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“The role of a dietitian in injury and rehabilitation — an underused resource”

(part of their Wider Issues in Catastrophic Injury series)

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Timestamp/Outline

00:02 Introduction 

05:09 Role of nutrition & dietitian in rehabilitation 

12:27 Muscle mass & muscle loss; protein requirements 

18:08 Nutritional challenges & deficiencies in brain injury 

25:06 Bone density 

30:18 Blood tests & investigations 

36:24 Diabetes and cholesterol 

40:24 Multi-disciplinary teams  

43:53 Role of dietitian in MDT 

48:28 Skin integrity & pressure sores 

52:38 Eating on a budget 

59:43 Making habit changes 

72:00 Closing remarks

Transcript

David: Good morning, and welcome to our podcast. My name is David Prichard, Head of Marketing here at Sintons. So, the podcast that we’re bringing to you today is the first podcast we’ve recorded in 2023. So Happy New Year to everybody. Thank you once again for the amount of people that tuned into our podcasts throughout 2022. Generally staggered by the amount of people that continue to tune in and to engage with our content. So, thank you for that. And we’re delighted to be launching this podcast series today. This is something that senior associate in the Serious Injury team, Jessica Gower, and myself and marketing have been working on for a number of months. And we are going to be throughout 2023, bringing you regular podcasts where we are considering wider issues in catastrophic injury claims. So that’s the umbrella of these podcasts that we’re going to be bringing to you throughout the year. For our first podcast, we’re delighted to have her back speaking to us again after a number of successful events that we’ve done with her over the past few years. And that is Sheri Taylor, who is a specialist dietitian, and director of Specialist Nutrition Rehab. So, we’re really delighted that we’re launching the first podcast with Sheri and that she’s agreed to give us her time. The podcast today lasts about an hour, an hour and a quarter and is going to consider the role of a dietitian in injury, rehabilitation, and is often an underused resource. So, as I said, we’re very excited about this series. I’m going to stop talking, I’m gonna pass you straight over to Jessica. Jessica. Good morning. And over to you. 

Jessica: Well, thank you so much for that introduction, David. And, Sheri, I wonder whether we might talk a little bit about your background and your career and how you came to be a dietitian and running your own business. So, thank you for joining us this morning. And could you just give us a little bit of an overview of your background? 

Sheri: Sure. So, I trained as a dietitian in Canada, and I worked 12 years in Canada as a dietitian, both in public health and in a community role. And then I decided I wanted to travel internationally, so I worked for a year in Indonesia, and then came to the UK in 2009. And when I first came to the UK, I did work initially in the NHS in a variety of different dietetic roles predominantly in the community. And after about eight years, I left the NHS to run my own business full time. 

Jessica: Perfect. And what does that entail? So, what does your current practice entail? 

Sheri: So, I run a company called Specialist Nutrition Rehab, which is a specialist dietetic service specifically for people with a brain injury, spinal cord injury, complex orthopedic trauma, or taste and smell loss. 

Jessica: Okay, perfect. And what was it that made you want to specialize in that particular area of practice? 

Sheri: It was interesting, because at the time I was first introduced to the role, I was working as a forensic dietitian, and a colleague of mine was doing some work in the brain injury sector as part of her private practice. And she knew I had the skills required to support that client base and asked me if I wanted to see a client that was close to where I lived, because she was at capacity. And as soon as I saw the very first client, I thought, oh my gosh, this is all the things that I love to do, kind of combined into one. So I can be incredibly holistic, which is how I naturally am anyway as a dietitian. It also included taste and smell loss and dysphagia and things that were seemingly random parts of my practice before. It just was such an excellent fit for me. So after the first client, word of mouth spread quite rapidly. I didn’t even have a website initially. And it became more and more apparent at that time that there was such an incredible need for a dietetic specialist in this area that I decided (I had another private practice at that time, but more for the general public), so I actually changed my entire business model, and dedicated it specifically to this client group. 

Jessica: I’m smiling and nodding not that you’ll be able to see on this podcast, but I was smiling and nodding for much of what you were saying there as a lot of that sort of resonated with me personally. A lot of the work that we do in the neuro trauma team at Sintons is obviously for clients who have been catastrophically injured, and they’ve predominantly suffered either brain or spinal injuries, often polytrauma and a combination of those injuries. So, it’s fairly normal practice for us to have a multidisciplinary team of professionals involved both pre and post discharge from a hospital setting. And often they’re involved in the years post injury. After the hospital setting, it strikes me that it’s quite common for a dietitian to be involved in that early trauma care and while somebody’s in an inpatient setting, but I don’t often see a dietitian involved quite as commonly as I do other members of that multidisciplinary team. It strikes me that when we’ve spoken previously, and when I’ve heard your presentations in the past, that this is very much an untapped resource that should probably form a part of the follow up in as many kinds of discharge cases as possible. And I just wondered whether you had any thoughts on, you know why that might be…why there’s not the involvement quite so commonly as other professionals, and whether that’s something that you’ve experienced in your own practice? 

Sheri: Yes, it’s definitely something that I’ve come across. And I would say probably in the first two years when I started this company, and started going to conferences and networking events, virtually every person I met couldn’t understand why I was there, what a dietitian had to do with brain injuries, or what I could possibly offer their clients. And that actually continues to be the number one question that I get asked. So my impression is that people just don’t understand what a dietitian does. They don’t understand what we can offer the clients or the multidisciplinary team. Because I’ve done a lot of work in the last six, seven years, trying to help people understand what dietitians do, how we can help people. And as soon as I explain it, then the penny drops, and they completely understand the benefits, and they’re completely on board with it. But most admit that it has never crossed their mind until they met me. What’s your experience just around that? 

