The Pocket Guide to Clinical Nutrition goes digital as PENG celebrates its 40th anniversary

11 October 2024

As the Parenteral and Enteral Nutrition Group celebrates 40 years, Chair Linda Cantwell looks back at the history of the group.

In 1982, a group of 70 dietitians with an interest in nutrition support met in Leeds, where it was decided to form the Enteral and Parenteral Nutrition Interest Group (EPNIG) and to apply to the BDA for specialist group status.

The initial committee was small, but it had the advantage of having some very enthusiastic, hardworking and ambitious committee members who were extremely keen to develop this new dietetic specialty.

At the time, the initial reaction from the BDA was that dietitians wishing to form a specialist group would be better to align themselves with one of the existing groups. However, the emphasis within many of these groups at the time was managing obesity or very specific clinical conditions.

These pioneering committee members knew that there needed to be a discipline dedicated to nutrition support.

In case you missed it… here’s a highlight of last weeks annual study day and our 40th birthday celebrations! #PENGannualstudyday #PENG40 pic.twitter.com/jXlHyJrWGA
— BDA Parenteral and Enteral Nutrition Group (@BDA_PENG) October 1, 2024

At the time, there was a big shift happening in enteral nutrition with the development of readymade tube feeds and wide-bore feeding tubes. Here was the opportunity for dietitians to get out of the kitchen and onto the ward.

However, at the time, dietitians in general were not very highly regarded by their medical colleagues, and this was partly because nutrition did not feature in the medical curriculum. In addition, the dietetic qualification was a diploma rather than a degree, and dietetic education was based more on ‘healthy eating’ and ‘special diets’ than on preventing undernutrition in patients.

There were no screening programmes to identify patients who might need nutritional support, and whatever feeding there was in this respect was usually started too late to be of benefit. There was little evidence in favour of providing nutrition during illness that did not have a direct nutritional component, and even less to support feeding patients aggressively in hospital. Nutrition teams as we now know them did not exist.

Parenteral nutrition remained in the domain of doctors and pharmacists, and dietitians were rarely, if ever, involved. To compound this scenario, dietitians had minimal training in the importance of multi-professional working or how to get involved with other healthcare professionals in the context of nutritional intervention.

The committee knew there needed to be a discipline dedicated to nutrition support that would lead and advance the profession and demonstrate its value in the management of nutrition support in enteral and parenteral nutrition interventions to treat malnutrition.

The group campaigned for its own specialist group status and, in 1984, the group became recognised as a specialist group of the BDA and was renamed the Parenteral and Enteral Nutrition Group (PENG).

One of the initial objectives of the group was to educate and train the dietetic workforce, enhancing its skills to meet the growing demands of parenteral and enteral nutrition in both hospital and community settings. This aimed to increase the workforce capability and capacity, and demonstrate how dietetic interventions could improve patient and clinical outcomes.

The committee organised national meetings and study days biannually, using their newsletter to share case studies, service developments, journal articles and conference feedback. However, the innovative committee members soon realised the need for a more formal approach.

They developed a short course to offer practical experience in nutritional and clinical assessments, launching the first session in Trent in 1985, with committee members serving as tutors. This course evolved into the nationally recognised Clinical Update course in 1986.

Each tutor provided session handouts, forming the foundation of the first Pocket Guide to Clinical Nutrition. The initial version, published in 1989 with support from an educational grant by Abbott, was an A5-size bound document, with five sections covering paediatric and adult assessments, including body composition, amino acid profiles, and electrolyte solutions. Despite its name, the original version was far from pocket-sized!

By 1997, the 2nd Edition had a black cover and a more compact Filofax style, making it closer to what we recognise today as the Pocket Guide. It expanded to include more detailed processes of nutrition support and access routes for enteral and parenteral nutrition, and introduced nutritional screening with four key questions about weight, weight loss, height and dietary intake.

After consultations with members, and as partnerships were forming with universities, additional sections were added in 2000, addressing diabetes, thermal injury, microbiological control, and refeeding syndrome.

The 3rd Edition was released in 2004, updating sections on disease-specific conditions such as kidney, liver and critical care issues. It included significant updates in paediatric nutrition and monitoring of adult nutritional needs.

