Nasogastric tube feeding in line with new dietetic guidelines for the treatment of anorexia nervosa in a specialist children and adolescent inpatient unit: a case series.

BACKGROUND: The present study reports a case series where three adolescent patients with anorexia nervosa (AN) (two cases with typical AN and one case atypical AN) received nasogastric tube feeding under restraint in line with new dietetic clinical guidelines. METHODS: Three cases were chosen out of 61 admitted patients over the period of 1 year who were fed via a nasogastric tube under restraint in a specialist eating disorders unit for children and adolescents. These cases were chosen to highlight a range of clinical scenarios that clinicians may encounter. They also represent clinical scenarios where decisions to feed patients under restraint were rendered more complex by additional concerns. RESULTS: Despite the complexity of the cases, all patients tolerated the feeds well and were discharged home eating solid food. CONCLUSIONS: The decision to feed a patient against their will is never an easy one. Sadly, there have been some recent high-profile deaths of adult patients on medical wards where treatment opinion was not considered, and the patient received no or minimal nutrition when awaiting specialist treatment. Dietetic guidelines have been published to help inform clinicians for whom feeding under restraint may be out of the scope of their daily practice. This case series highlights clinical scenarios that illustrate the utility of the guidelines, which we hope will support clinicians when making, potentially lifesaving decisions in children and young people.

The development of consensus-based guidelines for dietetic practice in nasogastric tube feeding under restraint for patients with anorexia nervosa using a modified Delphi process.

INTRODUCTION: Nasogastric tube feeding against a person's will, under restraint, can be a lifesaving intervention for patients with severe anorexia nervosa. Dietetic guidelines have been developed to support dietitians in this specialised area. METHODS: A modified Delphi process was used in the development of the guidelines; stage 1, initial stakeholders created a draft; stage 2, creation of the working group; stage 3, comments and feedback on draft; stage 4, final draft agreed; stage 5, external review from Psychiatrists, patients and carers; stage 6, endorsement. Specialist mental health dietitians working in both adult and Child and Adolescent Mental Health Services (CAMHS) across four countries contributed to the development of the consensus guidelines. RESULTS: New guidance is outlined specifically for NGT feeding under restraint, which details the process, rate and volume of feed to comply with lawful guidance. CONCLUSIONS: Clinical guidelines were developed for dietitians treating patients with anorexia nervosa, using a modified Delphi process, incorporating both expert opinion and all available evidence. The guidance provides new information to dietitians and clinicians in how to enterally feed patients under restraint where none previously existed.

Guided self-help to manage binge eating in a dietetic-led community weight management service.

An estimated 30% of patients accessing community weight management services experience symptoms of binge eating disorder (BED). Guided self-help (GSH) is the recommended first line of treatment for BED. This study is a preliminary investigation into the effectiveness of GSH delivered by dietitians for patients with binge eating within a weight management service and a consideration of the association between wellbeing, therapeutic relationship and outcomes. The study was conducted as a single group, pre- and post-intervention study with 24 patients reporting symptoms of binge eating who completed the self-help manual with guidance from a trained community dietitian. Primary outcomes were eating disorder psychopathology and behaviours (Eating Disorder Evaluation Questionnaire), depression and anxiety. Principle results showed a significant reduction on all subscales of eating disorder psychopathology, anxiety and depression. There was a reduction in loss of control over eating but the 40% reduction in binge episodes was not statistically significant. Mid-treatment sessional ratings were positively associated with outcome. In conclusion, the GSH intervention was appropriate for dietitian delivery to patients with obesity and binge eating behaviour. This research indicates potential for other dietetic-led weight management services to deliver such interventions and support patients with binge eating accessing their service.

A Systematic-type Review of Observational Studies and Controlled Trials Examining the Effect of Dairy Products and Glycaemic Load on Acne Vulgaris.

Background: Acne vulgaris, a skin condition prevalent among teenagers and young adults, can be physically and psychologically detrimental to the sufferer’s quality of life [1]. A common perception is that diet can cause or worsen acne symptoms [2]. In recent years there has been an emergence of studies looking at links between diet and acne symptoms, the primary focus of which has been dairy products and glycaemic load. Despite this, there are currently no dietary guidelines or recommendations surrounding treatment for acne. The aim of this study was to review the available evidence from both observational studies and controlled trials to determine the effect of dairy products and glycaemic load on acne vulgaris. It is the first systematic-type review since 2005 to consider the influence of dairy foods and glycaemic load on acne and/ or the quality of the studies in this area. Methods: Search terms “Acne AND (Carbohydrat* or sugar or glycemic or glycaemic or Glucose or dairy or milk or lactose or diet*) were entered into seven databases, including Medline and Science Direct. Abstracts of papers published between January 2005 and January 2013 were screened for suitability by two researchers. Comprehensive inclusion and exclusion criteria, robust quality assessment criteria and associated quality ratings (2= all or most criteria, 1= some criteria, 0=no criteria met) were applied (Centre for Reviews and Dissemination 2009). Results: 10 studies among adolescents and young adults, scoring 2 or 1 in the quality assessment, were identified and included in the review. Six studies, including two prospective cohort studies, three case controls and one cross sectional study examined dairy products and acne. Of these five found statistically significant independent positive associations i.e. increased consumption of dairy products was associated with greater risk of acne. Overall, the effect sizes for these associations (prevalence ratios and odds ratios), where stated were modest ranging from 1.17-1.78 (p<0.05), but particularly evident for skimmed milk. Three studies reported the association between glycaemic load and prevalence of acne. Two case control studies showed significantly higher dietary glycaemic load among acne cases compared to controls (p<0.05). One prospective cohort study showed no significant association between glycaemic load and development of acne. Treatment of acne vulgaris with low glycaemic load diets was explored in three controlled trials. Two showed improvement in acne symptoms with a low glycaemic load diet over periods of 10 and 12 weeks, respectively. The third trial reported improvements in acne associated with both low and high glycaemic load diets but with no baseline dietary data with which to assess change in the glycaemic load of diets since the start of the intervention, was methodologically flawed. Discussion: Our review supports previous findings that a diet lowers in both dairy products and glycaemic load may help prevent or improve acne. The studies included in the review had a number of strengths with large sample sizes and validated measurement tools, but also methodological weaknesses in some studies, such as poor assessment of diet or acne, and unknown causal direction of associations in the cross-sectional study. High-quality randomised-controlled trials of the effect of both dairy foods and glycaemic load on acne vulgaris are required to make the evidence base more robust before dietary recommendations can be proposed. Conclusion: The message that a healthy, balanced diet, lower in glycaemic load may prevent or improve acne vulgaris in adolescents and young adults could help to improve the diets of teenagers. When considering restriction of dairy foods, however, calcium intake needs to be closely monitored and advice regarding this in relation to treatment of acne vulgaris should only be given by qualified practitioners.