


250 or less

12

15 (total fat) 5 (saturated fat)

1.5


250 or less

12

15 (total fat) 5 (saturated fat)

1.5

5 or less

0.4

Potatoes, alternatives and vegetables

No added fat

Desserts (also less than 15g added sugar) Table 2 - Dietary coding

Menu information - dietary coding If you have been advised to follow a specific diet, look for the symbol on the menu against the dish which may help you choose suitable items: Healthier Choices are lower in fat, salt and sugar and are suitable choices if you have been advised to follow a ‘healthier diet’ for example for your diabetes or for your heart health or if you are trying to lose weight.

Core menus: • • • •

Energy Protein (kcals) (g)


Nourishing soup

Higher energy choices

Nutritional targets An important reference to use for agreeing the nutritional targets for the menu is the BDA Food and Hydration Digest (2) produced by the Food Counts Group. This reference is invaluable for all dietitians involved in patient catering. The tender process at Leeds was prior to the publication of this document and so it was necessary to set nutritional targets for individual products being supplied through the catering contract. However, these targets are generally in line with those in the Digest. The Day Parts approach in this reference provides a useful method of planning the overall multi-choice menu and ensuring adequate nutrition at each meal period. However, for the purpose of the tender, it was important to set nutritional targets for individual products so that each could be assessed against this. The minimum targets per portion served agreed for this process at Leeds are seen in Table 1.

Table 1: Nutritional targets agreed for LTHT for assessing individual dishes

Healthier choices

The evaluation process has put Nutrition as a top priority. All products were assessed against the Trust’s nutritional targets and if they achieved the minimum standards, they were put forward to taste and quality testing panels, which consisted of patient representatives and various staff groups. Consideration has also been given to the other fresh items on the menus. As a result, milk is supplied from the Yorkshire Dales, fresh dairy ice cream is produced by one of the well-known Yorkshire ice cream dairies, sandwiches and salads are produced locally and fresh cakes are supplied from a local Leeds bakery. Most of the vegetables and jacket potatoes on the menu are fresh and are sourced locally for at least 48 weeks in the year. Local produce is promoted on the menu to ensure that patients are aware of this.

✶

Higher Energy items are suitable if you have a small appetite or require food high in energy due to your illness, weight loss or surgery.

S Soft items are easily eaten and easy to chew. V Vegetarian items are free from meat, poultry, fish and gelatine. GF Gluten free these are No Gluten Containing Ingredients options if you follow a gluten-free diet. Gluten-free bread is also available. If you have diabetes and are ‘Carbohydrate Aware’, the ward staff will be able to give you some information on the CHO content of the menu. We also have a range of separate menus suitable for other dietary requirements, including African Caribbean, kosher, multicultural, vegan, low potassium, gluten free, or if you require a different texture modified food.


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Modified consistency: • • • •

Thin puree (Texture B) Thick puree (Texture C) Pre-mashed (Texture D) Fork mashable (Texture E)

Missed meal menus (24-hour menus) Specific menu information has also been developed for other special dietary needs, for example, low iodine for patients receiving radio-iodine treatment, neutropenic diet. Most clinical needs are provided for by these menus. However, it is important to remember that our patients are faced with these choices and decisions every day at home and so we should respect the importance of self-management and decision making while in hospital. The dietary coding used on menus has been reviewed with the aim of helping to guide patients on their choices from the menu and this helps to accommodate all special dietary needs without the need for complicated dietary coding or a range of therapeutic menus. Additional information has been developed to help patients choose from the menu if they have specific dietary needs. This includes the carbohydrate content of the menus for children with diabetes and using DAFNE principles for adults (for those who are ‘Carbohydrate Aware’), information for low fibre, restricted salt, low potassium and weight management. A Special Diet Request form is used by dietitians and ward nursing staff to order specific items which are not available on the menus, but which are required for patients with very specific dietary needs (such examples include, chylothorax, ketogenic, GvHD). A menu holder has been printed, so that the daily menus can be slotted into it. The menu holder contains information about the catering service, dietary coding, timing of meals, breakfast and hot beverages choices available. All menus and related information is available for patients, relatives and staff to access in Ward Catering Menu Portfolio (located behind every nurse station), the Patient Catering pages on the Trust intranet and the dietitians shared drive. Menus are available in a printed format for patient use.

