Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Okay. Say thank you, everyone for attending. It's a real honor to be asked to give this presentation today. Um, I had to kind of think about a little bit what I wanted to talk about. And I changed it a little bit recently because I just wanted to make it most irrelevant as I could, Um, for kind of the situation you're in. I understand you're kind of using kind of, uh, emergency, um, medicine at the moment. So I try to kind of add a little bit in there that I thought might be useful for you, But generally speaking, I'm gonna be talking about healthy eating. But then also a little bit about the emergency nutrition and a bit about malnutrition as well. Um, I probably won't take a full hour speaking, so there'll be time for questions at the end. So please do ask me any questions that you want to at the end. So this is what I'm going to be talking about. I'll talk a little bit about what dieticians do, who we are. I'll tell you a bit about me so that you kind of know where I'm coming from. And my experience is, um, I'm going to be talking in quite a lot of detail about healthy eating for the general population, and I guess also kind of what can happen if there are deficiencies in those different food groups. Um, I'll talk about malnutrition and the effects of that. What that can have on the population. Um, but a bit more about kind of imagining nutrition in diabetes and burns cause I thought those were kind of the two areas which were most kind of linked to nutritional requirements. And with the most kind of perhaps likely thing that you might be coming across. Um, at the moment, which is really important consideration as a nutrition and then just a little bit about how you can perhaps decide how to refer to a dietician, it suddenly needs a referral to a dietician. Obviously, I don't know how that's done specifically in the different hospitals, but hopefully you'll kind of go away from this and find out and and work on that yourself because it is something that is very important to know how to do because there is a scarcity of referral to dietitians, for sure. I think there's a little bit of doctors thinking, not really understanding what dieticians do. Perhaps hopefully that will help today. Um, so if we get started, then so a little bit more about dieticians. So dieticians are It's a protected term. It's really the only food nutrition title that is protected by the law. Only those registered with the statutory regulator the Health Care Professions Council, can use the title. So you have to do a degree, um, to to do this, um, to have the R D letters behind your name. So what do the dietician do so well qualified and regulated health professionals we assess, diagnose and treat dietary and problems on an individual level and also a wider public health level. Um, is nutritionist only kind of deal with the wider public health level? Dieticians are more able to deal with that 1 to 1 individual basis, especially in disease. So we use the most up to date public health and scientific research on food, health and disease, and then translate that into practical guidance to help people make lifestyle changes and food choices appropriate for them and their situation. And as I said, it's protected by law. We can work in lots of different places. So a lot of dieticians recently graduated, goes through the N h s. You can also work in private clinics, which is what I do now. Um, they can work in the food industry in specific workplaces as their dietitian. In catering, you get catering dieticians, whether that be in the NHS or elsewhere in education and sports, you get sport dieticians and then media. So a lot of dieticians, many the freelance dieticians will kind of also have a little bit of media input as well. And you see them kind of in newspapers and magazines quite regulated. There are specific people that do that more regularly. Um so what? We can help with lots and lots of different things really quite varied. So it could be anything from, you know, digestive problems, managing a diagnosed medical condition like diabetes or high BP. Other cardiovascular problems see, like dizzy HIV. It really does go on. And we help organize and calculate oral enteral and parenteral nutrition requirements in hospitals. Um also specialized nutrition requirements in Children. So that's a special pediatric dieticians will deal with those. So you do have to be qualified and trained in pediatrics do that I'm not. So you don't tend to get that in the UK as a basic training. Um, you would have to do some extra courses. There are some places in the world that incorporate that into the BSC in nutrition dietetics, but we don't hear so also help with the weight loss in a safe and sensible way we don't ever recommend and extreme, I hope. Anyway, diets, fad diets, those types of things. It's just not evidence behind them, and they're not very safe weight gain as well. So the opposite side after someone's been ill or as a result of a medical condition, preparing people for surgery for weight loss as well something else a specialist and, uh, specialist bariatric dieticians do. And we can also help people improve their athletic performance since fitness level, giving advice about breastfeeding and weaning and allergies and intolerances as well is something else that we do a lot of. So I work quite a lot with gastrointestinal problems. Um, some dieticians advise with eating disorders, but again, you have to build up a bit more kind of have that specialist training to do that. Um and also get in come some support for people that are looking after people who have kind of special diets or nutritional problems, or if they need to care so that we can be. We can do kind of a supportive role In terms of that, there's lots and lots of different things that we can do. And usually dieticians will specialize area relatively quickly. So we kind of work up our way in the NHS, Um, two more and more specific. So you have to put to progress. You really do have to kind of specialize a little bit, but so a little bit more about me. So just as I said, you know where I'm coming from. So I graduated in July 2013 from King's College, London, with nutrition dietetics degree. Um, I was already a mature student by that point, so I have a degree before