Jessica: Very similar. I mean, it’s something that I see almost always in hospital notes, as I’m reviewing those as part of the case. And I can see that almost always, there’s a dietitian involved in the hospital setting. And then what I find is, as soon as my client becomes discharged, there is almost a, 

that they almost fall off a cliff effectively. And in that sense, in that it’s, you know, they’re back home, they’re able to meet nutritional needs themselves largely. And so, it’s almost, unless it’s something that’s specifically addressed by professionals, it’s not something that’s routinely kind of followed up in the community is my experience, albeit it probably should be. Unless there is a very obvious need, that the client can’t take nutrition themselves, or has some sort of restriction, it strikes me that quite often, that it becomes a forgotten need almost. And it shouldn’t be you know, that’s part of why we’re having this discussion today. And why I wanted to explore these issues with you in this podcast, because I think you’re quite right. Often there is this misconception that is, well, how is that going to benefit a client with a brain injury? And how can that possibly meet an ongoing need, and I think it’s really important that we explore today, your role, and how that can help and what the impact is, and what the benefits are for the client, for the MDT. And I know from when I’ve seen you speak previously, that actually, even in the context of somebody who hasn’t had a catastrophic injury, there’s some really interesting statistics that you can share for how your diet as an ageing member of the general population has a massive impact. And I think those are some of the things that I would definitely like to explore with you today, if you’re happy for us to do that. 

Sheri: Yeah, I totally am. And I think the best place to start would be with an analogy that I’ve come up with, that people seem to really resonate with, and it really helps them understand what nutrition has to do with brain and spinal cord injuries and complex orthopedic trauma. So, would it be okay if I share that with everyone? 

Jessica: Absolutely. 

Sheri: So, I’d like you to think of your body like a house. And inside this house is a 24-hour live-in renovation team. And anytime there’s a dent on the wall or a scratch or something in the house breaks down, bam, your renovation team is right there repairing the damage as quickly as possible. Now, as you can well imagine, the quality of the repair job that your renovation team does, is going to be highly contingent on the quality of the building materials and supplies that you make available to them. So, for example, are you giving your renovation team brick and marble and high quality paint? In which case the repair job is going to be done to a very high standard. Or are you giving your renovation team duct tape and cardboard in which case no matter how good they are, there’s a limit to what they’re going to be able to do with those building materials. Now, what does that have to do with these clients after a brain, spinal cord injury or orthopedic trauma? Well, for the purposes of this analogy, their house or their body has been through the equivalent of a hurricane. There is structural damage as in the bones, there is cosmetic damage as in the skin, and there is damage inside the house, as in the internal organs. The question is what building materials or supplies are your clients making available to their renovation team to repair all of that damage? So are they eating lots of vegetables and fruit, high quality protein, healthy fat, calcium rich foods, which would be the nutritional equivalent of brick and marble and high-quality paint? Or are they living on chocolate, fast-food takeaway, ready meals, which will be missing critical building materials and supplies that their renovation team needs, which means that the repairs either are not going to be done at all, or they’re going to be done maybe to not very high standard or it is going to take the renovation team longer in order to repair the damage. So that is probably the best way that I’m I’ve come across to explain why nutrition matters in this population. So, their house has been through a hurricane, the renovation team is working double time trying to repair the damage. So, while nutrition is always important for everybody, just for the general wear and tear within our body, this population, at this time, the nutritional requirements and needs and importance are immense. Does that make sense? 

Jessica: It makes perfect sense. And I think it’s a really accessible and useful analogy that anybody is able to understand. And I think that’s part of the difficulty as well around nutrition is that it isn’t always accessible or easily understood as to what the benefits are. And I think that put that way, in a way that is very accessible to almost all, you know, that makes it very easy for somebody to understand actually why this is important and why it needs to be a priority. I wonder if it’s helpful for us to take those kinds of components individually and in turn, then you mentioned obviously, kind of muscles and bones and internal organs and their kind of damage to the structure that this hurricane of a catastrophic injury causes. I wonder if I can ask you to kind of take each of those in turn with me Sheri and just sort of talk about how those things would usually be impacted and kind of the general aging population versus after an injury such as that we’ve described. 

Sheri: Sure. So, I’ll start with muscle mass. Because from a nutrition perspective, after a major trauma injury, I would say preserving muscle mass and rebuilding muscle mass as quickly as possible, should be the number one priority. And the reason it is so important is because your muscle mass is ultimately what determines whether you’re going to be independent or not. So, you need sufficient muscle mass in order to be able to stand up out of a chair, in order to be able to walk. So, if we want our clients to be living independently, if we want them to require the minimum amount of support package around them, we need them standing, moving, walking, able to transfer independently as much as possible. And muscle mass is going to be what makes or breaks that really. So, from a general population perspective, we all start to lose muscle mass after the age of 30. Unless you are actively doing some kind of strength or resistance training two or three times a week to stop that from happening, it is naturally going to happen, typically at a rate of sort of 3 to 8% muscle loss per decade. So that means by the time you’re sixty, you’re looking at probably sort of 9 to you know 24% muscle loss. By the time you’re 80 you’re looking at about 40%. Unless you’re actively doing something to prevent that. Now after a major trauma or injury, there is enormous amounts of inflammation in the body. The person is not able to do physical activity. Often, they are bed bound for long periods of time. Often their food intake is minimal because of just not feeling well or having to be nil by mouth for various surgeries or procedures. So, there’s a lot of factors going on at the same time. And the consequence of that is that people lose huge amounts of muscle mass very quickly. And the rates around clients in the ICU for example, are that you lose about 3% of your muscle mass per day. So general population 3 to 8% muscle loss per decade. Clients after a major injury, 3% per day. So that means 10 days in the ICU, you’re looking at a 30% loss of muscle, which is enormous, significant, and huge.  

Jessica: And from your perspective. then what can be done from a diet point of view and a diet intake to assist with that? So, where’s the benefit of having a dietitian at that point? 

Sheri: Well, the reason we often see dietitians heavily involved in the acute sector is because we know there is tremendous amounts of evidence around making sure that protein requirements are met in those very early stages, making sure protein and calorie requirements are met. So, people have very high calorie needs, their metabolic rate is almost in overdrive for an initial short period after a trauma or injury, and they have higher protein requirements. So, dietitians will often be involved, you know, either around tube feeding or nutrition supplements or other things in that very early period to try and minimize the amount of muscle that’s lost. There’s still probably even with those factors in place, they’re still gonna be some muscle loss. But we’re trying to minimize the amount of muscle loss that takes place. So, we need to ensure that clients are getting sufficient calories and sufficient protein and sufficient nutrients as well, obviously, but calories and protein are the most critical from a muscle perspective. And then working closely with the rest of the multidisciplinary team, physio for example, getting the client more immobile, doing as much movement and activity as they are able to do as early as it’s safe for them to be doing it, we need to be working closely together to ensure that happens to kind of minimize the amount of muscle loss. And then after the acute period, then dietitians work very closely with again, personal trainers or physiotherapists to try and rebuild any muscle that has been lost to the greatest extent we can. 

