The SMILES Trial

The smiles trial

& Why it’s important for Dietitians to know about!

In 2017, the SMILES trial was published. Led by Felice Jacka, founder of the Food and Mood Centre in Australia, this was the very first randomized control trial (RCT) using dietary intervention (via accredited dietitians!) in the treatment of depression.

67 men and women with moderate to severe depression were recruited to participate in this 12-week trial. Their depression scores were measured before and after using the MADRS (Montgomery Asperg Depression Rating Scale).

Half of the group received social support through “befriending” sessions aimed at keeping participants engaged and positive (such as through conversation or board games) while the other half received 7 x 60 minute sessions with a dietitian who provided individual dietary support, written materials, meal plans, recipes based on the ModiMed adapted from the Australian & Greek dietary guidelines plus foods recommended to prevent depression. The ModiMed group also received a food package with the basics of the diet to get them started.

The diet consisted of whole grains, fruits, vegetables, dairy, 3 tablespoons of olive oil daily, nuts, legumes, red meat, fish, poultry, up to 6 eggs per week, up to 2 standard drinks of alcohol in the form of red wine, and 3 “extras” per week.

After 12 weeks, participants in the dietary intervention group had a much greater reduction in their depressive symptoms and thus MADRS score with a reduction of 11 points versus 4 out of a total of 60. In fact, 1/3 of those in the dietary support group met criteria for remission of major depression (32% versus 8% social support group)! That’s amazing!

As most nutrition studies around dietary intake are observational and based on participants recalling what and how much they ate (who can remember this??), they are not the picture of accuracy. This groundbreaking study used dietitians to deliver the advice and increased adherence by providing meal plans, recipes, and staples of the diet. Participants were also not restricted with regards to quantity and were still allowed alcohol and the occasional treat so favorably reported high compliance. Win for participants and a win for dietitians.

I still find it so hard to believe that field of mental health and nutrition is just in it’s infancy.

I remember back in my final year of university at Cal Poly (2006), where we were all required to select a topic for our “senior project” during which we would research, conduct a small study, and write a mini-thesis. I remember wanting to choose the topic of food and mood however, at the time was told there was not enough research!! Little did I know, that the research around this subject was just beginning in Japan with findings showing the connection between the brain and the second brain-our gut microbiome- more on that at a later date!

If you’re interested in learning more about mental health nutrition, read my blog and my fav books on the subject here.

Happy Eating! x

PENG Nutrition Requirements Update

On 4th July, instead of celebrating American style, I celebrated dietitian style as I attended the BDA’s (British Dietetic Associations) PENG Update Nutritional Requirements study evening. As I’ve recently moved from London to Manchester this was my first meeting with the British Dietetic Association: North West England and North Wales Branch. Despite being difficult to get to without a car- I left at 3:30pm and didn’t arrive until 6:04pm!!! It was overall a successful meeting. There were quite a few dietitians there who’d I’d met from Salford, the Christie, and Stepping Hill Hospitals and the dinner was more than expected –lasagna, curry, jacket potato, sandwiches, and they catered to your dietary need whether it be vegan, gluten free etc. It turned out to be a late night as we were there doing the case studies until 9pm.

Getting to the point, the main updates revolved around energy and protein requirements and for extreme BMI’s.

For energy, the older 2011 guidelines were based on predictive equations , specifically the Henry equation, which was designed for healthy populations and then adjusted for illness (stress factor) and then adding the PAL (physical activity level). They noted that the majority of clinical studies used the Harris Benedict equation which was published in 1919. That’s a century ago! The patients we now see in hospital are much different than the ones they saw back then. In 1900, the top 3 causes of death were infectious diseases—pneumonia and flu, tuberculosis, and GI infections versus the chronic health conditions we see today. In fact the average life expectancy in the western countries looked to be around 55 years old versus 80 – 85 years old today. We are dealing with people 30 years older!

https://ourworldindata.org/life-expectancy

The updated guidelines for energy requirements were based on 5 systemic reviews (nearly 44,000 papers) which were weeded through to determine which met their criteria. Taking all this into consideration, the guidelines are now more specific, taking into account the medical condition, age, and BMI of the patient.

