Prescribing Policy: Gluten free foods

Transcription

1 Prescribing Policy: Gluten free foods Policy Statement: Date of Approval: 10 th December 2009 This policy defines the decision made by the NHS Western Cheshire Clinical Commissioning and Strategy Committee Western Cheshire PCT will provide NHS funding for individual patients to be prescribed the amounts of gluten-free foods described in Appendix 1 as a monthly maximum. Patients who wish to supplement their prescribed foods will be expected to purchase additional items. Many healthy eating options are naturally gluten free. Note: Patients who are not eligible for treatment under this policy may be considered on an individual basis where their GP or consultant believes exceptional circumstances exist that warrant deviation from the rule of this policy. Individual cases will be reviewed at the PCT Bespoke Care Panel upon receipt of a completed application form from the Patient s GP, Consultant or Clinician. Applications can not be considered from patients personally. Version 1.0 Approved by (committee) Clinical Commissioning and Strategy Committee Date Approved: 10 th December 2009 Date of implementation 1 st March 2010 Produced by; Prescribing policy development group Review Date: Earliest of either SHA guidance, Coeliac Society guidance or five years from issue.

2 Further information about this document: Document name Prescribing Policy: Gluten free products Category of Document in The Policy Schedule Commissioning Policy Author(s) Contact(s) for further information about this document This document should be read in conjunction with Published by Copies of this document are available from Prescribing policy development group Telephone: Prioritisation framework NHS Western Cheshire 1829 Building Countess of Chester Health Park Liverpool Road Chester, CH2 1HJ Main Telephone Number: (Freephone) Main Address: Website: Copyright NHS Western Cheshire, All Rights Reserved Version Control: Version History: Version Number Reviewing Committee / Officer Date 0.1 Prescribing policy development group October Area Prescribing Committee 26/11/ Clinical Commissioning and Strategy Committee 10/12/09 1

3 This document can be made available in a range of alternative formats including various languages, large print, Braille and audio cassette. To discuss your requirements please ring

4 3

5 Contents 1. Background 2. Evidence 3. Conclusions 4. Responsibility for implementation 5. References 6. Route for policy development and ratification Appendix 1: local prescribing guidelines adapted by the Nutrition and Dietetics Department at the Countess of Chester Hospital NHS Foundation Trust. The following terms are used in this document Coeliac UK Coeliac UK is the leading charity working for people with coeliac disease and dermatitis herpetiformis (DH). 1

6 1. Background 1.1 The purpose of this policy is to outline the decision taken by NHS Western Cheshire Clinical Commissioning and Strategy Committee regarding the prescribing of gluten free products. This policy applies to all prescribers, both medical and non-medical. 1.2 Patients suffering from coeliac and other diseases related to gluten intolerance need to adhere to a gluten free diet. Many foods are naturally free of gluten, which mainly exists in cereal products such as those made from wheat. 1.3 In certain circumstances, gluten free foods may be prescribed. Coeliac UK has produced guidelines outlining the quantities of specialised foods required by coeliac patients depending on their age and levels of physical activity. These have been adapted locally by the Nutrition and Dietetics Department at the Countess of Chester Hospital NHS Foundation Trust. 1.4 Additional dietary requirements should be achieved by choosing healthy foods which are naturally gluten free. 2. Evidence 2.1 The evidence base for the recommendations of Coeliac UK is listed in section 5. This evidence has not been further reviewed by the prescribing policy development group. 2.2 The guidelines are based on the balance of good health model and gluten-free prescribable foods providing 15% total energy (total carbohydrate should provide 50% total energy which includes naturally gluten-free foods such as rice, potatoes and breakfast cereals, intrinsic and milk sugars as well as glutenfree prescribable foods). 3. Conclusions 3.1 There is evidence that adhering to a gluten free diet improves symptom control in patients with coeliac disease. 3.2 Although the recommendations made by Coeliac UK refer to minimum quantities, they are sufficient to maintain health. 4. Responsibility for implementation 4.1 Responsibility for implementation lies with the Practice Based Commissioning Consortium and the Area Prescribing Committee. 2

7 5. References 5.1 The National Diet & Nutrition Survey: adults aged 19 to 64 years. Types and quantities of foods consumed. A survey carried out in Great Britain on behalf of the Food Standards Agency and the Department of Health by the Social Survey Division of the Office for National Statistics and Medical Research Council Human Nutrition Research Route for policy development and ratification Evidence researched by Public Health Specialist Evidence reviewed by Task & Finish Group and draft policy developed Draft policy reviewed and agreed by Area Prescribing Committee Draft policy finalised and ratified by Clinical Commissioning and Strategy Committee Policy distributed to relevant stakeholders and uploaded on the PCT extranet and website 3