Jessica: in your view, is there kind of an optimum period of involvement or regular period of assessment in that context, where you have somebody who has had a catastrophic injury, and you’re in the very early stages of recovery, perhaps out of that early ICU stage, but they’re very much in the ongoing period of recovery, which, you know, can take a number of years? Is there a period of time that or a kind of point where you would say, actually, I no longer need to be involved? Do you have any thoughts on that? 

Sheri: I think the timing with dietetics is quite important. Obviously, we want dietitians involved as early as possible in the acute sector. And I think for the most part, the NHS in the UK is quite good on that front. The challenge becomes when the client is discharged from either the hospital or kind of any rehab unit, is that they often as you mentioned earlier, may not ever see a dietitian again. And that’s hugely problematic for a variety of reasons. So, depending on the nature of the client’s injury, and what challenges they’re experiencing in terms of meal preparation, or purchasing food, or being able to follow a recipe or, you know, some of those basic skills that many of us take for granted. If the client is really struggling in those areas, then their food intake is going to change as a result of that. And they may choose fast, easy things because that’s all that they’re able to manage at that time. So, we need somebody, you know, case managers or solicitors to be identifying clients that could be at particular risk, and referring to dietitians at that point. But for clients with capacity, I think the other factor is we need to make sure that the client understands the benefits and are on board with a referral to a dietitian, because I’ve occasionally come across clients that they don’t see the benefit, and they’re not interested. I’m obviously very limited then in terms of the assistance that I’m able to offer, just because they don’t want to implement any changes, you know, so the timing is sometimes quite critical. If clients are really struggling with tons of expert appointments or a really rigorous rehab, and therapy schedule,  they’re going to need a lot of support in order to change eating habits, change the food that they’re purchasing to be able to prepare food. We just need to make sure that the timing is right, so that they’re set up to be successful with any dietetic recommendations that we make.  

Jessica: I can see that I mean, it strikes me that a number of my clients, for example, have cognitive challenges. That means that either they forget to eat meals or the meals that they do cook or prepare, as you say, are quick, easy, might be the same meal on repeat, because that’s something that they’ve been able to learn and they’re confident in preparing, but actually other meals that they’re not either confident in preparing or not able to prepare. And that in the absence of your involvement, that a balanced nutritional diet that kind of meets their needs, to kind of help facilitate some of the other goals that they’re working on either in, you know, physiotherapy, for example, where they’re trying to work on strengthening exercises, or in their occupational therapy sessions, where they’re doing cooking tasks for example. It strikes me that in the absence of doing some of those things alongside you that actually progress could be quite limited. Would that be a view that you shared? Or is that something that you kind of disagree with? 

Sheri: No, I would agree in terms of that would be the main role of a dietitian. I think with these clients, the main thing that dietitians can offer is, number one, we can arrange for the clients to have some blood tests either through the GP or privately. Because we really need to understand clinically, where are we at? Like, do they have iron deficiency, Vitamin D deficiency? Vitamin B12, or folic acid deficiency? Are their blood sugars too high? You know, we really need some blood tests, because many clients that I see have been out of hospital for years and have never had another blood test, even if they’ve been to hospital. So, we really need to be looking at that very clearly, to know, okay, what’s the clinical picture at the moment? Is there anything here interfering with the client’s rehab and recovery, because if we don’t pick that up early, there could be something really small, really easy to fix, like an iron deficiency, for example, that gets missed and carries on for years, and the client is fatigued, and it gets attributed to their brain injury, when in fact, it’s something that we could have fixed, you know, a long time ago, and they’re not able to engage in neuropsychology or physiotherapy because they’re too tired. And it’s something that we could have easily fixed. So that would be one of the main roles of a dietitian is we can arrange for blood tests to be made, we can interpret the blood tests, work with the GP to correct any deficiencies, explain the blood test to the client. The other role of a dietitian would be to refer on to any consultant or secondary care that we think is required. So whether it’s a gastroenterologist, endocrinologist, allergy specialist, whatever we think the client needs, we can either ask the GP to refer on or we can help the client find somebody privately, that may be able to benefit. And then we can look at the client’s nutritional status, do diet analysis, computerized data analysis on that, pick up any nutrient deficiencies, you know, look at what supplements they are taking, make any kind of recommendations around that. And I think dietitians alongside rehab consultants are two of the main professions that look very holistically at the client and ask a lot of questions about a lot of different factors like sleep, stress, mood, what to eat, medication, supplements, physical activity. We have to look at all of those factors in order to do my assessment. And as part of that process, usually many things outside of dietetics get flagged up. And I refer on at that point. So I think there’s a lot of benefits for what a dietitian can offer. I think some of it is being aware that dietitians can offer it and just kind of assessing the timing as to when would be the most appropriate and suitable time and beneficial time to get a dietitian involved. 

Jessica: I mean, I would wholeheartedly agree with that. And I think your role is very much central to the rehab process and often helps kind of facilitate other areas of the team’s work and I don’t think your role is to be underestimated. Just kind of moving back a little bit. We obviously explored kind of the impact on muscle mass. And it strikes me that while we’re talking about other areas of the multidisciplinary team and also kind of further down the rehabilitation journey. Can we just explore a little bit more about some of the other statistics that are impacted such as bone density and skin integrity? Before we kind of move a little bit further on, I’m just keen to give a bit of an overview about that generally, and to members of the public, if you like, what kind of their age what the aging population looks like, versus after a catastrophic injury and those various kind of heads?  

Sheri: Yeah, for sure. So, we’ve talked about muscle mass and how that changes. So, in terms of bone density, the general population will lose bone density at a rate of around 3 to 5% per decade after the age of 30. Okay, so that means that by the time you’re 60, you have lost sort of 9 to 15% of your bone, by the time you’re 80, you’ve lost about 25% to your bone, okay? After a major trauma or injury, or actually, anytime somebody’s bed bound, so that could be for a completely different reason, bone loss is at a rate of around 1 to 4% a month. So again, the general population 3 to 5% per decade after the age of 30. Whereas after a major trauma injury, or anytime somebody’s bed bound, 1 to 4% per month, obviously, is significant. So, if someone is bed bound for a year, that means that they could potentially lose kind of 12 to 48% of their bone in that period of time. And I’ve had young fit healthy men in their early 30s, with osteoporosis, because they were in a wheelchair with no standing frame or anything like that for five or more years, maybe on a medication that wasn’t helpful from a bone density perspective. And we had to fight actually very hard to get a DEXA scan to even check their bone density. And once they did, they were immediately put on medication for osteoporosis. So, bone density is obviously critical, because if somebody then falls and then ends up with a fracture, or you know, needs a hip replaced, or something like that, that just compounds all of the problems they already have, and just delays the rehab or recovery so much longer. It goes on. 