I decided I want to be a dietician, so I had to do another full degree. My first first job out of Kings was as an oncology dietitian. It's already kind of a little bit specialist, and that was just for a year. But I did learn an awful lot there and and then I moved to Saint George's Hospital as a community dietician. So I was working at the community for a few years and I saw all kinds of different things. That was really, really varied. And I think I really enjoy that because I got a lot of kind of knowledge around the different health conditions and how to manage those with diets. Um, my main interest is gastroenterology. So I was really lucky to get a job as a specialist. Gastroenterology, dietician, eastery hospital. These are our NHS so far in November 2017. And then I decided that I wanted to go private. So do freelance. Um and that was because I had young Children, mainly. So I set up my kind of my company green health dietetics working as a freelance dietician. And that's what I've been doing for the last year. And I'm really enjoying it and seeing lots of variety and mainly kind of obesity. So weight loss and gastrointestinal problems. But I get all kinds of people kind of asking me for help. So it's really, really varied. And, uh, you know, I can manage my time, which is lovely. So if we kind of go into talking a little bit about healthy eating for the general population. Um, really, This is very, uh, not not basic at all, but very general. So obviously, you know, this is healthy eating for everybody. This is very good for preventing diseases as well. If you follow these kind of guidelines, obviously, if we look at kind of managing certain medical conditions, we might have to alter these a little bit. So this is kind of the the first line. Let's say, first line type of dietary advice that we give people and it's the tool. The eat well guide is a tool from public health England that we use to define the government recommendations on healthy eating to achieve a balanced diet. And it really shows you how much of what we should eat. Um, across the different food groups to achieve a healthy, balanced diet. It's not across the one meal or one day, but kind of thinking about it. Even course of about a week or so, you know, up to a week And, um, if we look at the individual, um, sections, so just firstly, I guess you know, you can see there are different macro nutrients. So we've got carbohydrates and we've got protein and different parts of the diet, including fruits and vegetables and dairy and alternatives. Um, so we'll talk about section, um, as we go along. So if we talk about the carbohydrates first, so the we should be facing our meals on these types of foods. So potatoes, bread, rice. These are all starchy carbohydrates, and they mainly give us energy as well as being a good source of energy. They can give us a lot of fiber B vitamins, calcium and iron, too, so it should be about a third of our diet should be made up of count of carbohydrates. And it's always a good idea to choose the higher fiber wholegrain varieties because they've got so much more fiber in and in the fiber or in the kind of the skins. There's lots of vitamins and minerals there as well. Fiber helps us get rid of waste products, and we know that a higher fiber diet can reduce your risk of certain diseases, particularly things like bowel cancers. Um, B vitamins. You know, they help to release energy from food and help the body work properly. So kind of There's another way that it's really important for keeping energy levels up is through kind of providing the vitamins as well. So the higher fiber wholegrain varieties could be your whole wheat pasta, brown rice, brown bread or just kind of leave. The skins on potatoes will give you loads of fiber, and so just kind of playing a little bit more about the specific carbohydrate foods and why they're good. So potatoes also gives us a lot of vitamin C. And in England, um, it's our main source of vitamin C, which is a little bit concerning because, you know, obviously you get loads of vitamin C from fruits and vegetables. That just shows that our intake probably isn't too high. Um, from bread, we get, as I said, B vitamins, but also vitamin E in fiber and other minerals as well. Um, cereals give us iron because they mainly they add iron and the same as well added back into cereal. If they do take any out during the processing. So that can be quite a big source of iron for us and fiber, and also a bit of proteins that Actually, surprisingly, cereals have got quite a lot of protein in, um, as well as those examples. You know, you can get, um, carbohydrate from wheat, oats, barley, rye, rice, couscous called tapioca. So all of the kind of the beige types of foods, you know, they're really, really great for energy. And they should be eating regularly throughout the day, ideally kind of 2 to 3 times a day or, you know, even more as long as it's regular. And that's really, really important just to avoid kind of dips in energy to help, you kind of feel awake throughout the day and reduce any risks of kind of hypoglycemia. If you do have Type two diabetes, I want to talk a little bit more about that later as well. So these do you know, ask me questions as we go along as well, if you want to. If it's kind of a good time, you know, if I can, um, answer at the end of the slide and right, so moving on then to fruits and vegetables. So these that's in the way. I'm just going to move my screen thing so we should be having at least five portions per day of fruits and vegetables, and a portion is about what you can hold in your hand. So, um, really nicely, kind of. A lot of the fruits are already portioned out for us, so you know, an apple or a banana will be a portion, Um, or if if it's a smaller fruits, it might be a couple of sacks, sumers or, you know, hand full of grapes, for example. But officially it's 80 g, and that can be from fresh, canned or frozen fruit or veg. It doesn't really matter. You can also get a portion from dried fruit, but that will be just 30 g because the water's all been removed and these are really good sources of vitamin C carry teens and other antioxidants, folate, fibre and potassium. So it should be again about just like carbohydrates should make up about a third of what we eat every day. Um, so