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2016 Michael Pittilo Student Essay Awards – runners-up

First launched in 2010 by the College of Medicine, the Michael Pittilo Student Essay Award

recognises and celebrates the integration of conventional and complementary approaches to

healthcare.

The award is open to UK students studying any healthcare discipline at degree level or above,

including CAM therapies that are statutory regulated or on an Accredited Register, approved by the

Professional Standards Authority. The FHT is delighted to have been a member of the judging panel

and publisher of the winning essay for seven consecutive years.

Congratulations to Amber Tompkins, who received second prize, and Alison Zander, who was

awarded third. We hope you enjoy their essays.

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‘Food the forgotten medicine; how can clinicians and

patients maximise its potential benefits?’

Amber Tompkins

Word Count: 1497

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We are reaching a critical point, where obesity levels and the prevalence of conditions such as

Diabetes Mellitus Type 2 (DMT2) are soaring (1). Yet, mixed messages about what we “should” and

“should not” eat are relentlessly being exploited by the media, and unhealthy foods are more

accessible than ever (2). Approximately 62% of the UK population are defined as overweight, with

almost 25% of those being clinically obese (1). In addition our children are suffering too, 19% of 10-11

year old are obese and a further 14% are overweight (1). This is the legacy we are leaving for the next

generation. Therefore, we, as healthcare professionals, have the responsibility to make the change,

educate our patients and their families into changing their attitudes to food and ultimately taking

responsibility for their own health (3). However, the real question is how can we make people listen

and take action?

It could be argued that the Western world is becoming an overindulgent society where eating is no

longer purely to fuel our bodies (4). Consequently, we are no longer noticing or even understanding

what exactly we are putting into our bodies. Nowadays, the relationship people have with food is

often unhealthy and food has become the focus of society, but not always in a positive way (5).

Instead, perhaps our entire approach to food should be altered, and eating should centre around

nourishing and protecting our bodies.

On the other hand, there is a socioeconomic gradient where those at the lowest end of the spectrum

relying on energy-dense, nutrient poor food as the easiest and cheapest way to meet the

recommended daily calorie intake (6). For this reason, the highest rates of both obesity and DMT2 are

seen in the most deprived areas, but often with equally low levels of education (6). A similar picture

can be seen for healthy life years; Males living in the least deprived areas of Wales can expect to

have good health for 21 more years than in the most deprived, women can expect 16 healthy years

longer (7). Hence, we could ask ourselves, is education the key to improving socioeconomic issues

regarding healthy eating?

Early on in medical school, we followed the journey of an oncology patient; I was assigned to an

inspirational lady with metastatic cancer. She had been diagnosed five years previously and given

months to live, yet she was still here and living life to the full. She believed that alongside the

chemotherapy, she owed her health to what she put in her body. She had always put a lot of

emphasis on natural ingredients and home-cooked food, and this was only heightened after her

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diagnosis. There is an abundance of research into diet as a risk factor for cancer, however role of

nutrition in terminally ill patients is less understood, but it does make one question its significance.

Despite there being a clear association between malnutrition and reduced quality of life and survival,

all too often it is attributed to the natural progression of the disease rather than trialling early

nutritional support techniques (8, 9).

The magnitude of studies performed to attempt to demonstrate links between diet and a whole host

of diseases is daunting. Cancer is a huge focus of this research because diet is one of the most

modifiable risk factors. Hence, it has been estimated that up to 35% of cancers are associated to

some extent with dietary factors (10). There is general agreement that a “healthy diet" consists of

fruit, vegetables, whole grains, fish, nuts and ‘good’ fats, whilst alcohol, processed meat, saturated

fat, refined flour and sugars should be limited or avoided (10). This is often referred to as the

Mediterranean diet, with studies showing a 10% reduced overall cancer mortality (11). For each

specific cancer, the World Cancer Research Fund and American Institute for Cancer Research have

produced a list of best-established associations between dietary factors and cancer mortality rates

(10). However, due to the long latency period for cancer development and complex pathogenesis,

isolating specific foods is always going to prove a challenge (10).