Jessica: And some of these statistics are absolutely terrifying, as somebody who has been injured, and just an ageing member of the population, but then when you hear actually, how much more terrifying it is post injury, you know, especially if you’re in that position, through no fault of your own, you are relying on the professionals around you to kind of help combat some of these issues. And it’s, it’s terrifying, you wouldn’t necessarily be aware of these statistics, if you and I were not speaking today, I know I certainly wasn’t until we’ve spoken before. And do those statistics, particularly with bone density alter, depending on whether you’re male or female, or the age of kind of male or female. 

Sheri: So, yes, I mean, all of the statistics would be obviously greatly influenced by somebody’s age and genetics and nutritional status before the injury happened. And you know, all of those things obviously make a huge difference. But obviously, women are at higher risk of bone loss a) because their bones aren’t as strong as men’s to begin with, typically, combined with the fact that there’s such a significant reduction in bone density, particularly in the five years after the menopause, at a rate of around, you know, you lose kind of 10 to 20% of bone in those five years after the menopause unless somebody is taking some kind of hormone replacement. So that puts women at particularly high risk. In terms of muscle loss, I haven’t come across any statistics kind of differentiating between men and women. But again, men typically start with more muscle mass to begin with. So maybe they can handle a 30% loss perhaps easier than females with starting with a lesser amount of muscle or an older person that’s perhaps already naturally started to lose a bit of their, their muscle or bone over time. So, it really depends on the age of the person, you know, a variety of different factors, but it just gives you a rough overview of some potential complications that could happen as a result of these major traumas.  

Jessica: Absolutely, and I guess I should say that whilst we’re speaking about these things, generally that you know, each individual will be a case by case basis and would depend on their lifestyle factors, their background, the injuries that they’ve sustained and period of in hospital and what support they’ve received in an inpatient setting and what they’ve received in an outpatient setting, I guess very much has an impact on the work that you do and the specific recommendations that you have. 

Sheri: Yeah. And often, that’s why I request blood tests, DEXA, scans, various things like that, because I try not to guess, you know, like, if there’s a way for us to know, for sure what’s actually going on in this person’s body. Let’s assess it, let’s identify it, you know, and then we know exactly where we’re at, and exactly what we need to do in order to sort the problem. So as much as possible, I do really encourage and promote getting blood tests, DEXA, scans, various investigations, so that we know the actual clinical picture for this individual person, because everything is so personal, and individual, as you know. 

Jessica: I do and, and I guess the other thing is that you don’t always want to be relying on information that you’re receiving secondhand that might not necessarily be current to that person’s current prognosis and picture, and it might be something that actually as to you know, this is a scan or a test that has taken place six months ago. And for you to kind of be reliant upon that data might not necessarily be giving you a full picture as to the needs today if you were to do those same tests today.  

Sheri: Absolutely. And I mean, those are things that we want to be identifying early. I don’t want to wait until someone has really severe osteoporosis before we pick it up. I don’t want to wait until the iron deficiency is so severe that the person can barely function because their fatigue is so bad, like I would really rather identify it as soon as we possibly can because obviously, prevention is better than treatment any day. And if we can’t prevent it, then at least let’s identify it early and treated as quickly as possible. So, it has the minimum negative impact on that person’s rehab and recovery. 

Jessica: Absolutely. I just wondered Sheri whether I mean, obviously, you would do an initial raft of testing, if you like kind of the point of your instruction or the point of your involvement. And I appreciate that this is probably very case specific, depending on what the outcome of that testing is, and where their kind of needs lie. But is there a process of testing again, or regular testing that you would recommend? Is there a specific timeframe for those tests to be repeated that you would kind of like to see so that you could assess progress, whether that be, you know, positively or negatively. 

Sheri: Ideally, I would say after a major trauma or injury, a client should have annual blood tests, at a minimum. If we’re actively working to correct a deficiency or bring blood sugar levels down or something along those lines, then perhaps a bit more frequent than that. We’re often restricted, you know, if we’re trying to get blood tests through the National Health Service, there’s a limit to how often they’re prepared to do them. And it’s becoming more frequent than the expectation is that some of the blood tests are going to be done privately. So that’s something else that we’re going to have to factor in kind of moving forward in this area in the future. 

Jessica: Absolutely. I’m obviously from my perspective, a lot of what I deal with, generally, is looking at how these things can be arranged privately, because as you say, it’s often much quicker for my clients to arrange them privately than rely upon and being done on the NHS. And that and I say that without criticism, purely just kind of from an observational point of view and an access to support for a client generally, it’s quicker to do that privately. It’s tricky, isn’t it? Because I’m considering this from very much the perspective of the clients that I asked for. And I’m very well aware that actually, there’ll be a number of people who have had a catastrophic injury or a life changing injury where they don’t have a personal injury action and where they don’t have a solicitor on that side. And they are very much reliant upon the NHS and they may well have had support whilst in hospital, but they may be completely unaware that actually repeat blood tests annually might be beneficial for them. Are there things that you would recommend that somebody speak to their GP about or keep an eye on and speak to somebody, a health professional about, regularly if they did have concerns about. 

Sheri: Do you mean in terms of which blood tests they should be requesting specifically, 

Jessica: Just if there are things that have been noticed within the hospital setting. If there are any specific deficiencies that are noted within that setting, whether that would require follow up that they should be quite keen to speak with a GP about annually in terms of annual blood tasks 

Sheri: The ones that I would recommend would be full blood count; urea and electrolytes to check kidney function; HbA1c, which would check blood glucose levels; fasting cholesterol to check cardiovascular risk; ferritin, which is a storage form of iron. I usually recommend that be checked as well, just because we’ve had a few cases where maybe their hemoglobin has been all right, but their ferritin, or their storage iron is virtually completely depleted. Vitamin D I recommend regularly because that is very commonly deficient in all of our clients. Vitamin B12, and folate, I recommend routinely. Thyroid function I recommend routinely. Liver function tests. So there’s quite a long list. But those are things that I would recommend, at a minimum every year for our clients. 