really five a day, the minimum you can have a lot more than that if you're having a third. You know, um, of what you eat in the day of fruit and veg, and we should be aiming for five portions as I said, And that could be, You know, um, that could also be juiced, too. But you can only use one portion from the juiced, um, or smoothie because of the breakdown of sugars. Um, we'll just say it's not good to have more than about 100 and 50 mils of the fruit juice or smoothie because of the extra sugar in there. And yeah, and what also counts as well can can be quite surprising to people as things like beans and pasta. So lentils, chickpeas, baked beans actually, even like spaghetti hoops because they're in a tomato sauce. They can count towards your fruit and veg in the day as well, so you can get it from quite a wide variety of things. What doesn't count as a vegetable is potatoes, yams, Kasaba or plantain. There most To start, you need to be counted as the vegetable. But what does count is sweet potatoes, parsnips, Swedes and turnips. So, um, there's a little bit kind of a It's a little bit of a gray area, I suppose, which can be a bit confusing, but, I mean, they're still very good for you. Obviously, you know the potatoes and cassava and yams. But just we'll we'll count towards as a carbohydrate. So moving on, then to protein foods. Um, so these are a really important source of amino acids, and obviously we have 20 essential amino acids that we need in our daily intake. They also provide a lot of iron, particularly from the meat and fish. Also a lot from beans and pastors as well. B Vitamins again really important for your energy release zinc and magnesium. So those, um, minerals as well. And it's recommended to choose lean cuts of meats and lean mints when you can eat less red meat and processed meats like bacon hammer sausages because they have been linked to increased risk of certain cancers. So limiting your intake of those foods to about 70 g a day and 70 g is actually quite small. It's it's about two, probably about two tablespoons or so. So it's a good idea if you're eating, um, process meats regularly to cut that down. But obviously, you know, you just need to eat where you can if you if you've got a limited supply of different sources of protein, it's more important that you have the protein than kind of avoid it in the in the short term. So, um, really good sources, as well as things like pulses like beans, peas and lentils. So they're much less lower in fat and the fiber, so that makes them a really nice alternative, especially if you're trying to limit your fat intake. And and we do recommend a for two portions of fish every week as well. And that could be oily or white, but one of which should be oily like salmon or mackerel. And these are really good for Omega three intake. And we know this is essential for our cardiovascular health. And it can be an anti inflammatory, which is important for preventing um, disease as well in some situations, and moderating it and so example of of oily fish include herring, pilchards, salmon, sardines, trout, mackerel and fresh tuna, but not tin tuna. Unfortunately, because in the processing, we need to freeze removed. But if you don't eat fish, we don't have access to fish. Hopefully, you can find an alternative sauce, which could be, um, certain nuts, particularly all nuts or seeds, um, some vegetable oils as well and soy products to like, um, soy beans, soy milk and tofu. So, in fact, tofu is an excellent source of calcium as well. So that's a really, really good product to use and so trying to do your best there. And ideally, it should be about two portions, 2 to 3 portions of of protein per day, and a proportion is 100 g of meat, 150 g of fish. It's about the size of your hand, so kind of the thickness and the size of your hand. And the fish is more like the whole hand like that. And in terms of the bed, the kind of the let's see nuts. So it'll be a couple of tablespoons to be a portion, or things like beans and mentals spoons will be a portion or something like half a can if you had canned, and that will be a good amount to use at a meal. Um, so just a little note about that kind of deficiency. So in terms of um, protein, it can occur in certain situations. Protein deficiency. It's quite unlikely in the healthy population, because if you're eating enough calories, you're very likely to be having enough protein as well. Um, what can be a problem is if you, um if you have a traumatic injury, so as a result of kind of burn surgery or kind of some kind of injury and sepsis, Um, Or if you have a disease where you're not able to absorb your nutrients very well, like gastrointestinal diseases or liver disease, or you have lots of losses, that is, if you've got renal disease, you've had a hemorrhage, or you've got X elated losses from burns. Then you can have quite a lot of protein leakage from that, so your requirements in that are much higher. So those are really the main situations where you might be concerned about somebody not getting quite enough protein, and they would need a higher protein, um, diet. Essentially, without that, you could get stunted growth in Children, increased risk of infection, poor wound healing and also anemia. Um, obviously, as a result of kind of lower iron intakes. So, um, just a little note about the fish. So we just need to be a little bit careful about set oily fish like shark, swordfish and Mullins. There, particularly high mercury, so they shouldn't be had if anyone's pregnant or breastfeeding otherwise limited to once per week as well. So anybody can get mercury poisoning from having too much of those foods. Otherwise, kind of 22 full portions a week. Overall, fish is about the right amount. We wouldn't want to go to high again because of the mercury poisoning. Okay, so I'll move on. Let's just see a check If there's any questions. Mhm. Okay, we can talk about that. Perhaps at the end. The hypoallergenic diet. Yeah, sure. I'll touch that at the end. There's just another. Another question before that. So Oh, was that? Yeah, it was probably a but yeah, if we go through them at the end, I guess. Oh, I didn't see it. Yeah, we Perhaps if I I think I missed that one out. So I can only see one question about the hope that so maybe maybe Hannah, if you could let