Issue 91 February 2014NHDmag.com

bone health in galactosaemia

Dr Anita MacDonald & Pat Portnoi p15

obesity rePort

coeliAc DiseAse

DiAbetes

sPeciAl neeDs infAnt forMulAHelen ReamRegistered Dietitian

The hospiTal food journey in noTTingham. . . p25

ISSN 1756-9567 (Online)

dieteticJOBS • web watcH • New ReseaRcH

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NHDmag.com February 2014 - Issue 91 3

from the editor

chris rudd nHD editor

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

Did you get involved in the National Obe-sity Week from 13th to 19th January? Did you use the Pass or Fail cards and pres-ent these to supermarkets, depending on whether there was fruit or junk food at the checkout? It is predicted that by 2050 the cost of obesity to the NHS will be £49.9 billion. Last year 8,000 patients had bariatric surgery and it is estimated that two million more people in the UK would benefit from this procedure. There is real potential for dietitians to be pro-active and Hilda Mulrooney explains how in her article The ‘Measuring Up’ Obesity Report: op-portunities for dieti-tians to take the lead. Diabetes is a common lifelong health condition. There are three million people diag-nosed with diabetes in the UK and an estimated 850,000 people who have the condition, but do not know it. Read more on Diabetes: the invaluable dietetic advice from Mabel Blades. Our cover story is Bone Health in Galactosaemia by Dr Anita MacDonald and Pat Portnoi. This fascinating article

describes how to achieve optimal bone health for patients with galactosaemia and looks at the role that vitamin B12, vitamin C, potassium, magnesium and boron have in bone health. Want to know more about Special Needs Infant Formulas? If your answer is yes, then read Kate Harrod-Wild’s en-lightening article. Nutritional standards for food in hospitals is mentioned in Hilda’s ar-

ticle and Helen Ream tells us of her work with the Estates and Facilities section at Nottingham and her role in hospital food. Finally, may I encourage you to get involved

in the Nutrition and Hydration week, 17th to 24th March 2014? Together, let us raise the awareness and im-prove the understanding of the vi-tal importance of good nutrition and hydration. I am hoping for the larg-est ever Afternoon Tea to be held in Sheffield Care Homes on Wednesday 19th March - what are you hoping for? Enjoy the first digest-sized NHD!

Welcome to our new style NHD Magazine. We hope that you will like this digest format and please look out for some other radical innovations including the new nhD app which is now available on itunes and google Play app stores.

editor chris Rudd RDFeatures editor Ursula arens RDDesign Heather Dewhurstsales Richard Mair richard@networkhealthgroup.co.ukPublisher Geoff weatePublishing assistant Lisa Jackson

address suite 1 Freshfield Hall, the square, Lewes Road, Forest Row, east sussex RH18 5esPhone 0845 450 2125 (local call rate)Fax 0870 762 3713 email info@networkhealthgroup.co.uk www.nhDmag.com

www.dieteticJobs.co.uk

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

@nhDmagazine

Together, let us raise the awareness and improve the understanding of the vital

importance of good nutrition and hydration.

4 NHDmag.com February 2014 - Issue 91

chris ruddDietetic advisor sheffield Pct Medicines Management team

neil DonnellyFellow of the bDa Retired Dietetic services Manager

ursula Arenswriter, Nutrition & Dietetics

Dr carrie ruxtonFreelance Dietitian

Dr Anita MacDonaldconsultant Dietitian in IMD, birmingham children’s Hospital

Kate Harrod-Wildspecialist Paediatric Dietitian betsi cadwaladr University Health board, North wales

Pat PortnoiDietitian, Register coordinator, GsG

Dr Hilda MulrooneyRegistered Dietitian and Nutritionist

Helen reamRegistered Dietitian Nottingham University Hospitals NHs trust

emma coatessenior Paediatric Dietitian wrexham Maelor Hospital

Dr Mabel bladesIndependent Freelance Dietitian and Nutritionist

catherine blaikleyspecialist Prescribing support Dietitian berkshire Healthcare Foundation trust

sue HurrellDietetic support worker (Dsw) cumbria Partnership NHs Foundation trust

6 News

7 News / product news

9 Obesity report

20 FDF: food labelling report

22 Coeliac disease

25 Hospital food

29 Diabetes

32 Oral nutritional supplements

35 Special needs infant formula

39 Web watch

41 Career: The role of a dietetic support worker

43 dieteticJOBS

45 Events and courses

46 Neil’s column

15 cover storyBone health in galactosaemia

contents

editorial Panel

50years~"" brecstrmlkresearch

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NHDmag.com February 2014 - Issue 916

Dr carrie ruxton PhD, rD freelance Dietitian

neWs

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.nutrition- communications.com

@drcarrieruxton

vitamin D anD tyPe 2 Diabetes riskSerum vitamin D levels have been linked with reduced Type 2 diabetes mellitus risk. However, until recently, this has not been related to specific food sources. The European Prospective Investigation into Cancer and Nutrition (EPIC) Study mea-sured dietary vitamin D intakes in a subsample of cases with Type 2 diabetes (n=2,347), comparing these intakes with data from adult controls taking part in a cohort study. Dietary vitamin D intakes were not significantly associated with Type 2 diabetes risk, possibly because dietary vitamin D contributes only around 10 percent of total vitamin D status, with sun exposure contributing to the rest. Further research is now needed to consider the combined effects of vitamin D from dietary and supplement sources as well as sunlight. For information see: Abbas S et al (2013). European Journal of Clinical Nutrition [Epub ahead of print] www.ncbi.nlm.nih.gov/pubmed/24253760

latest on caFFeineIncreasingly, caffeine is available from drink products, raising questions about ‘how much’ is appropriate for children. A new systematic review paper pub-lished in the Journal of Human Nutri-tion and Dietetics considers this issue. The review pooled data from 11 randomised controlled trials and 13 observational studies, finding that high caffeine intakes (e.g. >5mg kg–1 body weight day–1) were associated with an increased risk of anxiety and withdrawal symptoms. However, smaller amounts were not linked with such effects and may even benefit cog-nitive (mental) function and sports performance, as demonstrated in adult studies. On the whole, evidence indicates that children and teenagers should limit daily caffeine consumption to 2.5mg kg–1 body weight day–1, the equivalent to one to two cups of tea or one small cup of coffee. Lower con-tributors of caffeine, such as tea (44mg to 50mg caffeine/serving), may be more appropriate for children as they represent a sugar-free source of fluid and provide flavonoids which may of-fer health benefits. For more information see: Rux-ton CHS (2013). Journal of Human Nutrition & Dietetics [Epub ahead of print] http://onlinelibrary.wiley.com/doi/10.1111/jhn.12172/abstract

telePhone suPPort Works For breastFeeDingObese women often have difficulties breastfeeding, i.e. milk production can be lower and infants may not at-tach as easily.

A new study recruited 226 mother-baby pairs and randomised these to re-ceive telephone support or standard care over six months to see if this could help to increase the dura-tion of breastfeeding. The group receiving tele-phone support breastfed

their babies exclusively for significant-ly longer (120 days) compared with an average of 41 days in the control group receiving standard care. The duration of exclusive breastfeeding was also as-sociated with reduced infant weight and length at six months, but breast-feeding support did not appear to af-fect infant growth. Overall, telephone support was very effective in prolonging the time spent breastfeeding amongst older mothers. Given the success of this approach, telephone support could also be used for other circumstances, such as weight management or diabetes care. For more information see: Carlsen EM et al (2013). American Journal of Clinical Nutrition 98: 1226-32. www.ncbi.nlm.nih.gov/pubmed/24004897

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asPartame sensitivity FounD to be a mythA double blind randomised crossover study de-signed to test aspartame safety was commissioned by the Food Standards Agency and peer reviewed by the Committee on Toxicity of Chemicals in Food, Consumer products and the Environment (COT). The study recruited participants who reported reactions after consuming aspartame, alongside con-trols who normally consumed foods containing as-partame without problems. Participants were asked to eat a snack bar containing (or without) aspartame and any side-effects were reported. Based on the findings of this study (yet to be published in the public domain), the COT concluded that ‘results presented did not indicate any need for action to protect the health of the public’, concluding that aspartame as a food sweetener appeared to be safe. Additionally, the European Food Safety Author-ity (EFSA) re-examined evidence on aspartame, re-porting that current intakes, i.e. an Acceptable Daily Intake of 40mg per kg of body weight appeared to be safe. Presently, this is the most rigorous review of available research related to aspartame. Interestingly, in this report, it was also mentioned that the rapid breakdown of aspartame into phenyla-lanine, aspartic acid and methanol is what appears to reduce the risk of health concerns - these components are all naturally present in many other foods and are safe at current levels of intake. More information:• Food Standards Agency (2013). COT position pa-

per on aspartame study published. Available at: www.food.gov.uk/news-updates/news/2013/dec/aspartame#.UsaYvNJdWil

• European Food Safety Authority (2013). EFSA completes full risk assessment on aspartame and concludes it is safe at current levels of exposure. Available at: www.efsa.europa.eu/en/press/news/131210.htm

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NHDmag.com February 2014 - Issue 91 9

There are 10 recommendations, divided into three distinct sections. While many of these recommendations have been made before or elsewhere, it is interest-ing to reflect upon where we as dietitians may fit in with them: what is our role in the obesity landscape and where are we as a profession, where should we be? Each recommendation, and thoughts on our potential role, is listed below.

1. action by healthcare professionsEducation and training programmes for healthcare professionals: Many di-etitians are already involved in training other healthcare professionals; this is a fundamental part of what we do. By involving ourselves in training, we both ensure that the role of dietitians remains highly visible and that evidence-based coherent messages are given to patients. Part of this should, in my view, involve periodic auditing so that training needs of other staff are regularly assessed, also ensuring that messages to patients re-main focused and up to date. The issue of healthcare professionals with weight problems themselves, should not be shied away from; we should act as role models to our patients in terms of our

health-related behaviours. The fact that many health staff themselves suffer from overweight or obesity demonstrates both the complexity and the difficulty of managing weight. It would be ideal if nutrition became part of the training that all staff new to the NHS receive, as well as part of annual updates – there remains a possibility that all staff may make opportunistic brief interventions with relation to weight and healthy life-styles and they should be equipped to do so.

Weight management services: Again, the role of the dietitian is fundamental in this, but most would agree that weight management services should be part of a care pathway with clear integra-tion of services, support for those who need it and a stepwise approach to care. Whilst dietitians should be involved in all levels of such a pathway, specialist dietetic skills may be restricted to the middle to upper tiers, i.e. those patients who have tried and failed with com-munity based programmes (commercial or NHS), those with complex needs or those with more extreme levels of obe-sity. The role of the dietitian in the lower

the ‘meASuring uP’ obeSity rePort: oPPortunitieS for dietitiAnS to tAke the leAd

Dr Hilda Mulrooneyregistered Dietitian and nutritionist,Kingston university and committee Member of DoM uK

dr mulrooney is a Senior lecturer in nutrition in the School of life Sciences at kingston university. She is a member of the bdA and the nutrition Society. Since 2006 she has been an active Committee member of dietitians in obesity management uk (dom uk), a special interest group of the bdA.

the academy of medical royal colleges (aomrc) released their long-anticipated report on obesity in Parliament in 2013. ‘measuring up: the medical Profession’s Prescription for the nation’s obesity crisis’ represents the work of the aomrc obesity steering group, which carried out a wide-ranging evidence-gathering exercise to form its views. both Dietitians in obesity management uk (Dom uk) and the british Dietetic association (bDa) submitted detailed evidence. the report marks both the end of the group’s investigations, and the start of a campaign (2).

obesity rePort

MEASURING UPTHE MEDICAL PROFESSION'S PRESCRIPTION FOR THE NATION'S OBESITY CRISIS

FEBRUARY 2013

NHDmag.com February 2014 - Issue 9110

parts of the tier would be indirect, e.g. training those providing community services, ensuring cohesive follow-up of those referred to com-mercial weight management programmes and - via public health - overseeing the provision and outcomes of community programmes, pos-sibly by decommissioning and commissioning as necessary.

Nutritional standards for food in hospitals: In-creasingly and unfortunately, dietitians have been edged out of this area, the focus being on celebrity chefs and new menus. Dietitians have long advocated improvements to hos-pital menus; the BDA Toolkit relating to this area was recently updated and re-launched (3). This Toolkit is focused on issues related to un-dernutrition, but also states that obese patients need to be considered, because many of these patients are sub-optimally nourished. The role of dietitians in this area remains fundamental, as does our role in training catering and ward staff. In addition, the issue of healthy meals for staff in hospitals should not be forgotten.

Increasing support for new parents: It is ironic that parenting, one of the most important jobs in our lives, is perhaps one for which there is least preparation. Early parenting is a time of being very receptive to health education issues and many of the behaviours we seek to encourage (breastfeeding, regular mealtimes, being active as a family) benefit from guidance at this time. A family-focused approach to managing child-hood obesity is advocated (5,1,4). The role of the dietitian as part of this agenda is likely to be indirect - supporting frontline staff like health visitors and midwives through regular training and encouraging audits of practice. This is an area where mixed messages abound and, in my view, the greatest service the dietitian can do, is to support other frontline staff with correct information and nutritional advice.