Jessica: Perfect. And just kind of, it strikes me that there are probably things that you  see quite commonly, throughout your practice, post hurricane if we if we call it that post hurricane. What type of I mean, we’ve spoken about loss of mass. We’ve spoken about bone density. We’ll come on to skin integrity shortly, because I suspect that’s quite a lengthy topic. But what types of other things are you seeing? Quite commonly, that you would say, are kind of issues after a catastrophic injury or hurricane 

Sheri: There’s a huge amount of nutrient deficiencies. So, deficiency in iron, B12, or folate and vitamin D, I’d say would be the top four. Most of the clients that I see are deficient in at least one of those, usually more than one. HbA1c. So, blood glucose levels also tend to be in the prediabetes or diabetes range for many of the clients. And that links back to the change in muscle mass and body composition that I referred to earlier. So, our clients lose significant amounts of muscle immediately after their injury, and muscles are what burn the calories. So the less muscle you have, the fewer calories you burn. And what I find post injury is that many clients after the initial kind of acute period where there’s loads of inflammation, and they actually have higher than usual energy requirements. But after that, their metabolic rate tends to be in my experience, and I haven’t seen any stats on this, but in my experience, their calorie requirements and metabolic needs are about 50% of what they were before their injury. And the problem is that many, many people eat based on habit and routine. And so, they will continue to eat the same portions, the same types of foods as what they did before their injury. But now they’re nowhere near as physically active. And their metabolic rate is about 50% what it was before. And so we see clients gaining significant amounts of weight after their injury. And most of that weight tends to be fat, specifically around their abdominal region. And the health risks around that are enormous, because that’s what increases the person’s risk of type two diabetes, heart attack, stroke, etc. Which is why even if somebody’s weight is identical to what it was before their injury, their body composition will be completely different. Their body is functioning now completely different. That’s the reason why it’s so important to be doing these blood tests. And why HbA1c for blood glucose is one of the ones on my list that I routinely check because the number of clients that have prediabetes or diabetes is very high. 

Jessica: Which is terrifying, really, isn’t it in itself that, you know, you’re seeing more and more of that and that that is a concern because of an injury. And it is something that although the injury can’t be helped, you know, that’s happened, we can’t change that, that actually, there are some steps and daily habits that can be taken and can be adjusted to help try and combat some of that. 

Sheri: Yeah, and cholesterol. High cholesterol is also very common for the same reason that type two diabetes is very common in this population, because of the change of body composition, the higher rates of abdominal obesity, you know, so, yes, I’m looking at acute kinds of short-term issues like nutrient deficiencies that are interfering with someone’s rehab and recovery. But I also want to be looking longer term at this person’s overall health risks, to try and minimize the problems they’re going to have in the future as well. 

Jessica: I can see that. And, you know, I think it’s quite right that we’re creatures of habit, humans are creatures of habit. And that naturally we do tend to do lots of things, because of what’s already in our routine. And I don’t kind of want to go down a bit of a rabbit hole here on psychology. But I also wonder whether there’s a bit of an interplay here as well with, you know, after an injury, doing things that are easy, or eating and drinking things that are easy or almost comforting, because there’s, you know, there’s lack of movement, or an inability to get back to things that they were doing pre accident that actually, there’s an interplay of psychology there as well. Is that something that you commonly see? And does some of your work overlap, I guess, with a treating psychologist, and do you work together and in that sense, as well? 

Sheri: I absolutely work very closely with other members of the MDT. But in terms of working together with psychology most definitely, around, so part of my assessment would be, if someone is struggling with their weight or gaining weight, I need to identify the root cause of the problem, you know, and that that is the basis of my assessment is okay, what’s going on here? Because people can eat, consume, too many calories for about 100 different reasons, you know, so is it comfort eating? Is it a side effect of medication? Is it they just don’t understand about nutrition? Is it you know; the support workers don’t know how to prepare a nutritionally balanced meal? So, there’s so many different variables that could be impacting somebody’s eating habits. So, I need to assess all of those in order to be able to identify the root cause of the problem. So, comfort eating, and mood in general, is something that we routinely ask in our initial assessments, because if someone has low mood, they’re not gonna be motivated to cook or shop or, you know, eat sometimes. It can have either an effect on weight, either people eat too much, or eat too little. Similarly, if someone’s really anxious, you know, that may interfere with their appetite and they may be struggling to gain weight because of that reason. So I’ve worked very closely with psychologists around that. I’ve also come across quite a few clients actually, where they had incredibly challenging behavior, which was attributed to the brain injury itself. They were already under neuropsychology that were doing all the amazing things that they do, but the situation wasn’t getting better. And in various situations, the fundamental root cause of the problem was that client had high blood sugar levels. And that as soon as we brought the blood sugar levels down within the healthy range, which we were able to do, within less than a week, the challenging behavior went away completely. 

Jessica: Wow. 

Sheri: SoI work closely with psychologists for that reason. Obviously so many of our clients struggle with fatigue, which is why we recommend all the blood tests that I’ve mentioned earlier, you know, to rule out a medical explanation for the fatigue. I come across quite often that people forget that you can have more than one thing wrong with you at a time, you know, and so and I find, particularly with clients after a brain injury, much of the fatigue specifically gets attributed to the brain injury itself. And that I find people don’t look any further in terms of, well, you can have a brain injury, but you can also have at the same time iron deficiency or vitamin D deficiency, you know, so let’s just rule out any medical explanation for the symptom before we just attribute it to the brain injury or whatever the polytrauma has been at that time. I think that’s quite important. 

Jessica: I think so too. And I think that having you involved as part of the MDT, it strikes me that there’s very much an integral role there, that if there are issues that have been raised in in other areas of practice, whether it be from the physiotherapist or from their psychologist, or, you know, you can at least sort of rule out any deficiency or rule in any deficiency so that you can then help to address that. That might then benefit another areas or another area of development and recap that actually, it’s very much a holistic approach that is a two way street, that in sharing that knowledge between you on an ongoing basis, actually, you can probably provide a better program of rehabilitation, and hopefully, a better outcome for the client. Part of what I wanted to explore in this podcast, which I think we’ve done already so far, but I wonder whether we might do it in kind of a more succinct way and a bit of a snapshot in your mind and in your view, what are the key benefits of having a dietitian involved as part of the multidisciplinary team? And when I say that what I mean is part of the team of professionals who are supporting an injured person outside of the hospital setting. So, after they’ve been discharged, and they’re either back in their home or back in a neuro rehab facility, and they’re being cared for in the community. What do you see as the key main benefits of having somebody like yourself involved? 

