Issue 110 December 2015 / January 2016NHDmag.com

CystiC fibrosis related diabetes

Dr Jackie Doyle University College London Hospitals NHS Trust

Mindfulness for dietitians. . . p33

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NHDmag.com December 2015 /January 2016 - Issue 110 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.

it only seems like yesterday that i was writing about issue 100 and now here is issue 110 for you! time certainly seems to be ‘flying by’ and recently i have been reading about ‘Why time flies as you age.’ it was an interesting account and looked at the key to time perception.

We all have routines in our lives, yet rou-tine, although comforting, makes time go faster, whereas unique and memo-rable events slow down time. Maybe, if we want to ‘slow down’ time, we should focus on changing routine and creating unique experiences for each one. We can also engage in greater mindfulness - fo-cusing on and savouring each passing moment. The old adage of ‘live for the mo-ment’ is the key to slowing down those quickly passing years. You may be thinking, how does this link in with this month’s NHD? Mindfulness for dietitians by Jackie Doyle describes mindfulness interventions and their potential appli-cation in healthcare. Two mindfulness interventions that have been developed for people with eating difficulties are also summarised. Early years nutrition is the topic for two articles. Kate Harrod-Wild tells us that the toddler years can be difficult and food can become a big issue with many young children. Kate covers fussy feeders, healthy snacks, ensuring adequate fluid intake and also some common nutrition related problems. Judy More and Melanie Pilcher look at the the role for early years’ providers in encouraging healthy eating habits for life. Food provision within early years’ settings has a significant role to play and the article covers the importance of investing in clear guidance, specific nutritional standards and training on healthy food provision in the early years of life as paramount.

For those of you working in the NHS you will know that innovative ways of working are being encouraged. Telemedicine is becoming more common. Noelle Cooper and Carolyn Jones share their experience of introducing and evaluating Skype clinics in Telemedicine and weight management. It seems that the patients had positive experiences and both the staff and Trust could see the benefits. Moving on to novel procedures, Karen Jackson tells us about Fistuloclysis or Distal Enteral Tube Feeding (DETF). If you are not familiar with this form of nutritional support then please read on. Karen also includes a case study with a lady who experienced problems with tolerance and compliance. Did you know that 27.6% of the cys-tic fibrosis population (1,924 people) has cystic fibrosis related diabetes? Cystic fibrosis related diabetes by Sarah Collins tells us more about pathophysiology, drug and nutritional management and their challenges and the importance of a MDT approach which can help reduce complications of the disease. Neil Donnelly has a nostalgic look at the dietetic past and present in The Final Helping to complete NHD for 2015. Finally, I hope that you all enjoy the festive celebrations and may I wish you all a very Merry Christmas and a Happy New Year. I wonder if 2016 will fly by as quickly as 2015 has.

NHDmag.com December 2015 /January 2016 - Issue 1104

Chris rudd, Dietetic advisor

neil donnelly, Fellow of the bDa

ursula arens, writer, Nutrition & Dietetics

dr emma derbyshire, Nutritionist, Health writer

emma Coates, Senior Paediatric Dietitian

noelle Cooper, Specialist Community Dietitian

Carolyn Jones, Specialist Community Dietitian

Sarah Collins, CF Specialist Dietitian

Karen Jackson, registered Dietitian

Kate harrod-wild, Specialist Paediatric Dietitian

Judy more, Dietitian and registered Nutritionist

melanie pilcher, Policy and Standards Manager, PLa

dr Jackie doyle, University College London Hospitals

dr fiona Carter, eraS UK Manager

6 News latest industry and product updates

8 Dietetic services: e-clinics telemedicine and weight management

19 Fistuloclysis or DETF nutritional challenges and management

23 Nutrition in the early years the challenges faced

30 Pre-school food provision the role for early years’ providers

33 Skills and learning mindfulness for dietitians

36 Book review Proteinaholic by garth davis

39 Web watch online resources and updates

40 ERAS UK Conference report

44 dieteticJOBS latest career opportunities

45 Events and courses upcoming dates for your diary

46 The final helping the last word from neil donnelly

13CoVer storyCystic fibrosis related diabetes

editorial panel

Contents

editor Chris rudd rDPublishing director Julieanne Murray Publishing editor Lisa JacksonPublishing assistant Katie Dawson design Heather Dewhurstadvertisement sales richard Mair Tel 01342 824073 richard@networkhealthgroup.co.uk

address Suite 1 Freshfield Hall, The Square, Lewes road, Forest row,east Sussex rH18 5eSPhone 0845 450 2125 (local call rate) fax 0844 774 7514email info@networkhealthgroup.co.uk www.NHdmag.com www.dieteticJobs.co.uk