2. The obesogenic environmentNutritional standards in schools: DOM UK and the BDA both called for the extension of manda-tory standards to independent schools and acad-emies. The current Government aim of increas-ing the numbers of academies, which are exempt from legal nutrient-based standards, represents a real risk of negating the years of work which went into getting school food recognised as a key priority. Sadly, much of the excellent dietetic work directly with schools, has either reduced or stopped as a result of cutbacks. Our role now may best be one of advocacy, ensuring that school meals remain a public health topic.

Fast food outlets (FFO) near schools: Dietitians working in Public Health may already be in-volved in this area through their work with Lo-cal Authorities. While FFO are highly visible and accessible signs of the obesogenic environ-ment, there are limits to what legislation alone can achieve. However, legislation gives a clear indication of where priorities lie and the voice of the dietetic profession could be used to advo-cate further work in this area, including explor-ing the effects of banning FFO close to schools. In my view, this approach should work hand-in-hand with a Healthy Schools approach, so that children are given messages about health within the context of a healthier environment.

Junk food advertising: It would be useful to get robust data on the extent to which the current limits on junk food and drink advertising to chil-dren have affected food choice. Many children watch TV programmes not specifically aimed at them, or beyond the 9pm watershed covered by the Ofcom regulations. The effects of laws with relation to television advertising may be limited, especially given the ubiquitous nature of online access for children and adults, none of which is subject to the same regulations as television ad-vertising. It is difficult to imagine how that situ-

obesity rePort

It is ironic that parenting, one of the most important jobs in our lives, is perhaps one for which there is least preparation.

NHDmag.com February 2014 - Issue 91 11

ation can be changed - even pan-European ap-proaches are unlikely to be sufficient.

3. Making the healthy choice the easy choiceHigh sugar drinks tax: While many dietitians may feel that a tax on sugary drinks can only be a good thing, there are differing views on this issue. Sug-ary drinks have been implicated in the develop-ment of obesity, particularly in children. Unlike foods containing fat which may supply additional important nutrients, sugary drinks are not likely to be needed to achieve adequate energy or carbo-hydrate intakes. It is not clear to what extent such a tax would impact on sugary drink consumption and the argument that those with least money to spend would be disproportionately targeted by taxes, remains valid. In addition, the tax would only be beneficial if sugary drink consumption fell significantly and the revenue raised went to support weight management (such as improving the built environment, increasing access to weight management services or reducing the prices of healthier food options). The extent to which con-sumption of sugary drinks would be affected by increased price is not clear, nor is the extent of the tax that would be required to act as a deterrent to intake. Nor should the determination of the drinks industry to oppose such a move be under-estimated - many may have seen the 2013 ads on national television by a leading soft drinks com-pany, seeking to gain the moral high ground in the obesity debate.

Food labelling: It is an important role of dieti-tians to help consumers understand nutrition

information presented on food labelling and most support consistent front of pack (FoP) labelling, based on a combination of colour coded ‘traffic light’, text and Guideline Daily Amounts, shown to be the preferred option of consumers. However, it is unlikely that as a sole mea-sure this will be enough. Not all food-related decisions are made rationale, and the issue of food choices is complex. Calorie labelling on restaurant menus is not welcomed by all, but is unlikely to be harmful and, for some peo-ple, may be enough to encourage change.

The built environment: The need for a healthi-er environment, making healthy choices more palatable, has been a staple item in public health reports in recent years. It is not im-mediately clear where dietitians fit into this debate; although two options spring to mind. Firstly, those dietitians working in a public health capacity can support measures that encourage physical activity, such as access to green spaces and adequate lighting in public areas. Secondly, what we would advise our patients and colleagues we can all do our-selves, e.g. using the stairs rather than the lift, or walking at break times. The ‘Measuring Up’ report on obesity is welcome and timely and there is much in it with which we may agree. Where we go from here, is up to us as a profession. All of the views expressed here are the author’s own: none reflect the views of either DOM UK or the DOM UK Committee.

obesity rePort

uk.com/publications/NutritionHydrationDigest.pdf4 National Institute of Health & clinical excellence (2006). Obesity: Guidance on the Prevention, Identification, assessment & Management of Overweight &

Obesity in adults and children. clinical Guideline 43. england: NIce5 scottish Intercollegiate Guidelines Network (2010). Management of Obesity. a National clinical Guideline. Guideline 115. sIGN: edinburgh. available from:

www.sign.ac.uk

High sugar drinks tax: While many dietitians may feel that a tax on sugary drinks can only be a good

thing, there are differing views on this issue.

References1 american Dietetic association (2009). Position of the american Dietetic association: weight Management. JaDa 109: 330-3462 association of Medical Royal colleges (2013). Measuring Up: the Medical Profession’s Prescription for the Nation’s Obesity crisis. aoMRc: London3 british Dietetic association (2012). the Nutrition & Hydration Digest: Improving Outcomes through Food and beverage services. available from: /www.bda.

Up to 6 months

From6 months

IMPORTANT NOTICE: Breastfeeding is best for babies. The decision to discontinue breastfeeding may be difficult to reverse and the introduction of partial bottle-feeding may reduce breast milk supply. The financial benefits of breastfeeding should be considered before bottle-feeding is initiated. Failure to follow preparation instructions carefully may be harmful to a baby’s health. Parents should always be advised by an independent healthcare professional regarding infant feeding. Products of Mead Johnson must be used under medical supervision. EU 11.564. *Trademark of Mead Johnson & Company. LLC. © 2013 Mead Johnson and Company. LLC. All rights reserved.

70 years. 70 studies.Only Nutramigen.

Breastfeeding is best for babies. The decision to discontinue breastfeeding may be difficult to reverse and the introduction of partial bottle-feeding may reduce breast milk supply. The financial benefits of breastfeeding should be considered before bottle-feeding is initiated.

References: 1. Dupont C et al. Br J Nutr 2011:1–14. 2. Canani R et al. J Allergy Clin Immunol 2012; 129:580–582. 3. Lothe L, Lindberg T. Pediatrics 1989; 83:262–266. 4. Koletzko S et al. J Pediatr Gastroenterol Nutr 2012; 55(2):221–229.

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From6 months

IMPORTANT NOTICE: Breastfeeding is best for babies. The decision to discontinue breastfeeding may be difficult to reverse and the introduction of partial bottle-feeding may reduce breast milk supply. The financial benefits of breastfeeding should be considered before bottle-feeding is initiated. Failure to follow preparation instructions carefully may be harmful to a baby’s health. Parents should always be advised by an independent healthcare professional regarding infant feeding. Products of Mead Johnson must be used under medical supervision. EU 11.564. *Trademark of Mead Johnson & Company. LLC. © 2013 Mead Johnson and Company. LLC. All rights reserved.

70 years. 70 studies.Only Nutramigen.

Breastfeeding is best for babies. The decision to discontinue breastfeeding may be difficult to reverse and the introduction of partial bottle-feeding may reduce breast milk supply. The financial benefits of breastfeeding should be considered before bottle-feeding is initiated.

References: 1. Dupont C et al. Br J Nutr 2011:1–14. 2. Canani R et al. J Allergy Clin Immunol 2012; 129:580–582. 3. Lothe L, Lindberg T. Pediatrics 1989; 83:262–266. 4. Koletzko S et al. J Pediatr Gastroenterol Nutr 2012; 55(2):221–229.

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NHDmag.com February 2014 - Issue 91 15

WHAt is gAlActosAeMiA?Classical galactosaemia is an autosomal recessive disorder of galactose metabo-lism caused by a deficiency of the enzyme galactose-1-phosphate uridyl transferase, the enzyme that converts galactose-1-phosphate to uridine-diphosphate (UDP)-galactose. The incidence in Western Eu-rope has been estimated to be between one per 40,000 to 50,000. The only therapy for patients with galactosaemia is a galac-tose restricted diet. Most patients present in the neonatal period, after ingestion of galactose, with severe liver dysfunction, jaundice and coagulation disturbances. Formation of cataracts is common. Long-term complications include low IQ, mo-tor abnormalities, primary ovarian insuf-ficiency, verbal dyspraxia and a decrease in bone mineral density.

WHAt Age grouPs Are AffecteD by loW bone MinerAl Density in gAlActosAeMiA? Bone mass is decreased in young chil-dren (8,11,15). It is evident in both males and females and bone loss is common in adults (1). In one study of adult patients (n=33) with galactosaemia, over half the women and almost one third of men had sustained at least one lifetime fracture (1). They found more women than men had a bone mineral density z score below <-2 (33 vs 8% for spine; 27 vs 6% for the hip (1) (a definition of osteoporosis is a bone

mineral content or bone mineral density that is more than -2.5 SD below the young adult mean for the population [18]).

bone MetAbolisMBone metabolism is a complex pro-cess involving constant bone remod-elling for the purpose of maintaining bone integrity. It occurs throughout life. During bone remodelling, bone resorption by osteoclasts is followed by osteoblasts laying down new bone; a process which is completed in three to six months (11). This process relies on complex signalling pathways in-cluding parathyroid hormone (PTH), vitamin D, growth hormone, steroids and calcitonin. During bone forma-tion, osteoblasts produce bone matrix proteins such as collagen. Osteoblasts produce non collagen proteins like bone specific alkaline phosphatase and osteocalcin.

cAuses of loW bone MinerAl Density in gAlActosAeMiAThe pathophysiologic mechanisms underlying skeletal losses in patients with classic galactosaemia are not well understood, but they include:1. a lifelong low lactose diet with a

consequential low consumption of calcium and vitamin D;

2. primary ovarian insufficiency in women (4,8,15);

bone heAlth in gAlACtoSAemiA

Anita MacDonald consultant Dietitian in iMD, birmingham children’s Hospital

and

Pat Portnoi, Dietitian, register coordinator, galactosaemia support group (gsg)

One of the UK’s top paediatric dietitians, anita’s specialism lies with inherited metabolic disorders. she spends 50 percent of her professional time in clinical work with children and 50 percent researching and teaching.

the galactosaemia support group (gsg) has recently published a new guide on calcium and galactosaemia for their families. this is available through the support group (email: sue@galactosaemia.org or write to GSG, 31 Cotysmore Road, Sutton Coldfield, West Midlands B75 6BJ). in galactosaemia, low bone mineral density is a common complication (1, 11, 8, 15), and hence the necessity to produce this dietary aid.

iMD

Galactosaemia Support Group

www.galactosaemia.org

This leaflet has been written with the help of Anita MacDonald (Head of Dietetic Services,

Birmingham Children’s Hospital) and Pat Portnoi (GSG Dietitian).

NHDmag.com February 2014 - Issue 9116

iMD

3. an increase in bone turnover from child-hood to adolescence with a possible im-balance between bone resorption and bone formation processes (5);

4. abnormal collagen formation due to deficient galactose residues needed for normal bone formation and mineralisation processes (8).

iMProving bone MinerAl DensityIn galactosaemia, to enhance bone mineral con-tent, it is important to optimise nutritional intake, physical activity and oestrogen supplementation (4). Calcium, phosphate, and vitamin D intake are particularly involved in healthy bone, but various other nutrients have been identified as integral to the development, physiology and maintenance of bone. Although selective intervention studies are needed to establish their respective roles in the maintenance of bone mass, evidence exists for zinc, copper, manganese, boron, vitamin A, vitamin C, vitamin K, the B vitamins, sodium, phosphorus, magnesium, potassium and vitamin B12. (6,13). Therefore, in addition to lactose-free calcium rich foods, it is important that patients with galactosae-mia eat a wide range of foods, particularly fruits and vegetables to ensure that they are receiving adequate sources of all nutrients involved in bone health. If dietary intake is poor, it may be necessary

to consider supplementation with a comprehen-sive vitamin and mineral supplement. Calcium: Calcium intake, turnover and absorp-tion and excretion rates determine the availability of calcium for bone growth and development (13). Unfortunately, dietary calcium intake is commonly low in galactosaemia (8,10,16). Wherever possible, calcium requirements should be achieved by eating foods and drinks high in calcium. Some non-dairy foods contain an appreciable amount of calcium. Calcium bioavailability can be an issue if the prima-ry sources of calcium are from plants and typical cal-cium absorption is low from foods containing high concentrations of oxalate and phytate. Low lactose cheese, sardines, mackerel, sesame seeds, lentils are very useful dietary sources. Calcium fortified foods include soya drinks (120-140mg/100ml), dairy -free yoghurts, calcium fortified breads and juices. If cal-cium intake remains low, it will be necessary to give calcium supplements, preferably co-administered with vitamin D and given in more than one dose per day (Table 1). Adherence with calcium supple-mentation may be poor. Vitamin D: This is essential for calcium uptake and bone remodelling. Vitamin D enhances calci-um absorption by stimulating active transport in the gut. Additionally, vitamin D works with the PTH to enhance renal calcium absorption. Osteo-

NHDmag.com February 2014 - Issue 91 17

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nutrient bone health role

vitamin b12elevated homocysteine concentrations and low vitamin b12 status are strongly associated with lower bone mass and higher fracture risk in the elderly (17).

vitamin c

vitamin c is essential for the formation of collagen and for fracture healing. the evidence for supplemental vitamin c in the management of osteoporosis is weak, but increased bone mineral density has been observed in postmenopausal women taking vitamin c supplements (14).

Potassium

this affects bone calcium homeostasis via urinary calcium losses. A low potassium diet causes elevated urine calcium (13). serum potassium has been shown to have a positive correlation with bone mineral density in postmenopausal women (7).