Further studies expand on the role of dietary patterns on non-transmissible chronic diseases

(NTCDs). It is widely acknowledged that DMT2 can be reversed by diet alone (12). However, the role

of calorie restriction (CR) in other conditions is beginning to show promising results in a variety of

species, even suggesting an increase in life expectancy (13). In humans, specifically overweight

individuals, preliminary studies appear to support CR with regards to enhancing mitochondrial

function, improving insulin sensitivity and reduce various cardiovascular risk factors (14). For example,

a liquid based intermittent fasting (IF) CF regimen has been shown to modulate visceral fat mass and

pro-atherogenic adipokines resulting in a protective effect against coronary heart disease (15). Two

mechanisms in particular, the reduction of oxidative damage and increased cellular stress resistance

have been found to promote the beneficial effects of IF and CR (16). Interestingly, these effects have

shared mechanisms with regular physical exercise (16). Similarly, there is a consistent link with

reductions in inflammation and oxidative stress showing favourable effects on the cardiovascular

system, such as attenuation of atherogenesis within the vasculature and preservation of left

ventricular function (17). Therefore, CR and it's protective role in obesity, DMT2, cancer and other

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diseases, may be the key to extending not only life expectancy, but healthy life years (17). However,

the limiting factor is that most individuals struggle to maintain long-term restriction, so research has

focused on alternative techniques such as intermittent fasting (i.e. the 5:2 diet) (14).

Another relatively new area is Nutrigenomics, the term created when scientists started to question

how the fundamental molecular processes are affected by food, and thus the positive or negative

impact on the health of an individual (18). Examples include modulating the chronic process of

inflammation in obesity by anti-inflammatory bioactives such as caffeic acid, tyrosol and lycopene

(19). Or minerals such as Selenium, Prostacyclins and Zinc acting as protectors against cancer

development (19). The idea would be to create and thus, prescribe customised diets according to the

individual’s genotype (19). This is particular relevant in the area of NTCDs, as it would be possible to

alleviate the symptoms of existing diseases or prevent future illness (19).

The best-seller Ella Woodward’s story highlights how diet can sometimes succeed where medicine

cannot (20). Previously, a self-confessed sugar and processed food addict, until the development of

Postural Tachycardia Syndrome forced her to be bed-bound due to chronic pain (20). It is a rare

condition with limited management options and no licensed pharmacological treatment (21).

Overnight she adopted a plant-based, whole foods diet and within months started to feel revitalised,

ultimately giving her, her life back (20). There is no current evidence that diet has any role in treating

this illness, however it opens our eyes to the power of food and healing properties, if not physically

but perhaps on a psychological level it can have a massive impact. Furthermore, dietary patterns

have also been found to be key in functional disorders. Irritable bowel syndrome, the most common

functional gastrointestinal disorder, estimated to affect more than 10% of the population globally,

now has a sufficiently strong treatment evidence base in the form of the FODMAP diet (22, 23). Level II

evidence demonstrates benefit in 75% of patients on this diet, supporting the need for widespread

application (23, 24).

In addition, there is now growing evidence into the use of natural ingredients playing a role in

numerous chronic conditions including autoimmune, cardiovascular and neurological disorders (25).

For example, Curcumin, the active component of Turmeric, described in Chinese medicine for years,

now shows promise in modern science due to its potential to modulate several important molecular

targets (26). Clearly, there will be limitations, as issues such as poor bioavailability are inevitable in

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natural elements, however it does pose the question of whether the focus should be shifted onto

personalised diets specific to one's genotype and/or underlying conditions (25).

