News Round-up

 

Update on Covid Airborne Protection Alliance (CAPA)

Dr Barry Jones, Chair CAPA & BAPEN IAC

You may recall that back in the early stages of the pandemic, and bearing in mind the government’s assertion that it would “follow the science”, I posed the question: “What if the science is wrong?”. Sadly, the answer to my question has proved all too true. Despite the best efforts of BAPEN and its professional colleagues in CAPA, we have been unable to shift guidance to the point where airborne transmission is explicitly stated, together with the appropriate respiratory protective equipment (FFP3 or equivalent).

Current guidance is now based on the Infection Prevention and Control (IPC) manuals, of which there are 4, one for each nation! Each says something different, particularly in Scotland where droplet transmission is still the only game in town. Hence the recommendation that fluid-repellent surgical masks (FRSMs) are adequate protection for the wearer. In England, airborne and droplet transmission are both mentioned, but you only get to wear FFP3 RPE (filtering face pieces/respiratory protective equipment) if performing an AGP or if a risk assessment indicates high risk. You will immediately recognise how difficult it is to perform a risk assessment if you are not explicitly informed of the agreed mode of transmission. Control of Substances Hazardous to Health (COSSH) regulations impart strict responsibilities to your employers, although many have chosen to ignore them.

These inconsistencies in guidance have prevailed throughout the pandemic due to intransigent entrenched opinion in the IPC Cell of the Department of Health and Social Care (DHSC). Even when World Health Organization (WHO), European Centre for Disease Prevention and Control (CDC) and European Centre for Disease Prevention and Control (ECDC) changed their guidance to include airborne risk, our IPC guidance did not follow suit. Interestingly, the UK Cabinet office issued such advice early in 2022, but this has now disappeared from the GOV.UK website. Both WHO and CDC in the USA simply state that you should wear RPE if entering an infected patient’s room. How simple is that?

So what has CAPA been doing about this? We have written time and again to all levels of government and the DHSC. Most recently, we have concentrated our campaign on Health and Safety Executive (HSE) and UK Health Security Agency (UKHSA). HSE has denied any responsibility for healthcare workers (HCW) safety during the pandemic, claiming that this is a public health issue. UKHSA’s Chief Medical Adviser, Dr Susan Hopkins has replied to our letters (initially sent to the Chief Medical Officer, Sir Chris Whitty) by repeating the dogmas of the IPC Cell, and ignored the evidence we presented regarding WHO, CDC and ECDC, not to mention the overwhelming evidence that Sars-CoV-2 is airborne, as when breathing, talking, coughing, singing or sneezing. We await a further response. We remain perplexed by this obstinate failure to take a precautionary approach in the face of scientific uncertainty and to opt to advise the best protection practicable RPE. Once again, we must remind the reader that FRSM are not legally permitted to be used as personal protective equipment under HSE and COSSH regulations.

To date, we know of 35 Trusts in the UK that have taken it upon themselves to opt for higher grades of protection, and many can demonstrate the efficacy of this approach with lower nosocomial and HCW infections.

In light of the frustrations, CAPA members have experienced, we have agreed to suspend our active campaign, but we continue to respond to correspondence received from government bodies, such as UKHSA. We have been strongly supported by our colleagues in the British Medical Association and Royal College of Nursing, for which we are extremely grateful. The next step is to prepare for the Covid Public Inquiry for which terms of reference have now been agreed. We await to hear if BAPEN and others from CAPA will be afforded Core Participant status, but we are encouraged by the agreed terms of reference.

So where does that leave BAPEN members? If you are having difficulty getting RPE from your trust when likely to be caring for suspected or proven COVID-19 patients, BAPEN will support you in your efforts to do so, as indeed have other CAPA members like Royal College of Speech and Language Therapists. You can find all the necessary documents on BAPEN website.

We hear that 2300 health and social care workers have died from COVID-19 to date, most of them having acquired their infection at work. Don’t become another statistic. Take proper precautions. At the time of writing, 1 in 18 of the UK population has the infection. It is not always mild. Long Covid is a real threat even if the disease seems mild initially. And, finally, remember that good ventilation at work is essential for your safety but at close quarters (1-2m), ventilation is ineffective and only RPE can be relied upon to protect you.

