Anne Holdoway: the burden of disease, the benefit of diet and the expert dietitian

Anne Holdoway: the burden of disease, the benefit of diet and the expert dietitian


If I could have your attention please
and good afternoon and welcome to everybody here today to Eat Fact Not
Fiction. My thanks must go to Tom and the BDA
communications team and head office staff for bringing together this event
prior to our AGM at 6 o’clock today. We’ve got an exciting lineup of speakers
and I’ll be kicking off first. My name for those who don’t know me is Ann Holdoway. I’m a consultant dietitian based in the southwest of England and
I’ll be kicking off first before we move on to our other speakers. So firstly I’ll
just be setting the scene here in the Horizon at Leeds and talking about
some of the background about what is happening in the modern healthcare
environment and our healthcare landscape. I’ve been specifically asked to look at
the burden of disease, the benefit of diets and the role of the expert
dietitian. My experience in this field is based on 30 years experience as
a registered dietitian spanning the commercial sector, the NHS research and
clinical practice; and today what I’m going to be talking about really is the
actual role of the dietitian and the expert dietitian in the management of
chronic disease – helping to improve quality of life in many individuals
affected by chronic disease and life-limiting conditions around the
country. Much of my experience in recent years is based on my work at
Dorothy house that’s just to the right-hand side of this slide. This is a
the hospice base just outside that’s where I work and I’ve been there for
about the last four years and in that position I find that I’m really bringing
together all of the expertise over my thirty years to try and support patients
with life-limiting conditions and considered at the end of their life but
just to clarify end of life these days is the last year of life and palliative
conditions now affect thousands of people in the UK and they can be living
with it for many many years so it’s all about providing timely appropriate
nutritional care these individuals to transform their
quality of life so I’m going to be drawing on some of my experience from
that field in particular where I’m going to be talking about the burden of
chronic disease and the role of a dietitian. I’ve also had the privilege
over the last two months of hearing from many Dietetic leaders at various
events around the country and what they’ve shown to me is some of the
trailblazing work that’s very evident amongst our profession in the field of
things like childhood allergy, adult allergy, irritable bowel syndrome, cancer
management, and other chronic diseases and and I hope it comes through
today of some of the work that dietitians can do in this field in
conjunction with significant others around us whose help we need to
actually actually influence the agenda and actually improve the life and
well-being of our population. In the next 10 minutes or so I’ll be looking at
the healthcare landscape long-term conditions and chronic disease – the
burden of that to our health care environment – the impact of many of those
conditions on dietary intake and nutritional status, and how I believe the
dietitian can really make an impact in this field. I’m going to be concentrating
on long-term conditions and if we just think about that at the moment in the UK
long term conditions take up around about £7 out of £10 spent in
the health and social care sector. They account for about half of GP
appointments and about two-thirds of all patients in-stay days. When we think
about chronic disease these are things like diabetes, heart disease, stroke and
and then also if you think about some of the factors contributing to these
chronic disease, obesity is probably one of the number-one factors that we have
to address. And here you’ll see on this slide our forecasts for obesity looks
fairly dire. In 2020 we’re anticipating 8 out of 10 men and 7 out of 10 women
being obese across the world. We’ll hear later on from Mary talking about
her role in bariatric surgery and the role of the dietitian in that field.
In terms of the impact of obesity it’s also rather worrying for some of
the younger siblings too and this is a letter written by a young child to David
Cameron to ask him for some help in actually managing his sister’s weight.
Another area where we’re seeing an increasing number of survivors is cancer.