‘Let food be thy medicine and medicine be thy food’ shows the link between food and health since

antiquity (27). It was not necessarily implying that food was medicine (27). Instead, that they work to

complement each other, and perhaps that diet may contribute towards the basis of managing our

modern-day conditions (27). In addition, there is a significant evidence base that a diet rich in the

typical "healthy foods" is related to better psychological well-being, which in return leads to reduced

levels of anxiety, stress and potential mental health issues (28). Hence, it our job as healthcare

professionals to encourage good food choices and ultimately change current ways of thinking and

attitudes towards food. This links back to education; So perhaps the answer is to demonstrate the

positive and negative effects of food on the body in both health and disease within schools. Hence,

giving the next generation the tools they need to confidently embrace the right food options and

succeed in tackling the growing obesity crisis and modern-day diseases.

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References

1. Public Health England, 2016. PHE Obesity Publications. http://www.noo .org.uk/NOO_pub/ [accessed 20 March] 2. de Vet E, de Wit JBF, Luszczynska A, Stok FM, Gaspar T, Pratt M, et al. Access to excess: how do adolescents deal

with unhealthy foods in their environment? European Journal of Public Health. 2013;23(5):752-6. 3. McMahon A. Wellness, wellbeing and food choice: a study of consumer and dietician perspectives. University of

Wollongong Thesis Collection. 2013 4. Swinburn B, Sacks G, Ravussin E. Increased food energy supply is more than sufficient to explain the US epidemic

of obesity. American Journal of Clinical Nutrition. 2009;90(6):1453 5. Grumett D, Bretherton L, Holmes SR. Fast Food: A Critical Theological Perspective. Food Culture & Society.

2011;14(3):375-92. 6. Drewnowski A. Obesity, diets, and social inequalities. Nutrition Reviews. 2009;67(5):S36-S9. 7. Public Health Wales, 2016. Public Health Wales Observatory. http://www

2.nphs.wales.nhs.uk:8080/PubHObservatoryProjDocs.nsf [accessed 22 March] 8. Nitenberg G, Raynard B. Nutritional support of the cancer patient: issues and dilemmas. Critical Reviews in

Oncology Hematology. 2000;34(3):137-68. 9. Caro MMM, Laviano A, Pichard C. Impact of nutrition on quality of life during cancer. Current Opinion in Clinical

Nutrition and Metabolic Care. 2007;10(4):480-7. 10. Holland J, Breitbart W, Jacobsen P, Loscalzo M, Butow P, McCorkle R. Psycho-Oncology: Diet and Cancer. 3rd ed.

New York: Oxford University Press; 2015. p. 8-14. 11. Schwingshackl L, Hoffmann G. Adherence to Mediterranean diet and risk of cancer: A systematic review and

meta-analysis of observational studies. International Journal of Cancer. 2014;135(8):1884-97. 12. Lim EL, Hollingsworth KG, Aribisala BS, Chen MJ, Mathers JC, Taylor R. Reversal of type 2 diabetes: normalisation

of beta cell function in association with decreased pancreas and liver triacylglycerol. Diabetologia. 2011;54(10):2506-14.

13. Ravussin E, Redman LM, Rochon J, Das SK, Fontana L, Kraus WE, et al. A 2-Year Randomized Controlled Trial of Human Caloric Restriction: Feasibility and Effects on Predictors of Health Span and Longevity. Journals of Gerontology Series a-Biological Sciences and Medical Sciences. 2015;70(9):1097-104.

14. Anton S, Leeuwenburgh C. Fasting or caloric restriction for Healthy Aging. Experimental Gerontology. 2013;48(10):1003-5.

15. Kroeger CM, Klempel MC, Bhutani S, Trepanowski JF, Varady KA. Improvement in coronary heart disease risk factors during an intermittent fasting/calorie restriction regimen: Relationship to adipokine modulations. Faseb Journal. 2013;27.

16. Mattson MP, Wan RQ. Beneficial effects of intermittent fasting and caloric restriction on the cardiovascular and cerebrovascular systems. Journal of Nutritional Biochemistry. 2005;16(3):129-37.