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The role of the facilities dietitian The role of the dietitian in Food Services is covered in the BDA Food and Hydration Digest (2). There are significant benefits in having a dietitian working within the facilities/patient catering team. It enables the dietitian to be an integral part of the team and be involved in meetings and discussions to develop the patient catering strategy, both on a formal and an informal basis. It also enhances the knowledge and understanding of nutrition and its importance for hospitalised patients amongst the facilities team. At Leeds this has enabled nutrition to become a priority when selecting products for the menus so that menus are planned to ensure that they meet the minimum nutritional standards and are appropriate for the diverse needs of patients. It also gives opportunities for closer joint working between patient catering and dietitians and other clinical staff, ensuring that the facilities team are aware of the differing nutritional needs of specific patient groups and the reasons for this. In addition, it enables a full nutritional analysis of current menus to be maintained and available to dietitians, using this to undertake nutritional capacity analysis as assurance for the quality of this part of the nutritional care process. Specific initiatives

Hospital Catering Group

Multidisciplinary involvement in Patient Catering is promoted through the Hospital Catering Group, which is a sub group of the Trust’s Nutritional Care Steering Committee reporting through the governance process. A number of specific initiatives have taken place.

Older people’s menu

A sub group of the Older People’s Forum was formed to review the nutritional processes to support older people’s needs. From this some actions were identified to review menu suitability. Some work was undertaken, led by dietitians and dietetic assistants to gain feedback from patients, their carers and ward staff on the suitability of menu options for patients on the Older People’s wards. Actions were agreed between Patient Catering, facilities staff, nursing staff and dietitians to take this forward. The outcomes of this work have been to adapt the ‘bistro-style’ lunchtime menu for the Older People’s wards to incorporate smaller portions of food with a good nutritional content. This includes: nourishing soups, complete mini meals, easy-to-eat / finger Food selection, locally sourced Yorkshire ice-cream Afternoon tea has been introduced on these wards served with locally sourced fresh cakes. Further work has included: the production and use of picture menus; review of the items on the snack menu to ensure that these all meet the recommendations for ‘higher energy’ (2) snacks and are tasty and appealing. A picture snack menu has also been produced; developing the role of mealtime volunteers.


A Special Diet Request form is used by

Texture modified menus

Joint working between Patient Catering, Speech and Language Therapy and some of the specialist dietitians, has led to the development of four texture modified menus (Textures B, C, D and E) containing products which have all been assessed against the National Descriptor checklists (3). To aid the use of these menus at ward level, colour coding of menus and the individual products on these menus has been introduced. A poster using the same national colour coding of the menus has also been developed for use across the Trust for display at ward level and for use in training.

Children’s menus

A work programme has been in place in the Leeds Children’s Hospital to develop ‘child friendly’ menus. The challenge of this work has been in developing menus to suit the age range from one to 18 years old. Also to accommodate the wide range of familiar foods to children and the variation in eating habits amongst families. Some of the menus offered by school meals services were a helpful reference for this. As well as the Monday to Friday ‘bistro style’ lunch menu and 14-day weekend and evening meal menu, an alternative children’s choice menu is offered giving some ‘child friendly ‘options which can be mixed and matched with the children’s menus. All children’s menus are coded for the main allergens. Attention has been given to the presentation of the children’s menus so that the artwork is appropriate for this patient group.

Head and neck patients

An area that required some development was to offer appropriate food choices/menus for some of the oncology head and neck patients. This work involved Patient Catering and specialist speech and language therapists and dietitians who are working with this group of patients, who assessed products for their suitability of textures. A menu for use with specific patients was initially introduced and this work has now been developed further to introduce a Trust wide Texture B (thin puree) menu. Communication A key priority has been communicating developments made in Patient Catering within the Trust. This has included:

dietitians and ward nursing staff to order specific items which are not available on the menus, but which are required for patients with very specific dietary needs • Trust Senior Management Team/Board level - regular dialogue regarding the developments in the catering strategy has been maintained with the Trust’s senior management team and Board; • Dietitians and Dietetic Assistants - regular joint working takes place between Patient Catering and the Nutrition and Dietetic service. New members of staff spend some time in Patient Catering as part of their induction programme; • Student Dietitians - Patient Catering offers attachments for student dietitians on A, B and C placements. • Liaison with local facilities staff - there is close liaison with the local facilities teams including ward housekeepers, supervisors and managers as well as the Facilities Training Department; • Liaison with clinical services - nursing staff, dietitians and speech and language therapists have been closely involved in many of the developments, especially those relating to specific clinical/patient groups; • Patient Catering Update Bulletins - A regular Patient Catering Update Bulletin is produced for all dietitians and dietetic assistants. A similar update is also produced for other staff in the Trust, including the local facilities teams, nurses, speech and language therapists; • Intranet and internet - the Patient Catering pages of the Trust intranet have been developed to include access to all the menus, allergen information and other supporting information. To promote information being available for patients and their relatives, the Trust internet pages are also being developed to include this information. • Local patient support groups - bi-monthly meetings are held with the Leeds LINk group to ensure good communication and involvement with patient groups.

