Issue 2 9 £2.00 INTouch to non members

The Newsletter of the British Association for Parenteral & Enteral Nutrition ISSN 1479-3806 Printed Version ISSN 1479-3814 On Line Version ‘MUST’ puts malnutrition on the map

The British Association for Parenteral & Enteral Nutrition is a multi-professional association and registered charity established in 1992. Its membership is drawn from doctors, dietitians, nutritionists, nurses, patients, pharmacists, and from the health policy, industry, public health and research sectors. Principal Functions Television presenter and health campaigner, Lynn Faulds Wood, far right, chaired the hugely successful media launch of the ‘Malnutrition Universal Screening Tool, 'MUST' in early November at the Royal College of Physicians and Enhance understanding and headed an eminent panel of speakers [from left] Professor Jeremy Powell-Tuck, management of malnutrition Dr Angela Madden, Lynne Colagiovanni, Professor Marinos Elia, Professor Alan Jackson and Frank Ursell. Establish a clinical governance framework to underpin the nutritional Lynn Faulds Wood's personal perspective on bowel cancer management of all patients treatment and weight loss provided a powerful conclusion to the media launch of 'MUST' which was successfully webcast. Enhance knowledge and skills in It has been viewed independently by over 500 professionals clinical nutrition through education and communicators and is archived for on-going review at and training www.bapen.org.uk/webcast

Communicate the benefits of clinical The British Dietetic Association (BDA) supports the 'MUST' and cost-effective optimal nutritional wholeheartedly and is continuing to work with the care to all healthcare professionals, Malnutrition Advisory Group (MAG) to ensure nutritional policy makers and the public screening becomes embedded in practice. Dr Angela Madden, Chair of the Research Committee, represented the Fund a multi-professional research BDA at the media launch and pressed home this message. programme to enhance understanding Copies of the 'MUST' and its of malnutrition and its treatment accompanying explanatory booklet are being distributed with a forthcoming issue of Dietetics Today. Contents Care homes are being inspected on their food, nutrition and “MUST” Launch News p1 meals policy and practice; screening is expected to be in place to ensure that those unable or unwilling to eat, or Chairman’s Annual Report p2 already under-nourished, are identified and appropriate ‘MUST’ p3 medical care put into place. Frank Ursell, Chief Executive Officer (CEO) of the Registered Nursing Home Association (RNHA) confirmed his Child of Courage p3 organisation's support of 'MUST'. All RNHA members will BAPEN Annual Meeting p5 shortly receive a copy of the Tool.

Malnutrition in Obesity p5 Chair of a Founder Group of BAPEN the National Nutrition Nutrition in Critical Care p6 Nurses Group (NNNG), Lynne Colagiovanni confirmed that nurses in hospitals, in the community and in care settings TNutrition and Palliative Care p7 were the front line professionals who will deliver nutritional Journal Watch p8 screening. "We accept that responsibility and look forward to the support of our dietetic colleagues in driving home Nutrition & CateringFramework p9 implementation to the benefit of all." All NNNG members Future Events p11 will shortly receive copies of the Tool Continued on page 3 Food & Nutritional Carein Europe p12 All contents and correspondence are published at the discretion of the editors and do not necessarily reflect the opinions of BAPEN. The editors reserve the right to amend or reject all material received. No reproduction of material published within the newsletter is permitted without written permission from the editors. BAPEN accepts no liability arising out of or in connection with the newsletter. BAPEN Officers Contact Details Chairman’s Report

Dr Alastair Forbes Tel: 020 8 235 4016 2002 - 2003 BAPEN Chairman Fax: 020 8 235 4039 Since my last piece for In Touch, more than 600 of you email: [email protected] participated in our annual meeting in Telford. I am happy to be considered biased, but I thought the event went very Mr Niall Bowen Tel: 01225 711 571 well indeed, with a high standard of scientific Hon Treasurer Fax: 01225 711 798 presentations, focused educational and review lectures, and email: [email protected] a nice mix of multi-disciplinary contributions of all sorts. I believe that the two-day format has worked and that we are on the right road for the future. What is more, for the Mrs Pat Howard Tel: 0117 928 2049 first time the annual meeting will have returned a financial Hon Secretary Fax: 0117 928 3005 profit too. Many congratulations are due to the email: [email protected] Programme Committee and all those who helped the meeting to take shape. Ms Vera Todorovic Tel: 01909 500990 Ext: 2773 Special congratulations are also due to (PEN Group) Fax: 01909 502809 Vera Todorovic, our newest Lennard-Jones Chairman: Communications medallist, well known of course to readers & Liaison Committee of In Touch in her editorial capacity, and a email: vera.todorovic@bhcs- tr.trent.nhs.uk stalwart of BAPEN since its earliest days. We are making progress with the BAPEN Mr Geoff Simmonett Tel: 0116 286 7442 Themes for 2004. Nutrition Teams are to be tackled (PINNT) Fax: as telephone primarily from the standpoint of setting achievable Chairman: LITRE standards, as Pat Howard and I outlined in the closing email: [email protected] session of the Telford meeting. The greater involvement of BAPEN in the community will be Prof Agostino Pierro Tel: 020 7 905 2175 approached though ever closer collaboration with industry, Chairman: Research & Fax: 020 7 404 6181 and the November launch of the ‘MUST’ will prove a Science Committee tremendously productive entrée and subsequent lever for email: [email protected] this. BAPEN members should not forget our individual and collective role in promulgating ‘MUST’ and all that it stands for. Dr Ian Fellows Tel: 01603 288 356 Chairman: Education & Fax: 01603 288368 I fear that I have upset the Trustees by my comments in a Training Committee previous issue of In Touch, in appearing to suggest that they were under-performing in some way. This was certainly not email: [email protected] my intention. My comments followed on from discussions Prof Marinos Elia Tel: 0238 079 4277 (direct) in Council around the requirements of the Charity Commissioners, which make it clear that the legally defined Chairman: MAG Fax: 0238 079 6317 (secretary) charitable trustees of an organisation are necessarily those email: [email protected] with a responsibility for the day-to-day running of that organisation. Dr Barry Jones Tel: 01384 244 074 Chairman: BANS Fax: 01384 244 112 We had come to the conclusion that this was not a role we should be expecting of our existing Trustees, who we need email: b.j.m.j @btinternet.com to take a strategic and guiding stance, and on whom we should not expect to place too great a personal BAPEN OFFICE: responsibility. Any change is of course dependent on widespread agreement, and all of these aspects will form Secure Hold Business Centre, Studley Road, part of our collective review of the governance of BAPEN. Redditch, Worcs. B98 7LG We are working on an updating of the constitution as I Tel: 01527 457850 Fax: 01527 458718 described before. A provisional draft has been circulated to Council and to the Trustees for comments, and a second draft, taking into account comments received, will be To contribute to InTouch please contact the editors: available on the website shortly ..