Magnesium

this is found in the skeleton and is involved with the production of PtH and thus indirectly affects bone metabolism. A specific role of magnesium in the maintenance of bone is still to be established (18). Dietary sources of magnesium include almonds, cashew nuts, peanuts, brown rice, kidney beans, black eyed peas and lentils.

boronthe precise mechanism of the action of boron in bone health is unknown, but boron stabilises and extends the half life of vitamin D and oestrogen (14). Dietary sources include prunes, raisins, dried apricots and avocado.

table 1: function of nutrients

Presentationavailable

calcium mgvitamin D µg

Adcal–D3 (Prostrakan) calcium carbonate chewable tablet/ effervescent tablets

tablet 600 10

cacit-D3 (Proctor and gam-ble Pharm) calcium carbonate granules

sachet 500 11

calceos (galem) calcium carbonate chewable tablet

tablet 500 10

calcichew D 3 (shire) calcium carbonate chewable tablet

tablet 500 5

calcichew D 3 forte(shire) calcium carbonate chewable tablet

tablet 500 10

natecal D3 (chiesi) calcium carbonate chewable tablet

tablet 600 10

sandocal +D 600 (novartis) effervescent (calcium lactate gluconate, calcium carbon-ate) effervescent tablet

tablet 600 10

table 2: suitable calcium preparations in galactosaemia

NHDmag.com February 2014 - Issue 9118

clast formation, differentiation and bone resorp-tion are also stimulated by vitamin D (6). Vitamin K: This acts as a co-factor in the car-boxylation of osteocalcin which has a regulatory role in the mineralisation and remodelling of bone (15). Some studies suggest that vitamin K insuffi-ciency is associated with low bone mineral density and increased fractures (3). In a group of children and teenagers with galactosaemia, a combination of calcium (750mg/day), vitamin K (1.0µg/day) and vitamin D3 (10µg/day) significantly improved bone formation markers and bone mineral content (12). Some now advocate vitamin K in addition to calcium and vitamin D in galactosaemia (2). Useful dietary sources of vitamin K include fresh spinach, Brussels sprouts, iceberg lettuce and prunes. Zinc: Bone specific alkaline phosphatase and osteocalcin are zinc dependent (11). Thirty percent of the zinc that is stored in the body is found in bone. Zinc deficiency is associated with reduced bone mass and stunted growth and zinc

supplementation has been shown to be beneficial in bone health when given to postmenopausal women with a low zinc intake (9). Phosphorus: This is required for the appro-priate mineralisation of the skeleton and a deple-tion of serum phosphate leads to impaired bone mineralisation and compromised osteoblast function (13). Phosphorus intake should be ad-equate in patients with galactosaemia (10).

suMMAryAchieving optimal bone health is essential for pa-tients with galactosaemia as poor bone mineral den-sity is commonly reported. Even though conclusive evidence to support benefit of supplementation is still to be determined for some nutrients, there is some evidence to suggest that many nutrients play an interactive role in bone health. It is therefore important in galactosaemia, to not only monitor calcium intake and vitamin D, but to encourage a healthy diet that provides good quality nutrition.

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References1 batey La, welt cK, Rohr F, wessel a, anastasoaie V, Feldman Ha, Guo cY, Rubio-Gozalbo e, berry G, Gordon cM. skeletal health in adult patients with classic

galactosaemia. Osteoporos Int. 2012 apr 192 berry Gt, walter JH. Disorders of Galactose Metabolism. In saudurbray J-M, van den berghe G, walter JH (eds). Inborn Metabolic Diseases Diagnosis and

treatment. berlin: springer-Verlag, 2012, p141-1493 bügel s. Vitamin K and bone health in adult humans. Vitam Horm. 2008, 78:393-416.2008;78:393-4164 Fridovich-Keil JL, walter JH. Galactosaemia. In: Valle D, beaudet aL, Vogelstein b, Kinzler Kw, antonarakis se, ballabio a (eds) scriver cR, childs b, sly w

(emeritus eds) the Online Metabolic and Molecular bases of Inherited Disease. New York: McGraw-Hill, 2008, p1-645 Gajewska J, ambroszkiewicz J, Radomyska b, chełchowska M, Ołtarzewski M, Laskowska-Klita t, Milanowski a. serum markers of bone turnover in children and

adolescents with classic galactosaemia. adv Med sci. 2008, 53: 214-206 Heaney RP. Dairy and bone health. J am coll Nutr. 2009, 28: suppl 1:82s-90s7 Liu sZ, Yan H, Xu P, Li JP, Zhuang GH, Zhu bF, Lu sM. correlation analysis between bone mineral density and serum element contents of postmenopausal women

in Xi’an urban area. biol trace elem Res. 2009, 131: 205-148 Kaufman FR, Loro ML, azen c, wenz e, Gilsanz V. effect of hypogonadism and deficient calcium intake on bone density in patients with galactosaemia. J Pediatr.

1993, 123: 365-709 Nielsen FH, Lukaski Hc, Johnson LK, Roughead ZK. Reported zinc, but not copper, intakes influence whole-body bone density, mineral content and t score

responses to zinc and copper supplementation in healthy postmenopausal women. br J Nutr. 2011, 106: 1872-910 MacDonald a. calcium and Galactosaemia. a compilation of papers presented at the 2nd Dietitians’ meeting at the society for study of Inborn errors of Metabolism.

Gothenburg, sweden 1997 p2-611 Panis b, Forget PP, van Kroonenburgh MJ, Vermeer c, Menheere PP, Nieman FH, Rubio-Gozalbo Me. bone metabolism in galactosaemia. bone, 2004, 35 982-712 Panis b, Vermeer c, van Kroonenburgh MJ, Nieman FH, Menheere PP, spaapen LJ, Rubio-Gozalbo Me. effect of calcium, vitamins K1 and D3 on bone in

galactosaemia. bone. 2006, 39: 1123-913 Prentice a. Diet, nutrition and the prevention of osteoporosis. Public Health Nutr. 2004, 7: 227-4314 Price ct, Langford JR, Liporace Fa. essential nutrients for bone health and a review of their availability in the average North american diet. Open Orthop J. 2012,

6:143-915 Rubio-Gozalbo Me, Hamming s, van Kroonenburgh MJ, bakker Ja, Vermeer c, Forget PP. bone mineral density in patients with classic galactosaemia. arch Dis

childh, 2002, 87 57-60.16 Rutherford PJ, Davidson Dc, Matthai sM. Dietary calcium in galactosaemia. J Hum Nutr Diet, 2002, 15 39-4217 van wijngaarden JP, Dhonukshe-Rutten Ra, van schoor NM, van der Velde N, swart KM, enneman aw, van Dijk sc, brouwer-brolsma eM, Zillikens Mc, van

Meurs Jb, brug J, Uitterlinden aG, Lips P, de Groot Lc. Rationale and design of the b-PROOF study, a randomised controlled trial on the effect of supplemental intake of vitamin b12 and folic acid on fracture incidence. bMc Geriatr. 2011, 11:80

18 world Health organisation. Prevention and Management of Osteoporosis. Report of a wHO scientific Group. 2003, wHO technical Report series 921

Even though conclusive evidence to support benefit of supplementation is still to be determined for some nutrients, there is some evidence to suggest that many nutrients play an interactive role in bone health.

Are you sure UK toddlers

are getting enough vitamin D?

www.in-practice.co.uk

The Reference Nutrient Intake (RNI) for toddlers 1-3 years of age is 7µg per day. The average UK toddler is only getting 27% of this from their current diet1.1. Bates B, et al. National Diet and Nutrition Survey: Headline results from Years 1 and 2 (combined) of the Rolling Programme: London: HMSO, 2010.

COW-14-118 Network Health Diet 223x160.indd 1 09/01/2014 17:51

NHDmag.com February 2014 - Issue 9120

Delegates were polled by FDF at Nu-trition & Health Live 2013, a leading conference for HCPs held in London in November. Ninety-eight percent of those polled agreed that food and drink labels can be a useful tool to encourage healthier eating (5). Of the practising HCPs polled, 64 percent re-sponded that they always talk to pa-tients about how to use labels to make healthier choices, with a further 34 percent doing so often or occasionally. The new resource, ‘Food and drink labelling: a tool to encourage healthier eating’, provides a breakdown of forth-coming changes to nutrition, allergen and ingredient labelling. The resource, which also offers tips for HCPs on the best ways of communicating this in-formation to patients, was developed

with Registered Dietitian Nigel Denby, Head of Nutrition at www.Grub4Life.com (6) Nigel said, “I am delighted that FDF has produced this resource to help HCPs to be able to explain nutrition labelling to our patients. It is invaluable in helping them check the calories, fat, sugars and salt in a food at a glance and compare similar products. Good labelling will also provide information on, say, any al-lergens contained within a product. The more patients compare products before they buy, the more they become aware of what’s in the food they’re eating. All of this is need-to-know information for our patients.”

fdf: hCPS’ role in CommuniCAting ChAngeS to food lAbelS iS VitAl

labels on all pre-packaged food and drinks are changing due to a new european regulation (1) and healthcare professionals (hcPs) have a vital role to play in helping people to adapt to these changes. in advance of December 2014, the deadline for the introduction of most of the changes (2), the Food and Drink Federation (FDF), the voice of uk food and drink manufacturers (3), has launched a new, free resource (4) for hcPs which explains these changes.

neWs feAture

References1 the ‘eU Regulation 1169/2011 on the provision of food information to consumers’, commonly referred to as the ‘Food Information

to consumers Regulation’2 Key changes that people will begin to see on pack include the use of the term ‘Reference Intakes’ which will replace ‘Guideline

Daily amount’; allergens will be more clearly indicated in the ingredients list and mandatory nutrition labelling will appear on most products. this nutrition information will be provided (on a per 100g basis) for energy (both in kilojoules and kilocalories), fat, saturated fat, carbohydrate, sugars, protein and salt (in that order)

3 the Food and Drink Federation (FDF) is the voice of the food and drink manufacturing industry - the UK’s largest manufacturing sector. www.fdf.org.uk

4 the new resource ‘Food and drink labelling: a tool to encourage healthier eating’ is free to download. to request free copies of the guide, contact FDF tel: 0207 420 7118. email: anna.taylor@fdf.org.uk

5 FDF polled 100 delegates at the Nutrition & Health Live 2013 conference, an event primarily attended by nutritionists, dietitians, practice nurses and other health workers. Fifty-five percent of respondents are currently practising HcPs; the remainder is made up of student nutritionists and dietitians, as well as others in academia and industry with an interest in nutrition

6 www.Grub4Life.com is an online community offering advice and news updates on early-years nutrition

Food and drink labelling:A tool to encourage healthier eating

A resource for healthcare professionals

The Food and Drink Federation 1913 - 2013

www.in-practice.co.uk

1. Children between the ages of 6 months to 5 years receiving less than 500ml of infant milk formula each day should take a daily supplement containing vitamin D to help them to meet the requirement set for this age group (at least 7µg per day). Letter from UK Chief Medical Officers.

Available at https://www.gov.uk/government/publications/vitamin-d-advice-on-supplements-for-at-risk-groups [Accessed January 2014].

2 x 150ml beakers of Cow & Gate Growing Up Milk provides 9.3 µg of Vitamin D.

sure with Cow & GateGrowing Up Milk

Now you can be

Redeveloped in consultation with UK healthcare professionals, it now provides at least 100% of a toddler’s daily dietary vitamin D need

With just 2 x 150ml beakers each day as part of a healthy, balanced diet

Provides other essential hard-to-get nutrients including iron and omega 3

New Cow and Gate Growing Up Milk helps parents meet the Chief Medical Officers’ guidelines for vitamin D intake1

New Formulation

COW-14-118 Network Health Diet 223x160.indd 2 09/01/2014 17:51

NHDmag.com February 2014 - Issue 9122

Our paediatric patients are encouraged to continue to attend the adult dietitian-led coeliac clinics once they reach the transition age of 16. The clinics provide annual reviews for established coeliac patients and regular reviews for newly diagnosed patients during their first year of diagnosis. These clinics also offer protected time for coeliac patients with additional health issues such as Type 1 diabetes, faltering growth and other allergies/intolerances to discuss their GF diet. The clinics also offer support and management for coeliac patients as described in the recently updated BSPGHAN and Coeliac UK guidelines for the diagnosis and management of coeliac disease in children (2). Our paediatric dietitian-led clinic is held every two months. The clinic is organised and co-ordinated by the dieti-tian. For example, annual review blood tests and additional blood tests, e.g. se-rum ferritin and FBC post supplemen-tation, are ordered by the dietitian in time for the clinic appointments. Each paediatric coeliac patient has a named paediatrician and they will be reviewed annually within the paediatrician’s clin-ic or sooner if concerns are raised within the dietitian-led coeliac clinics. A Coeli-ac UK or GF company representative is also invited to hold a stand at the clinic, which offers patients and their parents/carers further opportunities to discuss their GF diet and ask any questions.

initiAl AssessMentOur paediatric coeliac patients are usual-ly seen within two to three weeks of their diagnosis and the GF diet is discussed along with the additional issues this can arise. Other issues to discuss may be la-belling, iron and calcium sources, codex wheat starch, oats (advised to exclude until Anti IgA TTGs and symptoms are stable), cross contamination, eating out and GP prescriptions for example. Growth, development and symptoms will continue to be monitored at each review. We also discuss the benefits of joining Coeliac UK and other suitable/reliable online sources of information.