8 Appendix 1: Local prescribing guidelines Guidance on the prescribing of gluten free foods and immunisations for patients with coeliac disease There are a variety of gluten-free foods currently available on prescription to help replace staple foods. As coeliac disease requires lifelong exclusion of gluten and patient compliance with this can be difficult, these products can be key to successful management. The recommended maximum monthly prescribable quantities of gluten-free foods are as follows (this is based on diet and nutrition surveys and healthy eating guidelines) Age group Suggested number of units per month Child 1-3 years 10 Child 4-6 years 11 Item The number of units represented by the prescribable item is as follow: Number of units Child 7-10 years g bread 1 Child years g roll/baguette 1 Child years g bread mix/flour mix etc 2 Male years g biscuits/crackers ½ Male years g biscuits/crackers ¾ Male 75+ years g biscuits/crackers 1 Female years g pasta 1 Female 75+ years g pasta 2 Breastfeeding Add 4 units 2 x g pizza bases 1 3 rd trimester pregnancy Add 1 unit High physical activity level Add 4 units The Eatwell Plate is an important consideration in the prescription of gluten-free foods ( ). Eating a healthy, well-balanced diet may not be the first consideration for an individual immediately following diagnosis, but in the long-term is as important as it is for the general population. It is also becoming increasingly important at the time of diagnosis, as more individuals are presenting now at a healthy weight or even overweight at this time. It can be quite difficult to decide what an appropriate prescription of gluten free products is for patients, whilst bearing these factors in mind. 4

9 Useful questions to ask a patient include the following: a) Does this person understand their condition and the importance of compliance? b) Have they tasted any samples of gluten-free foods? c) How old is the patient? (an elderly patient may require smaller quantities than a younger adult for example) d) How active is the patient? (for similar reasons as above) e) What was the person s consumption of similar foods (i.e. bread, flour, pasta, biscuits) prior to diagnosis? If particularly high the person may struggle without similar foods on prescription f) What else is the patient eating to ensure a balanced diet? This is a particularly important question, as research suggests that these foods make up at maximum approximately 30% of a coeliac patient s diet. If the rest of their diet is relatively low in fat, high in fruit and vegetables and contains suitable protein sources, it should be fine to proceed with their prescription preferences. Below are some examples of patient scenarios and how these might be effectively managed. Example 1: Young male, aged 20 years: On questioning, the patient was very active (>1 hour exercise daily), ate a well balanced diet, and particularly enjoyed complex carbohydrates such as bread and pasta. Not keen on cooking therefore not interested in bread/flour mix. Struggling to maintain weight (BMI 20). Suggested prescription = 20 units/month (the 18 units for this group is only a recommendation and can be exceeded), comprising 10 x 400g loaves of bread 2 x 250g pasta (or 1x 500g) 2 x 200g biscuits 2 x 200g crackers 2 x (2x110/180g) pizza bases 2 x 400g baguettes Example 2: Middle aged male, aged 45 years: On questioning the patient was sedentary (20 mins exercise x 2/week), ate a reasonably well balanced diet, and was trying to monitor his weight (BMI 32). Dislikes the prescribable bread, therefore purchases this in a supermarket. Suggested prescription = 8 units/month (though he is entitled to more than this), comprising: 2 x 250g pasta (or 1x 500g) 1 x 200g biscuits/crackers 2 x 500g flour mix 2 x 400g rolls 1 x (2 x 110/180g) pizza bases Encourage this patient to make up the remainder of his diet with wholegrain complex carbohydrates and some low fat protein sources, and plenty of fruit and vegetables. It would not be appropriate for this type of patient to ask for the remainder of his prescription (i.e.10 units more) to be comprised entirely of biscuits, though it would be acceptable to make a compromise here (e.g. suggest ½ packet biscuits per week therefore prescribe 2 packets per month). 5

10 Example 3: Elderly female, aged 75 years: On questioning the patient was sedentary and had poor mobility, ate a well balanced diet, and was underweight (BMI 18). Enjoys most foods but dislikes pizza and pasta, and had a poor appetite in general. Suggested prescription = 10 units/month (though she is entitled to more, the patient felt that she would struggle to have more than this), comprising: 5x 400g loaves of bread 3 x 200g biscuits 2x 400g rolls Encourage this patient to follow a well balanced diet, and to eat little and often to try to improve both her nutritional status and weight. It can be quite difficult to estimate appropriate quantities of gluten free foods to prescribe. A useful starting point is to ask the patient to estimate the quantities of these types foods that they would normally consume per month (i.e. before they started experiencing symptoms/were diagnosed). Having agreed on a list of gluten-free foods for prescription, it is important to provide the patient with flexibility to change items. A person s needs or preferences for food often changes over time, and they may wish to try new items as they become available. If you are unable to ascertain whether the person is following a balanced diet, it may be worth referring them to a Dietitian for assessment. Immunisations for coeliac patients Individuals with Coeliac Disease have a risk of immunosuppression due to splenic dysfunction. This is believed to be the case for approximately 25% of patients; however it is not possible to identify which ones are at risk. It is therefore recommended that all patients with Coeliac Disease are vaccinated against: Influenza Pneumococcus Haemophilus influenzae type b Meningococcal group c (PCSG 2006, British National Formulary, and Immunisation against infectious disease - 'The Green Book' 2006). Produced by Sharon Becker, Specialist Gastroenterology Dietitian, Countess of Chester Hospital NHS Foundation Trust June