Vera Todorovic Tel: 01909 502773 The constitution should represent the vision of as many of email: vera.todorovic@ bhcs-tr.trent.nhs.uk BAPEN’s members as possible, and in asking for your contributions to this process I should like also to take the Niall Bowen Tel: 01225 711571 opportunity to wish everyone a happy and fruitful 2004. email: [email protected] Dr Alastair Forbes Chairman BAPEN

2 ‘MUST’ puts malnutrition on the map

continued from page 1 campaign and the and care home "BAPEN is extremely commitment of BAPEN professionals. proud of the and MAG members. development of the Additionally, the ‘MUST’ 'MUST' and the Such coverage has itself, The MUST contribution it will helped to establish Explanatory Booklet and the make to improving malnutrition in the Executive Summary of The clinical outcomes for minds of healthcare ‘MUST’ Report are now patients and those in the community," professionals and the available to download from stated Professor Jeremy Powell-Tuck, public as a key health the BAPEN website, BAPEN Council member, at the 'MUST' issue. www.bapen.org.uk media launch. "We all congratulate Marinos Elia and the MAG members Printed copies of these, plus the full on this significant achievement. “MUST” at BAPEN Report, are available to purchase from BAPEN will be pressing the the BAPEN office. appropriate authorities to ensure that Supported by the British Dietetic Rhonda Smith nutritional screening becomes Association (BDA), nurses’ BAPEN Media Co-ordinaror embedded in policy and practice as organisations, including the NNNG quickly as possible." and the Royal College of Nursing (RCN) and the Registered Nursing ‘MUST’ – 6 page full colour flowchart Massive Press Coverage Home Association (RNHA), the ‘MUST’ with BMI chart, weight loss table and also enjoyed a successful launch to alternative measurements. healthcare professionals at the BAPEN £2 per copy A highly successful launch resulted in Symposium. massive coverage on TV, radio and in The ‘MUST’ Explanatory Booklet – 32 the newspapers – and healthcare Over 600 delegates received their pages, two-colour guide to using the professionals flocked to the BAPEN ‘MUST’ pack, which contained a copy ‘MUST’. Ideal for training. Symposium to have first sight of the of the Tool and supporting £5 per copy ‘MUST’ materials. documents. Many also attended Round Table Surgeries where they The ‘MUST’ Report – 140 pages, fully Malnutrition in the UK was top line were able to discuss implementation referenced report. £20 per copy news on BBC and independent issues with MAG members. television and radio and in the All prices quoted inclusive of post & newspapers on 11 November, 2003 ‘MUST’ materials are currently being packing in UK. For overseas orders add thanks to a concerted media distributed widely to nursing, dietetic £5 for receipt of all three documents. Samuel - a child of courage

"The best bit was collecting my A Reception at Downing Street, where medal," said Samuel Bell, aged 5, who the children and their families met has been named a Child of Courage Tony and Cherie Blair, was also a great and accepted his Award from 2003 success - with little Leo being brought Fame Academy winners Alex Parks down to play with the children! and Alistair Griffin. Raising awareness about Samuel, who is on Total Parenteral Nutrition (TPN), walked up on his own artificial nutrition to collect his medal at the star- studded Christmas-themed ceremony Carolyn Wheatley of Patients on in Westminster Abbey on 10 Intravenous and Naso-Gastric December 2003. The event, hosted by Nutrition Therapy (PINNT), who Samuel meets Santa at Harrods Anthony Andrews, was organised by attended the Westminster Abbey Woman’s Own magazine and featured ceremony, said: "It was a humbling PINNT (Patients on Intravenous and many TV stars including those from experience seeing all those oh so Nasogastric Nutrition Therapy) and Coronation Street and Eastenders. brave children. I feel very privileged to now run the Scottish group of this have been part of it – and without UK-wide patient support organisation. doubt Samuel’s win has raised the Awards for bravery and profile of artificial nutrition. He took A magical trip to Harrod’s to meet the extraordinary courage great pride in showing off his real Father Christmas – Simon Cowell rucksack and feeding kit to many had stood in at Westminster Abbey 12 children collected awards for celebrities and guests!" the day before! – rounded off an bravery, having earned this special extraordinary trip for Samuel and his accolade for overcoming ill-health or Samuel’s story is unique; he is the only family, a trip that not so long ago his demonstrating extraordinary courage person in the UK to have total family would not have believed in the face of danger. intestinal Hirschsprung’s disease. possible. Samuel’s family are active members of