Sheri: I would say the top four would be, number one is that we assess the client holistically. And so we’re able to pick up issues around gut health, mood, swallowing issues that may or may not have already been identified. So that’s probably number one. Number two is that we can request blood tests and work with the GP or arrange for them to be done privately to get a good clinical picture of where the client is at the minute. Number three is we can refer or get the GP to refer on to secondary health in terms of gastroenterology, endocrinology, allergy specialist, and number four is we can do a computer analysis of the clients food intake and or supplements and provide advice and guidance around changes that need to be made to ensure the clients, at least their minimal nutritional needs are being met. I would say those would be the top four. 

Jessica: And on the flip side of that, and obviously we’ve explored these from an individual perspective on a number of different areas. But looking at it as a more general kind of snapshot. What from your personal perspective, would you say, are the risks or the impact of not having somebody like yourself involved. 

Sheri: I would say the number one risk would be you’re going to miss something. You’re going to miss something, sometimes basic and fundamental, that is going to have an enormous negative impact on that client’s rehab and recovery. So whether it’s they’re dehydrated, whether they’ve got iron deficiency, whether their blood sugar levels are too high, you know, they they’re not significant in terms of, it’s not hard to identify them. But the impact if you miss that is enormous. And I can give you a really good example of that around skin integrity, because I know we’re coming on to that next is that I’ve had a number of clients that have been bed bound for literally years, because of pressure sores that were not healing. And they had amazing district nursing teams that were doing amazing things with dressing, and those pressure sores were not healing. And the clients could not progress with any of the other part of the rehab and recovery. They couldn’t go to the community. Physio couldn’t do what they needed to do, because of these pressure sores. And in the end, the fundamental problem was insufficient protein, not enough vitamin C, or zinc and blood sugar levels that were too high. And it absolutely breaks my heart that these clients suffered for years with something that we were able to resolve within a few months. You know, so that would be the number one risk of not getting dietitians involved earlier is that you are going to miss something really significant, that’s going to have a massive impact on the rest of that client’s rehab and recovery. 

Jessica: Absolutely. And while we’re on skin integrity than let’s delve into that. Let’s talk about pressure sores. And, and obviously you and I know how limiting pressure sores can be and how terrible that impact can be. But can you just explain a little bit about pressure sores, and from your perspective, how your involvement would help in the treatment of those or in the prevention. 

Sheri: So, clients after a major trauma injury are incredibly high risk for pressure sores, and just kind of slow wound healing in general, for a variety of different reasons. Partly because they’re often bed bound, or wheelchair bound for long periods of time. They might not be able to reposition themselves independently. They could be reliant on somebody else for that. But also their nutritional intake has a massive impact on skin integrity. So the amount of fluid you drink, whether you have enough iron in your body, whether you’re consuming enough protein, all of those things impact skin integrity. And if we think of the analogy that I gave earlier, in terms of your body being like a house and you need the building blocks and materials in order to repair the damage, the skin integrity and pressure sores are actually the perfect illustration of this because you can’t build skin out of thin air. It’s made out of the amino acids from the protein. It’s made from the zinc and the vitamin C. You need those fundamental building materials and supplies in order to repair that skin. And if they’re not there, it doesn’t matter how good the district nursing team is and how great their dressings are, you need the fundamental building materials and supplies to repair that damage. So that would be the number one role of the dietitian. And I’ve had case managers tell me that, you know, the district nursing team couldn’t understand why the dietitian needed to be involved. I would say if there’s a grade three or grade four pressure sore, that should be an automatic referral to a dietitian, because you have to ensure that there is sufficient building materials and supplies to repair the damage. And actually, clients have higher than usual requirements in those situations, which can sometimes be incredibly tricky to meet. So often, because clients have very low calorie needs after a major trauma injury, because of the muscle loss that I’ve explained earlier, but high protein requirements, because they’re maybe trying to prevent or they want a wound to heal, then that’s a very tricky combination to get sufficient protein with not too many calories, that doesn’t impact the you know, bladder stones and catheters and various other things that the client has going on at the same time. It’s quite a challenge. And you do need the expertise of a dietitian in order to be able to manage that. 

Jessica: Just touching upon briefly something you said there, obviously, you said, if there is a grade three or grade four pressure sore, that should to your mind automatically trigger a referral and the involvement of a dietitian. In an NHS setting, does that occur? Is there an automatic trigger? Or is that something that you think should happen? 

Sheri: I think you will find that varies tremendously based on the NHS Trust and the clinical commissioning group. They all have various levels of dietetics service provision. They all have different criteria about what threshold needs to be met before the person qualifies to be seen by a dietitian. So while in theory, I would hope that that would always happen everywhere in the country, the practical part of me has to believe that I would imagine that’s probably not happening on a regular basis. 

Jessica: And I think you’re quite right, it often in theory, you know, there are guidelines there, but it very much comes down to postcode and where you are in the country as to what level of support is available, and what kind of local resource there is. It strikes me Sheri, that we are in the middle of a cost of living crisis and that diet plays such an integral role for a number of various different outcomes, whether that be in the general aging population, or for somebody who has suffered a traumatic injury and is in the process of rehabilitation. Have you within your practice, noticed any impact of that at the moment or anything that has kind of caused difficulties to the people that you’re assisting. 

Sheri: Clients on my caseload have varying levels of income, I find. And so, while it’s possible to eat nutritiously and meet all your requirements on a limited budget, you do need to have sufficient budgeting skills, food shopping skills, cooking skills, in order to cook that food and meet those nutritional requirements. And I find that depending on the nature of the client’s injury, a huge problem, you know that they may have is a limited amount of money, but their executive functioning has been so massively affected as a result of their brain injury, that, you know, the budgeting the food preparation is too challenging for them. So then they have support workers that are perhaps assisting with varying levels of cooking skills themselves. And it does create a bit of an issue in that sense. 

Jessica: Yeah. And does part of your role extend or I guess this is very much budget dependent, but would part of your role extend to educating the extended team. So you spoke about support workers, for example, who will often assist our clients in kind of day to day living. Would you routinely kind of help provide education to them on you know, needs and meal preparation, alongside perhaps an occupational therapist? 