17. Weiss EP, Fontana L. Caloric restriction: powerful protection for the aging heart and vasculature. American Journal of Physiology-Heart and Circulatory Physiology. 2011;301(4):H1205-H19.

18. Ronteltap A, van Trijp JCM, Renes RJ. Consumer acceptance of nutrigenomics-based personalised nutrition. British Journal of Nutrition. 2009;101(1):132-43.

19. Sales NMR, Pelegrini PB, Goersch MC. Nutrigenomics: definitions and advances of this new science. Journal of nutrition and metabolism. 2014;2014:202759-.

20. Woodward E. Deliciously Ella: My Story. Great Britain: Yellow Kite; 2015. p. 7-11. 21. Patient - Professional Reference, 2016. Postural Tachycardia Syndrome. http://patient.info/doctor/postural-

tachycardia-syndrome-pots-pro [accessed 27 March] 22. Canavan C, West J, Card T. The epidemiology of irritable bowel syndrome. Clinical epidemiology. 2014;6:71-80. 23. Gibson PR, Shepherd SJ. Evidence-based dietary management of functional gastrointestinal symptoms: The

FODMAP approach. Journal of Gastroenterology and Hepatology. 2010;25(2):252-8. 24. Shepherd SJ, Parker FC, Muir JG, Gibson PR. Dietary triggers of abdominal symptoms in patients with irritable

bowel syndrome: Randomized placebo-controlled evidence. Clinical Gastroenterology and Hepatology. 2008;6(7):765-71.

25. Shishodia S, Sethi G, Aggarwal BB. Curcumin: Getting back to the roots. Natural Products and Molecular Therapy. 2005;1056:206-17.

26. Prasad S, Gupta SC, Tyagi AK, Aggarwal BB. Curcumin, a component of golden spice: From bedside to bench and back. Biotechnology Advances. 2014;32(6):1053-64.

27. Wegener G. 'Let food be thy medicine, and medicine be thy food': Hippocrates revisited. Acta Neuropsychiatrica. 2014;26(1):1-3.

28. Conner TS, Brookie KL, Richardson AC, Polak MA. On carrots and curiosity: Eating fruit and vegetables is associated with greater flourishing in daily life. British Journal of Health Psychology. 2015;20(2):413-27.

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Michael Pittilo Essay Prize 2016

Food the forgotten medicine: how can clinicians and

patients maximise its potential benefits?

Alison Zander, 2nd Year Graduate Entry Medical Student, Swansea University

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In 1974, Charles Butterworth discovered the ‘skeleton in the Hospital closet’1. He found that the

nutritional status of patients worsened over the length of their hospital stay. This iatrogenic

malnutrition, he said, “undoubtedly contributes to increased mortality and morbidity.” Indeed, any

degree of malnutrition is associated with hospitalisation, with up to 40% of adults admitted to

hospital being malnourished to some degree2. Putting the two together, we have a population of ill

people who are malnourished and requiring hospital care, being treated in an environment that in

recent history did not adequately support nutrition. Nutritional status has long been a secondary

consideration in hospital settings, with the focus being on direct treatment of disease. However,

recent evidence is changing the hospital approach to nutrition for the improvement of patient

outcomes.

In clinical settings, medicines can be applied for three different purposes: to prevent illness, as a

supportive treatment, and as a curative agent. Hippocrates said, “Let food be thy medicine and

medicine be thy food.” This states his belief that food has a purpose within all three potential

applications as a medicine. Do clinicians’ today use food as medicine, and if so, in what capacity?