 

Ten Years of Tackling Malnutrition in the Community

June 2022 marked the 10th Anniversary of the launch of the Managing Adult Malnutrition in the Community guidance.

Since its launch by a multi-disciplinary consensus panel in 2012, the Malnutrition Pathway website has received nearly a quarter of a million visits. In the past year alone, the website has been visited by over 30,000 professionals, patients and carers from over 150 countries around the world. Over 60,000 copies of the Managing Adult Malnutrition in the Community document and nearly 16,000 of the corresponding patient leaflets were downloaded in 2021. Year-on-year growth in visits and downloads, reflects the ongoing need for guidance and resources to help support the 3 million people in the UK who are at risk of malnutrition, 93% of whom live in the community.¹

The guidance document was developed to assist non-nutrition experts in the identification, treatment and prevention of disease related malnutrition in the community. Now in its third iteration, the Managing Adult Malnutrition in the Community document has received consistent endorsement from ten professional and patient organisations and includes an endorsement statement from the National Institute for Health and Care Excellence (NICE).²

The resources are accessed by a broad range of healthcare professionals in the community, including dietitians, nurses, GPs, pharmacists, physiotherapists, speech and language therapists, healthcare assistants and care homes personnel, to support the identification, treatment and prevention of disease-related malnutrition. Pilot studies have demonstrated a positive impact on patient outcomes and a reduction in healthcare usage through better nutrition.^{3, 4}

Feedback from end-users over the past ten years has facilitated the creation of additional materials, including patient and carer leaflets and new resources focusing on key areas in clinical nutrition such as COPD, COVID-19, cancer and sarcopenia. The website now hosts sections dedicated to specific healthcare professional groups involved in the care of patients at risk of malnutrition. A patient and carer section enables care professionals and patients and family members to easily access resources relevant to them.

“Advancing age and the presence of an acute illness or long-term condition can have a profound impact on appetite, absorption of nutrients and the ability to source food, prepare meals and consume enough to maintain nutritional status, predisposing an individual to the deleterious effects of malnutrition. Given that health and social care costs for individuals with malnutrition are three to four times more than managing a nourished individual,⁵ it is crucial that nutritional screening and nutritional care is embedded into clinical care pathways to identify and treat those at risk of malnutrition at the earliest opportunity,” says Dr Anne Holdoway, Chair of the Malnutrition Pathway panel.

“The expertise of Dietitians in assessing patients with nutritional issues and providing bespoke advice is not to be underestimated but as a relatively small workforce we cannot currently treat everyone. Transferring knowledge and skills and providing tools and resources to empower members of the healthcare team to look for malnutrition especially in those at increased risk, enables early action to be taken to improve healthcare outcomes and manage costs. This was the driving force behind the development of the managing adult malnutrition in the community pathway and resources. It has been hugely rewarding to see that 10 years on, the resource and its updates remain as relevant as when they were initially launched and thus continue to help the health and social care teams provide nutritional care and advice to some of our most vulnerable individuals.”

^{References: 1. Elia M and Russell CA (2009). Combating Malnutrition: Recommendations for Action. Report from the advisory group on malnutrition, led by BAPEN; 2. The ‘Managing Adult Malnutrition in the Community’ document and supporting patient materials have been supported by 10 key professional and patient associations: • The British Association For Parenteral And Enteral Nutrition (BAPEN) • The British Dietetic Association (BDA) • The British Pharmaceutical Nutrition Group (BPNG) • The National Nurses Nutrition Group (NNNG) • The Patients Association • The Primary Care Society for Gastroenterology (PCSG) • The Primary Care Pharmacy Association (PCPA) • The Royal College Of General Practitioners (RCGP) • The Royal College Of Nursing (RCN) • The Royal Pharmaceutical Society (RPS). In addition, the guidance also includes the following NICE endorsement statement: This booklet supports the implementation of recommendations in the NICE guideline on nutrition support for adults. It also supports statements 1, 2 and 5 in the NICE quality standard for nutrition support in adults. National Institute for Health and Care Excellence Endorsed December 2017. Updated June 2021; 3. Brown F, et al. (2020). Economic impact of implementing malnutrition screening and nutritional management in older adults in general practice. J Nutr Health Aging.; 24(3): 305-311. 4. Cawood A, et al. (2017). Local implementation of a pathway to manage malnourished COPD patients in the community. Eur Respir J.; 50(suppl 61): PA1609.; 5. Elia M, on behalf of the Malnutrition Action Group (BAPEN) and the National Institute for Health Research Southampton Biomedical Research Centre (2015). The cost of malnutrition in England and potential cost savings from nutritional interventions (full report); www.bapen.org.uk/pdfs/economic-report-full.pdf}