tHree-MontH revieWA further review after three months of this initial assessment is provided to discuss any teething problems with the GF diet. We discuss adherence to the GF, regular GP prescription orders, nutri-tional content of the GF and any altera-tions in symptoms since commencing the GF diet. It is common for parents to request a school visit during this time, as anxi-ety regarding GF school meal choices and cross contamination at snack, meal and home economics/cookery sessions are common worries. Our service cur-rently has the flexibility to provide a school visit; however, it is not always possible in other paediatric depart-ments. At school I will often meet with

life within And beyond the PAediAtriC dietitiAn-led CoeliAC CliniC

emma coatessenior Paediatric Dietitian, Wrexham Maelor Hospital, betsi cadwaladr university Health board

emma has been working as a Paediatric dietitian for five years and her caseload includes hetf, disability, coeliac disease, cystic fibrosis, Pku and childhood obesity. She has been a local Coeliac uk group organiser for 18 months.

coeliac disease affects one in 100 people in the uk (1) and it is treated by a lifelong gluten-free (gF) diet. For many dietitians managing coeliac patients and their journey towards getting to grips with the gF diet is ‘bread and butter’ type work, but not all coeliac patients have good access to regular dietetic support. over the last five years i have become more interested and involved with this patient group both within and beyond the dietitian-led coeliac clinic. in that time, i have held a paediatric dietitian-led coeliac clinic and there has been a similar service provided by our adult gastroenterology dietitian.

coeliAc DiseAse

NHDmag.com February 2014 - Issue 91 23

the school cook, class/form teacher and any other relevant staff, e.g. teaching assistants, to discuss the GF diet and the options available at school meal and snack times. Most local au-thority catering services can provide a GF op-tion each day, however, the patient’s personal food preferences and choice should always be considered. Many school cooks have the facili-ties to cook and freeze suitable GF meals from the standard school menu or adjust a standard meal to provide a GF option, e.g. have GF pasta, bread and pizza based on hand for use in school. A total guarantee of non-cross contamination is not possible in kitchens where the handling and cooking of gluten-containing foods is its prima-ry function. Discussion with staff around mini-mising cross contamination at school is vital and this should include the dining areas where children will be seated to eat. Gluten-containing food should be cleaned away before a coeliac pa-tient is seated at the table or some schools have of-fered a ‘priority lunch pass’ to allow the coeliac patient and a friend to at-tend the dining hall first, which can help to mini-mise contact with gluten-containing food debris. Early entry to the dining hall also allows the coeliac patient and school catering staff to communicate regarding their GF options for that day before the mealtime peaks and staff become very busy.

six-MontH revieWAfter six months of diagnosis, a further review takes place and repeat blood tests including, Anti IgA TTGs, FBC, serum ferritin, folate, vita-min B12, calcium, LFTs and TFTs are taken. The blood test results are discussed with the patient and their parents/carers. Any further alterations to the GF diet and methods to limit contamination are often discussed at this review. Ongoing issues with nutritional deficiencies and symptoms such as constipation are also addressed. Also, any fur-ther intervention, e.g. the prescribing of iron sup-plementation or laxatives such as Movicol will be

requested from the GP or named paediatrician. Stable patients will be reviewed at their annual review, which will be approximately six months after this review. For patients with ongoing is-sues with the GF diet and/or symptoms, faltering growth or additional intolerances an extra review after three months may be offered.AnnuAl revieWApproximately 12 months after diagnosis, an an-nual review appointment will be offered to all patients. Annual review blood tests are ordered in advance of this appointment and include, Anti IgA TTGs, FBC, serum ferritin, folate, vita-min B12, calcium, LFTs and TFTs. These blood results will be discussed with the patient and their parents/carers. Any deficiencies and pos-sible treatment options will be discussed, further intervention will then be requested from the GP

or named paediatrician as per the six month re-view. Patients who have stable Anti IgA TTGs and asymptomatic may reintroduce pure oats at this stage, however, it may take longer than 12 months for some patients to achieve stabilised bloods and symptoms. An overall assessment of the patient’s compliance with the GF diet and the nutritional adequacy of

the diet will be discussed. Any concerns and questions from patients and their parents/carers are also addressed. Following their annual review stable pa-tients will continue with an annual review only. However, parents can contact the department for additional support or advice in the meantime if they have queries or concerns. Patients with un-stable blood results or remaining symptomatic will be review as required.

life beyonD tHe clinicIn 2012 I became group organiser for our local Co-eliac UK group and I started working with both adult and paediatric patients once again. We currently have around 700 members. In May 2013, Coeliac UK ran its ‘Gut feeling’ campaign to raise awareness of co-

coeliAc DiseAse

Following their annual review stable patients will continue with an annual review only. However,

parents can contact the department for additional support or advice in the meantime if they have queries

or concerns.

NHDmag.com February 2014 - Issue 9124

eliac disease and its symptoms. The campaign hoped to help find the thousands of undiagnosed coeliacs in the UK by asking people to ‘listen to their gut feel-ings’ and visit their GP for screening. It also called for healthcare professionals to be more aware of symp-toms and the correct screening methods. During this campaign our group held a stand at a local supermar-ket to promote the campaign. We also promoted the campaign via posters and leaflets in and around the hospital, GP surgeries and other local supermarkets. The feedback we received during this cam-paign regarding the dietetic and medical ser-vices received from existing coeliac patients re-flected a mixed bag of experiences. There were many adult patients who reported not seeing a dietitian since their diagnosis and there were many patients who informed us that it had taken many years of ‘pestering’ their GP to test for coeliac disease before they were diagnosed. This is consistent with the Coeliac UK findings (1) regarding patient’s diagnosis experiences. On average, patients wait up to 13 years to be diagnosed and one in four patients have been

given a diagnosis of IBS before coeliac disease. The ‘gut feeling’ campaign hoped to improve primary care health professional’s awareness of coeliac disease symptoms and how to screen ap-propriately. For example, the 2008 NICE guide-lines for the diagnosis and management of IBS in primary care (3) recommends that coeliac screening should take place before a diagnosis of IBS is considered. However, this may not al-ways occur or coeliac screening at the time was negative. It is estimated that only 10 to 15 per-cent of people with coeliac disease are actually diagnosed. Through our local Coeliac UK group meetings and events, we have been encourag-ing existing coeliac patients to discuss and share their pre diagnosis symptoms and experiences with others, as well as encouraging possibly un-diagnosed patients to visit their GP. As a local Coeliac UK group, we aim to provide support and information in order to empower patients (diagnosed and undiagnosed) to contact the relevant health professionals in order to ensure their health is being appropriately managed.

coeliAc DiseAse

with

J000761 ARTWORK 1AR/RH DL 24 01 14

References1 coeliac UK website (accessed 02/01/14)2 Murch s, Jenkins H, auth M et al (2013). Joint esPGHaN and coeliac UK guidelines for the diagnosis and management of coeliac disease in children. arch

Dis child 98:806–8113 National Institute for Health and care excellence (2008). Irritable bowel syndrome in adults - Diagnosis and Management of Irritable bowel syndrome in

Primary care. [cG61]. London: NIce

Through our local Coeliac UK group meetings and events, we have been encouraging existing coeliac patients to discuss and share their pre diagnosis symptoms and experiences with others . . .

NHDmag.com February 2014 - Issue 91 25

Catering has come a long way for patients at Nottingham University Hospitals NHS Trust. Today the food for patients is cooked in an on-site central produc-tion unit (CPU) and served to patients by our own Food Service Assistants, but it hasn’t always been this way. In 2004, Nottingham City Hospital and the Queens Medical Centre merged to become Nottingham University hos-pitals NHS Trust (NUH). Until 2013, patient meals on City Campus had al-ways been produced and served using a traditional ‘cook serve’ system. Chefs would prepare main meals and special diets for lunch and supper each day, which were transported to the wards between 11 to 12 noon and 4 to 5pm, then served to patients by our Food Ser-vice Assistants. The catering team on City Campus led the way in purchasing meals sustainably, supporting the local farmers by purchasing meat, milk and fresh produce locally. For this work, the catering team was awarded the Soil As-sociations’ Food for Life Bronze Award.

QMc cAMPusQMC campus had a contract caterer in place until March 2010 using a cook freeze meal system of meals purchased from a food manufacturer. Food service assistants plated meals at ward level which were taken to patients by the nursing staff. In April 2010 the catering team members became NHS employ-ees and work commenced to provide a consistent service to patients across NUH campuses.

cAtering 2010 to Present DAyOver the past three years, the concept of the CPU to provide patient meals across NUH came to life and was funded by the Trust with the complete support of our patient representative committees. In 2013, the CPU opened and meals are provided using an in-house cook freeze system and served to patients by our teams of food service staff.

fooD QuAlity is KeyWe all know that the quality of food is key in ensuring that a meal gets eaten and the nutritional benefits are gained from it. A huge amount of the planning for the CPU was based around ensur-ing that patients receive a meal that was of excellent quality when it had been cooked at ward level. All of our main meals are cooked from scratch us-ing fresh raw ingredients and made to a standard recipe. Meals are weighed into portion packs to ensure a consis-tency of portion and that the nutritional content of the meals is as consistent as possible. Catering managers, ward staff, dietitians, speech therapists and patient groups were involved in many food tasting sessions until the final recipe and portion size was agreed upon. The aim of this work was to ensure that pa-tients receive a meal that is as close to a ‘home cooked’ meal as possible.

Menus AnD cHoiceNUH developed a new main menu and a number of special diet menus to en-sure that the diverse range of nutritional

the hoSPitAl food journey in nottinghAm

Helen reamregistered Dietitian, nottingham university Hospitals nHs trust

helen has been a registered dietitian for over 20 years, working in a variety of clinical and management roles. Clinical interest has always involved the provision of food and food service due to the huge impact this has on patient care.

it is a privilege to work as a dietitian for estates and facilities, which is a job that allows me to care for patients through supporting the provision of excellent food and food services. below i describe the hospital food journey that nottingham university hospitals nhs trust has undertaken and how a dietitian is an essential part of the team.

HosPitAl fooD

NHDmag.com February 2014 - Issue 9126

needs and dietary requirements are catered for. The launch of these menus allowed us to provide the same menus across both campuses for the first time. The main menu is a seven-day cycle with five main meal choices available at each mealtime (a typical day from the menu is shown below). Main menus are coded with vegetarian and softer choices only and we have always avoided strings of diet codes for patient meals. For this main menu we decided to add in our multicultural and vegan a la carte menus towards the back of the booklet, as some of our Black and Minority Ethnic patients were telling us that they didn’t get offered these menus. We also wanted to be clear that all patients can have a choice from these menus to add vari-ety if they wish to. As part of informing patients about nutritional needs, I wrote a piece for the front of the main menu booklet about appropri-ate meals to eat if patients want to follow ‘healthy eating’ principles in hospitals, and what patients should eat if their appetite is poor.

sPeciAl Diet MenusFolders containing the special diet menus are available on every ward which includes:• No Gluten ingredients• No milk ingredients• No nut ingredients• Renal menu• Modified texture menu ‘C’ puree• Modified texture menu ‘E’ fork mashable• Lower fibre menu• Extra choice menu

The extra choice menu is a relatively new menu containing a list of popular dishes for both adults and children. It includes children’s favou-rites (e.g. chicken nuggets, burgers), but also an ‘all-day breakfast’, jacket potato options and some alternative roast meat and softer meals for patients looking for an alternative to the main menu. This menu is well used across NUH and allows food service and nursing staff to offer an alternative choice to patients when necessary.

fooD service stAffOur food service assistants play a crucial role in ensuring that our patients have their nutritional needs and preferences met in hospital. They work as an integral part of the ward team and get to know their patients well. They receive training on food hygiene, customer care and nutritional needs and are encouraged to present their meals in an appealing way and portion meals appro-priately so that patients are well fed if they are hungry, but not faced with a large portion if their appetite is poor. Many will also offer second portions of food to patients where appropriate. Team working with nursing staff is a crucial part of the role and they play an active role in NUH’s ‘Mealtimes Matter’ campaign.

MeAltiMes MAtter At nuHNUH’s answer to protected mealtimes for pa-tients comes in the form of ‘Mealtimes Matter.’ The campaign focuses on protecting the meal-time for patients and outlines the nursing care that should be provided before, during and after mealtimes to ensure that the care is joined up with nutrition screening and care planning. The catering service has played an active part in sup-porting this campaign, working with nursing staff to organise mealtime practices differently and changing mealtimes and meal provision where necessary.

tHe role of tHe DietitiAnI have worked as an Estates and Facilities di-etitian for two days per week since 2008 and worked alongside the team during all of the changes. My role is varied and includes: Menu development - I work with the ca-tering managers to develop the main menu, thinking about the number of choices, mix-ture of dishes and number of courses. I also work alongside the chief dietetic technicians from the main dietetic department to agree the types of special diet menus that we require and the number and variety of choices that these

HosPitAl fooD

Our food service assistants play a crucial role in ensuring that our patients have their nutritional needs and preferences met in hospital.