3 Highlights from the BAPEN Annual Meeting

The 13th Annual BAPEN meeting, held at the Telford International Centre, hosted two days of presentations to well over 600 delegates. This short report aims to present just some of the topics covered during this highly successful meeting which included six main sessions, three key note lectures and 62 original contributions given as oral presentations or posters. ‘MUST’ the ‘Malnutrition Universal Screening Tool’

The launch of the ‘Malnutrition • Step 3 - Establish acute disease the identification of people at risk of Universal Screening Tool’ (‘MUST’) effect and score malnutrition – in all health and care took centre stage at the meeting and settings as well as in the community. was hailed as a real breakthrough by • Step 4 - Add scores from Steps1, 2 BAPEN Chairman, Alastair Forbes. and 3 and obtain overall risk score ‘MUST’ and early screening

"I am proud of the work that BAPEN • Step 5 - Use guidelines and/or in the elderly is doing in enhancing understanding local policy to develop care plan. of nutrition among healthcare ‘MUST’ has already been used in a professionals, policy makers and the Multidisciplinary care and survey by Claire King and colleagues public," he said. Oral Communication (OC54) who responsibilty investigated the prevalence of ‘MUST’ is a five step screening tool malnutrition amongst patients for use in hospitals, the community, This tool was developed by the referred for district nurse care. nursing and residential care settings. Malnutrition Advisory Group (MAG) a Supported by the British Dietetic Standing Committee of BAPEN and is Use of ‘MUST’ in this group of Association, the Royal College of designed to promote patients indicated a higher than Nursing and the Registered Nursing multidisciplinary care and average risk of malnutrition, with a Home Association, the ‘MUST’ is responsibility with consequent statistically significant increase in designed to screen adults for risk of improvements in clinical outcome. prevalence of risk in those older than malnourishment, and identify under- BAPEN and MAG tested the tool for 65 years compared with those under nutrition or obesity. user-friendliness, validity and 65. reliability. The tool also contains management The importance of early nutritional guidelines to aid the development of The ‘MUST’ package consists of the screening, particularly in the elderly, care plans which can then be tailored ‘MUST’ itself, with chart, tables and was also highlighted by a new study using local policy guidelines and guidance on alternative by Jackie Eddington et al from driven by the individual needs of measurements if BMI cannot be Abbott Laboratories (OC17) who patients. obtained; The ‘MUST’ Explanatory showed prevention of Booklet, a guide to using the ‘MUST’; malnourishment is the key to The five steps of ‘MUST’ and The ‘MUST’ Report, the full improving outcome – in already evidence base on screening for malnourished, elderly patients malnutrition and use of the ‘MUST’. providing nutritional supplements • Step 1 - Measure height and after hospitalisation may be too late. weight and get a BMI score (chart provided) Information and training For more details on ‘MUST’ please contact BAPEN office or visit the • Step 2 - Note percentage BAPEN will be providing information, website www.bapen.org.uk. unplanned weight loss and score dissemination and training (tables provided) opportunities throughout 2004 to ensure that ‘MUST’ becomes embedded into practice and increases

Mike Stroud - an Unexpected Bonus

Mike Stroud’s epic “Seven by Seven by achievement in the seven consecutive Seven” marathon achievement in marathons by a donation to a charity which he accompanied Sir Ranulph which I know he would approve of, Fiennes on a gruelling schedule of and which needs money even more seven marathons in seven days on than the British Heart Foundation he seven continents has brought an extra and Ranulph Fiennes supported. I bonus to BAPEN. therefore enclose a cheque to BAPEN.”

A letter arrived at the BAPEN Office The donor particularly requested with this simple message: “I have anonymity wanted to recognise Mike’s astonishing Mike Stroud, a seven marathon man 4 Telford International Centre – November 2003 The Way Forward Nutritional support teams Muriel Gall and colleagues (OC41) expected to have and key tasks they found that by developing a are likely to undertake. and screening multidisciplinary decision-making As a result, BAPEN hopes to develop an A major emphasis in BAPEN has always pathway, supported by training, they appropriate organisational structure to been on the need for multidisciplinary were better able to ensure the support CNSTs both locally and team work and several presentations appropriateness of referrals for home nationally, and in this way, all patients were aimed at different aspects of this enteral feeding. referred to CNSTs in future years topic. should receive an explicit, consistent Under-utilised talents and and high quality service. In a study on the impact of a nutritional support team (NST) on the ad hoc organisation One way such teams may operate more gastrostomy services of a district Clinical nutrition support teams (CNSTs) cost effectively would be to use the hospital, Edwards et al (OC60) were currently appear to be organised in an talents of dietitians and pharmacists able to show that screening by such a ad hoc manner in the UK with no more widely. A study reported by team had identified 65% of patients as Kristine Farrer (OC8) showed that a unsuitable for the dietitian and gastrostomy for "We have found that multidisciplinary NST working, pharmacist can which they had including carers and patients where possible, provides a safe, competently been referred. "We prescribe and have found that high quality, equitable service for patients in both the clinically manage multidisciplinary NST primary and secondary health care setting." TPN for a cohort of working, including surgical patients. In carers and patients where possible, consistent standards of service, said Pat this study, a total of 243 clinical provides a safe, high quality, equitable Howard, who outlined BAPEN’s activity decisions were made, the majority of service for patients in both the primary in this area and its attempts to which made a significant improvement and secondary health care setting," improve such inconsistencies. BAPEN to patient care (53%) and none of commented Edwards. proposes to identify key areas of CNST which were judged as unsafe. activity in which standards could be In another study in nursing home set, together with identifying skills Further information about BAPEN 2003 patients, screening reduced referrals which such teams can collectively be can be found on the BAPEN website for enteral feeding by a massive 80%. www.bapen.org.uk Malnutrition in Obesity