Cancer is expected effect one in two of us being diagnosed with cancer in our
lifetime and we are getting more effective at managing it and treating it,
but in in terms of survival what we’re now seeing is that many of these
patients actually have long term consequences of cancer treatments. In
addition we know that obesity can contribute to the development of cancer
and recurrence and that means it’s a big role for dietitians and the healthcare
arena to climb tackle obesity as well as manage the long term consequences of
cancer treatments going forward. We know that many life limiting conditions will pre-dispose an individual to malnutrition but I’d like to emphasize
that many of those long-term conditions will actually also mean that that
patient will experience a number of dietary challenges and I’ll explore some
of those areas as we go through but in terms of facts and fiction I’d like to
debunk a common myth really amongst many of my colleagues and doctors in
particular and that is …. ..that malnutrition is considered to be
an inevitable part of disease and old age, and the fact is it doesn’t have to
be. We should be looking at actually preventing malnutrition from arising and
then treating it effectively if it does arise. In terms of how many people that
affects, we’re talking about 3 million that’s about how many people read the
Daily Mail and the Sun each day so that figures into context and if we believe
we’re doing something positively in terms of tackling malnutrition and
here’s the latest fact that malnutrition accounted for 128 thousand bed days in
2010 to 2011 that number went up by 40% in 2015 to 2016 so that’s a reminder
really that if we actually want to tackle malnutrition we haven’t done that
much about it in terms of reducing the numbers over the last five years. One
could argue that we’ve become better at measuring it so that could account for
the increase in numbers but we certainly got a long way to go in terms of
actually tackling malnutrition which is on the other end of the public
healthcare spectrum to obesity. I believe this fact: that optimum nutrition,
excellent nutritional care and tailored dietary advice does have the power to
transform lives. Do others believe in that? Well,
increasingly we’re seeing the role of dietitians and the role of dietary
advice in managing chronic diseases and life-limiting conditions being referenced
in important national documents like NICE guidance and quality standards. In
addition, I believe that appropriate nutritional care has the capacity to
meet all five domains of the NHS outcomes framework and you could
probably say the same too about effective nutritional care and optimal
nutritional status actually achieving the same in public health. For many of my
patients the reality is that diet cannot cure them of their condition but I
believe it can play a significant role in symptom management and well-being
along with reducing health and social care costs associated with poor
nutrition and malnutrition in individuals with life limiting
conditions. Another fact is that poor nutrition – malnutrition in particular –
that causes consequences in terms of quality of life, activities of daily
living and functionality that malnutrition is what costs the health
service a huge amount of money every single year and yet we’re still not
tacking effectively. These are the latest figures published by Professor Elia and
the NIH are in 2015 and in England alone the consequences of malnutrition the
Health and Social Care costs associated monitoring when nineteen point six
billion pounds – far more than what we actually have to pay out for managing the obesity and its consequences. Just to
put that into context in relation to our individual patients: a patient with a
life limiting condition or a chronic chronic disease
who’s malnourished costs 5,000 pounds a year more to manage than a person who’s
normally nourished; and therefore I believe if our Secretary of State for
health actually understood those figures what he’d be doing tomorrow is going out
to recruit a whole host of dietitians both in hospital and the community.
The other issue that we’re facing in our healthcare landscape is that multi
morbidity is a growing issue and many of our older people beyond the age of 50
will actually be experiencing a number of chronic conditions and so it’s not
just one chronic disease but they may be managing three chronic conditions and in
those cases where you’ve got a case of a patient with the consequences of cancer
treatments, COPD and diabetes, I’d like to ask you who is best qualified at
tailoring that dietary advice to that individual and putting things like
public healthcare messages into context. We’ll hear more later on about
public health messages and the role of diets out there perhaps getting through
to the wrong people. So I believe because multi morbidity is a growing issue that
dietary advice does have to become personalized using the expertise of
dietitians and because one diet doesn’t fit all and if we’re going to provide
appropriate nutritional care for many of these individuals with chronic disease
and life limiting editions then that advice needs to be predictive of their
condition, preventive of other conditions and it needs to be personalized and
patient-centered so participatory. If we just look at some of the common
issues facing many of our patients with chronic disease and life-limiting
conditions, summarized here on this chart, and trying to deal with these when
you may be socially isolated and aging can be a real challenge. So I believe
as registered dietitians not only do we work from an evidence base
but where the evidence is lacking because we don’t always have the
randomized controlled trials to rely on that we utilize our knowledge of food
and diet and health and well-being what’s in our food, physiological
knowledge, the knowledge of biochemistry disease management, health and well-being, all combined together to hopefully provide advice for an individual is
tailored for their individual needs and is both acceptable and practical. And I
believe another area that people perhaps overlook in terms of the role of
dietitians is that we’re very effective educators so when it comes to managing
chronic conditions, life-limiting conditions
I feel the feedback I get from my patients is often about the fact that’s
the first time somebody’s sat down to explain not only what diet perhaps would
be beneficial to me, but the actual condition itself. The reality is
there are only about 9000 registered dietitians in the UK so it’s clear we do
have to work with others but perhaps what we can do as dietitians to be
effective is ensure that the knowledge out there is underpinned by good science
and the best evidence available. In fact learning from our colleagues over
the water in the USA we perhaps need to move towards the stratification of
patients or those that those that are most needing actually get our impact on
a one-to-one basis whereas group sessions and self-management can be
promoted to those who are less needy. So I believe nutrition does matter
and I strongly believe with 30 years experience and the work I currently do
that dietary advice has the power to transform patient care and just going to
spend a couple of minutes looking at where I believe we can have a real
impact. If we think about our cancer patients going through treatments we
know that diet can help optimize tolerance to radical interventions and
alleviate symptoms both during the treatments but also beyond it into
survivorship. We’ll hear more later on from Rachel about the impact of her work
in the Durham area around education and management of nutrition in
older people. We do know from clinical studies that good nutrition can maintain
independence reduce isolation through even such things as dining clubs, it can
improve cognition, increase activities of daily living and maintain independence.