It is well known that nutritional deficiencies cause disease. For example, acute micronutrient

deficiency of vitamin B1 (thiamine) causes Beriberi, which can chronically escalate to Wernicke-

Korsakoff syndrome; deficiency of vitamin B3 (niacin) directly causes Pellagra, whose symptoms

include dermatitis, diarrhoea and dementia; deficiencies of vitamin K cause problems with clotting;

scurvy, of naval fame, is caused by vitamin C deficiency; vitamin D deficiency causes Rickets in the

young and increases bone density loss in the elderly. Thus, adequate nutrition is essential for

disease prevention. Clinicians do prescribe micronutrient supplements when there is suspicion of

disease caused directly by a deficiency.

Additionally, some medications cause the body to either not absorb micronutrients properly,

increase their need for them, or excrete them more quickly than normal. For example,

chemotherapy induces a loss of serum calcium, which results in muscle spasms, pain, and cardiac

arrhythmias. Diuretic medications increase potassium and magnesium loss, which can cause

constipation, cramps, respiration difficulties and changes to the electrical conductivity of the heart.

Supplements are therefore prescribed as a prophylactic to ensure the patient undergoing treatment

does not suffer these consequences.

In a direct cause-consequence situation, clinicians are very good at supporting patients with

supplements. However, supplements are different to food and are applied as a short term fix. For

long-term problems, food and eating well should be considered for maintenance of adequate

nutrition.

I had the opportunity to help a patient on the ward who suffered from Parkinson’s disease. His

swallow was insufficient and had caused food to fall into his lungs resulting in pneumonia. In

hospital, to help with this, his drinks were thickened and his meals were mushed. Other than a

physical instability and shaky hands, he had all of his faculties, a very sharp wit and a cheeky

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personality. He made his dislike of the meals and thickened drinks very well known. I sat with him

and helped him with his lunch: mashed potato, mushy peas and white fish in a white sauce all

mushed-up. To me, it seemed as good a meal as he could have in the situation. For him, he had

eaten the same lunch for two weeks since being admitted for his infection. He did not want to eat it.

He was not allowed another choice, as the pieces of chicken breast or pie were too risky with his

swallow and should it go into his lungs, it would make his pneumonia worse. He ate three mouthfuls

and shook his head, refusing any more. It was his choice not to eat that meal as he had become

bored with it. For his wife, the burden fell to her to provide palatable food each visiting time that he

wanted to eat. His pneumonia improved and he was discharged home. Despite dietetic intervention

and everyone’s best efforts, over the course of his three week admission, he lost 4kg in weight.

This case is a good example to show the complexities of nutrition. Food has often been a secondary

consideration in a hospital setting because it is a complex multifactorial issue with many intrinsic and

extrinsic influences. Body composition, physiology, activity levels, morbidity, comorbidity, mental

capacity, feeding support, food availability and patient cooperation all influence what a person

successfully eats, absorbs and utilises from their diet. Insufficiency of nutrition can be caused by any

one of those factors going wrong.

Illness brings a triple threat to nutrition status: it increases a person’s energy and micronutrient

requirements, it makes it harder for the body to absorb nutrition from food, but it also makes the

act of eating more difficult, by reducing appetite, and increasing patient’s physical difficulty in

feeding, chewing or swallowing. This means that patients enter a catabolic state and become more

malnourished throughout their hospital stay as a direct result of their illness.

The problem is further compounded by the day-to-day regime of the hospital, which is a strong

influence on how much a patient gets to eat. On the catering level, there is an amount spent per

patient per day for meals, and choice is maximised as much as possible within budget confines.

However, inappropriate meals are still served, for example where there is difficulty chewing, or

holding cutlery, and this puts pressure on ward staff to ensure whatever is served is consumed.

Furthermore, there are just not enough staff to sit at each bedside and feed each patient each

mouthful of their meals. If patients do not get support to eat, their food will go cold and uneaten.

Additionally, when a patient is not in their ward bed at meal times, they do not get fed. My own

mother missed breakfast, lunch and dinner due to being in surgery, and on her hungry return to the

ward the only available food was two slices of toast.

