I really enjoyed writing the article on small intestinal bacterial overgrowth and probiotics; fiend or foe for CN Magazine.
It's always a good opportunity for me to do a deep dive into the evidence behind a purported treatment for gastrointestinal conditions.

What is Small intestinal bacterial overgrowth?
Small intestinal bacterial overgrowth (SIBO) is characterised by either an abnormal increase in the number or type of bacteria (or indeed both), in the small intestine. 
This occurs in the duodenum and jejunum, not designed to host a high microbial load.
SIBO is commonly associated with gastrointestinal (GI) symptoms including bloating, abdominal pain, flatulence, diarrhoea or constipation. Symptoms can occur because of the newly colonised Gram-negative aerobic and anaerobic species (usually found in the colon), feeding off sugars and fermentable carbohydrate, producing methane, carbon dioxide and hydrogen.

In this article I look at what SIBO is, how it is diagnosed and what the risk factors are for this condition, and how it is traditionally treated. The evidence base behind the use of probiotics with SIBO is inconsistent. I found some clinical trials were for and against the use to support improvement in symptoms. I do reference some probiotics that have had promising results. So look out for this article when it is published shortly in CN Magazine.

Have you recently been diagnosed with Coeliac Disease (CD) or have had a diagnosis for a while and are developing new symptoms or looking to change up your diet or your weekly meals?
When I ran classes for patients who were newly diagnosed with CD we would have fabulous discussions around where to seek help and support that was reliable and useful!
Here are the top 5 I would recommend:-

1. Number 1 has to be Coeliac UK website. They are a fantastic organisation that uses membership money to fund the website, research and resources for people with coeliac disease. www.coeliac.org.uk/home/
2. Support groups on Facebook for example. As I worked in the Wirral I would always recommend my local group to new patients. There are usually great conversations about restaurants and café recommendations, questions about their gluten free food prescriptions, sharing experiences of going abroad etc. Obviously, the contributors are patients, and not healthcare practitioners, so it's important to remember this if people share their pearls of wisdom!
3. A specialist dietitian - Dietitian's like myself who specialise in gastrointestinal disorders are invaluable if you want personalised and efficient support. Sadly, waits for NHS appointments can be considerable. Search for experts via websites such as the British Dietetic Association www.bda.uk.com/find-a-dietitian.html
4. Reliable sources on social media are also fantastic for resources such as recipes, or lists of the latest gluten free food products in supermarkets, or announcements from the FSA. Such examples are www.facebook.com/coeliacbydesign and 
glutenfreecuppatea.co.uk/
5. Other websites such as Guts UK, Patient Info, and NHS UK all provide a wealth of information for you to read and review.

If you have gastrointestinal symptoms which occur regularly (and sometimes simultaneously) such as bloating, change in bowel habits, fatigue, pain or vomiting - in particular when eating foods containing gluten, please book to see your GP. Continue to include gluten in your diet in order for any future tests to be accurate. Your GP can order a coeliac screen for you which involves a blood test to look for raised antibodies specific to coeliac disease. Coeliac UK website also has a self-assessment test you can conduct for further insight: - www.coeliac.org.uk/do-i-have-coeliac-disease/?&&type=rfst&set=true#cookie-widget

The British Dietetic Association has some fab information on what a dietitian is and what they do.. here's a little snippet for your reference:- 
The full article can be found here:- 
www.bda.uk.com/about-dietetics/what-is-dietitian.html
Dietitians are qualified and regulated health professionals that assess, diagnose and treat dietary and nutritional problems at an individual and wider public-health level.
They use the most up-to-date public health and scientific research on food, health and disease which they translate into practical guidance to enable people to make appropriate lifestyle and food choices.