Outcome and screening in responses in order to predict Powell-Tuck discussed the outcome in obese and lean management of short-term intestinal obese patients individuals. As well as predicting failure in obese patients, where clinical response from models of appropriate energy requirements can UK statistics suggest that obesity is metabolic response, it is important be difficult to calculate. increasing dramatically and that that obese individuals undergo figures have roughly doubled since proper nutritional screening, prior to Although several guidelines exist, the mid 1980s with 17% of men and or after surgery. very few units have the resources to 21% of women currently classed as offer routine indirect calorimetry for obese (BMI >30 kg/m2). Current screening definitions, artificially fed obese patients. One however, mean that many obese approach in critically ill patients, in Whilst malnutrition in obesity may patients will be classed as having whom it may be difficult to assess seem unlikely, such hospitalised obese little or no risk of under-nourishment body weight or ideal body weight, is patients may present particular after injury, said Isobel Davidson and to intentionally under supply energy. problems and as Professor Marinos Sara Smith from Edinburgh in their Elia outlined, there are different presentation on Nutritional Although this is associated with metabolic responses to both injury Assessment in Obesity. severe negative nitrogen balance in and starvation between obese versus early studies in patients with multiple lean individuals. This could be a problem since it may trauma, recent studies of such hypo- negate any further monitoring and, caloric feeding have given more Although obesity may give survival as a consequence, clinically significant encouraging results and should be benefit in situations of starvation it weight loss may go unrecorded and considered – the most recent of these does not appear to confer the same increases in morbidity and prolonged was a study undertaken by Dickerson benefits following injury when rehabilitation could result. and colleagues reported in Nutrition metabolic response is exaggerated in 2002 18; 241-246 these individuals. Intestinal failure and Claire Gurton Such observations, said Professor Elia, feeding strategies BAPEN Symposium Rapporteur highlight the need to interpret the Feeding obese patients can also clinical relevance of metabolic present problems. Professor Jeremy

5 Highlights from the BAPEN Annual Meeting Nutrition and Metabolism in Critical Care

Cytokines and hormones - Are patients who are Are guidelines always new therapeutic receiving nutritional followed - enteral feeding in interventions support being fed properly? ICUs?

Critical illness is associated with Malnutrition affects both surgical and Patients who are critically ill may go various different degrees of critically ill patients with 43% of ICU through a starvation period prior to malnutrition and these may be patients being considered as illness or during illness and are often associated with particular malnourished. Although this may be malnourished on admission to biochemical changes, such as the the result of many factors, are intensive care units. In these release of specific cytokines and patients who are receiving nutritional patients, enteral feeding has been acute metabolic responses that result support being fed properly? shown to improve outcome, but are from hormonal changes. guidelines for use always used? This was the question posed by Clare Andrew Milestone and colleagues Lyle Moldewer from Florida Reid in her presentation on the from London (OC12), presented an presented up to date information on nutritional requirements of surgical original audit from their hospital specialised proteins or cytokines and critically ill patients. which showed some generally which play an important role in the encouraging findings. However, critically ill patient, since it is the Although indirect calorimetry is the some adjustments to practice were pattern of cytokine production that gold standard for assessing energy needed since in 62% of their patients will determine whether or not the requirements, this is rarely used in there was a delay in starting enteral patient displays a strong everyday clinical practice and various feeding and guidelines were not immunological response to injury, surveys have attempted to produce followed (unjustifiably) on 22% of trauma and/or infection. guidelines for the energy patient days.

Modulation of cytokine response is currently under …most patients require no more that 2-2.5 Litres of water and 60- investigation and appears to 100 mmol of sodium per day to prevent a positive fluid balance. have the potential to improve outcome. However, much more requirements of various different research work is needed before such groups of surgical patients. Don’t overlook fluid and theories can be put to the test in critical illness. The optimal energy requirements for electrolytes critically ill patients are more difficult Frank Weekers discussed the acute to assess, and although 25kcal/kg/day The appropriate prescribing of fluid metabolic responses that occur in may be an acceptable target intake and electrolytes post-operatively can critical illness which are thought to for many, septic or trauma patients decrease morbidity and mortality and be adaptive and to help healing in may need more - if we fail to give is just as important as other wounded tissue. adequate energy, or conversely give nutritional needs in critically ill and too much, we can significantly alter surgical patients, said Dileep Lobo in It has now become clear that these the outcome and prognosis of these his key note presentation (Nutrition acute stress responses are not severely ill individuals. Society Cuthbertson Medal Lecture) persistent throughout the course of on the physiological and clinical critical illness and as these adaptive Following on from this theme, Tony aspects of fluid and electrolytes. responses wane, destructive Murphy looked at a way of metabolic processes can take over. evaluating the energy requirements He discussed the relatively inefficient of hospital patients based on a ml/kg physiological response to salt excess Research has indicated that the lack approach to commercially available by the body and said that salt and of certain pituitary hormones Parenteral Feeds (PN) feeds. water overload could have associated with later illness may be considerable adverse effects. the cause and can be reversed by For these calculations the actual body administering the relevant weight is used for underweight He recommended that excessive hypothalamic releasing substances. patients and an adjusted body maintenance fluids should not be weight, equal to ideal plus 50% of prescribed once the need for As a result, said Dr Weekers, there is the difference between ideal and resuscitation has passed and that now the possibility of developing actual, is used for obese patients. most patients require no more that 2- therapeutic interventions that would 2.5 Litres of water and 60-100 mmol interfere with the cachexia of Based on these results an average of sodium per day to prevent a prolonged critical illness. patient with BMR of 25kcal/kg may positive fluid balance. need between 21-41 ml/kg of PN feed depending on the commercial feed Claire (med writer) used.