The Elia nomogram for stress level adjustments was replaced with stress factors, and physical activity and diet-induced thermogenesis (PAL) values were introduced for mobile community patients. A critical review of papers on energy expenditure and requirements was included, along with methods for estimating energy needs for patients with a body mass index (BMI) of more than 30kg/m².

The Malnutrition Universal Screening Tool (MUST), launched in 2003, was incorporated into the identification sections, and the monitoring and refeeding sections were later revised following the 2006 NICE guidelines on Nutrition Support in Adults.

As the Pocket Guide to Clinical Nutrition approached its 20th anniversary, it had become an essential resource for dietetic students and departments nationally and internationally, thanks to its global sales.

The 4th Edition, in 2011, marked the transition from the Schofield equation to the Henry predictive equation for estimating energy requirements in adults, though this was to be short-lived. PENG and the authors conducted numerous educational sessions nationwide to disseminate this change.

This edition included new indicators, such as calf circumference for total fat-free mass (FFM) losses (especially for older adults) and bioelectrical impedance analysis (BIA), and removed the subjective global assessment. Additionally, disease-specific sections on chronic obstructive pulmonary disease (COPD), bariatric and pancreatic were introduced.

From 2016 to 2018, under the leadership of Bruno Mafrici and Vera Todorovic, significant updates were planned for the 5th Edition. This revision involved more than 50 dietitians and featured a systematic review of adult energy requirements, leading to a substantial revision in how these are estimated – shifting from using predictive equations based on estimated basal metabolic rate in healthy individuals to methods based on systematically reviewed studies that did measured resting energy expenditure (REE) in patients with actual disease state (using an energy per kg of body weight or FFM).

These changes, formalised through a guideline development review process that included five systematic reviews, were complex and delayed the physical publication of the 5th Edition until 2019. In appreciation of their patience, the 5th Edition was made available for free to all PENG members registered at that time.

In November 2017, the PENG study day launched these updates, also setting the ambition for the eventual digital transformation of the Pocket Guide to Clinical Nutrition. Some additional online resources to support the adults’ nutritional requirements section were uploaded to the website and made available for free to all. In 2020, the section on estimating nutritional requirements, monitoring and critical care were made freely available online to all BDA and non-BDA members, aiding dietitians redeployed during the COVID-19 pandemic. In 2023, a statement on ideal body weight was released and uploaded online.

The BDA began developing an electronic version of the Pocket Guide to Clinical Nutrition 5th Edition, aiming to launch its first app.

However, the complexities of app development, the unique format of the Pocket Guide, and the pandemic have caused significant delays. Notably, the Pocket Guide contains more than 1,000 references that each needed to be hand-sourced for electronic linking. Our thanks to Alison Culkin, who joined Bruno Mafrici as editor to take on this enormous task, and Louise Pritchard, Chief Operating Officer at the BDA, who has brought the vision together.

Throughout this period of development, we said goodbye to the founding mothers of the Pocket Guide to Clinical Nutrition, Vera Todorovic (1952-2021) and Ann Micklewright (1943-2024).

Vera humorously remarked in 2017 that had they known the guide’s future success, “we would be millionaires by now and we would be floating off to a Caribbean island somewhere”.

We know Vera and Ann would like to recognise the contributions from early PENG committee members Doug Scott, Rita Hopkins, Pat Howard and Christine Russell, and would be thrilled to see the Pocket Guide to Clinical Nutrition’s success as PENG celebrates its 40th anniversary.

This article is dedicated to their memory, celebrating their foundational contributions to the field of nutritional support, which has now, fittingly, become truly ‘pocket-sized’.

Download the brand new PENG e-Pocket Guide!

What’s different?

Competitive pricing – the 5th edition is FREE for current PENG members
Accessible – You now have the ability to bookmark, enlarge and search, speeding up your use of the guide
Portable – It can be viewed on a phone, tablet and PC whenever you need it.
Personalised – By having the ability to bookmark, save and highlight areas, you can have the key areas you need to focus on ready.
Sustainable - The e-version is more sustainable and can easily be updated between versions.
New liver chapter - You get a bonus updated liver chapter.
Links - All references are linked to the web original source so you can find out more and read around a topic there and then.