The main message of the evening was that there are flaws to all the predictive equations and thus, the guidelines are moving toward a quicker way of estimating requirements - using kcal/ kg for Resting Energy Expenditure (REE) then multiplying by a single combined factor for physical activity and DIT. I do think will make our jobs a lot quicker. The new PENG provides over 20 pages of tables that are broken down by age and medical condition and also cites the study to support the information as well as providing the grade of evidence (ie ABC).

For protein they did a systematic review of the published guidelines for protein- 16 of them. Most of the studies used urine urea nitrogen to assess for adequate intake. They stressed the importance of having adequate protein AND energy intake except for BMIs over 30 where they made reference to the Choban studies recommending high protein, hypocaloric feeding.

Read more here: https://www.abadiazumaque.com/docs/recursos/r6.pdf

Extreme BMI’s over 30kg, the 2011 PENG suggests using BMR, stating that some countries use an adjusted body weight (I was doing this in the USA) though it’s not validated. If the patient is not metabolically stressed, they recommend to calculate requirements as usual per the Henry and subtracting 400 – 1000 kcal for weight loss OR <14kcal/kg actual weight and with high protein 1.2gm/kg actual weight vs 2-2.5gm/kg IBW. There was some question over what ideal body weight to use. I always used the Hamwi method for determing IBW and didn’t realize that it was really a USA based method though it is based on pounds and inches so I probably should have guessed. In the UK, some dietitians have said they were using the low end 18.5kg/m2 for the underweights and  upper end 24.9kg/m2 for obese individuals.  

In short, the new guidelines recommend the following:

For Underweight <18.5kg/m2 – use 25 – 30kcal/kg

For Obese >30kg/m2 - use Mifflin

I’ve been trying the new guidelines against the previous recommendations and it’s been fun to compare and contrast. Many of the results are quite similar and I particularly like the specific recommendations for the femur fractures as I’ve been covering that ward lately!

Let me know in the comments what you think of the new guidelines.

The new PENG pocket guide is set to come out end of July and the lucky members of PENG for the 2017 - 2018 year will receive a free copy!

Happy Calculating,

Kelly

Update: I received my copy of the PENG (yay!) and as amazing as it is, it’s super heavy and has many pages to flip through that I decided to create a 4 page cheat sheet instead. Click below for your cheat sheet!

Shadowing at the Christie

As my 2 month contract job has come to an end, I decided to make the most of my time and shadow at the very reputable cancer hospital near my house. I’ve recently become interested in this area of nutrition as I’ve found cancer cases are often complex, require nutrition support (feeding through a tube), and the patient population is younger and still often with much fight in them. I also find that they are keen to research the best diet for recovery and prevention whether it be vegan, Gerson therapy, or the keto diet which can be very confusing and have a big impact on their nutrition status.

 The Christie is a tertiary hospital that provides specialists oncology services. I learned about a few of the very specialist procedures that people travel far and wide across the UK to have completed. One of the procedures is the Total Pelvic Clearance. This is done when organs in the pelvic area have been affected by cancer and thus need to be removed. The procedure involves removing the bladder, lower bowel and potentially the uterus, ovaries, prostate, rectum.

I also learned about the HIPEC (hyperthermic intraperitoneal chemotherapy) procedure during which the organs are removed from the abdomen and a highly concentrated chemo solution is directed at the cancerous cells for 90 minutes (rather than circulating the whole body as with standard chemotherapy). The solution is then drained and all the organs put back in their place. This technique is used with Pseudomyxoma Peritoneii (PMP), a rare tumor that causes a build up on the jelly like substance mucin in the abdomen. 

What is common about these complex procedures is that they have a significant impact on nutrition status. After major procedures like these, the bowels need time to rest and recover. There is also increased risk of ileus (temporary lack of intestinal movement after surgeries which can lead to blockage and potential obstruction). Because of this, the majority of these patients require parenteral nutrition (intravenous nutrition) for at least 5-7 days before they can begin advancing their diet from “soup/sweets” to light meals, low fibre solids, and upwards. All patients can have sips of water immediately following surgery, however must otherwise refrain from eating or drinking nutrition by mouth; all their nutritional needs are met via PN.

During my visit, I shadowed dietitians covering the head & neck, esophageal, gynecology, and surgical wards, attended a ward round, spoke with the research dietitian about her role, and sat in on a meeting which discussed nutritionally complex patients. Much of the head and neck patients will require nasogastric feeding with some needing RIGs (radiologically inserted gastrostomys) instead of PEGs if their esophagus is too narrow to place the endoscope. RIGs are placed using barium in the stomach and with xray guidance.