me know if there's anything kind of pressing that it seems like a good time for me to answer. Otherwise, I'll just answer them at the and thank you. So, um, if we talk now about dairy, so, um, this is very important because It is the main source of calcium on our diet, but it also provides protein, a quite significant amount of protein, so you can get 20 g of protein from a pint of milk, for example. It's also got a lot of riboflavin and vitamins A and D, but only in full fat milk. Because, um, there are certain vitamins that are fat soluble, so a, D, E and K you can only get from, um, that so if you have a fat deficiency and if you're not eating enough fat, you might potentially lead to a deficiency in those vitamins as well. Any. We'll talk about that in a minute. So just a little note. They are high in saturated fat because obviously the animal products so just be a little bit wary of that. Try to go for the lower fats and also low sugar if you can. Just the general health um, like the 1% about milk or uh or kind of semi skimmed and skimmed Reduced fat sheet is and plain, low fat yogurts. But Children should be using full fat milk until the age of two years because they can't they need the extra energy. Essentially, we don't want to put them on a low fat diet and reduce and risk kind of malnutrition and then under semi skimmed until at least five. And so kind of a note, I guess, about just making sure that we're possible. Um, new moms can breastfeed for at least six months. Uh, and you know, even longer and particularly if there is a lack of, um, nutrition performed, uh, infant formula. And if that is something that's the case at the moment, then it's really kind of all really useful to encourage mothers to to breastfeed a little bit more than perhaps they are, because I think the rates are relatively low in Ukraine. I just look it up, and a lot of people give up quite soon. So perhaps thinking about kind of a little bit of extra support there just to help. So see that can lead to lots of different infant too. Well, mainly. So the examples of some milk cheese you're getting from our spray, um, those that don't tolerate dairy. There are quite a few people that do have kind of lactose intolerance. Um, you can go for the calcium fortified dairy alternatives like the soy milks and your guts and cheeses. Those types of things, Um, and just a little bit of a note about who could be most at risk of calcium deficiency. So many kind of infants in young Children, people over 65 pregnant women cause they have much higher requirements and breastfeeding as well. So and really high requirements of calcium in that otherwise kind of it risks the mother becoming, um, having Austria, Malaysia. Um, so anybody with a vitamin D deficiency because they're not able to absorb the calcium as well. So it's just kind of, um, something to be wary of and that can cause rickets in Children in Austria, Malaysia and even can be linked to osteoporosis in adults as well. Um, the main things I wanted to say about that and, um so if we go on to this, this is a very kind of small part of it, but important. So we do need fats in our diet, like I was saying earlier about kind of the fats over vitamins and minerals, so they are really essential, but we don't need very much at all. Um, and it is better to choose the unsaturated fats and fatty acids because they're a bit healthier in terms of our heart health. So things like Rapeseed oil, olive oil, um, they're the best with the mono, unsaturated fatty acids and sunflower oils, and we'll put fully unsaturated but better than butter. Um, all fats are high in energy, though, so even though they are healthier, limit the amount that you're having. Because too much fat can increase weight, which obviously kind of increase your risk of various diseases. Obviously, if there's an energy shortage, using fat fatty products can be very helpful for helping people maintain their weight and their, um, immunity, Um, and their health generally. But obviously you want to be careful a lot of the saturated fats that can increase your risk. Your your cholesterol, um, and fats help the body absorb fat soluble vitamins A, D, E and K got the K there, Um, so if you don't have enough vitamins A, D, E and K, you can kind of increase your risk of things like deficiencies of vitamin A can lead to problems with your sights, your skin integrity, growth, retardation, um, vitamin D. Obviously, as I mentioned about Ricketts and Children in Austria, Malaysia and so Ian K. Are very rare. Obviously, K. It's just something that we need to give up birth. Otherwise, it's very kind of present in lots of different foods. Um, and then just to get a note about the higher and foods in fat, salt and sugar just to eat them less often for a healthy diet, things like cakes, chocolate biscuit, sugary soft drinks. But, uh, I scream, they're not necessarily needed. But actually, they can be very, very helpful for nutrition. Um, in situations of malnutrition. And you know, if somebody is underweight, then dietician will offer often recommend these types of things just to help push to wait up because it's more risky to have a lower weight than to eat these foods short term so they can be very, very useful, um, to gain weight fast. And the last thing to talk about in terms of healthy eating is just a note really about fluids. So these obviously are essential to life. If you don't drink for a few days, then you will die. So we do need those so chronic dehydration can cause things like constipation, headaches, let the Gmail, too. Confusion and obviously, increase your risk of UTI s. We need about 30 to 30 five mills of a kilogram per day in adults, so it might be around 2, 2.5 1000 meals and said Better to choose water or low fat milks, low sugar, sugar, free drinks, tea and coffee. All count as well, so you can add those in, Um, we do count fruit juice and smoothies, but they contain lots of free sugars that can damage your teeth, as I said earlier, just to limit those 250 miles a day. But again, these really do have their uses. If somebody is energy deficient, they need a little bit more energy and also for treating, um, hypoglycemia as well in touch your diabetes and type one diabetes. So if you do, you have somebody that's dehydrated. Obviously, to maximize the absorption