Most of us familiar to get a new pair of shoes not necessarily high heels if
you’re male but how painful a pressure sore can feel and so just imagine what
this feels like and pressure sores currently cost the NHS about £43 to nearly £400 a day to manage. My argument with these patients is if poor
nutrition is stopping the healing of that pressure ulcer then why is
there not investment in community services of dietitians to actually optimize
nutrition and some of these patients where improved nutrition could increase
the rate of healing and actually reduce the need for services like district
nurses going in on a daily basis to dress such wounds. Another factor in
conditions like chronic obstructive pulmonary disease is a plethora of
evidence looking at the effectiveness of oral nutritional support on length of
stay, hospital readmissions, infections, and mortality. Many patients who
have neurological conditions – things like motor neuron disease – we know that
appropriate nutrition can reduce the risk of aspiration and maintain
the nutritional status of an individual safely and soundly. But I would argue
that they need one-to-one dietetic advice and support for the patient and the
carers to achieve that. We know that going forward we can’t afford to provide
all our care in hospitals and if we look at the average length of stay in 2014 as
less than a week so the argument now should be that actually our focus should
be on increasing the Dietetic access in the community. And what can dietitians
achieve in the community I believe we can empower patients to self manage
their conditions, reduce the demand on GP time and we know GPs are in a crisis at
the moment, make prevention possible, optimize the use of nutritional products
as well as medicines, reduce secondary care referrals and reduce the need for
hospitalization or utilizing technology effectively to make us as efficient as
possible. What we do well in particular and I think is fairly unique to what we
offer is that we consider all of the challenges around food from both the
client and the carer perspective and look to support them to handle their
dietary issues on a daily basis. I believe if you’re able to educate and
motivate to enable individuals to achieve change
and we can offer individual advice and think about putting key messages and
public health messages into context . Overall I think we apply a degree of
pragmatism in all of the cases that we deal with: setting mutually agreed
realistic goals to optimize quality of life, nutritional status, along with the
enjoyments that we should derive from eating and drinking. And we must not
forget that it’s not all about just achieving adequate nutrition and
optimizing nutritional intake but foods should be a pleasurable experience. For
many of my patients it may no longer be that and it’s about then supporting
the individuals to cope with that along with their carers. So my key
messages for today are that nutrition should be an integral component of care
for patients with long-term and life limiting conditions. I believe the
appropriate dietary advice can transform lives and the evidence is there to
support that. It can also transform the patient experience and is crucial for
disease prevention and preservation of optimum health. It’s true that probably
one diet doesn’t fit all and which is why the wrong messages often get to the
wrong people and we know that GPs are under a huge amount of pressure but I
think they need to look around themselves and look at the
multidisciplinary team members available because dietitians can help deal with
some of the issues that our GP is are currently faced with tackling and we
might be able to deal with them more effectively. Without dietitians, I believe
the NHS will remain as that national sick service and we have a lot to offer, but
in terms of potential … potential means nothing if you don’t do anything
with it. So I’d like to finish on the last note about fact and fiction and
currently this statement in terms of how do we tackle some of our health care
issues? Quite simple: we need investment in Dietetics and Dietetic Services, and
that’s currently fiction – I’d like to ensure that our Secretary of State for
health going forward believes that as fact.
Thank you very much

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