References 1 The Picker Institute Europe, Adult Inpatient Survey 2 The Nutrition & Hydration Digest: Improving Outcomes through Food and Beverage Services, BDA Food Counts Group, 2012 3 Dysphagia Diet Food Texture Descriptors, National Patient Safety Agency, March 2012

dieteticJOBS.co.uk

The UK’s largest dietetic jobsite

To place a job ad in NHD magazine or on www.dieteticJOBS.co.uk please call 0845 450 2125 (local rate) NHDmag.com June 2013 - Issue 85

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NHD CLINICAL - lactose intolerance

Lactose intolerance Many people, including community health professionals, are confused about the difference between lactose intolerance and cows’ milk protein allergy. Food hypersensitivity is the term that has been recommended by the World Allergy Organisation (WAO) to refer to all reactions to food that are not psychologically based (1).

Kate Harrod-Wild Specialist Paediatric Dietitian, Betsi Cadwaladr University Health Board, Wales

The WAO defined food hypersensitivity as any objectively reproducible symptoms or signs that could be reproduced even if disguised (blind). If immunologic symptoms can be demonstrated, then the reaction is defined as food allergy, again subdivided into IgE mediated if the reaction can be attributed to IgE (this is what was previously known as food allergy), or nonIgE mediated if other immunological mechanisms are involved (previously known as food intolerance). All other reactions should be known as non-allergic food hypersensitivity. NICE (2) has recently published guidance for the diagnosis and assessment of allergy in children and young people in primary and community settings to aid community practitioners (primarily GPs) in the assessment, diagnosis and care of children and young people with allergic reactions. However, a key confusion among GPs and health visitors alike, is the difference between lactose intolerance and cows’ milk allergy in infants. • Lactose intolerance is the inability to digest lactose (milk sugar), due to the relative or absolute absence of the enzyme lactase in the small bowel. • Cows’ milk allergy is caused by an allergic response to one of more of the milk proteins.

Kate Harrod-Wild is a Paediatric Dietitian with over 20 years’ experience of working with children in acute and community settings. Kate has also written and spoken extensively on child nutrition.

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Lactose intolerance Lactose intolerance, as described above, is caused by varying degrees of deficiency of the enzyme lactase in the brush border of the small intestine. Lactose that remains undigested in the bowel causes osmotic diarrhoea and is also fermented by colonic bacteria. This results in symptoms such as abdominal distension, flatulence and explosive watery diarrhoea, which is often acidic, causing irritation to the perianal area, seen as severe nappy rash in babies. It may be caused by the following: • Primary alactasia - a rare, hereditary condition characterised by profuse, watery diarrhoea from birth. Symptoms occur as soon as the first feeds of breast milk or infant formula are given. Treatment is total and life-long avoidance of lactose. Breastfeeding is contraindicated as it contains lactose, so a lactose-free formula must be used instead (see later in the article). Paediatric dietetic advice is vital from weaning to ensure that weaning foods are lactose free and that the diet is nutritionally adequate. • Primary lactase deficiency causes progressive lactose intolerance from late childhood. This varies between ethnic groups, being rare in Northern Europeans, to almost endemic in some Asian and African populations. Some milk is usually tolerated (for instance in


tea and coffee), but ingestion of larger amounts will lead to diarrhoea. It is important that sufficient calcium and Vitamin D are obtained from other sources to support bone health. • Secondary lactase deficiency is the most commonly seen in clinical practice. Typically an infant will suffer from gastroenteritis causing diarrhoea, which recurs whenever milk is regraded into the diet. This is caused by damage to the villi by the infection. Since the lactase enzyme sits at the end of gut villi, it is very vulnerable to damage. Treatment is six to 12 weeks of a lactose-free formula (and diet if the infant is weaned), after which time the baby can usually be regraded back onto a normal formula. If this occurs post weaning, dietetic advice will be needed to ensure that the infant avoids sources of lactose, while consuming an otherwise adequate diet. Other gut conditions in all ages, such as coeliac disease, Crohn’s disease and ulcerative colitis, or other conditions causing gut damage may lead to lactose intolerance; this may well resolve once the underlying condition is controlled. • Colic is a controversial manifestation of lactose intolerance. Colic is defined as a baby crying for more than three hours a day, for more than three days a week, for at least three weeks. It is a debilitating, if common condition in early infancy that usually resolves by three to four months, but it can cause considerable anxiety and distress to parents. Parents can also find it very debilitating, as dealing with a baby who cries for several hours every day is extremely tiring. The cause(s) of colic are largely unknown, but one theory is that, in some babies, symptoms may be caused by lactose intolerance. Therefore, in a bottle fed baby, where symptoms are not resolving with other common measures (e.g. changing bottles/teats, colic drops, reassurance), a trial of lactose-free formula may be indicated. Where helpful, symptoms usually resolve within a couple of days. As the natural history of colic is that it is a relatively short-lived condition, the baby will probably be able to go back on to a normal formula and diet by the time of weaning. Lactose-free diet