Sheri: Yes, absolutely. I do work very, very closely with the occupational therapists because they’re often doing you know, assisting with the food shopping or arranging for that online or in person. They’re often you know, assessing to see if the client is going to be able to cook food themselves and they can usually tell me what format the recipe needs to be in and how easy or complicated they can manage. So, I do work very closely with occupational therapists. But yes, I do offer training for the support workers quite routinely. Because we all need to be on the same page, we all need to understand what the goals are and what we’re trying to accomplish. And not all support workers have a particularly strong understanding of nutrition. But I found it’s always very well received. And usually, once everyone understands what we’re doing, and why we’re doing it, that everyone gets on board actually quite easily. And then I can offer them whatever level of assistance they require. So, whether if they need the link for the particular grocery store for the particular food item that I want them to buy, I can do that. If they need pictures of breakfast options, or if they need just meal ideas, or if they need recipes, or whatever they need in order to allow them to implement that, I can make it happen. 

Jessica: I think that’s really helpful. Because a lot of kind of the strength here in your role is making you more accessible to more members of the team and to more people, more people who have been catastrophically injured. And if your involvement isn’t in a key role, it’s very difficult to be able to ensure that the recommendations that you make are carried through, you know, without the members of the team being educated on the importance and where the needs are, it strikes me that you know that need won’t be being met. And then obviously, you haven’t got the progress that you need to see. On the flip side of that, if I consider the absence of having you involved. There is, after our discussion, I think I would have a major gap there. That’s evident that actually, if we don’t have a dietitian involved, what does that look like? Well, that that might mean that these needs are not being met. Because actually, we can’t be relying on other professionals to have this expertise and to assist in in these areas. You know, their specific expertise is within one very distinct area. And albeit they may have a good kind of knowledge or overview. Without having a dietitian involved, there are very clear gaps in progress, it seems to me that will always be there in terms of a person’s support and rehabilitation. Is that fair to say? 

Sheri: Yes, I would agree. I think other professionals or other people involved with the client, family members or whoever are perhaps able to identify glaring errors where there could be improvements. If they’re not having any vegetables, or they’re eating, you know, copious amount of biscuits or chocolate. I mean, I think a lot of people would identify that perhaps not an ideal situation, but they wouldn’t necessarily be able to go the next level, which is why is that happening? You know, is it purely Oh, I just didn’t realize that I needed to eat vegetables? Or is it, I don’t have the capacity to understand the consequences of my food choices and I actually need people to be making best interest decisions on my behalf. Or is the issue that, you know, the support workers are, you know, responsible for preparing the food and support workers just don’t quite understand what the nutritional needs of the clients are. So there’s so many reasons why people are doing what they’re doing. And I find other professionals don’t have the time, you know, or, or the clinical expertise to be able to pick out what is the actual root cause of the problem, because without it, it’s very difficult to find a successful long term solution. 

Jessica: And again, I guess a lot of what we’re discussing is, is very much dependent on the baseline, if you like for the client, that you’re dealing with and their individual needs. A lot of it will come down to pre accident, what their level of own education and habits were like whether they have changed post-accident, by virtue of the injuries that they’ve sustained, and what their new needs are, as opposed to kind of what their previous needs were. So, a lot of it will be very much because dependent and person specific. And you know, any one of us any, any time could sustain a catastrophic injury. And I think that’s part of why this is all so fascinating. And, and I really enjoy hearing you speak I could hear you speak for hours Sheri and I could probably interview you and kind of do this this podcast for another four hours without hesitation. But it strikes me that we’re probably nearing kind of the hour mark and that if there are other things that we need to explore that we could perhaps do it in another podcast at a later date. But we’re obviously in a New Year. Lots of people will be thinking about their health generally and how to make small changes to every day to make some small improvements for themselves, regardless of whether they have, you know, sustained a life changing injury. Is there anything that you might be able to share with us from your own daily habits perhaps, or any kind of general advice that might help us all to be a little bit healthier and better prepared should the worst ever happen so that our bodies are in the best possible, I guess, state that they can be if the worst to occur? I guess what I’m saying is how do we best ensure our houses are in order? 

Sheri: Well, I think most people are able to identify maybe one or two areas, that of their diet that could be improved slightly. And I find that this time of year, people are really trying to use a lot of willpower to sort of force themselves to make changes that they think need to be made. And they also tend to be quite rigid and withholding particular foods or food groups, because they think that’s what’s required in order to, you know, change their weight, or change their nutritional status, or whatever it is that they’re trying to change. And my suggestion would be to first focus on identifying the root cause of the problem. So, if, for example, at this time of year, you are dealing with a bit of extra weight that you’ve gained over the holidays, it’s really worth thinking carefully about why that happened. You know, so was it the availability of the food that was tempting you? Was it an increase in alcohol intake? Was it you were visiting friends and family and things were outside of your control? Was it that you were having reduced levels of physical activity? You know, as you can see, there’s literally 100 reasons why that could have happened. So, before you jump into some kind of rigid weight loss program, or whatever you’re planning to do at this time of year, I would really invite you to think carefully about why did that happen in the first place? And would you do anything different next year to stop that from happening, or to minimize the change that you’ve experienced. Because the solutions are perhaps a bit different than what you may realize. So for example, I did this activity with a few clients recently. And what they identified is that, obviously, the availability of a variety of different foods that they wouldn’t normally have in the house was suddenly an issue, because people were gifting food and bring in food, and you know, those types of things, which do happen quite often at this year. And I really encourage them to think, so of all those things that you’ve eaten in the last two weeks or month, or however long it’s been, which ones are your favorites, you know. And they were very easy, you know. It was quite easy to identify, you know, their favorite foods. And so it’s like, so how about if you eat those and all the other food that you ate just because it was there, but you really didn’t enjoy it, and you really weren’t fussed either way, whether you had or not, how about at another time, you kind of eliminate that either request in advance that people don’t, you know, offer you food as gifts, or give the food away, or however you want to manage that situation. But as you can see, just by doing that process alone, and you know, in the minute, we’re gonna get to what you need to do differently to kind of deal with a situation that you’re now in. But you could easily prevent that in the future if you just take a few minutes to identify what the actual root cause of the problem. For now, when you’re dealing with a consequence of whatever choices you’ve made in the last month or so, I would invite you to think about what change can you make to last the rest of your life? You know, so often we’ll be really rigid and cut out whole food groups or, you know, really restrict our food intake or whatever and I will ask, can you eat that way for the rest of your life, because if you can’t, then that’s going to be a very short-lived strategy. So, we need to be looking at something a bit more sustainable. So that would be my first suggestion is do a root cause analysis, why did it happen? And then so you can do something differently next year to stop it from happening again. Based on the situation at the minute, you know, what change do you need to make, but how can you do it in such a way that you can do it for the rest of your life? My only other suggestion at the moment around that would be sometimes people find it helpful to come up with little easy to follow simple food rules to guide some of their food choices. So, by that I mean, you could create a rule that I’m going to eat vegetables every day at lunch and evening now. You know, it’s very simple, very specific. You can apply it in any situation that you’re in. And it’s just sort of a rule of thumb that this is what I’m going to do, because I’ve identified that would really be helpful or beneficial to my house. Or another rule of thumb could be, I’m going to buy a pint glass that I can use for my water. And I’m going to make sure that I drink four of those a day. Or I’m going to buy a water bottle with the time markers on them. And I’m going to make sure that my fluid intake is up, you know, so people sometimes make their goals a little bit too big, which is why they’re very difficult to sustain. So, if we really identify the root cause the problem is I didn’t eat any vegetables for last month. I’m going to resolve that by setting a rule. I’m going to have vegetables at my lunchtime and evening meal, you know, that is something that you could do conceivably for the rest of your life.  