NHDmag.com February 2014 - Issue 91 27

should contain. Collectively, we work with the specialist dietitians and speech therapists to agree their appropriate menus including renal and modified texture menus. Team support, challenge and problem solv-ing - A dietitian in my role develops a detailed understanding of the capabilities and limita-tions of a catering and food service system, whilst knowing the requirements of patients in ward environments. I, therefore, spend time working with the team to develop improve-ments in the service where required, but also deal with requests from clinical areas to work out if their request is part of the service that we are required to provide considering the constraints that we face. Through this work, I both support and challenge the catering and clinical teams and help to solve issues when they arise. Mealtimes Matter: I have worked alongside a practice development matron to support nurs-ing staff with the Mealtimes Matter project and support changes in practice at ward level to en-sure that appropriate mealtime care is provided. I carry out ward mealtime observations with nurses to assess practice and act as an indepen-dent assessor of the essence of care benchmark for nutrition. We carried out a project, with support from the Foundation of Nursing Stud-ies, to look out how mealtime practices can be improved by organising mealtimes differently, without it taking more time for busy ward staff. We achieved some positive results from this study which supported the implementation of the ‘Mealtimes Matter’ project. Teaching and training: I teach and train about food, catering and nutritional care at ev-ery, and any, opportunity! This includes teach-ing sessions and catering updates to our non-registered nurses, nutrition link nurses, ward representatives and food service assistants. In 2012, every chef completed a ward visit with me to observe a meal service and speak to pa-tients who gave positive feedback about their food. I see teaching and training as an impor-tant part of this role in increasing knowledge, encouraging good practice and working to-gether to enhance patient care. Strategic work: I often get asked to take part in projects linked to our services, their

overall provision and how we can provide an excellent service whilst balancing the books. I have had to decide whether menus can be streamlined in order to save money and al-ways put the patient at the heart of any deci-sion I make. I recently worked with our head of catering to write a catering specification for the Trust who is embarking on a market testing exercise of our Estates and facilities services. My involvement in this allowed us to ensure that all aspects of the service have been included to ensure that the quality of the catering services can be maintained and monitored in the future. Menu Analysis: I receive a huge amount of help from my colleagues in dietetics who analyse the recipes provided by the cater-ing team. We work together to carry out a check of the menu capacity to ensure that it can meet the range of patients’ nutritional requirements and ask for changes to recipes where ingredients need changing, although this is relatively rare. National work: I have been a committee member of Food Counts specialist group of the BDA since the group formed in the year 2001 and in November 2013 I stepped into the role of Chair of the group. I have learnt so much from my Food Counts colleagues and are really proud of the work we have carried out over the years, not least the recent publi-cation of The Digest (The Nutrition and Hy-dration Digest: Improving outcomes through food and beverage services July 2012), and our cross professional study days. Over the next 12 months, I am keen to continue our work in this group to see how we can work closer to-gether with our catering and nurse colleagues at a national level, because I have experienced first-hand how we can enhance patient care by working together with our multi-professional colleagues at a local level. All members of the catering team play an equally vital role in ensuring that a high qual-ity catering service is provided which meets patients individual nutritional needs. I feel that having a dietitian within Estates and Facilities is an essential part of this team and I hope that every hospital will eventually invest in their own Estates and Facilities dietitian.

HosPitAl fooD

http://www.foodmatterslive.com/

NHDmag.com February 2014 - Issue 91 29

DiAbetes

This centuries old quote remains perti-nent today, especially with the manage-ment of diabetes and the role of dietary advice. The term ‘diabetes’ originates from the Greek word meaning ‘a si-phon’ and in the 2nd century AD, a Greek physician, Aretus, explained that patients “passed water like a siphon”, when they suffered with what today is termed polyuria. He named the condi-tion ‘diabetes’ (1). It was also noted that the urine was sweet, hence the term ‘mellitus’ meaning ‘sweet like honey’. Today, the term diabetes mellitus (which is usually abbreviated to diabetes or DM) is used to describe the condition resulting in polyuria and polydipsia, plus glucosuria due to a malfunction of the pancreas. This distinguishes it from such conditions as diabetes insipidus where polyuria and thirst also occur but not glucosuria. Diabetes is a chronic condition that has been diagnosed in approximately three million people in the UK. This gives a prevalence of almost five per-cent of the UK population having dia-betes (2) there are 20,000 young people with Type 1 diabetes under the age of 15 years. Diabetes UK also says that there are an estimated 850,000 cases of undi-agnosed Type 2 diabetes in the UK. This means that around one person in every 70 has an undiagnosed case of the con-dition (3). The UK is not alone in having large numbers of people with diabetes and, according to the International Dia-betes Federation, in 2013 worldwide, there were 382 million people with dia-betes. By 2035 this will rise to 592 mil-lion. The number of people with Type 2 diabetes is increasing in every country and 80 percent of people with diabetes live in low and middle income countries

such as China, India, USA, Brazil and Russia. The greatest number of people with diabetes are between 40 and 59 years of age (4).

tyPes of DiAbetesThere is no one type of diabetes and they have different causes and manage-ment requirements including different emphasis as regards diet.The Insulin Dependent Diabetes Trust says, “All too often the different types of diabetes are put together under the gen-eral umbrella of diabetes. This blurring of the lines between Type 1 and Type 2 can cause unnecessary fears, confusion and misunderstandings that can be dan-gerous. The misconception that diabetes is simply a lifestyle condition minimises the public perception of the seriousness of both types of diabetes.” (5) The main types of diabetes are:• Type 1 which used to be called in-

sulin dependent or juvenile onset diabetes.

• Type 1.5 Latent autoimmune diabe-tes of adults (LADA).

• Type 2 which used to be called non-insulin dependent or maturity onset diabetes.

• Gestational diabetes which affects women during pregnancy.

• Pre-diabetes or metabolic syndrome which used to be called syndrome X.

tyPe 1 DiAbetesThis type accounts for about 10 to 15 percent of the people diagnosed with diabetes. It usually affects children and adults up to the age of 40. The number of children diagnosed under the age of five is markedly increasing. It was also referred to as insulin dependent diabe-tes or juvenile diabetes.

diAbeteS: inVAluAble dietetiC AdViCe

Dr Mabel bladesindependent freelance Dietitian and nutritionist

As a registered dietitian, all aspects of nutrition enthuse mabel. She is passionate about diet and diabetes and did her Phd on this topic. mabel is a member of the rSPh and also of the bdA, nAge, food Counts and freelance dietitians Specialist groups

“No illness which can be treated by diet should be treated by any other means.” maimonides, 12th century physician

NHDmag.com February 2014 - Issue 9130

DiAbetes

It is caused by the body’s immune system attacking the insulin producing beta cells in the pancreas. The body no longer produces insulin and blood glucose levels rise. Insulin injections, or delivery by an insulin pump, are always re-quired for the management. It is usually diag-nosed as an acute condition. Most people are treated with synthetic ‘human’ or analogue insu-lin made by genetic engineering and only about 20,000 people are treated with the traditional form of natural animal insulin. There is no cure for Type 1 diabetes and a specific cause has not been established. It is thought that there may be several causes with a genetic link in some people. Research shows that a common virus may trigger the body’s immune system to attack its own insulin-producing pan-creatic cells. Thus Type 1 diabetes can be said to be an auto-immune condition.

tyPe 1.5 DiAbetesThis type of diabetes is also called Latent Auto-immune Diabetes of Adults (LADA or 1.5 dia-betes) and is based on a concept introduced in 1993 to describe slow-onset Type 1 autoimmune diabetes in adults. Adults with LADA are often initially misdiagnosed as having Type 2 diabetes based on their age, not aetiology. Such individu-als often rapidly progress to requiring insulin for their control (6).

tyPe 2 DiAbetesThis type of diabetes affects 85 to 90 percent of the total number of people diagnosed with dia-betes. Thus over two million people have been diagnosed with the condition, and it is thought that there is an equal number of people who are undiagnosed. It occurs mainly in people over the age of 40. Type 2 diabetes was also referred to as non-in-sulin dependent diabetes. The diagnosis of Type 2 diabetes is becoming increasingly common in both children and teenagers, especially in those who are overweight and obese (7). The pancreas often still produces some in-sulin but insufficient amounts, or it is not used properly by the various cells. Consequently, there is excess insulin in the systems plus also raised glucose in the blood. Type 2 diabetes often remains undiagnosed for several years during

which time the raised blood glucose levels may cause damage and result in some of the compli-cations of diabetes. People with Type 2 diabetes are often diagnosed as a result of having com-plications rather than because they suspect they have Type 2 diabetes. Type 2 diabetes can be sometimes managed with diet and exercise alone. Also it is often man-aged with oral blood glucose lowering medica-tion and then treatment with insulin may be nec-essary.

gestAtionAl DiAbetes This occurs during pregnancy but disappears af-ter the baby is born. It affects up to five percent of women giving birth. It can often be controlled with diet and exercise but some may need medi-cation (8).

Pre-DiAbetesPre-diabetes means blood glucose levels that are higher than normal but not high enough to be called diabetes. People who are 45 years plus are more likely to develop pre-diabetes. With pre-di-abetes people are more likely to develop Type 2 diabetes, heart disease and strokes. Most people with pre-diabetes don’t have any symptoms. Losing at least five to 10 percent of weight can prevent or delay the onset of Type 2 diabetes or even reverse pre-diabetes.

Diet for DiAbetesThere is no single diet for people with diabetes and thus advice to individuals based on type of diabetes, medications, other health issues present, lifestyle and normal diet from someone with ex-pertise on this can be invaluable to assisting the person with diabetes in managing their condition. However, often people - particularly soon after di-agnosis - are confused about what to eat (9). Current advice for people with Type 1 dia-betes is to take a well-balanced and nutritionally adequate diet. Regular meals are advised with carbohydrate intake balanced with insulin. Excess saturated fat is not recommended due to links with coronary heart disease or alcohol due to ef-fects on glycaemic control. For those with Type 2 diabetes weight loss is key which means again a nutritionally adequate diet with a reduction in en-ergy levels by limiting fats, sugar and alcohol.

I" ,."

NHDmag.com February 2014 - Issue 91 31

DiAbetes

Carbohydrates are considered to be pre-ferred of the low GI type as well as in moderated amounts due to the effect of the glycaemic load on blood glucose levels (10, 11). Traditional advice on basing meals on carbohydrate foods is being chal-lenged due to the erratic blood glucose levels this can cause. While sugars are not forbidden as part of the diet for anyone with diabetes, it is consid-ered that low calorie sweeteners can be helpful in foods and beverages in assisting with both cutting calories and carbohydrate (12).

PAtient-centreD cAreNICE’s recommendations are that people diag-nosed with diabetes and any carers should be offered an education programme about man-aging diabetes. Such programmes should have an evidence-based approach that is tailored to individual needs, is targeted at enhancing self-management, has a formal curriculum and is

delivered by trained educators. While there is some crossover with such education pro-grammes and there are also local bespoke edu-cation programmes in general, there are the fol-lowing resources:• DAFNE, (Dose Adjustment for Normal Eat-

ing) for those with type 1 diabetes (13) • For those with type 2 diabetes there is DES-

MOND, XPERT and Conversation maps (14,15,16)

• Role of Registered Dietitians

Whichever type of diabetes someone has, advice about food and diet is invaluable in the control. Registered dietitians can not only ad-vise individuals, but also be involved in edu-cation programmes and spearhead services for people with diabetes and get involved with more diverse clinical roles such as managing education including for insulin pumps.

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References1 brown a (1966). Practical Nutrition for Nurses. william Heineman Medical books Ltd. London2 Diabetes UK www.diabetes.org.uk/about_us/what-we-say/statistics/Diabetes-prevalence-2012/3 Diabetes UK www.diabetes.org.uk/about_us/News_Landing_Page/warning-about-the-one-in-70-people-who-have-undiagnosed-diabetes/4 International Diabetes Federation www.idf.org/diabetesatlas/data-visualisations5 Insulin Dependent Diabetes trust (2009). Understanding Your Diabetes. IDDt. Northampton6 Diabetes UK www.diabetes.co.uk/diabetes_lada.html7 american Diabetes association (2000). type 2 Diabetes in children and adolescents. Diabetes care, Volume 23, Number 3, March8 NHs choices www.nhs.uk/conditions/gestational-diabetes/Pages/Introduction.aspx9 Insulin Dependent Diabetes trust (2012). Diabetes everyday eating10 Glycaemic index www.bda.uk.com/foodfacts/GIDiet.pdf11 blades M (2007). GI counter. Kyle cathie. London12 International sweeteners association (2013). Low calorie sweeteners. International sweeteners association. brussels.13 DaFNe www.dafne.uk.com/14 DesMOND www.desmond-project.org.uk/15 XPert Health www.xperthealth.org.uk/people-with-diabetes/x-pert-diabetes16 conversation maps www.lillypro.co.uk/diabetes/patients/conversation-maps-online

Whichever type of diabetes someone has, advice about food and diet is invaluable in the control.