1. Infant formula in infancy

Historically, lactose intolerance in infancy was treated with a soya infant formula, but these have not be recommended in the last 10 years (3,4) - particularly in infants under six months - because of the theoretical risks to future fertility (particularly in boys), but also

NHD CLINICAL - lactose intolerance because of the significant risks of cross reactivity with cow’s milk protein, particularly an issue for infants with non-IgE mediated cow’s milk allergy. However, lactose free infant formulas are available. These contain cows’ milk protein and all the other usual ingredients of a normal infant formula, except the lactose is replaced by another carbohydrate. Since some community health professionals do not understand the difference between lactose intolerance and cow’s milk allergy, nor the differences between different formulas, there is a risk that an unnecessarily specialist formula, which is not needed (and is more expensive) will be used. Ensuring that these formulas are only used when necessary, only prescribed when parents genuinely cannot afford the relatively modest extra cost and stopped when no longer needed, is a serious issue within the increasingly difficult financial climate facing the NHS. Anecdotally, community health professionals recognise that ‘social prescribing’ of these formulas is an increasing issue. That is, families will attend the GP asking for these formulas to be prescribed alleging ‘colic’ or other symptoms, to avoid paying for their formulas. As GPs are often unsure of the indication and longevity of need, once started, these formulas are often used for an inappropriately long time; an issue we are looking at in North Wales at present.

2. Diet

As already described, many infants will no longer need a lactose-free diet once they reach weaning. However, for those individuals of all ages who need a lactose-free (or low lactose) diet - but particularly infants and children - it is important that they receive advice from a dietitian. The diet is similar to milk free, but with important differences. Many individuals with lactose intolerance will tolerate some low

lactose milk containing foods within the diet. Butter and cream contain little lactose and are therefore often tolerated. Some hard cheeses such as parmesan, Emmental and West Country cheddar are low in lactose and so will often be tolerated. Some individuals will tolerate yoghurt; for instance, one yoghurt a day may be fine, but increased quantities will cause diarrhoea. Individuals with lactose intolerance will usually tolerate the small amounts of lactose in baked goods, but may not tolerate foods (or medications) where lactose has been used as a filler. Trial and error is needed to establish the individual threshold for symptoms. The cause of the lactose intolerance (that is whether it is following gastroenteritis/other gut disorder or due to inherited primary lactase deficiency) will determine whether tolerance is likely to get better or worse with age and the patient advised accordingly. From the age of one year, lactose free milks and dairy products are available from the supermarket, which can help to ensure that adequate amounts of calcium are consumed. Conclusion In infancy, most patients with lactose intolerance will be able to return to a normal diet in a matter of weeks or months; in any case, prescribed products will almost never be needed after the first birthday. In contrast, in older patients, lactose intolerance may in fact become more problematic with time and it should be ensured that they have advice on ingesting enough alternative foods to meet their calcium requirements. Where lactose intolerance is secondary to other disease processes, patients should be encouraged to review their intake of lactose if their gut health improves. However, with many people self-diagnosing lactose intolerance, supermarket products have risen up to meet the demand, meaning it has never been easier to follow a lactose-free diet.

References 1 Johansson SGO, Bieber T, Dahl R et al (2004). Revised nomenclature for allergy for global use: Report of the Nomenclature Review Committee of the World Allergy Organisation. JACI 113, 832-836 2 NICE (2011). CG 116 Food allergy in children and young people: Diagnosis and assessment of food allergy in children and young people in primary care and community settings. www.nice.org.uk/nicemedia/live/13348/57929/57929.pdf 3 CMO (2004). Update No. 37 www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4070176.pdf 4 Paediatric Group of the British Dietetic Association Position Statement (2010). Use of infant formulas based on soy protein for infants. www.bda.uk.com/publications/ PaediatricGroupGuidelineSoyInfantFormulas.pdf

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nhdmag.com NHDmag.com June 2013 - Issue 85