of the fluid, you can add a bit of glucose and salts in there, And that's obviously what oral rehydration solutions are based on. And that just helps in terms of absorption across the gut barrier. Yes, right. So I wonder if I should look at any questions Now, if there's nothing more, uh, I can't see any extra, so we'll just go on, if that's okay. Yeah, if there's anything relevant, Should I read the first one, then the one that, Yes, but the first one, I think I must have missed it. Um, one of the main points of hypo allergenic diet in general and what is strictly forbidden. So, um, try to answer this, but I'm not an expert in it, but it's really about kind of avoiding things that could increase your risk of it. Depends on what kind of high pandemic, hypoallergenic diet you talking about cause there's lots of different allergies, so it'd be good to get a little bit more information about that. If we're just talking about kind of reducing if somebody's kind of immunocompromised, that type of thing, you can do things like avoid certain cheeses, which might have a risk, um, of listeria. And then also, um, you know, making sure you're reheating right properly. Those types of things I just would be good to get a little bit more information about that. And then perhaps I can come back to that at the end, so I just thought that one about how much chicken is advisable. So chicken is, um, uh, it's relatively low fat meat, so it's quite leaned, which is a good thing. Um, and you can have too much protein, so it's not necessary to go above and beyond in terms of the requirements. So kind of 2 to 3 portions of, uh, protein per day. And that will be 100 mil 100 g of chicken proportion. So, I mean, I guess you could say kind of too 100 to 300 g a day maximum. If you were only having chicken pox, you got to think about the other sources of protein as well in your diet. So if you're having chicken, one meal and you might have eggs, another meal and another meat, and then just kind of 100 g is a decent portion are protein requirements are about 1 g per kilogram of weight. So if you're 60 kg, about 60 g of protein and you get about 20 g of protein from a portion, so again, that kind of leads into about three portions per day. Um, after five years, what kind of milk is healthy for Children so it's really just an X that you should be ideally continuing semi skimmed. But if if you're noticing the child is becoming very overweight, you can put them on to 1% milk on it on the on the very low fat milk on the skimmed milk, just to kind of moderate the total energy intake and fat intake without reducing their so calcium intake. Because it's actually there's more calcium in the lower fat milk because it's a little bit more concentrated. There's less fat there, so you can continue with semi skimmed. But if you wanted to, you can use skimmed if the child has a problem with being overweight. Um, right now, if I don't answer the question fully, please just let me know if you don't have any more questions. Is frying olive oil for cooking advisable and healthy yet so olive oil is fine for cooking. It's a good one to use because it's monounsaturated fat. Just try not to heat it, too, too high temperature, so that it's to the point where it's kind of steaming. Um, because then it starts to break down a little bit and produce other products which can be bad for your health in large amount. So you know things like deep frying with olive oil because you're having to heat it lots and lots for a long time. It's probably not a good idea to do that regularly, but using a bit of olive oil and cooking on a general basis is a good idea and rapes it all as good as well as an alternative to olive oil. Okay, I hope that's okay. That's if there's no more questions about healthy eating that I can move on to malnutrition. So, um, just be good for you to ask more questions. We have a long has been defined as a state of nutrition in which a deficiency or excess or imbalance of energy, protein and other nutrients causes measurable adverse effects on tissue body form such as body shape, size and composition, body function and clinical outcome. So it's quite a worthy definition, and it's just interesting to note that it's not just a lack of nutrition. It could be excess nutrition where you're in a state of malnutrition as well, and just not as well. You know, obesity, obesity people can become malnourished as well, so you know, for example, if if it's an acute state of being undernourished, you can still be obese, so don't use kind of just seeing somebody in at one time as an indication of their nutritional status. You always have to look a little bit closer and ask some simple questions so some of the consequences of malnutrition could be impaired immune function, which increases your susceptibility to infection and sepsis. Nutrient deficiencies. So, for example, like I was speaking about with calcium and vitamin D, Austria Porosis and rickets, um, delayed wound healing and increased risk of pressure ulcers, particularly the pressure ulcers. And you rely on having excess protein to help them heal as well. Muscle wasting and weakness, which can affect a few different functions of the body, including the respiratory function, which can increase your risk of chest infections. If you don't get enough nutrition cardiac function, you're more liable to heart failure without significant, uh, enough nutrition mobility, so increased risk of thromboembolism and pressure ulcers as well. If your mobility is affected because of the muscle wasting, it can also alter your gastrointestinal structure and function, so that's not working properly. It can lead to apathy and depression, which then can lead to a reduction in, um, nutrition as well, because they don't feel like cooking and eating healthy foods. And perhaps they're just going to be relying on unhealthy foods, general weakness and illness, which affects the ability to eat properly. Also in Children, adverse effects on learning and behavior. Um, right on. So particularly, um, looking at malnutrition in Ukraine at the moment, Um, it's becoming more evident in Ukraine with the war, we have an estimate of 65% of trapped Ukrainians objected to face food shortages by the end of 2022. So obviously this is a big thing to think about, not just kind of in