Is the title of 'dietitian' protected by law?
Yes, the title ‘dietitian’ is the only food and nutrition title that is protected by law. Only those registered with the statutory regulator, the Health & Care Professions Council (HCPC) can use the title.
Who are they regulated and quality assured by?The role of the HCPC is to protect the public. It is an independent, UK-wide health regulator. The HCPC keeps a current register of health professionals who meet its standards and takes action if registered health professionals fall below those standards. Registered professionals must keep up-to-date through compulsory Continuing Professional Development (CPD).
If an individual is not happy with the treatment they are given, or if they are worried about the behaviour or health of a dietitian, they can approach the HCPC who will investigate and take action.
HCPC Registration
Dietitians are the only nutrition professionals to be regulated by law, and are governed by an ethical code to ensure that they always work to the highest standards.
All dietitians are regulated by the HCPC. The HCPC exists to protect the public. They publish a register of dietitians and other health professionals who meet their standards. Only those on the Register can call themselves dietitians.
You can find out details of all dietitians who currently practise in the UK by visiting the HCPC website and checking its register.
If you see an unregistered person claiming to be a dietitian, please get in touch with the HCPC.
What qualifications do dietitians have? The minimum requirement is a BSc Hons in Dietetics, or a related science degree with a postgraduate diploma or higher degree in Dietetics.
Dietetic courses are structured to include biochemistry, physiology, applied sciences and research methods that underpin nutrition and dietetics. These are complemented by social and behavioural sciences and the theories of communication to support the development of skills required for professional dietetic practice.
All courses require a period of supervised practice including NHS settings, where an individual must demonstrate clinical and professional competence before being eligible to apply for registration.
The British Dietetic Association (BDA) is the professional body and Trade Union and is also responsible for designing the curriculum for the profession. Courses must be approved by the HCPC and demonstrate that graduates meet the Standards of Proficiency for Dietetics.
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I had the pleasure of writing this article recently with the aim to review the IBD management clinical guidelines produced by three organisations, 1) The British Dietetic Association (BDA), 2) the British Society of Gastroenterology (BSG), and finally 3) the European Society for Parenteral and Enteral Nutrition (ESPEN) see Table 1. These guidelines were developed by clinical experts and patients. They involved the systematic review of thousands of published articles and recommendations were produced via the eDelphi online consensus agreement platform. The guidelines frequently rely on expert opinion-based recommendations or ‘Good practice points’ (GPP) due to limited empirical evidence available within a particular research area. Generally,  guidelines are developed to improve access to current research evidence for practitioners. The BDA states their ultimate aim with this guideline is to
“increase equality of care in nutritional assessment and dietary management of IBD.” (BDA, p.368)
It was great to have an in-depth look at the guidelines and being able to reach a wider audience to support their learning as well as mine!
The full article is available at 
​https://nutrition2me.com/

The Northwest Gastro Dietitians Group (NW GDG) established in October 2021, is an active voluntary group comprised of gastroenterology specialist dietitians working in NHS Trusts across NW England. The group was established following the publication of the Getting It Right First Time (GIRFT) gastroenterology report in September 2021. This report highlighted the need for regional networks to enhance collaboration, and share best practice within gastroenterology professions, with the aim to improve patient care. GIRFT is “a national programme designed to improve medical care within the NHS by reducing unwarranted variations”. 
The event hosted a range of esteemed speakers who delivered educational sessions relevant to dietetic practice and service management. This excellent study day was kindly sponsored by Stanningley Pharma and Abbott Nutrition Ltd.
​My write up of the day has been published in CN Magazine: 
https://nutrition2me.com/publications/complete-nutrition/

Topics included: 

1. Pre-habilitation in Liver Disease
   
2. Business Cases in Dietetics 
   
3. How to transition patients from paediatrics to adult Care 
   
4. Allergy in Adults
   

Key takeaways
1. Liver disease: Research suggests that 40-70% of patients with liver cirrhosis patient can present with sarcopenia, which is characterised by the loss of muscle mass, strength (Sinclair M et al 2016) and is associated with poor treatment outcomes (Son, 2021)​. This loss of muscle mass is associated with poor dietary intake and protein energy - malnutrition. Therefore, key nutritional strategies can be implemented to overcome this complication in chronic liver disease. Indeed, as practitioners we should encourage patients to have high calorie, higher protein-containing snacks to improve their protein intake and reduce the incidence of sarcopenia.
2. Business cases in Dietetics -key tips!
1. Build up your case​ by collecting data such number of dietetic referrals, utilisation rates, service evaluations, patient satisfaction surveys, etc.
2. Rationale: focus on patient benefit​ and therapy outcomes
3. Don’t give up (you will be rejected a lot), keep going​!
4. Wait for the right opportunity​
5. Sometimes this means do different roles, and make different connection​s
6. Be enthusiastic!​
7. Make friends- life is too short and the NHS is a surprisingly small place
3. From paediatric to adult care
Communicating well can be key to a smooth transition and this session provided some thoughtful tips to consider!  Top tips!