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NHD CLINICAL - web watch

web watch Online resources and useful updates. Social media guidance for GPs A practical guide to help UK doctors navigate their way around the ethical and confidentiality dilemmas of social media has been published by the Royal College of General Practitioners (RCGP) in collaboration with Doctors.net.uk and LimeGreen Media. The Social Media Highway Code is a collation of practical and supportive advice based around a 10-point plan. The advice was provided by a range of people with an interest in social media including doctors, nurses, journalists, lawyers, students and patients. It is intended to help and encourage healthcare professionals to communicate effectively using various social media channels whilst adhering to the conventions that their patients, their colleagues and the public might reasonably expect. RCGP: www.rcgp.org. uk/news/doctors-in-the-fast-lane-on-social-media-guidance.aspx; Social Media Highway Code: www.rcgp.org.uk/social-media Government response to report on future of NICE In its response to the Health Select Committee’s report on the future role of the National Institute for Health and Clinical Care Excellence (NICE), the government has confirmed that NICE will have a crucial role in the future value-based pricing arrangements for branded medicines and build on its current drug evaluation processes by giving it broader scope to assess a medicine’s benefits and costs. The aim is to make sure that the price the NHS pays for new medicines is more closely linked to their value to NHS patients and society. The government also welcomed the committee’s call for better information about drug trials and a new code of practice. The Government announcement comes as NICE is also preparing to take on other new responsibilities. From April, its remit will be extended to cover social care, as well as the NHS and public health. This will assist in the development of better integration of services between different health and care organisations. www.dh.gov.uk/health/2013/03/ response-hsc-nice/; Press release: http://mediacentre.dh.gov.uk/2013/03/21/nice-to-assessvalue-of-medicines-from-2014/ Nutrition analysis surveys The Department of Health has published four updated reports on the nutritional values of different food types: • Nutrient analysis of fruit and vegetables www.dh.gov.uk/health/2013/03/nutrients-vegfruit/

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• Nutrient analysis of eggs - www.dh.gov.uk/ health/2013/03/nutrient-eggs-2013/ • Nutrient analysis of fish and fish products www.dh.gov.uk/health/2013/03/nutrient-fish/ • Nutrient analysis of processed foods with reference to trans fatty acids - www.dh.gov.uk/ health/2013/03/nutrient-trans-fats/ NHS atlas of variation in healthcare for people with liver disease NHS Rightcare has published Liver Disease: the atlas of variation in healthcare for people with liver Disease. The atlas concludes that premature death from chronic liver disease is rising, largely as a result of lifestyle issues such as alcohol, drug taking and obesity. There is significant variation in these mortality rates, with deprivation a key factor. In 2011, the Department of Health estimated the cost of alcohol misuse to the NHS was £3.5bn. Over 24 percent of the population (33 percent of men, 16 percent of women) consume alcohol in a way that is potentially or actually harmful. www.rightcare. nhs.uk/index.php/atlas/liver-disease-nhs-atlasof-variation-in-healthcare-for-people-with-liverdisease Putting Patients First The Department of Health has issued a press release stating that the quality of patient care will be put at the heart of the NHS in an overhaul of the health and care system in response to the Francis Inquiry. The Health Secretary has announced how a culture of compassion will be a key marker of success, spelling an end to the distorting impact of targets and box ticking which led to the failings at Stafford Hospital. Hospitals and care homes will be encouraged to strive to be the best, the basic values of dignity and respect will be central to care training and, if things go wrong, patients and their families will be told about it. www.gov.uk/government/news/ putting-patients-first-government-publishesresponse-to-francis-report Food statistics National Statistics has published Food statistics pocketbook 2012. This publication provides a concise round-up of statistics on food covering the economic, social and environmental aspects of the food we eat (excluding agriculture). It contains a mixture of national statistics, official statistics and unofficial statistics. Unofficial statistics are used where there are gaps in the evidence base. www. gov.uk/government/publications/food-statisticspocketbook-2012

Public Health England marketing plan Public Health England has published its marketing plan for 2013/14. This plan explains how PHE marketing will motivate and support people to improve their health. It is an update of the 2011-14 strategy, ‘Changing Behaviour, Improving Outcomes: A new social marketing strategy for public health’. The intended audience is public health and marketing professionals. www.gov. uk/government/publications/public-healthengland-marketing-plan-2013-14 Care Quality Commission strategy 2013-16 The Care Quality Commission (CQC) have launched their new three-year strategy ‘Raising Standards Putting People First: our strategy 2013-2016’. The strategy sets out the CQC plans for the period and defines some of the changes that they are going to introduce including: appointing a Chief Inspector of Hospitals, a Chief Inspector of Social Care and Support and considering the appointment of a Chief Inspector of Primary and Integrated Care; developing new fundamental standards of care; making sure inspectors specialise in particular areas of care and lead teams that include clinical and other experts and experts by experience (people with experience of care); introducing national teams in NHS hospitals that have specialist expertise to carry out indepth reviews of hospitals with significant or longstanding problems; improving understanding of how well different care services work together by listening to people’s experiences of moving between different care services; publishing better information for the public, including ratings of services and strengthening the protection of people whose rights are restricted under the Mental Health Act. www.cqc. org.uk/public/news/our-strategy-2013-2016 Child health app Public health professionals can now access local authority child health profiles from their smartphone or tablet. Child Health Profiles give a snapshot of child health and wellbeing for each local authority in England, using key health indicators. Users can compare this information to local, regional and national data. Data in the app covers a wide range of issues affecting child health, from levels of childhood obesity, teenage pregnancy and underage drinking, to hospital admissions, educational performance and youth crime. DH press release: www.gov.uk/government/news/ new-child-health-app-for-health-professionals; Child Health Profiles: www.chimat.org.uk/profiles

hef watch

Dietetics on top of the world Experience of a ‘Group Study Exchange’ to Nepal.

