Beyond tube feeding….

8 ways that dietitians can help people with brain injuries

I love telling people that I’m a dietitian for people with brain injuries and neurological conditions. People seem to have a genuine interest and curiosity about my job which is not something that I have experienced at other times in my career.

While there is a lot of up-and-coming research in the area of nutrition and brain injuries, such as how omega 3 and gut bacteria affect cognitive functioning, there isn’t quite enough solid evidence yet to give people the clear cut recommendations that they are looking for. What I find interesting is that while many people are generally very keen to pursue cutting edge treatment, I often find that the very basics of nutrition and hydration are often not being met in this population. How can this be?

The act of buying, preparing and eating food can be very physically and mentally demanding and many clients with brain injuries are already struggling with fatigue. Sometimes support workers have limited cooking skills and limited knowledge of nutrition, so while they make sure the client gets enough to eat, the foods they offer may not always be the most nutritious. Sometimes a brain injury changes someone’s capacity to understand the consequences of their food choices and leads the person to make food choices based purely on taste, without consideration to the long-term health effects. Other times there are sensory issues with food or dysphagia which may limit the person’s food choices.

While most case managers, solicitors and allied health professionals are very clear on the need to get a dietitian involved when someone is tube fed, many do not realise all of the other ways that a dietitian can benefit someone with a brain injury or neurological condition.

Here are 8 situations (other than tube feeding) when it would be a great idea to get a dietitian involved:

1.  Fatigue

Fifty percent of people with brain injuries rate fatigue as their worst symptom (1) and yet I often find that key blood tests have not been done to rule out an underlying medical issue contributing to the fatigue. Vitamin and mineral deficiencies, electrolyte imbalances, dehydration, thyroid problems and fluctuating blood sugar levels can all contribute to feelings of fatigue. Click here for a complete list of which blood tests to ask for.

A dietitian can advise on which foods to offer to prevent nutrient deficiencies from happening in the first place. Or, after working with the GP to ensure nutrient deficiencies have been identified and corrected, a dietitian can advise on ways to improve food intake to ensure the person meets their fluid, protein and nutrient requirements in the future.

2.  Weight management

Sixty-eight percent of adult men and 58% of adult women without brain injuries in the UK are considered overweight or obese.(2) I’ve been unable to find any statistics specific to people following a traumatic brain injury, but The National Centre for the Dissemination of Disability Research reports that adults with “physical disabilities” have a 66% higher rate of obesity compared to people without “disabilities.”  Excess weight increases the risk of cardiovascular disease, diabetes, sleep apnoea, and certain types of cancer (breast, prostate, colorectal, & gall bladder) (3) and can also affect mobility.

A dietitian is able determine how much food a person needs to eat to achieve a healthy body weight and can offer training, meal ideas and/or recipes to support family members and support workers in offering this. A dietitian can also assist with a capacity assessment to determine whether a person understands the consequences of their food choices. He/she can also work with the Occupational Therapist to ensure that adaptations to food shopping and cooking, support an optimal nutrient intake.

3.  Malnutrition

Sixty-eight percent of people with a severe traumatic brain injury develop malnutrition within the first two months of their injury.(4) The Malnutrition Universal Screening Tool is used in the UK to determine the likelihood that someone is malnourished.  It considers the person’s BMI, percent weight loss in the last 6 months and whether the person has an acute illness which may interfere with their eating.  Anyone who scores 2+ (out of a possible 6) is considered to be at high risk of malnutrition and should be referred to a dietitian.

The role of the dietitian in these situations is to identify and resolve the barriers which are reducing someone’s appetite or ability to eat. Constipation, fear of choking, ill-fitting dentures, oral thrush, medication, anaemia, depression and nausea are just a few of the reasons why people stop eating. If oral nutrition supplements are required, a dietitian can advise on which supplement(s) would be most appropriate. If your client dislikes nutrition supplements, a dietitian can advise on dietary ways to help someone gain weight using regular food and drink.

4.  Tissue viability

Adequate nutrition and hydration are fundamental to the prevention and treatment of pressure sores. Dehydration, lack of protein, inadequate calorie intake and a lack of certain vitamins and minerals such as vitamin C and zinc, can make skin more fragile and lead to poor wound healing.(5) A dietitian can calculate a person’s protein and fluid requirements and assess whether vitamin and mineral needs are being met. The dietitian can then provide practical tips on how to use a combination of food, fluid and supplements to help that person meet their requirements.

5.  Dysphagia

Rates of dysphagia can be as high as 61% in the acute phase after a brain injury (6) and 25% during rehabilitation.(7) Sometimes a texture-modified diet (eg. Soft or pureed diet) will be advised by the Speech and Language Therapist to reduce the risk of choking and aspiration.

In my experience, clients, family members and support workers sometimes struggle to come up with interesting meal ideas which adhere to the Speech and Language Therapist’s recommendations. As a result, I sometimes find clients existing on little more than mashed potatoes, yogurt and nutrition supplements. A dietitian can help people with brain injuries, and their support team, come up with nutritious, delicious and varied meal ideas which adhere to the Speech and Language Therapist’s recommendations for texture-modification (and/or thickened fluids). If oral nutrition supplements are required, a dietitian can advise on the the most appropriate supplement to meet the person’s needs.

6.  Loss of smell or taste

It is hard to get excited about eating when the food has very little (or no) flavour. Over 75-95% of a food’s characteristic flavour actually comes from the smell molecules going up the back of your throat into your nose.(8)  If someone has a reduced sense of smell, the food will have a lot less flavour and people may complain the food has “no taste.” People with brain injuries experience olfactory dysfunction 20 – 68.4% percent of the time, even though the person may not always be aware of it.(9)

If someone’s sense of smell is just diminished (but not completely absent), smell training can be helpful for improving their sense of smell.(10) If there is no smell and/or taste at all, the focus then becomes giving the person other sources of sensory stimulation, like alternating food temperatures, enhancing the texture of food (as long as they don’t have dysphagia) and serving more foods and drinks which make the tongue tingle such as adding carbonation, spicy foods, ginger, and menthol. A dietitian can work with clients, family members and support workers to provide advice, suggestions and training to how to make meals more enjoyable in these situations.

7.  Gut problems

Bloating, wind, abdominal pain, constipation, diarrhoea….these unpleasant symptoms and can affect people with brain injuries and contribute to agitation, spasticity levels and can even prevent them from being able to access hydrotherapy. A dietitian can help identify the underlying cause of the problem and ask the GP to rule out medical reasons for these symptoms. A dietitian can then advise on high/low fibre diets, low FODMAP diets (for Irritable Bowel Syndrome), diets to manage food allergies and intolerances, and advise on recommended fluid intake.

8.  Diabetes Mellitus

In the UK, at least one person in every sixteen has diabetes mellitus.(11)  This refers to the general population as I was unable to find any statistics specific to people with brain injuries. High blood sugar levels can contribute to fatigue, prevent wound healing, negatively impact circulation and lead to other chronic health problems like heart disease or kidney problems.(12) Diabetes can be managed with lifestyle interventions alone, or in combination with medication. A dietitian can help people lose weight (if needed), provide education on self-monitoring of blood sugar levels and help people adjust their food choices to keep blood sugar levels within a healthy range. A dietitian can also provide training to support staff on what diabetes is and how food and lifestyle can be used to manage the condition.

Summary

Dietitians can do so much more than monitor tube feeds. Ensuring someone is offered a nutritious diet is definitely a team effort, but dietitians are uniquely qualified to assess the reasons why things go wrong with eating and can help people resolve a variety of symptoms just by adjusting their food intake and lifestyle.

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