The Christies uses PN bags from Baxters and we reviewed specifications for their standard bags including a starter bag for off hours and those at risk of refeeding, fluid restricted (often used for haematology patients who can become very oedematous), low fat, fat free, and electrolyte free when electrolytes such as potassium are running high.

I also got to discuss the patients on the critical care unit which is different than a typical critical care as there are no trauma patients, but cancer patients experiencing cardiovascular issues, AF, sepsis, and neutropenic fever often as a result of chemo.

Special thanks to Lorraine, Debbie, Kerrie, and Hannah.

How to Pass the CNSC

Oh how I wish there were more tips out there when I went to study for this exam. It may have saved me hundreds! It’s hard to believe with the internet and youtube there were no dietitians putting themselves out there with tricks and tips for this exam like there are for nursing exams (at least that I’ve found). Only very few words from a couple people on Dietitian Central …booo!

Anyways, passing the CNSC has been a year in the making for me as I had the unfortunate experience of failing (I literally missed by 1 point :P). It’s getting more challenging too as it has become more comprehensive to even the playing field for dietitians, physicians, and pharmacists alike.

Here are my latest tips as of May 2015.

1)      Review the Book (ASPEN Adult Nutrition Support Core Curriculum)! Don’t spend forever reading it, but do speed read and believe me you will get something out of it. I have an awful memory and it still helped me.

2)      Review all the chapters. Yes, all the chapters. The first time I took the exam I had completely skipped the sections on policies and names of QA programs as I didn’t think they would be that important. I thought the main focus would be on calculating enteral and parenteral nutrition, but the exam is really quite well rounded and I unfortunately ended up getting a lot of questions from these sections. Ouch!

3)      Experience. If you are even attempting this exam, you must know the ins and outs of calculating tube feeding and parenteral nutrition. These are the basics (for example- common percentages of macronutrients of enteral formulas, kcal/gram of macronutrients for parenteral nutrition, how to calculate osmolarity etc.).

4)      Statistics/ Research. Be familiar with research terminology and types of studies. The book does not have all of this information so I suggest you read up on statistics on your own if you are not familiar with the subject (p values, independent/ dependent variables etc.). The Nutrition Support Fundamentals and Review Course does have a section on this now. It did not a couple years back (2013) if you are using older materials. *Note: I also recommend familiarizing yourself with this if you plan on attending Clinical Nutrition Week which I highly recommend.

5)      Equations. You need to memorize them! I did not do this the first time as I usually just carry my binder with me at work and refer to them as needed. You won’t have to memorize any equations for estimated needs (such as Harris Benedict or MSJ), but do know: nitrogen balance, corrected calcium, and free water deficit.

6)      Pediatrics. There are not many questions on peds so I wouldn’t spend additional money on the Pediatric Core Curriculum, but do know how to determine their basic calorie and fluid needs. I got questions on how to determine their fluid needs multiple times (using Holliday-Segar).  

Also know anything nutritionally unique about them with regards to TF formulas/ amino acids. I would review the section from the review course.

7)      General. Do study: vitamin/ mineral needs in EN/ PN, signs and symptoms of vitamin/ mineral deficiency, medication interactions, fluid/ electrolyte disorders and correction, acids/ bases, EN/PN stability.

8)      A Word on the Modules. Overall these did not help me significantly. My fellow co-workers and I purchased these and studied them each week. I knew all the answers, researched everything related to these questions, and made tons of online flashcards with the help of Anki (a flashcard program that helps you study). There were maybe two questions out of hundreds of flashcards that I made. It was a gut wrenching feeling having spent hours on these and then going into the exam feeling like I had not prepared. Take my word for it and don’t put all your focus on those modules. Take them into consideration, but don’t think you can just buy and study the modules and you’ll be good to go.

9)      Keep Up with the Latest. ASPEN does a great job of keeping up with the latest research and updating the test content accordingly. The last time I took the exam, they had already included some questions on physical examination which is fairly new for dietitians. Get on the ball and read up on this, including how to evaluate bowel activity through a stethoscope.

Now get studying! :)