the in the whole world and the effects of, you know, grain production thinking many about in Ukraine right now. Those at most at risk are young Children and pregnant breastfeeding mothers and the elderly. Um, I understand that there's a limited access to income formula which increases the risk of illness and mortality in the Children that are breast fed, and that's not just at the time, that's a long term. So we know that breastfeeding reduces risk of lots of different problems diseases, illnesses in future. So having trying to increase breastfeeding where you can is it really, really important? As a result of poor diet in pregnancy that can cause maternal anemia, preeclampsia, hemorrhages and ultimately could lead to death and any infants it can cause birth, the birth, weight wasting and then long term, longer term for the child developmental delays as well, so you can see that good nutrition at the point of pregnancy and shortly after is really, really important for the child. So I understand that you n World food program of providing food packages, but it's just not enough to meet the local needs as well. So this is quite a big problem at the moment. And it would be really great, actually, if there's anything specific that you wanted to ask me about, kind of how to make healthy swaps for things that aren't available, because I couldn't really find any information about exactly the kind of diet that Ukrainians are eating at the moment and how much it's been affected. Um, so just then going on, I will come back to malnutrition a bit at the end, But I just wanted to talk about a couple of situations, which I thought might be helpful to touch on which are related to nutrition in emergency situations. So first one is diabetes. Um, so I found out that seven around 7% of Ukrainian population has diabetes, and that accounts for 2.3 million people, those with type one diabetes. Obviously, access to insulin is essential for survival, and not having insulin for a few hours can really, really risk that help. Um, there's limited supplies because of fighting around kiw and which is obviously the base for indoor and pharmac, which are the biggest pharmaceutical companies in the area. Um, as a result of roads being destroyed, set curfews and pharmacy has been looted. That's limited the supplies of certain things as well, and some freezing weather as well. So if the intern has become frozen, then it's actually ineffective that point. So any intern that you do have that's been frozen, it can't be used. So, um, the American Diabetes Association have got a really nice resource for diabetes in, uh alongside the Ukrainian crisis. So I put the link there, and there's lots of information there, including kind of tips on, you know, medication swaps that you can make and advice on how to manage that and kind of in practice in the field. So just then talking a bit more about kind of hypoglycemia and hyperglycemia as well. So in hypoglycemia, it can be caused in metabolic stress, so as a result of illness, infection, a general stress, which obviously is going to be something that's happening at the moment. So steroid induce hypoglycemia is something, and a lot of people will be treated with steroids for different conditions. So it needs to be kind of born in mind if someone has diabetes, that it is very likely to increase their bug glucose levels. Dehydration as a result of kind of being very warm or kind of increased exercise levels. Um, that is something that's very closely linked to hypoglycemia, so hypoglycemia can cause dehydration. Equally, dehydration can cause hypoglycemia, so it's a very closely linked to something that's really important to kind of keep an eye on the symptoms of hypoglycemia. I'm sure you're aware. Excessive thirst, increased urination, weakness, blood site, Um, and after a while it can result in the acidosis. This takes just a few hours for Children. Um, it takes a little bit longer for adults 1 to 2 days, ultimately fatal coma, which can occur if I'm not treated in terms of management. Kind of thinking from the diabetic perspective. Um, it's really important to one to the blood glucose levels regularly closely testing blood and urine for ketones. Where possible. I've seen Type one to continue the insulin, and if you can increase it and hypoglycemia. Obviously, I know that's not always possible, but I yes, what you can do, uh, in terms of perhaps altering the diet you can. You can reduce the carbohydrate intake slightly if it's not possible to get any insulin, and that will reduce the requirements as well. So it's really about balancing insulin with enough carbohydrate to prevent the kippah glycemia as well, so you can use sugary drinks and and it could food just to help to balance it. So it's a little bit, uh, close between hypoglycemia, hyperglycemia sometimes in terms of management, obviously preventing dehydration and in a risk of hypoglycemia, use the sugar free fluids so that you don't raise it even further, thinking now about hypoglycemia, so this can be caused by kind of, obviously taking your insulin and self and all your ears, which actively, um, reduces blood glucose levels. And it can be caused by vomiting and diarrhea, which causes dehydration and then reduce food absorption as well. So although you're eating, you're actually absorbing the food very well because you're vomiting or you've got diarrhea. So you're having less carbohydrate than you expect, which then kind of affects the amount of insulin you need. Also not eating as much as you usually do, for example, in the case of food shortages. Or it could be with miss meals or delayed me well so you can. Just delaying a meal can obviously put you into hypoglycemia because the lack of carbohydrate, just to be aware that if somebody has lost weight because if they're reduced nutritional intake, then it will alter their requirement for insulin as well. So it's something to always ask somebody if you kind of change. If your weight's been coming down and it might need, they might need a reduction in the insulin as well. If someone's been doing more, it's got activity. Obviously, they're they're using up the glitz and their blood, so they're going to be using, um, going to be needing a little bit less insulin in that situation as well. So in terms of symptoms, what we're