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

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From birth to discharge and beyond, the ESPGHAN-compliant1 Nutriprem range is designed to aid the development of preterm babies. For products that support feeding

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Important notice: Breastmilk is best for babies. Nutriprem Breastmilk Fortifi er is a nutritional supplement designed to be added to expressed breastmilk for feeding preterm and low-birthweight infants. Nutriprem Protein Supplement, Hydrolysed Nutriprem, Nutriprem 1 and 2 are foods for special medical purposes. They should only be used under medical supervision, after full consideration of the feeding options available, including breastfeeding. Hydrolysed Nutriprem, Nutriprem 1 and 2 are suitable for use as the sole source of nutrition for preterm and low–birthweight infants. Reference: 1. Agostoni C et al. J Pediatr Gastroenterol Nutr 2010; 50:85–91.

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

NHDmag.com December 2015 /January 2016 - Issue 1106

newS

Sugar has been a hot topic in the news recently. This has largely been driven by the

SACN report on Carbohy-drates and Health which has led to a number of new publications in this area. Two new papers published in Nu-trition Reviews have focused on the roles of ‘added sugars’ (those added to foods and drinks during processing and preparation) in relation to dietary quality and health. The first paper reviewed evidence from 22 studies, with all but one sug-gesting that higher intakes of added sugars were associated with reduced diet quality. A further 21 out of 30 stud-ies found higher intakes of added sug-ars to be associated with lower micro-nutrient intakes.

A second paper looked at the effect of added sugar intakes in relation to ectopic fat (fat that builds up in places other than beneath the skin). Findings from 14 RCTs suggested that excess sugar intakes were linked to larger fat depots, especially in the liver and mus-cle fat. That said, report bias was likely in some of these studies. Subjects were also tested under hypercaloric condi-tions, i.e. when they ate more calories than needed. Taken together, these are interesting findings suggesting that ‘added’ rather than total or intrinsic sugars pose most risks to health. Now further well de-signed RCTs with adequate power and duration are needed. For more information, see: Louie JC and Tapsell LC (2015). Nutrition Reviews [Epub ahead of print] and Ma J et al (2015.) Nutrition Reviews. [Epub ahead of print].

Fluids, but especially water, are essential to life. Unfortunately, fluid intakes are often overlooked from studies in favour of food and nutrient intakes. Now, new research has focused solely on evaluat-ing fluid intakes. A systematic review of studies was undertaken, focusing on healthy chil-dren, teens and adults living in cities. It was found that total beverage in-takes ranged between 0.6 and 3.5 litres per day. Plain water contributed to 58%, 75% and 80% of total beverage intakes in children, teen and adults, respective-ly. Milk was consumed more often in childhood, soft drinks during the teen-age years and tea, coffee and alcohol in adulthood. Overall, water contributed most to total fluid intakes, while the consump-tion of other drinks tended to vary ac-cording to life stage. For more information, see: Ozen AE et al (2015). Journal of Human Nutrition & Dietetics Vol 28, Issue 5 pg 417-22.

eat fisH to imProVe VitamiN d status?Fish is an important natural source of vitamin D. However, it’s still out on the jury whether habitual intakes alone are enough to maintain adequate status. A new paper has looked at this in detail. A meta-analysis published in the American Journal of Clinical Nutrition analysed data from seven RCTs and two unpublished studies (640 subjects in to-tal), all measuring fish intakes in rela-tion to vitamin D status (as 25(OH)D). When compared with controls, it was found that eating fish increased vitamin D levels by an average of 4.4nmol/L. Eat-ing fatty fish led to a mean difference of 6.8nmol/L when compared with controls. These findings show that while fish (particularly oily fish) is an importance source of vitamin D, current intakes and, indeed, recommendations are un-likely to lead to the attainment of opti-mal 25(OH)D status. For more information, see: Lehmann U et al (2015). Amer-ican Journal of Clinical Nutrition Vol 102, no 4, pg 837-47.

latest studies oN sugar

NeW fluid iNtake aNalysis

NHDmag.com December 2015 /January 2016 - Issue 110 7

newS

berries to imProVe memory?Berries are a great source of polyphenols, which are thought to support brain neurogenesis (the growth and development of nerves), which in turn, is involved in learning and memory. Now, new animal research has studied this further.