NHDmag.com February 2014 - Issue 9132

NHS staff are constantly hearing about reducing budgets, increased demand and cost savings. The NHS talks about the £30 billion funding gap (1) and the challenges facing the NHS, including an increasingly elderly population who are living longer with long-term conditions combined with a growing demand from the public. This amplified demand on services, combined with patients’ high expectations, as well as the need to inte-grate 21st century technologies, means that innovative, effective ideas are vital and should be at the forefront of NHS employers minds. But what does that actually mean to us as dietitians? Obesity costs the UK £5.1 billion an-nually and affects about 63 percent of the population (2), or around 35 million people. The latest policy, entitled ‘Reduc-ing obesity and improving diet’, sets out targets and strategies to reduce this eco-nomic burden. Malnutrition costs the UK more than £13 billion annually, nearly triple that of obesity, and affects about five percent of the population or around three million adults (3), thus making it a key focus from both a financial and health perspective. The figures for both health conditions are continuing to rise. The National Institute for Clinical Excellence (NICE) suggests that making considerable improvements to malnutri-tion treatment will result in the fourth largest potential source of savings. BAP-EN estimate savings of £130 million a year if one percent of public expenditure on malnutrition was saved (3). Dietitians can help decrease this funding gap by reducing the spend on oral nutritional supplements (ONS). ONS are designed to meet the nutri-tional deficit between a patient’s nutri-tional intake and nutritional require-

ments. They are often inappropriately prescribed or continued unnecessarily and thus cost savings are possible.

tHe role of tHe Prescribing suPPort DietitiAnOne strategy to implement ONS sav-ings would be the appointment of a Prescribing Support Dietitian, of which posts are increasing. The role focuses on combating the problem of inappropriate prescribing of ONS, but also includes in-fant formulae and gluten-free products. The London Procurement Pro-gramme is a leader in this area and, in 2013, the Prescribing Support Dietitians Group was officially launched as a sub-group of Nutrition Advisory Group for Older People (NAGE); however, the group was first started in 2010. The role of the Prescribing Support Dietitian can be adapted depending on regional need. Dietitians may recom-mend ONS prescriptions, although, ul-timately, prescribing remains the GP’s responsibility. The prescribing support role may include frequent appropri-ate training for clinicians about regular nutritional screening (such as MUST) which is vital to increase knowledge. This can also improve confidence in commencing appropriate dosages and ceasing inappropriate ONS prescrip-tions. Empowering patients to take responsibility for their own health by liaising with their GP regarding ONS prescription, especially when their oral intake and weight has improved, is also important. I am currently on a year’s second-ment as a Prescribing Support Dietitian working with the Medicines Optimisa-tion Team. The remit of this role is to re-view all GP surgeries, primarily to reduce

orAl nutritionAl SuPPlementS

catherine blaikleyspecialist Prescribing support Dietitianberkshire Healthcare foundation trust, currently on secondment to central southern commissioning support unit

Catherine has experience as a Community dietitian, primarily outpatient clinics, weight loss groups and palliative care. Several months ago, Catherine started a secondment as a prescribing support dietitian.

reducing inappropriate prescribing of ons: can we as dietitians impact the £30 billion funding gap?

ons

NHDmag.com February 2014 - Issue 91 33

ONS inappropriate prescribing, with a secondary focus on infant formulas and finally focusing on gluten-free products should time allow. The role also stretches to writing and implementing new policies and protocols in order to prevent future inappropriate prescribing of such products. After conducting the audit and reviewing relevant patients, I provide recommendations to GPs regarding the continuation, change or ces-sation of ONS prescriptions. If these changes are approved by the GP the savings are calculated and recorded. My main current findings are that ONS are often issued without any anthropometrics at the start or throughout the course being recorded, so there is little evidence to prove their effect. Com-munity patients started on ONS by someone other than a dietitian/district nurse often have little/no follow up regarding their ONS and are often prescribed longer than necessary. Finally 1kcal/ml ONS are often prescribed mistakenly instead of a 1.5kcal/ml as recommended on lo-cal MUST action plans and by the HCP. The main changes implemented so far:

• Making and distributing a prescribing flow chart for GP practices to help reduce inappro-priate ONS and a reminder to take anthropo-metric measurements regularly.

• A powdered shake is now first-line advice in care homes, which they request via a form designed and implemented to save money on ONS in care homes.

• Distributing comparison ONS charts de-signed to help GPs prescribe products as per the local contract wherever possible.

• Conducting MUST training in care homes in-cluding educating chefs on food fortification and MUST action plans.

• Food fortification leaflets updated and dis-tributed widely.

• Doctors and practice nurses educated on the use of MUST and appropriate action plans.

• Regularly updating ScriptSwitch to inform prescribers of the latest ONS prescribing guidelines.

The key outcome from the seven months is that over £90,000 has been saved from ONS alone, with 42 out of the 55 GP surgeries audited so far. I have also started writing the policy re-garding specialist infant formula prescribing, to be completed and launched before the end of the financial year.

conclusionONS are often inappropriately prescribed or continued for an unnecessary length of time. As dietitians, we can impact on this spend by effectively training relevant clinicians, staff and patients themselves on the ‘food first’ approach and when it is appropriate to start and stop ONS. As a profession, we must also keep the cost of ONS in the forefront of our minds when consid-ering their prescription, without impacting on patient care.

ons

References1 NHs england call to action Policy. Online at www.england.nhs.uk/2013/07/11/call-to-action/ [last accessed 13.10.13]2 Department of Health (2013). Reducing obesity and improving diet policy. Online at www.gov.uk/government/policies/reducing-obesity-and-improving-diet

[last accessed 13.10.13]3 brotherton, simmonds and stroud (2010). Malnutrition Matters, Meeting Quality standards in Nutritional care. On behalf of the baPeN Quality Group

My main current findings are that ONS are often issued without any anthropometrics at the start or throughout the course being recorded, so there is little evidence to prove their effect.

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NHDmag.com February 2014 - Issue 91 35

nicHe forMulAsFormulas have been produced to help with minor digestive problems in infan-cy. The main two categories are:1. Anti-regurgitation formulas - these

thicken in the stomach and so may be useful for some babies who have troublesome vomiting - but are oth-erwise well. An alternative to this is to add a thickening agent to the milk - however options are limited for in-fants and rely on the parent or carer being given appropriate advice on how to use the thickening agent.

2. ‘Comfort’ formulas - these are mar-keted for colic and constipation and again may have a place for babies who have gastrointestinal symp-toms that are troubling their parents, but do not require medical interven-tion. These formulas have a few modifications that are said to help; they contain partially hydrolysed protein, are lower in lactose, thicker and contain prebiotics.

PreterM forMulAsThe third trimester of pregnancy repre-sents the most rapid period of growth in the life cycle. If infants are born pre-

term, they therefore have nutritional re-quirements that are higher than a term infant, even before considering the extra requirements of breathing, temperature regulation, possible infection (caused by immature immunity) etc, that a foetus would not encounter (see requirements in Table 1).1. Breast milk fortifier - expressed

breast milk from an infant’s own mother is the most suitable milk for a preterm infant. It is known to reduce the risk of necrotising en-terocolitis (NEC), a life threatening complication of prematurity leading to inflammation, necrosis and even perforation of the gut. It also has benefits including anti-inflammatory components (IL-10), growth factors (EGF), erythropoietin, lysozymes and immunoglobulins, as well as pre and probiotics which favourably affect gut microflora. However, par-ticularly for infants <1.0kg, after the first two to three weeks, breast milk alone is unlikely to meet the infant’s requirements, particularly for pro-tein, even if given in high volumes. Therefore, breast milk fortifier, a powdered product in sachets, can be

SPeCiAl needS infAnt formulAS

Kate Harrod-Wildspecialist Paediatric Dietitian, betsi cadwaladr university Health board

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.

infant formulas have become extremely diverse since their original inception - and now come in many different forms. these range from those for healthy-term infants with ingredients designed to mimic the compositional and functional outcomes of breast milk, to those for a multitude of conditions from lactose intolerance to prematurity, from malabsorption to inborn errors of metabolism.

PAeDiAtric nutrition

energykcals/kg/d

Protein g/kg/d

vitamin aug

vitamin Diu

ironmg

calciummmols

Phosphate mmols

term infants (0-3 months)

100 2.1350

Per day340

1.7 Per day

13.1 Per day

13.1 Per day

Preterm infants

110 – 135

4.0 – 4.5 (<1.0kg) 3.5 – 4.0

(1.0-1.8kg)

400 – 1000 /kg/d

800 – 1000Per day

2-3 /kg/d

3.0 – 3.5 /kg/d

1.9 – 2.9/kg/d

table 1: nutritional requirements of preterm infants (1)

NHDmag.com February 2014 - Issue 9136

used, which increases the calorie, protein and vitamin content of the milk, while allowing the full volume of breast milk to be given.

2. Preterm formulas - for infants whose moth-ers cannot or choose not to provide breast milk, they need formulas that will meet these extra requirements. Preterm formulas are designed to meet these higher require-ments, typically containing 80kcals/100mls and 2.6g protein/100mls (compared with 67kcals/100mls and 1.3g protein/100mls in a term formula), as well as higher amounts of vitamins and minerals to meet their addi-tional requirements.

3. Post-discharge formulas - even once dis-charged, nutritional requirements may be higher than for a term infant of the same p o s t - c o n c e p t i o n a l age. Therefore, post-discharge formulas have been produced, which are half way between preterm and term formulas in composition - to help meet the ex-preterm infant’s requirements for energy, protein, vitamins and minerals and to allow catch up growth.

fooD HyPersensitivityFood hypersensitivity is the term that has been recommended by the World Allergy Organisa-tion (3) to refer to all reactions to food that are not psychologically based. This encompasses non-allergic food hypersensitivity (which in-cludes lactose intolerance and coeliac disease) and food allergy: IgE mediated and non-IgE me-diated (the new term for what used to be called food intolerance). NICE (5) have recently published guidance for the diagnosis and assessment of allergy in children and young people in primary and community settings to aid community practi-tioners (primarily GPs) in the assessment, di-agnosis and care of children and young people with allergic reactions. A key confusion among GPs and health visitors alike is the difference

between lactose intolerance and cows’ milk al-lergy in infants.• Lactose intolerance is the inability to digest

lactose (milk sugar), due to the relative or absolute absence of the enzyme lactase.

• Cows’ milk allergy is caused by an allergic response to one of more of the milk proteins.

treAtMent of lActose intolerAnceLactose intolerance may be temporary or perma-nent and may be caused by:• primary alactasia - a rare condition character-

ised by profuse watery diarrhoea from birth;• primary lactase deficiency - which causes

progressive lactose intolerance through childhood. This varies between ethnic groups, being rare in Northern Europeans, to almost en-demic in some Asian and African populations;• secondary lactase de-ficiency - the most com-monly seen in practice. Typical history is of a bout of gastroenteritis in an in-fant 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 usual-ly be regraded back onto a normal formula.

Historically, lactose intolerance was treated with a soya infant formula (these are not now generally recommended - see later), but lactose-free formulas are now available. These contain cows’ milk protein and all the other usual ingre-dients of a normal infant formula, except the lac-tose is replaced by another carbohydrate. Since some community health professionals do not un-derstand the difference between lactose intoler-ance and cows’ 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.

PAeDiAtric nutrition

Lactose intolerance is the inability to digest lactose (milk sugar), due to the relative or absolute absence

of the enzyme lactase. Cows’ milk allergy is caused by an allergic response to one of more of

the milk proteins.

NHDmag.com February 2014 - Issue 91 37

coWs’ MilK AllergyThe symptoms of cows’ milk allergy are many and diverse (see Table 2 taken from NICE 2011: 5). NICE (5) have issued guidance for the assess-ment and diagnosis of allergy in children and young people for primary care. IgE mediated al-lergy is easier to diagnose, as symptoms occur at the time, or shortly after, ingestion. However, non-IgE mediated allergy may be more difficult to identify as symptoms take longer to appear, making identifying a trigger(s) possibly more problematic. For eczema resistant to compre-hensive topical treatment, a trial of a milk-free formula is recommended (4) and for other symptoms such as severe colic or frequent type 7 stools, a trial of a milk-free formula may be in-dicated. Choices of alternative protein source for formulas are as follows:1. Soya - this has not been advised for almost 10

years (2, 6) - particularly in infants under six months - because of the theoretical risks to future fertility (particularly in boys), but also because of the significant risks of cross reac-tivity with cows’ milk protein, particularly for non-IgE mediated cows’ milk allergy.

2. Extensively hydrolysed protein - this can be based on whey or casein protein. Whey hydrolysates are said to be more palatable, however, casein hydrolysates have smaller protein fragments and are therefore said to be less allergenic. Versions of these formulas are also available with a proportion of the fat as medium chain triglycerides (MCT), mak-ing them also suitable for infants with malab-sorption syndromes.

3. Amino acid mixes - one brand is made in a to-tally milk-free environment, making it the gold standard for diagnosis of cows’ milk allergy.

fAltering groWtHHistorically, when infants had episodes of fal-tering growth (or failed to thrive as it was then known), usual practice was either to concentrate a standard formula (i.e. more powder in less water), or to add carbohydrate and/or fat to the feed. However, in recent years, the importance of protein for adequate catch-up growth has become better recognised; at least nine percent energy from protein is needed to allow acceler-ated or catch-up growth to occur. Nutrient dense

PAeDiAtric nutrition

ige mediated non ige mediated

Pruritus Pruritus

erythema erythema

Acute urticaria Atopic eczema

Angioedema gastro-oesophageal disease

nausea loose or frequent stools

colicky abdominal pain blood and/or mucous in stools

vomiting Abdominal pain

Diarrhoea infantile colic

upper respiratory tract symptoms (nasal itching, sneezing, rhinorrhoea or congestion [with or without conjunctivitis])

food refusal/aversion

lower respiratory symptoms (cough, chest tightness, wheezing, shortness of breath)

constipation

signs or symptoms of anaphylaxis or other systemic allergic reactions

Perianal redness

Pallor and tiredness

faltering growth (in conjunction with at least one or more gi symptom above (with or without atopic eczema)

table 2: signs and symptoms of possible food allergy (4)taken from page 6 of nice guideline no.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.