 

 

Resistant Starch Could Have a Preventative Effect on People with High Hereditary Risk of a Range of Cancers

An international trial between 1999 and 2005 – CAP2 – involving almost 1000 patients with Lynch syndrome revealed that a regular dose of resistant starch (also known as fermentable fibre), taken every day for an average of two years, did not affect cancers in the bowel, but reduced cancers in other parts of the body by more than half.

This effect was particularly pronounced for upper gastrointestinal cancers including oesophageal, gastric, billary tract, pancreatic and duodenum cancers. The effect was seen to last for 10 years after stopping taking the resistant starch supplement. In the period of follow-up, there were just 5 new cases of upper GI cancers among the 463 participants who had taken the resistant starch compared with 21 among the 455 who were on the placebo.

The study, led by experts at the Universities of Newcastle and Leeds, published in Cancer Prevention Research, a journal of the American Association for Cancer Research, is a planned double blind 10-year follow-up, supplemented with comprehensive national cancer registry data for up to 20 years in 369 of the participants.

Previous research published as part of the same trial, revealed that aspirin reduced cancer of the large bowel by 50%.

“We found that resistant starch reduces a range of cancers by over 60%. The effect was most obvious in the upper part of the gut,” explained Professor John Mathers, professor of Human Nutrition at Newcastle University. "This is important as cancers of the upper GI tract are difficult to diagnose and often are not caught early on.

Resistant starch can be taken as a powder supplement and is found naturally in peas, beans, oats and other starchy foods. The dose used in the trial is equivalent to eating a daily banana; before they become too ripe and soft, the starch in bananas resists breakdown and reaches the bowel where it can change the type of bacteria that live there.

Resistant starch is a type of carbohydrate that isn’t digested in your small intestine, instead it ferments in your large intestine, feeding beneficial gut bacteria – it acts in effect, like dietary fibre in your digestive system. This type of starch has several health benefits and fewer calories than regular starch. We think that resistant starch may reduce cancer development by changing the bacterial metabolism of bile acids and to reduce those types of bile acids that can damage our DNA and eventually cause cancer. However, this needs further research.”

Professor Sir John Burn, from Newcastle University and Newcastle Hospitals NHS Foundation Trust who ran the trial with Professor Mathers, said: “When we started the studies over 20 years ago, we thought that people with a genetic predisposition to colon cancer could help us to test whether we could reduce the risk of cancer with either aspirin or resistant starch.

Patients with Lynch syndrome are high risk as they are more likely to develop cancers, so finding that aspirin can reduce the risk of large bowel cancers and resistant starch other cancers by half is vitally important.

Based on our trial, NICE now recommend Aspirin for people at high genetic risk of cancer, the benefits are clear – aspirin and resistant starch work.”

The research is funded by Cancer Research UK, the European Commission, Medical Research Council and the National Institute for Health Research.

^{Paper: Cancer Prevention with Resistant Starch in Lynch syndrome patients in the CAPP2 Randomised Placebo Controlled Trial: planned 10 year follow-up. Cancer Prevention Research. DOI:10.1158/1940-6207.CAPR-22-0044}

 

Vegetarian Women are at a Higher Risk of Hip Fracture

A study of over 26,000 middle-aged UK women reveals those with a vegetarian diet had a 33% higher risk of hip fracture compared to regular meat-eaters.