1. Try not to speak in ‘young person’s lingo.
2. Speak to them directly (with eye contact) rather than to a parent/carer who may be present.
3. Speak clearly and concisely in layman’s terms rather than using complicated terminology.
4. Give them chance to respond to your questions, and do not fill in the silences
5. Encourage them to take ownership of their condition and treatment plan.

4. Allergy in adults
As practitioners we should ensure that a dietetic assessment includes a review of the symptom history alongside detailed dietary history. This should include questions on typical dietary intake (foods and fluids); assessment of anthropometric measures including any previous weight loss and adequacy of their diet. In terms of clinical history, this allows for identification of any possible mechanism of food allergy (i.e. IgE or non-IgE-mediated) and ensures that the correct foods/allergens are tested using the correct testing method. 

My most recently published clinical nutrition article was an interesting piece of work. Writing for magazines allows me to do an in depth review of research in a particular area. This in turn allows me to make sense of the detail and to bring to life the practical elements of research to inform our practice as healthcare professionals. 
Inflammatory bowel disease (IBD) is a term that is used to describe the different inflammatory conditions, including Crohn’s disease (CD) and ulcerative colitis (UC). Patient's with this disease can often embark upon dietary restrictions in order to control their symptoms whether they have active inflammation (in a flare) or if they are in remission.
Fibre is one of most popular nutrients to restrict due to misconceptions of fibre having adverse effects on symptoms. In this article, I review the 2022 British Dietetic Association consensus guidelines on the nutritional assessment and dietary management of patients with inflammatory bowel disease and highlight the guidance relating specifically to fibre intake. As part of this review, I spoke with one of the author's of the guideline, Dr Miranda Lomer, who is keen to promote the guideline far and wide. 
A fascinating area to review! If you would like access to my full article please contact me on [email protected].

 ​In my gastro clinic the topic of 'meal planning' comes up almost as regularly as discussions about 'bowel habits'. When patients are embarking on a radical shift to their dietary intake to improve their health, meal planning can be a helpful tool to navigate the first few weeks and months of meal times. Certainly in the early days it can be stressful for patients to not only deal with a new diagnosis but also to have to  think carefully every time they open the fridge or go to the supermarket to ensure they are eating the right foods!

An example of this is patients newly diagnosed with coeliac disease. They have a lot to contend with in terms of understanding this autoimmune condition and it may be the first time they have ever heard the word 'gluten' which needs to be removed from their diet (for life!) as their body deems it a toxin. As part of the introductory clinic session we talk extensively about the condition and what it means to them, but the session also includes information about the benefits of meal planning and getting organised at home. My article 'Going Gluten-free' published in CN Magazine in a couple of years ago (available in an earlier post) talks a little bit about this.


I have to admit meal planning when you do not have a dietary restriction can be difficult enough. We have tried several times to meal plan at home and it makes our life so much easier! But it is just as easy to fall into old habits and shop several times a week based on what we 'feel' like eating.

However, more recent times involving weaning Max has forced me to become more organised! Although still the early stages of exploration, he is fast approaching the need to have three set meals a day (albeit in very small portions). I'm certainly an advocate of not making 'special meals' as we want Max to enjoy the meals we eat eventually. However, when I'm in a rush and quickly make a cheese sandwich, Max certainly isn't at the stage to have something this convenient. The range of nutrients he requires (in particular iron) now that his milk intake is reducing requires a bit more thought and planning. And so I hear the echos of my own voice in clinic stating the benefits of meal planning! Ah here we go!
In an attempt to get organised I have been compiling a list of the foods max has tried so far for each meal and am attempting to add to them as time goes by and rotate them accordingly!
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Breakfast is by far the easiest! Currently I make my normal portion of breakfast and give him some teaspoons of it (though I will add my dried figs and whole nuts and seeds separately). Initially I blitzed the oats in the NutriBullet to make them more fine but now Max seems to take whole oats on board fine.  The breakfasts we have tried so far are listed in the bubble below. I tend to rotate these in the week. I'm now adding ground down linseed into the yoghurt for some additional good fats. Luckily max loves banana and berries and he has not reacted to nuts and seeds (phew!).