6 Telford International Centre – November 2003 Nutrition & Palliative Care BAPEN recognises that nutrition in and often leave patients feeling more to make the decision about when to palliative care is often under isolated and insignificant than stop feeding, the team must have a appreciated with needless patient before. clear understanding of all aspects of suffering the result. To draw this to the decision making processes. the attention of its members, one of After discussing the pros and cons of the major themes of this year’s both nasogastric feeding and PEG The withdrawal of nutrition and meeting was the critical role of tubes from the patient’s perspective hydration can have serious legal nutrition in palliative care. she concluded that, at present, the consequences and Barrister Charles benefits do not outweigh the Foster ended this session on palliative This lively session covered the burdens in patients where death is care by summarising the current state philosophy of palliative care, the inevitable. of the law on this matter.

The landmark case of Bland vs People need to feel love, to feel that they are Airedale Health Authority relied on significant and to have some certainty in their lives the fact that nutritional support was being omitted and also made the question of the patient’s ‘best benefits and burdens of end-of-life interests’ the touchstone for feeding and both the clinical and When to stop feeding? responsible decision-making. The legal aspects associated with the Bolam test is currently used to decide decision to stop nutritional support. In patients where withdrawal of whether or not the patient’s best nutritional support could in itself interests have been responsibly The first presentation was given by hasten death, when to stop feeding is assessed, which involves using a Kathryn Hopkins, a Macmillan Nurse a difficult question. Epidemiological reliable expert witness. Consultant in Palliative Care, who data show that the UK lags behind highlighted the fact that palliative other European countries and the However, the European Convention care does not just involve those with USA in its use of TPN. This may on Human Rights suggest in Article 2 malignant disease but also now suggest that we are not providing ‘the right to life’, in Article 3, the involves patients with COPD, CHD, optimal nutritional support for our right to ‘human and non-degrading dementia and chronic progressive terminally ill patients with malignant treatment’ and in Article 8, the right neurological diseases. diseases. to ‘respect for private and family life’.

She said that palliative care is all However, as Alastair McKinlay These articles are in conflict with the about addressing the quality of life highlighted, by using two very case of Bland and the Bolam test and and death in equal measure. It not different case studies, our use of TPN thus Mr Foster believes it is only a only involves a holistic approach to management but a multidisciplinary team effort. She felt that palliative ...nutritional care should be adaptive...as the care should be an essential part of disease,treatment and needs of the patient change the clinical practice of every healthcare worker and that all should be aware of the social, spiritual, in the UK may mean that we are matter of time before such psychological and medical nutritional thinking more carefully about the arguments increasingly intrude into needs of the patient and his/her decision of when to use TPN than the professional lives of all those family and carers. other countries. involved with TPN.

Kate Pickering from Leicester picked The decision making process is up on the importance of the needs of complicated and should involve the patient and family in her several factors associated with the presentation on the benefits and patients expectations, understanding INTouch burdens at the end of life. People and social circumstances, the disease need to feel love, to feel that they and its response to therapy and the are significant and to have some nutritional status of the patient at If you have a food or nutrition certainty in their lives she said, and diagnosis. related project or an article these are the very things that relevant to clinical nutrition that hospitalisation denies. Moreover, nutritional care should be adaptive and capable of evolution as you would like to discuss or publish details about, then contact These needs can also be seen in the the disease, treatment and needs of context of food and feeding where the patient change; whilst TPN for the editors to find out what you mealtimes involve social interaction malignant bowel obstruction may be need to do. indicated to maintain status prior to and nurture and are predictable. If a Vera Todorovic therapy and/or surgery, it may have decision is taken to start parenteral Tel: 01909 502773 nutrition, it can take away these no obvious benefit in patients with positive aspects of food and feeding, advanced untreatable disease. Thus, vera.todorovic@ bhcs-tr.trent.nhs.uk 7 Journal Watch - A Nurse’s View