NHDmag.com February 2014 - Issue 9138

formulas have therefore been developed, con-taining 90 to 100kcals/100mls and 2.0 to 2.6g protein/100mls, as well as higher levels of vita-mins and minerals.

sPeciAlist feeDsThere are many feeds that are produced for spe-cific conditions. These include:1. metabolic feeds - these are produced for a vari-

ety of inborn errors of metabolism, modifying (particularly) the amino acid profile depend-ing on the particular needs of the condition;

2. feeds for malabsorption - these have partly already been mentioned - feeds are available with different types and degrees of hydro-lysed protein, different percentages of MCT and different carbohydrates, depending on the indications for use;

3. modular feeds - in some case a modular feed will be constructed when there is no suitable proprietary feed available - this allows the use of separate protein, carbohydrate, fat, electrolyte, vitamin and mineral modules de-pending on the need of the infant.

PAeDiAtric nutrition

References1 agostoni c, buonocore G, carnielli VP (2010). enteral nutrient supply for preterm infants: commentary from the european society for Paediatric

Gastroenterology Hepatology and Nutrition committee on Nutrition. JPGN 50, 85-92 cMO (2004). Update No. 37 www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4070176.pdf3 Johannsson 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, October 2003. J allergy clin Immunol 113, 832-64 NIce (2007). cG57 atopic eczema in children: Management of atopic eczema in children from birth up to the age of 12 years. www.nice.org.uk/nicemedia/

live/11901/38597/38597.pdf5 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.pdf6 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.pdf7 simmer K, Patole sK, Rao sc (2011). Longchain polyunsaturated supplementation in infants born at term. cochrane Neonatal Group. accessed 15/5/2012

DOI: 10.1002/14651858.cD000376.pub3

Issue 91 February 2014NHDmag.com

BONE HEALTH IN GALACTOSAEMIA

Dr Anita MacDonald & Pat Portnoi p15

OBESITY REPORT

COELIAC DISEASE

DIABETES

SPECIAL NEEDS INFANT FORMULAHelen ReamRegistered Dietitian

THE HOSPITAL FOOD JOURNEY IN NOTTINGHAM. . . p25

ISSN 1756-9567 (Print)

NHD CLINICAL NEW RESEARCH

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neW nhD aPPYou can now read NHD on your tablet or smart phone for FREE!

Simply search for NHD Magazine on your App Store and download.

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Web WAtcH

web wAtCh

online resources and useful updates.

aDmissions avoiDance anD DiabetesA coalition of diabetes organi-sations reports that there are 10s of thousands of people with diabetes a year who are not receiving the support they need to manage their condition. ‘Admissions avoidance and dia-betes: guidance for clinical com-missioning groups and clinical teams’ indicates that there are more than 600,000 ‘excess bed days’ a year in people with diabetes. Press release: www.diabetes.org.uk/About_us/News_Landing_Page/Improv-ing-diabetes-services-could-reduce-pressure-on-hospitals/ Report: www.diabetes.org.uk/About_us/What-we-say/Improving-services--standards/Admissions-avoidance-and-diabetes/

cQc revieW oF Dementia careThe Care Quality Commis-sion is carrying out a themed inspection programme looking at the quality of dementia care in England. They will inspect around 150 care homes and acute hospitals and are asking patients and the public to share their experiences of dementia care. Press release: www.cqc.org.uk/media/cqc-launches-national-review-dementia-care Details of inspection: www.cqc.org.uk/public/publications/themed-inspections/themed-review-dementia-care

mental Wellbeing oF olDer PeoPle in care homes: Quality stanDarD

nice guiDanceNICE has issued guidance ‘Intra-venous fluid therapy in adults in hospital (CG174)’. This clinical guideline contains recommenda-tions about general principles for managing IV fluids and applies to a range of conditions and different settings. It does not include recom-mendations relating to specific con-ditions. Press release: www.nice.org.uk/newsroom/news/NHSPatient-sOnDripsAtRiskOfSeriousErrors.jsp Guideline: www.nice.org.uk/CG174 BBC News report: www.bbc.co.uk/news/health-25298855

nursing technology FunDNHS England has launched a £100m Nursing Technology Fund. NHS organisations can bid for part of the fund to buy innova-tive technology to support nurses, midwives and care staff with im-

proving patient care. It will fund mobile and digital technology to allow nursing, midwifery and care staff to work more flexibly and effectively. Availability of funds will be split £30m/£70m between projects which can be delivered in 2013/14 and 2014/15. www.england.nhs.uk/2013/12/09/nursing-technology-fund/

smartPhone aPPs For healthSmall businesses won a share of a £2 million innovation fund to come up with creative ideas for apps to help people stay healthy. The winners include a Drink Coach app that people can use to track their drinking over an evening and get prompts on their phone reminding them to slow down. www.gov.uk/govern-ment/news/smartphone-apps-to-treat-obesity-and-alcohol-abuse

enhanceD recovery care PathWayNHS Improving Quality has published ‘Enhanced recovery care pathway: progress review (2012/13) and level of ambi-tion (2014/15)’. This document demonstrates the support for Enhanced Recovery (ER) from patients and professional organisations. It describes some of the principles involved, with examples of specific steps that can lead to improvement. www.nhsiq.nhs.uk/resource-search/publications/enhanced-recovery-care-pathway-review.aspx

NICE has published its 50th qual-ity standard ‘Mental wellbeing of older people in care homes’ (QS50) covering the mental wellbeing of older people (65 years and over) receiving care in all care home settings, including residential and nursing accom-modation, day care and respite care. Press release: www.nice.org.uk/newsroom/news/NewAd-viceMentalWellbeingOlderPeo-plePareHomesMarksBoldStep-Forward.jsp; Standard: http://guidance.nice.org.uk/QS50

NHDmag.com February 2014 - Issue 9140

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care staFFing caPacity anD caPabilityThe Chief Nursing Officer in England has published ‘How to ensure the right people with the right skills are in the right place at the right time: a guide to nursing, midwifery and care staffing capac-ity and capability to make the right decisions about nursing, midwifery and care staffing capacity and capa-bility’. News report: www.england.nhs.uk/2013/11/19/staff-guid-ance/ Guide: www.england.nhs.uk/wp-content/uploads/2013/11/nqb-how-to-guid.pdf

volunteering in acute trusts in englanDThe King’s Fund has published ‘Volunteering in acute trusts in England: understanding the scale and impact’. Around three million people volunteer for health, disability and welfare organisations in England; the same number as the combined NHS and social care workforce. This research aims to help local providers and system leaders understand the contribution of volunteering and provide or-ganisations with benchmarking information, including possible returns on investment in vol-unteering. www.kingsfund.org.uk/publications/volunteering-acute-trusts-england

neW eu laW on mobility oF health ProFessionals across euroPeThe NHS confederation has published a briefing paper ‘New EU law on mobility of health professionals across Europe’. High-profile cases in the UK have highlighted concerns about the clinical competence and language skills of some healthcare profes-

sionals from other EU member states. The NHS European Office has consulted extensively with NHS organisations and chan-nelled their views to EU decision-makers in order to influence the final text of this Directive, which sets out the rules and procedures that apply when professionals (including health professionals) want to practise in an EU country other than the one in which they qualified. The revised Direc-tive aims to remove barriers to freedom of movement within the European single market, but there is the potential for conflict be-tween simplifying and speeding up procedures for professionals and improving safety, quality and transparency in the provision of healthcare services. www.nhscon-fed.org/Publications/briefings/Pages/New-EU-law-health-pro-fessionals-move.aspx

mortality anD morbiDity in chilDren anD young PeoPleA study commissioned by the Healthcare Quality Improve-ment Partnership (and part of the Clinical Outcome Review Programme: Child Health Re-views - UK (CHR-UK) project) has found that two thirds of children who die have a chronic condition. Other findings include: overall child mortality has declined by over 50 percent in the last 30 years; injuries are the single biggest cause of child deaths and young maternal age remains risk factor throughout childhood. The study used death registration data for UK children between January 1980 and December 2010. It looked at key areas such as multiple morbid-ity, child injuries, birth weight

and maternal age to assess the risk factors for child deaths. Press release: www.rcpch.ac.uk/news/two-thirds-children-who-die-have-chronic-condition-reveals-uk%E2%80%99s-largest-study-child-mortality; Reports: www.rcpch.ac.uk/child-health-reviews-uk/programme-find-ings/programme-findings

seven Day gP accessPeople will be able to see their GP seven days a week and out-of-office hours under new proposals set out by the Prime Minister for a first wave of GP groups offering extended opening hours across the country. The move will make it easier for people to see their family doctor from 8am to 8pm, seven days a week. Innovative practices will be able to apply to a new £50m Challenge Fund to set up a pioneer programme. Pio-neers will be established in every region of the country nine in total, which together are expected to cover up to half a million patients. Ministers want to use the pilots as the first step to rolling the scheme out across the country and encouraging hundreds more GP practices to sign up. This first wave of pioneers will form part of a wider plan to strengthen out-of-hospital NHS care and make it easier for practices to join up with each other, as well as other services provided in the commu-nity. Based on the success of the first wave, other groups will be encouraged and enabled to open their doors at the evenings and weekends. Press release: www.gov.uk/government/news/sev-en-day-8am-8pm-gp-access-for-hard-working-people; BBC News report: www.bbc.co.uk/news/uk-politics-24339484

NHDmag.com February 2014 - Issue 91 41

What made you choose this role?I had always been interested in nutrition and dietetics, my career path had led me into the catering industry ranging from ho-tels, nursing homes and latterly the school meal service. I came across a vacancy as a DSW, applied for the role and six weeks later found myself being interviewed for the job; needless to say I was successful. After the initial surprise, I was very excited and a little apprehensive, but I have always relished a challenge. I attended the British Dietetic Association (BDA) ‘Introduction to Nutrition for DSW’. We are a small but extremely busy team, consisting of four dietitians, one ad-ministrative assistant and myself covering both community and acute adult patients in a large rural area of Cumbria.

How are you finding your role?I soon realised that it was nothing like I had imagined. I was initially terrified to think that I would have to work out a patient’s nutritional requirements (maths was never my strong point) let alone have a consulta-tion with them! What a huge learning curve I have been on and still am, as I am also learning the convoluted ways of the NHS. Luckily, the Team Lead and my fellow col-leagues are very supportive and there is nothing I feel that I can’t ask them. I also feel that I have the freedom to develop the role myself with their guidance.

What do you like most about the job?What I love about my role is the variety of the work involved and that no two days are the same. I’ve always been a people person and enjoy a chat, so the job is well suited to my personality and brings me so much sat-isfaction, hoping that the advice I give may help someone.

What do you like least about the job?The array of different computer systems and all their idiosyncrasies

What’s a typical working week like?My caseload is mostly nutrition support patients and I have a designated ward such as Elderly Care within the hospital. I fully assess and review these patients. The unique part of working in acute and community within this department is being able to follow up patients in the community after they have been discharged home. It is lovely to hear how they are getting on. If we have referrals for nutrition sup-port patients who are unable to attend clinic, I usually have a telephone consulta-tion with them and put a plan in place, oc-casionally visiting the patient at home. Dur-ing one telephone review, as I was speaking to the patient’s wife who was the main carer, I asked how she herself was feeling, following a broken ankle. She complained of a sore and painful leg. I advised that she should see her GP. I felt concerned, so after speaking to a colleague, I contacted the GP. Six weeks later, (at the next review of the patient), the patient’s wife asked whether it was me who had called her GP. She in-formed me that I had saved her life as it had been a blood clot on her leg and the GP had told her that it could have been fatal. I couldn’t believe that I had inadvertently saved this lady’s life. Some weeks later I was surprised by a visit from the Lord Lieutenant of Cumbria who wished to thank me on behalf of the patient’s wife and the Cumbria Partner-ship Trust. I received a beautiful bouquet of flowers, a spa day treat and some vouchers. My colleagues had managed to keep the se-cret from me! It was a very humbling expe-rience and lovely to meet the patient’s wife and we have kept in touch since.

referrAlS, requirementS And reCiPeS

sue HurrellDietetic support Worker (DsW)cumbria Partnership nHs foundation trust

the role of a Dietetic support Worker

cAreer

NHDmag.com February 2014 - Issue 9142

My other patients include most of the local res-idential/nursing home nutrition support patients and I continue to forge good working relationships with the home staff. Working on the Food First Approach, I have de-veloped a range of high calorie recipes from tempt-ing desserts, nourishing drinks and a homemade shot. I encourage patients and care homes to try these, along with food fortification ideas, and there has been a great response and positive results. Coming from a catering background, I natural-ly feel very passionate about food and am always on the look out for recipe ideas and high calorie snacks. I have produced a ‘Homemade v Manu-factured’ supplements table and I am involved in some residential home training for healthcare as-sistants and catering staff. I feel that this training is crucial to get the Food First Approach across at frontline level and I take along my homemade supplements and high calorie mousses for the staff to try along with the recipes. It is something I am very proud of, as some of the residential homes are now making and using these and patients are benefiting from weight gain. Also the usage of oral nutritional supplements (ONS) is reducing, which is naturally cost effective to the NHS. Our Team Lead and I recently had a meeting with one of the larger GP practices in the area to discuss nutrition support in the elderly and we are currently working on local guidelines for GPs with regards to appropriate prescribing of ONS. I am currently in the process of having all these recipes formatted into a booklet to give to patients and care homes and have started working on an-other booklet entitled Healthy Meals on a Budget. Part of my job also involves giving short infor-mative talks on healthy eating to various patient groups, COPD, heart failure and falls groups, this takes me out of the office to different locations within our locality and meeting different people with differing dietary needs. As well as developing relationships with ward staff, I liaise regularly with kitchen staff for patients’ snacks and attend the catering meetings when pos-sible. As well as contributing to our monthly team meetings, I also attend and sometimes co-chair our quarterly Nutrition Link Nurse meetings which were historically for acute staff only. However, we have recently opened up the meetings to com-munity staff, where we share resources and ideas

and invite guest speakers along. This has proved a great success and a chance to build new relation-ships with other healthcare professionals, includ-ing learning disability nurses, community hospital staff and district nurses.