University of Leeds research, published in the journal BMC Medicine, investigated the risk of hip fracture in occasional meat-eaters; pescatarians, people who eat fish but not meat; and vegetarians compared to regular meat-eaters.

Among 26,318 women, 822 hip fracture cases were observed over roughly 20 years – that represented just over 3% of the sample population. After adjustment for factors such as smoking and age, vegetarians were the only diet group with an elevated risk of hip fracture.

This study is one of very few studies to compare risk of hip fracture in vegetarians and meat-eaters where the occurrence of hip fracture was confirmed from hospital records.

The scientists stress the need for more research into the exact causes of why vegetarians were at a greater risk of hip fracture.

Vegetarian diets can be ‘healthy or unhealthy’

Study lead author James Webster, a doctoral researcher from the School of Food Science and Nutrition at Leeds, said: “Our study highlights potential concerns regarding risk of hip fracture in women who have a vegetarian diet. However, it is not warning people to abandon vegetarian diets. As with any diet, it is important to understand personal circumstances and what nutrients are needed for a balanced healthy lifestyle.

Vegetarian diets can vary widely from person to person and can be healthy or unhealthy, just like diets that include animal products.

However, it is concerning that vegetarian diets often have lower intakes of nutrients that are linked with bone and muscle health. These types of nutrients generally are more abundant in meat and other animal products than in plants, such as protein, calcium, and other micronutrients.

Low intake of these nutrients can lead to lower bone mineral density and muscle mass, which can make you more susceptible to hip fracture risk. This makes it especially important for further research to better understand factors driving the increased risk in vegetarians, whether it be particular nutrient deficiencies or weight management, so that we can help people to make healthy choices.”

Plant-based diets growing in popularity

Vegetarian diets have gained popularity in recent years, with a 2021 YouGov survey putting the size of the UK vegetarian population at roughly 5-7%. It is often perceived as a healthier dietary option, with previous evidence that shows a vegetarian diet can reduce the risks of several chronic diseases, including diabetes, heart disease, and cancer compared to omnivorous diets.

There is also a worldwide call for reducing the consumption of animal products in an effort to tackle climate change.

Understanding hip fracture risk in vegetarians is therefore becoming increasingly important to public health.

Study co-author Professor Janet Cade, leader of the Nutritional Epidemiology Group in the School of Food Science and Nutrition at Leeds, said: “Hip fracture is a global health issue with high economic costs that causes loss of independence, reduces quality of life, and increases risk of other health issues.

Plant-based diets have been linked with poor bone health, but there has been a lack of evidence on the links to hip fracture risk. This study is an important step in understanding the potential risk plant-based diets could present over the long-term and what can be done to mitigate those risks.”

The team used data from the UK Women’s Cohort Study to investigate possible links between diet and hip fracture risk. The national cohort of middle-aged women was established at the University of Leeds to explore links between diet and chronic disease, encompassing a wide range of different eating patterns. Dietary information was collected using a food frequency questionnaire and was validated using a 4-day food diary in a subsample of women.

At the time they were recruited into the cohort study, the women ranged in age from 35 to 69 years.

Effect of low BMI

The research team found that the average BMI among vegetarians was slightly lower than the average among the regular meat eaters. Previous research has shown a link between low BMI and a high risk of hip fracture.

Lower BMI can indicate people are underweight, which can mean poorer bone and muscle health, and higher risk of hip fracture. Further investigation is needed to determine if low BMI is the reason for the observed higher risk in vegetarians.

Study co-author, Dr Darren Greenwood, a biostatistician in the School of Medicine at Leeds, said: “This study is just part of the wider picture of diet and healthy bones and muscles in older age.

Further research is needed to confirm whether there could be similar results in men, to explore the role of body weight, and to identify the reasons for different outcomes in vegetarians and meat-eaters.”

^{Paper: Risk of hip fracture in meat-eaters, pescatarians, and vegetarians: results from the UK Women’s Cohort Study. BMC Medicine; https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-022-02468-0}

 

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