Jessica: So small changes consistently over time and root analysis if there is a problem. 

Sheri: Absolutely. 

Jessica: Makes perfect sense. Sheri, thank you ever so much for your time today. It has been as always fascinating for me and I just love hearing about the work that you do and the insight that you have. I think it’s so important not only to the work that I do from a neuro trauma perspective, but just for all of us as healthy human beings that the small changes that we can make to everyday life to make sure that we’re all better equipped should the worst happen. Thanks ever so much Sheri. Is there anything else that you would like to add or you think might be helpful? Any final comments? 

Sheri: I think for this particular population of clients, so those after a brain injury, spinal cord injury or complex orthopedic trauma. I do think it’s important that solicitors, case managers, other health professionals realize that that these clients are best served by a dietitian specifically. So, if these clients need support around food and nutrition, I do encourage them to seek out a dietitian. You may already be familiar with various things that you see on Facebook and Instagram and all sorts of other places that there is a lot of nutrition advice out there. A lot of conflicting nutrition advice out there from a variety of different people from celebrities to self-proclaimed nutrition experts, and there’s very little regulation in the industry. So, the reason I recommend dietitians particularly is because it’s a legally protected title throughout most of the world. You cannot call yourself a dietitian, unless you have a degree in nutrition have completed a supervised practicum and are registered with that particular country’s regulatory body. And dietitians do specialize in using food and nutrition to manage and treat various medical conditions. So, whether it’s a brain injury, or irritable bowel syndrome, or diabetes, or whatever, dietitians do specialize in using food and nutrition in those specific situations. And we’re the only nutrition professional registered with the Health and Care Professions Council in the UK. So that means you must have a degree, you must have a practicum, you must, you know follow the ethical and continuing education requirements as other professionals such as neuro psychologists and occupational therapists and physios. So that would just be my one suggestion is if you’re looking for nutrition advice, particularly with this sector of the population. Because of their level of complexity and the number of medications they’re on and the number of health issues that they’re generally experiencing, I do recommend that you specifically seek out support from a dietitian. 

Jessica: I think that makes perfect sense sharing. Yeah, you’re absolutely right. Even as a layperson, consumer, somebody who uses the internet, you’ve only got to log on to Instagram or Twitter or you know, pop something in Google to be matched with just a vast array of information that can often be misleading, as you say, you know, you don’t know that person’s qualifications background, the legitimacy of what’s being said, and actually that can be quite confusing. So, to have a specialist dietitian, I think you’re absolutely right, it makes perfect sense, especially in this setting. 

Sheri: You certainly want to be following advice that’s evidence based as much as possible. And I realize in this these populations, there often isn’t huge amounts of evidence sometimes but you do want as much scientific basis and background to support what you’re doing as opposed to testimonials or you know, personal experience or you know, those types of things because the reality is anyone can go  on Facebook or Instagram or the internet and start giving out nutrition information, whether it’s accurate or not, and nobody’s going to stop them. So as a consumer, it’s really important that you are very careful about where you get your information from. And you make sure that it’s evidence based to the greatest extent possible. 

Jessica: Absolutely. And as you quite rightly mentioned that, you know, your practice is regulated by a regulatory body. But the risk in kind of any other area is that potentially that doesn’t have the same level of continuing practice, and professional development. And it’s not regulated in the same way. And so, if you are relying on, you know, comments, feedback reviews online, that are not necessarily substantiated by a professional body or supervised by a professional body, that it’s a very risky area. Well, Sheri, thank you ever so much for this morning. It’s been absolutely fascinating. I could still talk to you for hours and hours and hours, but I’m sure you have more than enough to do this Monday morning, or almost afternoon, I should say. So thank you ever so much. It has been an absolute pleasure speaking to you. 

Sheri: Thank you. I’ve really enjoyed being part of your podcast. 

David: Thank you, Jessica. And Sheri. I really enjoyed listening to that one. And that’s a great episode one of this podcast series. So, thank you. Thank you for your time and thank you for recording that. Very quickly from me, as I said at the outset, we continue to work hard to produce, release, deliver useful and relevant content which we’ll continue to do throughout 2023. Articles, podcasts, blogs, events, seminars, all of which can be found on our website at www.sintons.co.uk should you wish to take a look and there is such a lot of content on there. So generally, it is a really useful resource so suggest you do check it out. Contact details for Sheri. Sheri can be contacted via her website which is www.specialistnutritionrehab.co.uk and for Jessica by telephone 01912267878 or via email jessica.gower@sintons.co.uk and her contact details are also on the website. If I haven’t said the website address enough www.sintons.co.uk. Our next podcast will be with you in a few weeks. Just wanted to take this opportunity to once again thank Sheri for her time and for contributing to such a great podcast this morning. We generally do appreciate it. Thank you for tuning in. Stay safe everyone. And we’ll speak to you soon. Thank you.