Aged Fischer rats (n=344) were fed a control 2.0% strawberry or 2.0% blueberry-supplement-ed diet for eight weeks. Behavioural changes and brain function were monitored. It was found that rats eating the berry diets had improved cognition (brain function), with work-ing memory found to improve the most. Improve-ments in brain neureogenesis were also seen. While human trials are clearly needed, these are interesting findings suggesting that polyphe-nols found in berry fruits may help to support cognition and memory with advancing age. For more information, see: Shukitt-Hale B et al (2015). British Journal of Nutrition Vol 114, Issue 10, pg 1542-49.

CHoliNe iNtakes of euroPeaNsCholine is a B vitamin and an important nutri-ent. Nevertheless, it is often omitted from dietary surveys. Now, new work has estimated habitual choline intakes across a European population. Choline intakes were calculated using the European Food Safety Authority European Com-prehensive Food Consumption Database and food values derived using the US Department of Agriculture Nutrient Database. Interestingly, average choline intake ranges were: 151-210mg/d for toddlers (1 to ≤3 years old), 177-304mg/d for other children (3 to ≤10 years old), 244-373mg/d for teens (10 to ≤18 years old), 291-468mg/d for adults (18 to ≤65 years old), 284-450mg/d among elderly people (65 to ≤75 years old) and 269-444mg/d among very elderly people (≥75 years old). In most population groups, aver-age choline intakes were lower than adequate in-takes set by the Institute of Medicine, with meat, milk, grains and eggs providing most choline. While these findings are a useful guide to how much choline people are eating, more work is needed to improve choline food composition databases. That way, the accuracy of future work in this area can be optimised. For more information, see: Vennemann FB et al (2015). British Journal of Nutrition [Epub ahead of print].

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Issue 103 April 2015

NHDmag.com

NUTRITIONAL BENEFITS

OF YOGHURT

Helen Kingett

Bariatric Dietitian

INTENSIVE WEIGHT CONTROL

PROGRAMME . . . p20

WEB WATCH NEW RESEARCH

Carrie Ruxton and Frankie Phillips p25

ELDERLY CARE HOME NUTRITION

PEG FEEDING: CASE STUDY

FALTERING GROWTH

CANCER CARE NUTRITION

Issue 105 June 2015

NHDmag.com

ENTERAL FEEDING FOLLOWING STROKE

Dimple ThakrarPrescribing Support DietitianBolton CCG

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

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NHDmag.com December 2015 /January 2016 - Issue 1108

The NHS is challenged to move with the times to offer innovative solutions to meet the demand of the expanding population and healthcare costs. The use of and confidence with technology is increasing, with a rising number of homes having access to the internet. In Great Britain, 84% had internet access in 2014 compared to 27% in 2006.1 Skype and other forms of video conferencing also continue to grow. To address this, our service was interested to find out whether our patients wanted to access the dietetic service via interactive technologies. A three-month survey showed that 33% of new patients were interested in having a dietetic Skype appointment. Following on from this, from August 2014, Berkshire Healthcare dietitians introduced Skype consultations to our patients in addition to face-to-face outpatient appointments. The rationale behind offering these e-clinics was to make our dietetic service more accessible to patients. Benefits in-clude reducing time off work, transport problems, clinic car park pressures and stress/anxiety, particularly in time of acute illness.

telemediCineTelemedicine is defined as the use of technology to deliver care at a distance. It is rapidly growing and can potentially access more patients, enhance patient/healthcare professional collaboration, improve health outcomes and reduce medical costs. Examples include:

• remote patient monitoring using technological devices which can be transmitted back to a monitoring centre for evaluation and stored in patients’ medical records, e.g. undernutrition monitoring using ‘Health Call’ from Focus on Under-nutrition Team (County Durham and Darlington NHS Foundation Trust);2

• mobile technology such as smart-phone applications and text mes-sages to manage and track health conditions or promote healthy behaviours;

• real-time interactive technologies such as a two-way video, e.g. Skype.