looking at for for hyperglycemia as sweating, shakiness, nausea, increased heart rate and irritability. So just a note. Obviously, they're quite some to hypoglycemia. So it's always good to test whenever you can. And then longer term impaired brain function, which can lead to confusion, disorientation, slurred speech, aggressive behavior, which often looks a lot like alcoholism and then ultimately unconsciousness. So in terms of managing hypos, Um, first it's really important to get them 10 to 20 grand requiems all carbohydrates, so that should be only carbohydrates, so nothing else mixed in there like fat, so Phil and chocolate wouldn't be a good way to treat it. So what you need is, um, is glucose a glucose tablets or maybe a sugary drink, like a full sugar busy drink or some sweets, and that will increase the blood glucose by about 2 to 3 millimoles per liter within 45 minute. You may need to just eat fewer carbohydrates if access to diabetes medications is reduced, Um, for prevention, making sure that you're checking blood glucose levels frequently, especially before bed. Um, increase the carbohydrate intake if you are at risk of hypoglycemia, especially when they're exercising. So before, during and after you might need some extra carbohydrates. And that could be, um, better. The form of that is better as a starchy carbohydrate like we were talking about earlier. You know, the bread, rice, potatoes and avoiding alcohol because it does increase your risk of hypoglycemia, But even up to 16 hours after so you might have alcohol one night, and the next morning you would still be at risk of hypos as a result of the alcohol. So it does have really a long term, uh, term effect. Um, okay. Any questions about diabetes? If not, I will move on. I hope that was helpful. Um, so I've got quite a few slides on burn injury, but I'm not going to read through them all because I think I probably made it a little bit too detailed, but it will be there, obviously, if you need it. If you want to go back. I talked about what kind of different requirements. So burn injuries. Just a really, um, interesting one because it does elicit the most pronounced responses. Stress capable by the human body and the energy requirements are severely increased because of the home energies, breakdown of body and fat and protein, body fat and protein so that increased that can lead to a weight loss of 1.5 kg per day. And that's a significant amount. Um, and ultimately, if somebody leader said extent of the pre burn weight, then they are very likely to die. So prevention of weight loss is really, really important in Burns victims, um, and recognizing that the energy requirements are going to be higher than they were before. So all new ambitions, ideally, should be assessed by dietician within kind of 1 to 2 days of injury, but preferably before. But even before they seen by dietician nutrition support needs to be started ideally within kind of 4 to 8 hours. And just to prevent things like which are making sure that they provided enough nutrients to prevent weight loss, which can happen very early on, preserve their lean body mass and promote maximum wound healing and skin graft, take and maintain their immune competence. So, ideally, starting nutritional therapy as early as possible. Um, in terms of minor burn injuries, so that can mostly and that's kind of 10 to 15% body surface area burn. Most of that can be, um, uh doesn't require extra feeding so they might just need to increase their, uh, their nutritional intake orally. And that can be through the high energy products, like fatty sugary foods, just to help provide them with the energy that they need. Um, so that can all be done, all relieved. But in make plans injuries that affected over 20% of the body surface area. There's a very strong oxidative strength, stress and inflammatory response which can last for months, actually, and cata bolic response so they could continue to lose weight longer term. Um, generally speaking, I see you recommendations apply, and in terms of feeding, if you're doing enteral feeding, um, if it's if the intestinal tract isn't used really early on, like I said within kind of 48 hours, they are risk at risk of Adamia because of fluid resuscitation, Um, and also intestinal family ability, my eyes as well. So we need to start intral feeding very early, and it should be by the gastric route, as opposed to parentally. Um, this has been shown to reduce the stress hormone levels, increase the immunoglobulin production and reduce stress, ulcers and risk of malnutrition. So energy and there's a gastric tube is the best way you could be. Post poll Orrick, which is easier in Children. Um, or you could use peg as a backup. So per contagious and, um, endoscopy gastroscopy endoscopic endoscopy percutaneous endoscopic just completely. I haven't said that in a long time or parenteral nutrition. Use that as a last resort because it can increase the risk of, you know, things like infections. And it's very hard to match the energy requirements. The nutritional requirements with P. M. So the solution is just like any generic kind of ICU solution. So polym eric high energy, high nutrition with fiber Because the risk of conservation is very high in these in these patient's because of dehydration and because of problems with perhaps, um, early s, for example, and just to make sure that their bowels opening, Um, so the energy requirements? Yeah, as I said, um, prolonged metabolic response really increase the bar resting energy expenditure. Um, it's actually the highest five weeks after injury as well. So it continues to increase with time, and after that we'll continue. It will go down. Um, protein requirements are really increased. And so, as opposed to 1 g per kilogram per day for the general population, it's increased to 1.5 to 2 g per kilogram per day. Glutamine is an amino acid that has been found to be, um, conditionally essential. Um, various reasons so you can add it into, uh, it can't be absorbed very well across the gut, so it does need to be added peremptorily, um, for carbohydrates. It's recommended to be about 55 to 60% as of energy and and in terms of the guy seem in control. If you've got burn burn injuries with diabetes as well, really kind of keeping very, very close eye on that to avoid the