From a medical perspective, doctors cannot perform certain procedures without the patient’s

stomach being empty, and so if a patient is to have a procedure, they are often made to be ‘nil by

mouth’. If that procedure then does not happen, the patient may get to eat their evening meal

before being rescheduled for the following day and made ‘nil by mouth’ again. Procedural list

organisation is on a priority basis, with emergencies having to be seen in place of elective (read ‘non-

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urgent’) cases, meaning unpredictable changes are made to the lists at the last minute. The result is

nutritional depletion in the patient.

Most strikingly of all of the influences on hospital nutrition is the fact that the total energy provided

in all hospital meals per day averages at 1500Kcal: 500 calories too few for average women and 1000

too few for average men. It is an unfortunately enforced diet where the sickest who require more

are disproportionally affected.

The net result does not just impact a patient’s waistline. It has a multifactorial effect on the patient.

decreases muscle mass, visceral proteins, impairs immune response and wound healing and

increases the chance of multiple organ failures. Furthermore, it changes the way that medications

are absorbed, activated and used within the body. If dignified care is making all efforts to support

the patient, then where food is concerned, patient dignity is considered, but not necessarily

enacted.

However, thanks to recent research and application of evidence based practice, the nutrition tide is

turning. There are NICE guidelines for nutrition support in the hospital and community settings,

considering body mass index, weight loss, capacity to eat, absorptive capacity and catabolism3. We

are moving away from using the term ‘healthy eating’, which refers to an everyday diet beneficial for

most people, to ‘eating for health’, to better describe a therapeutic diet for individuals4. Dieticians

are employed to assess and monitor the nutritional status of all inpatients and communicate with

their clinical team if there have been any issues so that problems can be addressed. Elderly patients

undergoing surgery are now admitted prior to their scheduled surgery for preoperative feeding

because it decreases postoperative mortality5. Anecdotally, I have seen bananas be prescribed for

instead of potassium replacement medications. All of these interventions focus more on individual

cases and involves more healthcare professionals working directly with service users. This needs

rigorous procedure and communication. Importance is being on the maintenance and support of

nutrition to better patient outcomes.

Due to the complexities of nutritional status, in the past it has not been considered the primary

objective of disease treatment. However, recent evidence both enables and encourages clinicians to

use foods as a prophylaxis against disease, as a supportive agent to maximise patient outcomes and

as a curative in situations where a nutritional deficiency is caused by inadequate intake, absorption,

or over excretion. Publically, ‘eating for health’ should be promoted to encourage people to

maintain their nutritional status, to maximise their physical resistance to illness and avoid

hospitalisation. Within the hospital setting, patient needs should be monitored and supported with

greater flexibility. These interventions all require professional and service user responsibility,

agreement and cooperation. Nutritional support is always available when needed.

In the future, how we food as a medicine will depend on research and available evidence. In any

situation, healthcare workers and service users should always aim to work together for the best

possible patient outcomes.

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References:

1. Butterworth C. The Skeleton in the Hospital Closet. Nutrition Today. 1974; 9(2):4-8

2. McWhirter JP, Pennington CR. Incidence and recognition of malnutrition in hospital. British Medical Journal.

1994; 9;308(6934):945-8

3. National Institute for Health and Care Excellence (NICE) guidelines [CG32], February 2006. Nutrition support for

adults: oral nutrition support, enteral tube feeding and parenteral nutrition. Available at:

https://www.nice.org.uk/guidance/CG32/chapter/1-Guidance#indications-for-nutrition-support-in-hospital-and-

the-community [Accessed March 2016]

4. Department of Health: The Hospital Food Standards Panel’s report on standards for food and drink in NHS

hospitals, August 2014. Available from:

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/504866/Hospital_Food_Panel_

Report.pdf [Accessed March 2016]

5. Abunnaja S, Cuviello A and Sanchez J. Enteral and parenteral nutrition in the perioperative period: state of the

art. Nutrients. 2013; 5(2): 608-623