approval proCeSSAs part of a staff engagement pro-gramme (Listening into Action), our application was chosen by the Trust’s Executive Committee. We became a pioneer team with ongoing support from senior managers over a period of six months. Our team included an IT specialist who guided us through gaining clinical governance approval and creating a Standard Operating Procedure (SOP). We obtained Caldicott Guardian approval from our Clinical Director. Patient information leaflets were created to support Skype consultations, including guidance on how to download Skype. Patients were instructed that the dietitian would initiate the Skype call at their appointment time.

telemediCine And weight mAnAgement

noelle Cooper Specialist Community dietitian, berkshire healthcare nhS foundation trust

noelle and Carolyn have both worked in dietetics for over 20 years, with experience of working in acute and community settings. they currently work for Berkshire healthcare foundation trust.

from mobile working to skype consultations, berkshire Healthcare NHs foundation trust community dietitians have embraced the use of technology to offer more patient choice in their weight management consultation venues. this article looks at how they did this, how the processes they introduced are working one year on and asks you to consider whether you might apply this to your setting.

dietietiC ServiCeS - e-CliniCS

Carolyn Jones Specialist Community dietitian, berkshire healthcare nhS foundation trust

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Nutramigen with LGG® is not recommended for premature and immunocompromised infants unless directed and supervised by a healthcare professional. www.nutramigen.co.uk†Studied before the addition of LGG®. Calculated using data on allergic reactions after oral food challenge with an eHF from table 3 of Dupont C et al. 2012, as judged by the Committee on Nutrition of the French Society of Paediatrics. ‡vs an eHF based on casein, rice hydrolysate, soy and amino acid formulas. CMA, cow’s milk allergy; eHF, extensively hydrolysed formula; LGG®, Lactobacillus rhamnosus GG. References: 1. Dupont C et al. Br J Nutr 2012;107:325–338. 2. Nermes M et al. Clin Exp Allergy 2010;41:370–377. 3. Baldassarre ME et al. J Pediatr 2010;156:397–401. 4. Canani RB et al. J Pediatr 2013;163:771–777. 5. Data on file, 2014. IMPORTANT NOTICE: Breastfeeding provides the best nutrition for babies. *Trademark of Mead Johnson & Company, LLC. © 2015 Mead Johnson & Company, LLC. All rights reserved. LGG® is a registered trademark of Valio Ltd, Finland. This material is for healthcare professionals only. EU15.572/09–15.

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teChniCal requirementSIT uploaded Skype software onto department computers and sourced both headphones and web cameras. The aim was to ensure that the quality of our virtual consultations were on a par with face-to-face consultations.

Staff trainingStaff were offered in-house Skype training to ensure competency and confidence in delivering a good virtual consultation. Team members already using Skype on a personal basis were good advocates. As expected, there were some initial staff reservations for those unfamiliar with this form of communication, particularly around dealing with technical problems. These were overcome by the development of an SOP, enabling a consis-tent approach, along with troubleshooting tips.

marKetingAdministrative staff play a key role in recruiting and booking Skype appointments into our com-munity outpatient clinics. These appointments are well promoted and once agreed, further de-tails are collected including a patient’s Skype

username and contact phone number in case of failed technology. There are clear benefits to virtual consultations including a greater choice of where they are seen. Patients who are not able to attend an outpatient appointment and do not meet domiciliary criteria are now being offered a Skype appointment instead of a phone call. Clinic utilisation has also improved, as patients are being offered a Skype appointment when they phone to cancel their appointment. Skype appointments were first introduced in August 2014 and have now been running a year. Recruitment was initially slower than antici-pated, partly due to the waiting times. For new patients, there is still a preference to be seen face-to-face whenever possible. The numbers are now increasing with approximately seven patients re-ceiving dietetic advice via Skype per month.

patient feedbaCKFollowing a Skype appointment, patients were asked to complete an online survey. To date, 24 patients have reported their experience to be as follows:

NHDmag.com December 2015 /January 2016 - Issue 11010

dietietiC ServiCeS - e-CliniCS

Dietitians E-Clinic: Clinical Governance 29/07/14

Skyp

e ap

poin

tmen

tO

fferin

g Sk

ype

and

Book

ing

Remote clinic consultations, e.g. e-clinic, telephone, should maintain the clinical standards set for 1:1 clinic interventions. If by telephone, hands free ideal to avoid back injuries when typing. To ensure these standards are met, outlined below is a process to follow;