What are your future plans?I’m now 20 months into my post and I’ve learnt and experienced so much. I am embracing my role and looking forward to continuing to develop this within the department.

What the dietitians say about sueNever before have I had the pleasure of working within a team that utilises the role of a dietetic as-sistant to its fullest potential. Sue works above and beyond the call of duty; every day, she performs duties and tasks that are rarely found in a DSW job description such as making, trialling and analysing food fortification recipes at home. Her role and re-sponsibilities are so diverse which helps alleviate the pressure on our small team of dietitians. With our support, Sue manages a large nutrition sup-port caseload both on acute wards and in the com-munity, applying a naturally caring attitude that makes her well liked by patients and staff alike. She works hard to develop resources, protocols and projects to continue to improve our service and patient care. She is impeccably organised and well prepared for meetings and training sessions and is always eager to extend her own knowledge and skills for ongoing professional development. On top of all that, she makes a cracking lemon pos-set! Sue is one in a million and we are lucky to have her as part of our team. The role of the DSW should never be under es-timated especially in the new, ever-changing and at times challenging NHS.

nursing stAff feeDbAcK:“Pleasure to work alongside.”

“Efficient and fantastic help.”

Patient feedback

“I enjoy my food, especially the lemon possets.”

“Nothing is any trouble for her.”

cAreer

NHDmag.com February 2014 - Issue 91 43

cAreer neWs

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

please call 0845 450 2125 (local rate)

Dietitian - nuDge nutrition - heaD oFFice, nr bath£24-£28k – 12-month full-time posi-tion with potential for a permanent role. nudge nutrition are providers of expert nutrition and dietetic services to a broad range of clients across the foodservice sector. They are seeking to recruit an additional dietitian to support the delivery of a project to a major global client. This position provides an excellent opportunity for you to work within an industry where your nutrition expertise will be crucial. You will have exceptional communication and IT skills and an ability to coordinate activities and manage client expectations. The role will involve planning and adminis-tering activities to ensure that accurate allergen and nutritional information can be provided for customers. In addition you will use your nutrition and dietetic skills to support us with a range of other nutrition-related ac-tivities. For further information please contact coleen.fraser@nudgenutritian.co.uk. Tel 01225 632300. To apply please send CV and covering letter to coleen.fraser@nudgenutition.co.uk.

locuM bAnD 5 DietitiAn - centrAl lonDonPiers Meadows Recruitment are looking for a Band 5 Dietitian to work in Central London on a locum contract. The post is to start at the beginning of Febru-ary and is ongoing for approxi-mately three months initially. The post will be acute based, with a case load consisting primarily of gastroenterology, ITU and renal. Experience in TPN would also be

preferable. Full or part time hours are on offer, and no car is required for the post. For further informa-tion regarding this post, or for de-tails on other posts we have in the London area, please contact Anna on 020 7292 0730 or email anna@piersmeadows.co.uk.

locuM bAnD 6 PAeDiAtric DietitiAn - soutH West englAnDPiers Meadows Recruitment are looking for an experienced Band 6 Paediatric Dietitian to work in South West England on a locum contract. The post is to start ASAP and will be ongoing be for ap-proximately three months with the possibility of extension. The ideal candidate will have good experience within fussy eating, allergies, Type 1 diabetes, failure to thrive and nutritional support. Full time hours are on offer, no car necessary. For further information regarding this post, or for details on other posts we have, please contact Anna on 020 7292 0730 or email anna@piersmeadows.co.uk.

locuM bAnD 5 DietitiAn - nortH West englAnDPiers Meadows Recruitment are looking for a Band 5 Dietitian to work in North West England on a locum contract. The post is to start mid-February and is ongoing for two months initially, likely to be extended. The ideal candidate will have experience in community work including home visits, GP clinics, nursing homes and nutri-tional support (parenteral and en-

teral). The candidate will also need to have some oncology experience. Full time hours are on offer and use of a car would be preferable. For further information regarding this post, or for details on other posts we have, please contact Anna on 020 7292 0730 or email anna@piers-meadows.co.uk.

ne lonDon, DiAbetes DietitiAn - februAry stArt, ongoingWe are currently looking for a dia-betes dietitian with experience of carbohydrate counting and ideally XPERT experience. Covering clin-ics and hospitals throughout the Borough. A car is not essential but would be highly beneficial. Call Hayley Isitt at Elite now for infor-mation on the above post and other excellent posts we have available. Tel: 0800 023 2275 or 01277 849649 hayley@eliterec.com or visit www.elitedietitians.com. Elite is a Buying Solutions (PaSA) approved agency as well as an approved supplier to the London Procurement Pro-gramme (LPP). We have preferred supplier status to a number of Trusts and we are dedicated to dietetic re-cruitment. Call now for information on the above post and other excel-lent posts we have available.

bAnD 6 cHilDHooD obesity DietitiAn - PArt tiMeElite Recruitment are looking for a Band 6 part-time Dietitian two to three Days a week to cover a Childhood Obesity position, to work alongside the NCMP team with clinics and primary schools.

NHDmag.com February 2014 - Issue 9144

cAreer listings

Candidate will require to work at locations around South London and Kent. This position is to start ASAP and is ongoing. Please call 01277846946 or email hayley@eli-terec.com for more information on this role. www.elitedietitians.com

coMMunity PAeDiAtric DietitiAn - cuMbriABand 6 Community Paediatric Dieti-tian in Cumbria, experienced Com-munity Dietitian required to cover a position for two months in the beautiful area of Cumbria. Start date is ASAP. For this or other Dietetic vacancies with Elite please contact Hayley on 0800 023 2275 or email your CV and interest to hayley@eli-terec.com www.elitedietitians.com

bAnD 6 MAcMillAn DietitiAn - essexBand 6 Macmillan Dietitian required for a position in Essex. This would be a split services of acute and commu-

nity workload, so a car driver would be preferable. This is a full-time role for around three months but may ex-tend. To be considered for the posi-tion please either call 012277 849 649 or email hayley@eliterec.com

bAnD 6 PAeDiAtric DietitiAn - cHilD WeigHt MAnAgeMentWe are recruiting for a Band 6 Paediatric Dietitian with deliver-ing Child Weight Management experience based in London. For this and similar jobs please con-tact Patrice on 0800 032 0454 or 020 8874 6111. Email your CV to registration@pjlocums.co.uk. Our rates are competitive in the cur-rent market; we offer assistance with relocation and hospital ac-commodation. We provide you with a current CRB, full occupa-tional health check and can or-ganise your mandatory training. PJ Locums is an NHS Government Procurement and LPP framework

approved supplier for Allied Health, Health Science personnel and Nurses.

bAnD 6 DietitiAn - DiAbetesWe require a Band 6 Dietitian with diabetic experience to start in Feb-ruary for a full-time post based in London. For this and similar jobs please contact Patrice on 0800 032 0454 or 020 8874 6111. Email your CV to me registration@pjlocums.co.uk. PJ Locums is an NHS Gov-ernment Procurement and LPP framework approved supplier for Allied Health, Health Science per-sonnel and Nurses.

PArt-tiMe - bAnD 6 We require a Band 6 Dietitian with diabetic experience to start ASAP for a part-time post based in Lon-don. For this and similar jobs please contact Patrice on 0800 032 0454 or 020 8874 6111. Email your CV to me registration@pjlocums.co.uk

To place a job ad here and on www.dieteticJOBS.co.uk please call 0845 450 2125 (local rate)

To place a job ad in NHD magazine or on www.dieteticJOBS.co.uk

please call 0845 450 2125 (local rate)

dieteticJOBS.co.ukThe UK’s largest dietetic jobsite

~~:~Member

NHDmag.com February 2014 - Issue 91 45

cAreer - events AnD courses

Keep it s

imple

...

t: 020 7292 0730 e: info@piersmeadows.co.uk

www.piersmeadows.co.uk

Contact us for dietetic vacancies

nationwide

eVentS & CourSeS

international association For the stuDy oF obesity Specialist Certification of Obesity Professional Educationwww.iaso.org/scope/packages/lifestyle-interventionsRegister today and receive a free course.SCOPE e-learning provides the only internationally-recognised certificate in obesity management for health professionals. Try our course package on lifestyle interventions with courses on diet and physical activity of particular interest to dietitians.

university oF nottingham - school oF biosciences Modules for Dietitians and other Healthcare Professionals• Paediatric Nutrition - 1st May• Nutrition & Diabetes - 1st to 8th MayFor further details please email marie.e.coombes@nottingham.ac.uk, tel: 0115 951 6238 or check out the University website at www.nottingham.ac.uk/biosciences and click on short courses then ‘for practising dietitians’.

Practical Public Health13th FebruaryBVSC Enterprises, BirminghamEmail: Kirsten.whitehead@nottingham.ac.uk

3rd Asn congress19th FebruaryNutrition in Health & DiseaseJumeira Emirates Towers, Dubai, United Arab Emirateswww.nutrition.org/

eating Disorders Awareness Week24th February – 2nd Marchwww.b-eat.co.uk/

Diabetes uK Professional conference 20145th to 7th MarchACC Liverpooldiabetes.org.uk/conference

NHDmag.com February 2014 - Issue 9146

cAreers

It is wonderful to see NHD Magazine in this digest format. It brings back so many memories of carrying the old BDA magazine Adviser around in the pocket of my hospital white coat. Those days have gone, but the format was amazingly successful. NHD now succeeds this publication as ‘one of a kind’ in its field, cater-ing for a new generation of dietetic professionals. Talking of which, and this is where this column really starts, I recently received an invitation from the HCPC (that’s the august body that controls our professional regis-tration), to attend a ‘Meet the HCPC event’, taking place on Tuesday 18th February at the Preston Marriott Ho-tel. There were two identical meet-ings to choose from, one in the af-ternoon and one in the evening. The hotel is just a few miles away from my home and I decided that it would be a good opportunity to find out more about their work which would look at their ‘standards and current work, followed by an in-depth look at what it means to be an HCPC-registered professional’. It contin-ued: ‘These free events offer you the chance to hear from the HCPC, speak directly to us and allow us to answer your questions.’ Great, I’d love to come. There was no date on the letter, but it arrived in the second week in January. I decided I’d like to attend the afternoon meeting so rang up to book the same day. “Sorry, the after-noon meeting is fully booked.” “Oh,

alright; I’ll attend the evening then please.” “Sorry, the evening is fully booked; you can join us online.” Having been to three wedding banquets at this hotel over the years, gatherings of over one hun-dred guests with room to spare, I was somewhat surprised and disap-pointed. Anyway, I could of course join them and participate online. No need to attend then? Have a drink at home and blow a kiss to the bride! I’ve been registered with the HCPC (HPC) all my professional life and was elected by the membership of the BDA some years ago to rep-resent the dietetic profession on the Dietitians Board. This was a privi-lege and a pleasure. Despite no lon-ger working in the NHS, I maintain my registration, but it has made me think about what it really provides, at a not inconsiderable cost, to those of us reluctant to forsake our RD pro-fessional title. I may have to enquire in what other parts of the United Kingdom they are holding ‘Meet the HCPC’ events. Then again… To end with, if there are any indi-viduals out there who wish to bring other like matters to my attention which they think may warrant fur-ther dissemination to our readership, then I’m sure the Editor will happily pass them along to me whilst she gets on with her new demanding role. What a great job this is going to be!

Next time: obesity statistics, university sessional lecturing and car parking are included.

the finAl helPing

neil Donnelly

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

Welcome to my new NHD column in this new format magazine. here i have the opportunity to make observations on matters ‘of general dietetic interest’ that have taken place over the last few weeks and that this follower of victor meldrew of One Foot in the Grave fame has cause to comment on.

..

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Issue 91 February 2014NHDmag.com

BONE HEALTH IN GALACTOSAEMIA

Dr Anita MacDonald & Pat Portnoi p15

OBESITY REPORT

COELIAC DISEASE

DIABETES

SPECIAL NEEDS INFANT FORMULAHelen ReamRegistered Dietitian

THE HOSPITAL FOOD JOURNEY IN NOTTINGHAM. . . p25

ISSN 1756-9567 (Print)

NHD CLINICAL NEW RESEARCH

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