risk of hypoglycemia, because often the patient's will have lots of interruptions to their feeding, and they will be given obviously lots of energy and the insulin. And if they had that feed interrupted, then they're going to be having insulin where they're not needing it. So just be really wary of that as well. Um, yeah. Someone a fat is needed. Should be a bounce. Um, under 35% ideally, although most central fees provide 30 30 to to 52%. So just trying to go for the lower fat options if possible, and also being aware that if they're treated with proper fall, then that contributes the lipid intakes as well. Micro nutrients that also increased in the hyper metabolic response. Because of oxidative stress and the inflammatory response, they exhaust the indigenous antioxidant defenses, which are dependent on the micronutrients for working as cofactors. Um, so you can't actually provide these in standard nutritional feeds? Uh, so you do need to make sure they have an increased They might need some kind of infusion of B vitamin C E N d. And also copper, selenium and zinc Large losses from the burn exit it as well. So that's something to be really aware of. Okay, I don't know the outcome. I'm probably panels. I'm talking book. Um, so we're getting towards the end now and then we'll be a little bit of kind of questions, but I just wanted to go through what we use in the UK for screening malnutrition. And that's called that. I don't know what you use. Um, perhaps you could tell me that would be really interesting. Malnutrition. Universal screening tool We call it must. This is developed by the British advisory on group Inferential Enteral Nutrition Vape unknown and there's a link there to it. Is that even a kind of the one you can use on your mobile and it's used to establish nutritional risk. So is that medium or high risk? As a result of the must assessment? Uh, increased risk of mortality and complications and longer hospital stays and costs, ultimately obviously greater requirement for healthcare postdischarge and increased risk of admission Hospital again. So it's quite a long one, so you can imagine that it's kind of together. I'll just talk like step one, step forward and step five at the bottom so I'll just talk through it briefly with you. So Step One is to find out their B m I so body mass index and use that by dividing their weight in kilograms by their height in meters squared. Um, so anything above 20 is zero. If it's 18.5 to 20 it's one and if it's less than 18.5, it's too, So you can use other measurements to. If you don't know the the height and the weight, there are other measures that you can use so you can. For example, you can measure the middle Brahms a conference to get an estimation of their body weight. And you can use kind of different links like that on the length than the knee height as well to estimate their height. If you're unable to do that, um, Step two is the weight loss school. So you need to ask the people patient Sorry, how much weight they've lost and in what period of time. This is unplanned weight loss in just the past 3 to 6 months. So if they've lost less than 5% is a called score of zero. Um, if it's over 10% in 3 to 6 months and it's a score of two, or if the patient's acutely ill set three and there's been always like to be no interest in intake for over five days, then you possibly just give them a score of two. A score of two is enough for a referral to a dietician. It depends on the hospital they might accept. Must have one. Um, but if they're very busy, them to limit it to most of, too. But this is really important so that we dieticians can prioritize Patient's. So if you're saying somebody with a must score of six, that's obviously going to be seen straightaway. If they've got Moscow of two, then they might have a priority. So it's just something to be. Make sure that you're doing accurately so that you can refer with the right prioritization, but that gives you the overall risk. Um, and then ultimately, Step five is just how to manage it. Sorry. Sometime, Um, so zero is low risk. One is a medium risk just to observe. So don't refer. Um, but you can observe them and and keep doing the mask over time, too. Or more is really a referral to a dietician, as it says, Or nutritional support him. If you've got one that should have, um, a dietician nutritionist in it as well. Um, so really, that's it. And then ultimately, then you refer to the dietician and the British Artistic Association running a trusted dietician campaign, and this is the kind of a sign for it. So trust a dietician to know about nutrition. If there's any doubt about nutritional kind of problems in any of your patient's, then it just kind of refers to the dietician or ask the dietitian for support. Usually they're very helpful and really keen to help. And so that's really the end of my presentation. So if you've got any questions, I'm happy to take them. Now, I know that you've got about five minutes left. I can't believe how long I've spoken, but I just didn't expect it to be that one. But yeah. Please. I did see the one about the high allergenic diet, so contact dermatitis. Okay, I don't think I know enough about that. Really? To answer your question about that. But I could if you wanted to provide me with your email address. I can look into it or kind of direct you to somewhere where you can find more information about it. I've not done hypoallergenic diets myself, so I'm really sorry, but I can I'll try and help if I can. Any other questions at all? Yeah. Okay. That was your smoke. Sorry. Sorry. What's that. I don't think there's any other questions in the chat. Um, very much for your lecture was really interesting. Um um, that was useful. Yeah, sure. Yeah. Um, I just reminded. Want to remind everyone to do the feedback form, please? Um and I think other comments or feedback that you have You can write in the chat also. Um, and we have another five minutes so you can do the feedback. Or if you have any other last minute questions, take the chance to ask. Now, um, And if you want to re watch the lecture, the recording will be uploaded. Um, soon. Hopefully, um and yes. So please indicate that you've filled in the feedback form in the chat and then I'll send through the certificate. Thank you, everyone. I will end the recording now.