At appointment booking; Offer Skype appointment Skype Yes/No Yes

Offer standard appointment

No

Patient has Skype account

Take details and record, create appointment letter, including Dietitian’s Skype name. Upload to RiO documents

Yes

Send Skype account information (by

email)

No

Ask patient to contact service with Skype

username and record in RiO (separate process)

Book appointment and add to

comments box in the clinic

Identify yourself and confirm patientidentifiers e.g. name, DOB, address

Ask patient if they are happy tocontinue consultation (e.g. they are

comfortable/in a private place)

Thank them, say good bye and end the call

Document outcome in RiO and use the ‘Consultation medium:

Telemedicine web camera’ and book any follow-up/discharge as

required.

Verify connection, audio and visual, (can they see & hear you/can you see & hear them) IM

patient if problems are experienced

Clearly outline length of session and confirm reason for referral

Begin consultation, checking their understanding throughout particularly if no

video (body language)

Agree next steps and whether review required, whether 1:1 or e-clinic. IM

patient survey monkey hyperlink

Call quality OK?

Yes

Dietitians make contact with patient (Keep within 5 min slot)

Cancel Skype call and telephone patient to arrange appointment through

alternative medium. Record on RiO and outcome as ‘Session Cancelled’

NO

figure 1: technology dietitian workflow

NHDmag.com December 2015 /January 2016 - Issue 110 11

dietietiC ServiCeS - e-CliniCS

• 100% requested a future appointment and would recommend a friend

• 100% said the appointment was convenient• 95% rated the experience as ‘good’ or ‘excel-

lent’• 67% reported time off work was not needed• 63% would have been unable to attend a face-

to-face appointment• 78% did not experience any technical issues

Staff feedbaCKOverall, the experience has been positive with increasing staff confidence and competence. Technical issues were overcome by training as well as following the SOP and clinical gover-nance pathway. In our favour, technology is an important part of our working day with all staff having ac-cess to mobile working and using an electronic patient record system (RiO) to document dietetic intervention. A disadvantage of Skype appointments is the reliance on patient self-reporting, e.g. body weight. However, there is recent evidence that self-reporting has become more accurate amongst overweight and obese patients.3 For those unable to self-weigh, other measures could include clothes or waist size.

outComeSA wide variety of clinical conditions are being seen including nutritional support, weight management, gastroenterology, diabetes and paediatrics. Over the last year (Sept 2014 to August 2015), we have seen 66 patients (28 new patients and 38 follow ups) from all age groups (early 20s to late 70ss).

The following table shows the benefits of of-fering Skype appointments to patients, staff and the Trust:

ConCluSionSOver the last year we have shown that Skype appointments can be successfully applied to our dietetic practice without impacting on ser-vice delivery. Although Skype consultations are not suitable for everyone, they are an addition to and not a replacement for the traditional face-to-face appointments, hence giving wider patient choice. We have been fortunate to have Trust support in introducing Skype appointments early on and we envisage that, as patient demand increases, we will have the expertise and confidence to be able to meet this demand. As technology has be-come the norm in most people’s lives, the public is becoming more open to telemedicine as a form of healthcare delivery for preventive care, acute care and chronic disease management. Through the use of Skype appointments, we have raised the profile of the dietetics service across Berkshire Healthcare. The opportunity to run Skype clinics is now being opened up to other services within the organisation. We would encourage other dietetic services to consider patient benefits and introduce virtual consultations. For the future, dietetic e-clinic consultations could one day complement evidence-based online programmes and approved smart phone apps.

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

Patient outcomes staff outcomes trust outcomes

Saves on time off work and travel. good patient clinic attendance.efficiency and cost savings, e.g. less car park congestion.

Saves on fuel and parking costs.

Superior to email or telephone as can see body language and cooking environment. better understanding of portion sizes through seeing plate sizes, etc.

positive patient experience.

Safe alternative in adverse weather conditions.

Saves on clinical time due reduction in clinic travel.

working together increasing patient choice.

more choice where to be seen with increased access for some patients.

better able to meet patient needs in timely manner.

optimal clinical outcomes, seeing patients at right time and place.

table 1: the benefits of offering Skype appointments to patients, staff and the trust

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