2003 has been an exciting time for nurses, this year, straightforward articles such as no, really it has! A new journal this will help to imbed knowledge into enzyme arm and 8 control), which is a 'Gastrointestinal Nursing', (RCN current practice. I would recommend that lower occlusion rate than has been publishing) hit the racks earlier this year. all nurses involved in the administration of reported in the literature before. Although a year is a very short time in the medications by enteral tubes read this The authors report that the use of life of a new journal, the content is article. pancreatic enzyme is a relatively cheap relevant to nurses with an interest, or option to prevent occlusion in fine bore expertise, in gastroenterology, and most The Malnutrition Advisory Group (MAG of feeding tubes. They further suggest that of the articles are related to nutrition BAPEN) had a double page spread in this prophylactic use of pancreatic enzyme support. same issue of the Nursing Times to should be standard practice. coincide with the ‘MUST’ press launch. I think that the 'blanket' use of pancreatic The October edition (vol. 1, no.8) This gives a brief overview of the ‘MUST’ enzyme is probably not necessary but I will contained a review of the use of tool and its development (MAG 2003). I be looking into this further especially with probiotics in gastroenterology, (Hart et al hope that the Nursing Times continue to the 7fg surgically placed jejunostomy 2003) and a 'day in the life' interview with maintain interest in the ‘MUST’ tool as it tubes used locally. Once occluded these Pam Rogers (formerly a nutrition nurse gains momentum to improve its are difficult to salvage, The use of specialist). Pam now combines her acceptability amongst nurses. pancreatic enzymes may minimise the knowledge in gastroenterology, liver and occlusion rate and anything that will nutrition as a specialist paediatric GI nurse. Finally, a research article by Bourgault et al prolong the life of these tubes is (2003) published in Nutrition in Clinical beneficial. The National Nurses Nutrition Group Practice investigated the use of (NNNG) has been involved with the prophylactic pancreatic enzymes to reduce References: Nutrition Supplement of the Nursing feeding tube occlusions, a subject close to Bourgault AM, Heyland DK, Drover JW, Times for the past few years, and decided my heart. Some of the fine bore tubes Keefe L, Newman P, Day AG (2003) to up the profile, resulting in a very that we use in clinical practice are very Prophylactic pancreatic enzyme to reduce informative supplement (18 - 24 precious, because they are placed feeding tube occlusions. Nutrition In November 2003). surgically, endoscopically or radiologically. Clinical Practice. Vol.18, p 398 - 401. Blockages can be detrimental to the Hart AL (2003) The use of probiotics in the The supplement was chosen to re-launch patient, they miss essential nutritional treatment of intestinal and extra-intestinal the NNNG with a tie line of 'Good support and re-insertion of tubes can be disease. Gastrointestinal Nursing, Vol. 1, Nutrition Needs Nurses' in an editorial by costly (time and resources). No. 8, p26 - 31. Lynne Colagiovanni, Chair of the NNNG. MAG (2003) A consistent and reliable tool All of the editorial panel are NNNG 95 patients, involving 101 tubes, for malnutrition screening Nursing Times members. (intragastric or post pyloric) were Vol 99, No 46, p 26 - 27 randomised into receiving pancreatic Pickering K (2003) The administration of Kate Pickering (2003) had a very enzyme or water every 4 hours. The drugs via enteral feeding tubes. Nursing informative article, outlining the BAPEN results showed that the occlusion rates Times Vol. 9, No 46 p 46 - 49 'Administering drugs via enteral feeding and time to occlusion were significantly Andrea Cartwright tubes' working party publication. less in the enzyme arm, (p value < 0.04). National Nutrition Nurses Group Although the official launch was earlier 10 / 101 tubes occluded (2 from the Out of the ordinary

Vera Todorovic was awarded the John in Clinical Nutrition for Doncaster and Lennard-Jones Medal for outstanding Bassetlaw Hospitals NHS Trust. She is also an services to clinical nutrition at the BAPEN Executive Committee member of Bassetlaw Symposium 2003. PCT!

Chairmanship of BAPEN’s Communications Additionally, this is a commitment that has Committee is just one of the jobs that continued for many years – a commitment demonstrates Vera’s commitment to BAPEN that is certainly out of the ordinary! – and and clinical nutrition. As a member of fulfilled with great humour, grace and BAPEN Council, Vera contributes to the on- charm. going development and business of the Professor John Lennard-Jones congratulates charity, whilst her membership of the PEN The only answer ever is Yes! Vera Todorovic on her success Group of the British Dietetic Association keeps her in the forefront of developments "Whenever there’s a job to do, the only The John Lennard-Jones Medal is available in the field of clinical nutrition. Vera also answer ever from Vera is ‘yes!’" says Pat annually but is not routinely awarded. serves on the Malnutrition Advisory Group Howard, Honorary Secretary of BAPEN who Nominations are received by the BAPEN (MAG) , being a central contributor to the was centrally involved in the voting process Officers with a vote taking place among development of the ‘Malnutrition Universal for the John Lennard-Jones Medal. "Vera is Council members. Previous recipients of the Screening Tool’ (‘MUST’). permanently positive and a great Medal include Pat Howard, Carolyn Ambassador for clinical nutrition. She Wheatley, Professor David Silk and Professor And all this whilst she fulfils her thoroughly deserves this accolade from her Marinos Elia. considerable duties as Consultant Dietitian peer professionals and colleagues."

8 Nutrition and Catering Framework for Wales

In May 2002 the Welsh Assembly and timing of the principle meal of the Government (WAG) published a day are left to teams to arrange, An ongoing All Wales Nutrition and Catering Framework according to local operational needs. Catering following the Improving Health in The Framework requires introduction Framework/Nutrition Advisory Group is Wales plan. This document of risk screening as well as procedures suggested in the Framework and the incorporated 'Standard 23', being the for full nutrition assessment. Menus All Wales Dietetic Advisory Committee 23rd in a list of mandatory standards should be of known nutritional value strongly recommend that this be on which Welsh Trusts must report to in line with Nutrition Guidelines for implemented along with full funding WAG. Hospital Caterers (Department of for the Standard. Health 1995) A different approach Welsh representation for Focus on malnutrition joint initiatives The catalyst for the Framework was, of course, the English Better Hospital Untried and untested as yet is the Recently a representative for Welsh Food project, led by our English attempt to use 'food first' in the dietitians attended a joint planning colleagues. However, as in Scotland supplementing of patients with poor meeting of the British Dietetic latterly, WAG allowed a different appetite. A nutrition support snack Association, Hospital Caterers approach to be taken. The Framework should be available to those who are Association and Better Hospital Food. revised an existing standard for unable to meet their nutritional needs This is a positive step towards Catering, including 19 areas for through the menu. A standard has promoting joint initiatives in the UK. assessment on a range of issues from been suggested of minimum 10g We hope the recent EU Resolution on hygiene, purchasing, screening, food protein and 250 Kcalories. Again Food and Nutritional Care in Hospitals service and nutritional quality. implementation will be in accordance will be a useful driving force in Welsh with local policy. politics. For the purpose of writing the Julie Nedin, Caroline Hawkes Framework an All Wales Nutrition and The other specified nutrition standard On Behalf of the All Wales Dietetics Catering Group was created. is set for meal replacements. These Advisory Committee Representatives from Welsh must achieve a minimum of 15g professional groups created a lively protein and 350 Kcalories. This is to be mixed bag of views with Assembly aimed at patients who have missed a staff courageously attempting to keep meal during admission or because of a us to a very tight timescale. procedure or treatment due to being unwell at the time of their last meal. Putting nutrition high on the ESPEN 2004 agenda Targets set for 2002 were