Sarah Dornan Registered Dietitian, Nottingham University Hospitals NHS Trust

Four young professionals from the East Midlands were chosen to take part in Rotary International’s Group Study Exchange (GSE) programme, a unique cultural and vocational exchange opportunity. I was the first dietitian to take part. I work as a Specialist Home Enteral Feeding Dietitian for Nottingham University Hospitals Trust and I review patients in their home or nursing home. I look after about 47 tube-fed adult patients (age 18-96) and a 72-bed community rehabilitation hospital. Rotary is a humanitarian organisation for business and professional leaders. There are more than 34,000 clubs worldwide involved in local community and international programmes such as ‘End Polio Now’. We set off on a cold, foggy February morning unsure what to expect but very excited. Over one month we would stay with local families and travel throughout Nepal, visiting projects arranged by the Nepalese Rotarians. We did 40 presentations about ourselves, our professions and the area we call home. Nepal Nepal has a population of approximately 30.5 million. Sandwiched between India and China, Nepal has historic town squares, stunning natural scenery and some of the highest mountains in the world. It is also one of the world’s poorest countries. The UN estimates 40 percent live in poverty, with high rates of childhood malnutrition and mortality, especially in rural areas where levels of education are low. Strikes often bring the country to a standstill, and Nepal still feels the effects of a 10-year Maoist insurgency. There is little government funding for health, sanitation, education and infrastructure. Despite the poverty people are friendly, optimistic and very hospitable. With the saying ‘guest is god’ I was welcomed into nine different family homes. They shared their daily lives, celebrations and photo albums and really made me welcome. Family is very important to Nepalese people; children mostly stay in the family home until marriage when daughters go to live with their in-laws. Often several generations live together. Inadequate health and social care means people are heavily reliant on their families but there are low rates of elderly malnutrition. Very few live in nursing homes.

Sarah is currently working as a Specialist Adult Home Enteral Feeding Dietitian in Nottingham. She previously worked as an Acute Dietitian in Carlisle. Sarah’s hobbies include travel, cooking and scuba diving.

Food A typical day starts with a cup of chai (milky spiced tea) followed by the traditional dish Dal-Bhatt about 10am. This includes a large portion of boiled white rice, curried vegetables (mostly cauliflower and carrot although this is seasonal), spinach, and thin lentil curry. Occasionally, curried mutton is served as a side dish with poppadum and tomato pickle. Dal-Bhatt is eaten again at about 3pm. After one week on the Dal-Bhatt diet we craved the variety of food at home. The people are predominantly Hindu and/or Buddhist. Food plays an important role in celebrations so we tried a variety of festive foods and even cooked with our host families.

Vocational Visits I was lucky enough to meet one third of dietitians in Nepal which sounds impressive but there are only nine and all are hospital-based. One of them was Rashmi Bajimaya Shrestha, the only dietitian covering a 600-bed teaching hospital including outpatient clinics. Dietetics is not a registered profession in Nepal. Rashmi is treasurer of the Nepal Dietetic Association which was set up last year. They hope to be registered by the Nepalese Paramedical Council soon. Rashmi trained by completing a two year degree in nutrition at a government university campus. In Nepal you cannot be admitted to hospital without a family member present. Families bring in food for patients and Rashmi advises what they should bring. Most patients who need artificial feeding have Nasogastric or Naso-Jejunal tubes. Gastrostomy and Jejunostomies (which make up the majority of my caseload) are rare and are placed surgically. In Nottingham the main causes for patients requiring long-term home enteral feeding are Stroke, MS, MND and brain injury. Rashmi said there was a low incidence of MS and MND. Most tube feeding is due to obstructive masses or brain injury. Stroke is common but less likely to result in tube feeding. I shadowed Rashmi on her rounds. We met patients being bolus fed by relatives. The commercial feeds and pumps we use are not available so Rashmi teaches families to make their own using a combination of rice, vegetables, beans, flour, milk, eggs and oil, tailoring the recipe to specific needs. Families are taught to mix and administer feed. Without guaranteed electricity, feed might need preparing every two hours. Vitamin and mineral supplements are expensive and rarely used. Once discharged from hospital there is no follow-up support. In comparison we visit patients at home within one month of discharge, reviewing by alternate telephone and home visits every three months. Patients can contact us in-between. Feed and equipment are delivered to the patient’s home and nutrition nurses are available. How lucky we are to have the NHS. I visited Nutrition Rehabilitation Units where malnourished children are brought to reintroduce food and promote healthy weight gain. The units transformed emaciated children with protruding bones and sunken eyes into happy, healthy, playful children in a month. The units also teach mothers about nutrition and the importance of adequate diet for growth. Mothers then return to their villages to teach others. The GSE experience is best described as a rollercoaster, one moment laughing and joking with our hosts then visiting heartrending projects. Some did wonderful work while others were only scratching the surface of the problem. GSE was no holiday. We travelled hundreds of miles and met many people, but it’s an experience I would recommend. I know Nepal in a way that I wouldn’t as a tourist. With thanks to the Home Enteral Feeding Team at NUH for supporting me to take part in this trip. NHDmag.com June 2013 - Issue 85