So now I just need to refine lunches and evening meals..which I will endeavour to explore in part II

 It is great fun to watch Max enjoy new foods and textures. He seems quite confident now with a spoon which still amazes me! We started off wearing a standard bib which covers his arms and body...but quickly realised that the food making it into his mouth, certainly in the early days, more often than not will be spat out or thrown around! These bibs allow food to slide down into their lap onto their seat and the floor...lovely.
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So asking around and reading some reviews, we came across the BiBADO. Lots of mums rave about this bib which not only covers the baby, but is stretched across the high chair to create a 'well' where food can be caught. 
The bib was created by a mum with twins who was sick of clearing up the mess after meal times, after several redesigns this 'award-winning' bib was launched. The bib is wipe clean, waterproof and states that it will save 20-30 minutes of cleaning up after meal times. 
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We managed to find a £5 off code so the bib cost us £15. It fits Max well, though I find the velcro fastener slightly difficult at the back. It certainly catches his food which is a lot less messy and does save time afterwards. However, one thing I did notice that because of the brightly coloured and detailed design of the bib coverall Max seemed to find it more difficult locating the food in front of him. This may be because his weaning journey is just starting and he is learning that the items in front of him are food..but I would be interested to hear if anyone else found this with their babies? we solved it pretty quickly by only placing a small section of the bib on the eating area so the food wasn't lost. The downside is that sometimes food slips off and defeats the whole purpose of the bib! Hopefully, this will improve in the future!

It is fascinating to think that environmental factors such as nutrition from conception to the age of two can have such a profound impact on your lifelong health. There is strong research which shows that a good maternal diet is important not only for the prevention of neural tube defects (spina bifida for example) but also to set the blueprint for their baby's health and disease risk. Scientists talk about the importance of the first 1000 days in terms of a child's ability to thrive, specifically related to the growth and development of the brain.

Pregnant women are well versed in taking folic acid, but other nutrients such as Vitamin D, iron, iodine, and omega-3 are also integral for foetal development.
During my pregnancy I had 'morning' sickness (i.e. horrific all day and evening nausea) for about two months where I ate plain pasta, cheese, quorn sausages and yoghurt; not the balanced diet I normally enjoy! Luckily I was taking a supplement...and luckily the sickness only lasted 2 months as my diet was the only source of nutrition for Max!

Within these 1000 days are key stages. The weaning stage is of particular importance. Moving a baby on from breastmilk and/ or formula milk onto solids is an interesting time for babies and parents! It is also a key opportunity to expose babies to a range of different, nutritious foods. Taste exposure is critical to ensure that babies are more willing to eat a variety of wholesome foods setting them up for life, and on an aside, reducing the risk of fussy eating. It is startling to know that in 2012 the National Obesity Observatory reported that most children aged 5–15 years eat just one portion of vegetables each day, and 7% of children ate no fruit or vegetables at all. This highlights the importance of weaning babies onto a good range of fruit and vegetables (whether the parents like them or not!) at the time when they are most receptive to them.

Interestingly a study published in the journal Appetite in 2015 highlighted the improved acceptance of vegetables in quite a complex trial involving infants starting their weaning journey. The babies had repeated exposure to individual vegetables such as green beans, spinach and broccoli, which on the whole improved acceptance, and led to the babies trying and accepting other vegetables. Additionally, this team of scientists argued that whilst hiding veg in meals can lead to increased intake, the child will not learn to like, eat and recognise vegetables and their distinctive tastes. So perhaps keeping the vegetable whole rather than mixing it in with other flavours initially is of some benefit?

Over the last two decades there are countless studies which show that repeated exposure up to 10 times can increase acceptance of fruit and vegetables. So when your baby spits out foods, rejects them or simply pulls a 'what the!?' kind of face...don't give up..try that food again (and again and again!).

I was disappointed today that Max tried avocado and wasn't massively fussed about it. I LOVE avocado and am hoping it will become a staple in his diet. So based on the above he will certainly be trying it a few more times...lucky little fella.
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It is advisable to chop the veg into baton shaped portions so the baby can hold and place part of the vegetable or fruit into their mouth. It is incredible that a baby is born with the innate ability to grasp objects. I waited until Max was 6 months to start baby led weaning as I wanted to give him the best chance of success! The above picture of Max shows him using what is called a 'palmar grasp' which he then draws to his mouth. He hasn't mastered the 'pincer grasp' just yet so I placed peas slightly squished onto a spoon for him to place in his mouth. He loved them! It was great seeing him use a spoon so confidently as well. Certainly a surprise to me!