Consulting with their colleagues the • 100% of inpatients to be given group aimed to set common standards nutrition screening on admission while allowing Trusts some flexibility on how to achieve them. The goal • All inpatients to receive a suitable was to put nutrition high on the nutritional alternative when a meal agenda, but the team felt strongly has been missed that a particular focus should be on malnutrition and the responsibilities of • Where required inpatients are all staff to achieve better outcomes. assisted in eating their meals

The necessity for a co-ordinated • Trust multidisciplinary teams to approach from staff features high in produce an action plan for the Framework and each Trust must implementation of Standard 23 name a Board Director to take lead responsibility for nutrition, catering and food hygiene. Limited motivation The assessment method so far has The framework process been by self scoring and there are currently no plans to audit externally. Examples of the process in respect to Dietitians in Wales feel that until menus are the requirement for there external assessment is imposed there to be a certain number of choices will be limited motivation for available at mealtimes, a range of compliance. dishes to meet dietary needs and preferences of care groups served, Trusts have set up implementation replacements if meals are missed, groups usually chaired by a nurse (the choice of portion size, and a limit on named lead responsible to the the length of time between meals. Assembly is generally a nurse) but some have dietitian or medical staff However, the type of catering service chairing. 9 The 13th BAPEN Annual Meeting will be held 17th-18th November 2004 at the Telford International Centre

Featuring:- • The Pennington Lecture • The Nutrition Society Symposium • PEN Group Annual General Meeting and Award • NNNG Annual General Meeting • The Nutrition Society Cuthbertson Medal Lecture • BAPEN Annual General Meeting • Exhibition • Original Communications • BAPEN Annual Dinner

To register your interest contact the Conference Organisers

Sovereign Conference, Secure Hold Business Centre, Studley Road, Redditch, Worcestershire, B98 7LG Tel No. +44 (0) 1527 518777 Fax No. +44 (0) 1527 518718. [email protected]

10 Forthcoming Conferences & Events

United Kingdom Dates

5 Mar 2004 Critical Care United The International Convention Centre, Birmingham National One Day Sharing Event For details please email: [email protected]

15-19 Mar 2004 Intercollegiate Course Chilworth Manor, Southampton. Course Organiser: Janice Taylor, on Human Nutrition Institute of Human Nutrition, Southampton General Hospital, Tel: 023 80796317, Fax: 023 80794945, email: [email protected]

20-21 Mar 2004 British Society of Gastroenterology Glasgow, Scotland For further information, please contact: Scientific Meeting 2004 British Society of Gastroenterology, 3 St Andrews Place, Regents Park, London NW1 4LB Tel: 020 7387 3534 Fax: 020 7487 3734 Email: [email protected]

1 April 2004 Trent Inaugural Regional Dr Jeremy Nightingale Consultant Gastroenterologist Tel: 0116 2586324 BAPEN meeting Fax: 0116 2586985 email: [email protected]

28 Apr-1 May 2004 International Coeliac Disease Waterfront Hall, Belfast. For further details please contact: Happening, Symposium 65 Eglantine Avenue, Malone Road, Belfast BT9 6EW Tel: 028 9066 4020 Fax: 028 9038 1257 email: [email protected]

29-30 Apr 2004 Hospital Caterers Association Hilton Brighton Metropole, Contact Nicola Price Tel: 01425 485040 ` Conference & Exhibition 2004 www.hospitalcaterers.org

6 - 7 May 2004 National Nutrition Nurses Bass Brewery, Burton on Trent, Contact: Dawn Bromley, Tel: 01473 704218 Group Meeting

6 - 7 May 2004 Primary Care 2004 National Exhibition Centre, Birmingham. For details contact Sterling Events Tel 0151 709 8979 Fax: 0151 709 0384 email: pc2004@sterling events.co.uk

3 June 2004 SW Regional BAPEN Meeting Contact Dr John Lowes Tel: 01803 654865 Fax 01803 654896 email: [email protected]

10 June 2004 Enterocutaneous Fistula London & North West. Contact Dr Simon Gabe. Tel: 020 8235 4177 Study Day Fax: 020 8235 4001 email: [email protected]

7-11 June 2004 21st PEN Group Clinical Update Queen Margaret University College, Edinburgh For further information please visit: www.peng.org.uk

15-17 June 2004 Food Allergy & Intolerance University of Surrey Contact Miss Mercedes Romano Tel: 01483 686413 Centre for Nutrition and Food Safety Fax: 01483 686481 email: [email protected]

15-17 June 2004 BDA 2004 Annual Conference Thistle Hotel, Glasgow, For further information please contact Sovereign Conference Tel: 01527 518 777 email: [email protected]

5-8 July 2004 Nutrition Society Summer Meeting Trinity College, Dublin. For full details visit www.nutritionsociety.org & Association for the Study of Obesity

18-22 July 2004 Nutrient Interaction with Gene Expression SECC, Glasgow. Contact Nutrition Society Meetings administrator, PO Box 485, Tring Hertfordshire, HP23 6YT Tel: 01422 825568 email: [email protected]

13-17 Sept 2004 Intercollegiate course Course Organiser: Dr Carolyn Summerbell, Reader in Human Nutrition, School of Health on Human Nutrition and Social Care, University of Teeside,Tel: 01642 342769 email: [email protected].