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career

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METABOLIC SALES REPRESENTATIVE NUTRICIA Calling all dietitians looking for new and exciting opportunities! We have a vacancy in our specialist metabolics sales team within one of Europe’s largest medical nutrition companies and the market leader within the UK. This is a rare, unique and rewarding opportunity to work within the specialist area of Metabolics and Ketogenics supporting both customer and patients alike,• Contract type: 1 year fixed term contract with the possibility to extend to a permanent role. • Location 1: Midlands and East Anglia. • Start date: Mid July 2013.• Highly competitive salary (company car, bonus, private healthcare, 25 days annual holiday).For more information on these and all opportunities at Nutricia, please visit http://nutricia.co.uk/about/careers Contact: [email protected]. Closing date: 19th June 2013 SALES & MARKETING TERRITORY MANAGERS - VITAFLO We have two exciting and rewarding opportunities within our Sales Department for Sales & Marketing Territory Managers in the regions of Scotland and South London and the South East. Both field based positions are full time, permanent. Vitaflo specialise in the development and marketing of a range of clinical nutrition products for the dietary management of conditions such as inherited metabolic disorders, renal disease and products for the nutritional support of disease related malnutrition. The role will include responsibility for promoting and supporting the Vitaflo nutritional support product range to existing and new customers including dietitians, specialist nurses and consultants; developing relationships with key opinion leaders quickly and effectively; presenting to groups of health professionals, working at national conferences; identifying new opportunities to grow the business. Email your CV to pam. [email protected] or alternatively post to: Mrs Pam Beggs, Personnel Manager, Vitaflo International Ltd, Suite 1.11, South Harrington Building, 182 Sefton Street, Brunswick Business Park, Liverpool L3 4BQ. Closing date: 14th June 2013 SPECIALIST DIETITIAN - BAND 6 ST ANDREW’S HEALTHCARE £26,836.00 - £35,862.00 pro rata per annum, (dependent on experience). Part time, 15 hours per week Ref: WEB 2132. An exciting opportunity has arisen for a dietitian with excellent communication skills and self-motivation to join the dietetic team

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To place a job ad here and on www.dieteticJOBS.co.uk please call 0845 450 2125 (local rate) in St Andrew’s Healthcare Essex, a leading, not for profit, provider of in-patient psychiatric care. This role offers assessment, treatment, rehabilitation and longer term care for men of working and older age who present with needs related to their mental health, learning disability or autistic spectrum disorder within a secure forensic pathway. In order to apply, and view the job description and person specification please visit our website at www.stah.org/careers Closing date for applications: Sunday 16th June 2013 Band 6 Dietitian - Mental Health - London Band 6 full-time dietitian required to cover a position with experience in mental health, to start 3rd June for three months, Location: London. Car driver would be preferable. Call Hayley now for more information on the above position and other excellent roles we have available. Tel: 01277 849 649 or 0800 023 2275. Email: [email protected] Band 6/7 Dietitian - Clinical Paediatrics - Lancashire Band 6/7 full-time dietitian to start on 23rd June for three months, experience in clinical paediatrics. Location: Lancashire. Call Hayley now for more information on the above position and other excellent roles we have available. Tel: 01277 849 649 or 0800 023 2275. Email: [email protected] Band 6 Dietitian - Paediatric Diabetes Lancashire Band 6 dietitian to start asap for two to three days a week with a minimum of three months’ experience in paediatric diabetes. Car driver would be preferred. Location: Lancashire. Call Hayley now for more information on the above position and other excellent roles we have available. Tel: 01277 849 649 or 0800 023 2275. Email: [email protected] Locum Band 5/6 Dietitian - North West pay up to £26ph Band 5/6 Dietitian needed to start ASAP in a community nutritional support role. You will need to be a car user, due to the caseload being clinic and domiciliary work. Assistance with finding private accommodation can be provided. Duration: two months plus. For more information contact Daniel on 0207 749 8285 or [email protected]. Visit www.labmedrecruit.co.uk/dietitians Locum Band 6 Dietitian - East Midlands pay up to £28ph Community Dietitian required for an Adult/Paediatric role. The role is primarily Adults and requires a car driver due to the community setting. Experience in a wide range of dietetic facets is required, namely diabetes, gastrointestinal and obesity work. Accommodation is available and the post will be for around three months. For more information contact Daniel on 0207 749 8285 or dh@labmedrecruit. co.uk. Visit www.labmedrecruit.co.uk/dietitians

Locum Band 5 Dietitian - West Midlands - pay up to £24ph Our client in the West Midlands is looking for a Band 5 adult acute dietitian, to cover inpatient clinics and general wards. The role is to start ASAP, and is an ongoing post. Accommodation is available on site. For more information contact Daniel on 0207 749 8285 or [email protected]. Visit www.labmedrecruit.co.uk/dietitians Band 7 General Dietitian with Adult Inherited Metabolic disorders experience based in London Start date ASAP until the end of May. For this and similar jobs please contact Patrice on 0800 032 0454 or 020 8874 6111. Email your CV to [email protected] Our rates are competitive in the current market; we offer assistance with relocation and hospital accommodation. We provide you with a current CRB, full occupational health check and can organise your mandatory training. PJ Locums is an NHS Government Procurement and LPP framework approved supplier for Allied health, health science personnel and Nurses. Thank you for choosing PJ Locums. Community Food Worker We require a Band 3 Community Food Worker – London must have experience delivering practical cook & eat sessions. For this and similar jobs please contact Patrice on 0800 032 0454 or 020 8874 6111. Email your CV to [email protected] Band 7 Dietitian - Allergies We require a Band 7 Dietitian with allergies experience this post is based in London. For this and similar jobs please contact Patrice on 0800 032 0454 or 020 8874 6111. Email your CV to registration@ pjlocums.co.uk

EVENTS & COURSES Promoted events University of Nottingham School of Biosciences Modules for Dietitians and other Healthcare Professionals • Obesity Management – start 18.7.13 • Gastroenterology – start 12.9.13 For further details please email [email protected], tel: 0115 951 6238 or check out the University website at www.nottingham. ac.uk/biosciences and click on short courses then ‘for practising dietitians’. IPC 2013, International Scientific Conference on Probiotics and Prebiotics 11-13 June, Kosice, Slovakia, www.probiotic-conference.net

career

SPECIALIST DIETITIAN

Band 6, Salary: £25,783 - £34,530 pr pa 15 hpw, permanent Job reference No: 346-NYC-14-13

We urgently require dietitians for immediate vacancies s

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

s

Competitive rates

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

s

We offer inpatient and community UK & NI coverage

To find out your options call or email Freephone: 0800 032 0454 [email protected] www.pjlocums.co.uk

We are one of the largest specialist mental health and learning disabilities trusts in the country, with an annual income of £280m and a workforce of some 5,800 staff operating from over one hundred sites in Durham, Teesside and North Yorkshire. We provide a range of services to 1.6m people in addition to providing specialist services to other parts of Northern England. Are you interested in a career in the field of Child and Adolescent Eating Disorders? We are currently looking for an enthusiastic Registered Dietitian to join our team of Dietitians working within a specialist mental health and learning disabilities NHS Foundation Trust. This exciting post provides an opportunity to work with two Child and Adolescent Mental Health teams in Northallerton and Scarborough. Clinical areas will mainly include working with young people with eating disorders in a community setting as part of a multi-disciplinary team. The post holder will have the opportunity to participate in policy development, audit, research activities, pathway development, staff and student training. Candidates should be a registered Dietitian with significant postgraduate experience, preferably with some experience of working in a mental health and/or eating disorders setting. They should have excellent communication and IT skills. A working knowledge of motivational interviewing would be desirable. Regular clinical supervision with a Highly Specialist Dietitian will be provided and there will be a strong emphasis on Continued Professional Development and specialist training. For informal enquiries, please contact: Sue Dobinson, Highly Specialist Dietitian on (01423) 558200 or [email protected]

For more information and to apply visit www.nhsjobs.nhs.uk For more information about our Trust visit www.tewv.nhs.uk

Closing date: Interview date:

21 June 2013 10 July 2013

We are an equal opportunities employer and welcome applications from current and past service users.


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We’ve improved the No.1 high energy feed in the UK *

PER 100 ml

Kcal Protein g

GOS/ Fibre g FOS

Infatrini – the tried and trusted way to promote catch-up growth

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Ready to use 100ml and 200ml bottles and 500ml pack

s ./7WITHIMPROVED,#0RATIO!!$(! s .UCLEOTIDESSIMILARTOHUMANMILKLEVELS Infatrini is a Food for Special Medical Purposes for use under medical supervision, after full consideration of all the feeding options, including breastfeeding. Infatrini is a nutritionally complete, energy dense, ready to use feed for the dietary management of infants (from birth up to 18 months or 9kg in body weight) with faltering growth, or who have increased nutritional requirements and/or require fluid restriction.

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