Oct 19 2004 London Intestinal Failure Day London . Contact Dr Simon Gabe. Tel: 020 8235 4177 Fax: 020 8235 4001 email: [email protected]

International Dates

26-29 May 2004 13th European Congress on Obesity Prague, Czech Republic. For details visit www.eco2004.cz

28-31 May 2004 14th International Congress of Dietetics Chicago, USA. For further details visit www.internationaldietetics.org/icd.asp

19-22 June 2004 International Society of Renal Venice and Padua. For further information, please contact: Nutrition and Metabolism Marianne Vennegoor, 3 Cottage Grove, Surbiton, Surrey KT6 4JH (please include stamped 12th International Congress addressed envelope) email: [email protected] Or www.nutrition.metabolism-2004.it

3-7 July 2004 2nd World Congress of Paediatric Paris, France. For further information, please contact: Gastroenterology, Hepatology Colloquium, 12 Rue de la Croix, Faubin, France www.wcpghan2004.com and Nutrition

11-14 Aug 2004 2004 Nutrition Society of Brisbane, Australia. In association with the International Congress of Clinical Nutrition Australia Annual Scientific Meeting For more details and contact details visit www.nsa.asn.au/ and www.wccn2004.com.au

11-14 Sept 2004 26th ESPEN Congress Lisbon, Portugal. For further information please visit www.espen.org

15-18 Sept 2004 3rd Congress of the European Vienna. For further information Tel: +33 1400 71121 or email: [email protected] Union Geriatric Medicine Society 11 Food & Nutritional Care in Regional Representatives Hospitals!

The Council of Europe report Scotland Dr Alastair McKinlay "Food and Nutritional Care in Consultant Gastroenterologist Tel: 01224 553628 Fax: 01224 550711 Hospitals: how to prevent email: [email protected] undernutrition" was published in November 2002. Readers will Ireland Ms Sharon Madigan remember that this report was Community Dietitian produced by an expert committee Tel: 02890 366 877 Fax: 02890 311 353 chaired by Professor Lars Ovesen email: [email protected] from Denmark and made up of Wales Dr Campbell Edmondson colleagues from 15 member states Consultant Anaesthetist within the Council of Europe. Tel: 01978 725955 Fax: 01978 725932 email: [email protected] I am delighted to report that the Committee of Ministers at their meeting on 12th November 2003 adopted the North West Dr John Shaffer resolution containing the recommendations of the report. Consultant Gastroenterologist These recommendations will be music to the ears of BAPEN Tel: 0161 7874521 Fax: 0161 7874690 email: [email protected] colleagues – they are wide reaching and touch upon every aspect of nutritional care in hospital. There are five broad North & Yorks Dr Nina Polanska areas addressed: Consultant Chemical Pathologist Tel: 0191 454 8888 bleep 351 Fax: 0191 202 4145 1. Nutritional assessment and treatment in hospitals email: [email protected] including: Trent Dr Jeremy Nightingale • Nutritional risk screening Consultant Gastroenterologist • Identification and prevention of causes of Tel: 0116 2586324 Fax: 0116 2586985 undernutrition email: [email protected] • Nutritional support • Ordinary food West Midlands Alison Fairhurst Tel: 01902 643183 • When to withhold or withdraw artificial email: [email protected] nutrition support Eastern (West) Janeane Dart, Chief Dietitian Tel: 01865 221703 Fax: 01865 741408 2. Nutritional care providers including email: [email protected]

• Responsibilities for nutritional care in hospitals East / Anglia Dr Ian Fellows • Communication Consultant Gastroenterologist • Education and nutritional knowledge at all levels Tel: 01603 288356 Fax: 01603 288368 email: [email protected] 3. Food service practices including North Thames Dr Simon Gabe Senior Lecturer • Organisation of hospital food service Tel: 020 8235 4177 Fax: 020 8235 4001 • Contract food service email: [email protected] • Meal service and the eating environment South Thames Mr Rick Wilson • Food temperature and hygiene Director Dietetics & Nutrition • Specific improvements in food service Tel: 020 73463243 Fax: as telephone email: [email protected] 4. Hospital food including South West Dr John Lowes • Hospital menus and diets on medical indications (West) Consultant Gastroenterologist • Meal patterns Tel: 01803 654865 Fax: 01803 654896 • Monitoring of food intake email: [email protected] • Informing and involving the patient South West Mr Peter Rhodes (East) Principal Pharmacist 5. Health economics including Tel: 0238 079 6090 Fax: 0238 079 4992 email: [email protected] • Cost effectiveness/benefit South East Miss Naeed Hussain • Food service and waste Pharmacist Tel: 01932 723743 Fax: 01932 873632 A very broad agenda, I am sure you will agree, and an email: [email protected] excellent framework around which to develop nutritional care services in hospitals and other institutions. At the time Industry Liaison Ms Julia Stanford of writing it is not clear how the member states and the UK Head of Nutrition governments in particular will implement the resolution. Tel: 01628 773355 Ext: 4353 Fax: 01628 644510 Undoubtedly this is a great step forward and will help us email: [email protected] greatly. Rick Wilson BDA representative on the Better Hospital Food Panel

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