Sarcopenia, Malnutrition and Physical Activity feat. Stacy Jones RD

Episode Transcript
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Stacey Jones (00:00):
And I think as practitioners as dietitians,

(00:02):
we should then be taking moredetailed assessment in terms of
looking at muscle mass andstrength to better inform
our decision making andnutrition interventions.
And also, if it can helpdemonstrate effectiveness
of dietitians and measure ouroutcomes, then I think we
should be all doing that aswell.

Aaron Boysen (00:18):
Welcome to the dietetics digest podcast
with your host and dietitianme Aaron Boysen dietetics
digest is a podcast createdand produced by dieticians for
dietitians. We intervieweddieticians from around the
world to talk about theirjourney and their groundbreaking
work. This podcast willhelp inspire you and others
to become the best dietitianpossible. I'm your host Aaron

(00:42):
Boysen. And today we havemy guest Stacy Jones. So Stacy
Jones is an associateprofessor and curriculum
change lead at CoventryUniversity.
Stacy has worked in academia forthe past six and a half
years and prior to that workedas a specialist community
dietitian, as well as apublic health specialist
dietitian Stacy's undertaking apart time PhD in the area of

(01:04):
sarcopenia.
Looking at the role dietitianshave in preventing and managing
sarcopenia in older adults,she's passionate about leading
for the profession ofdietetics and evidence based
practice striving forexcellence in patient care
taking in a holisticpatient centred approach. Stacy
is a committee member of theUK BDA older people specialist

(01:27):
group, and is also part ofthe E f ad. As European
Federation of associateddieticians, older adults
specialist network in herspare time, she enjoys running,
cycling, and has morerecently taken on open water
swimming. In pre COVID timeshe enjoyed travelling the

(01:48):
world and learning aboutdifferent countries and
cultures.
Fortunately, she's got a bitmore time on our hands,
because that's not available.
And she's able to join ustoday. Thank you so much for
joining us, Stacey.

Thanks for having me, Aaron. That's
really great.

So obviously, you've got a large background, a
lot of interesting areas. So theinnovation and the sort of
pushing dietetics forward issomething that one of the
reasons why I really startedthis podcast interview some
really inspiring and insightfulpeople in the area of, of
dietetics. And I wanted todiscuss a little bit
today, a little bit about thearea you're working in,

(02:22):
what brought you to that,and how your journey has
been so far. So if you couldjust sort of give me an
outline of how you got whereyou currently are and where
you currently are.

My background started with a degree in
biology and sports science,and I wasn't really sure
what to do as a career. But Iknew that I enjoyed
learning about the human bodyand health. And also I was I
had a very strong interestin exercise. So that then led
me on to learning more about howexercise can actually impact

(02:50):
on the human body. And inhealth and disease. I was
particularly interested inthe nutritional aspects which
led me on to study apostgraduate diploma in
dietetics, to train as adietitian, and when I first
started working as a dietitian,I went straight into public
health. I then went on to workas a community dietitian in a
more clinical area, mainlyworking with patients who were

(03:11):
malnourished, lots of elderlypatients and preventing
malnutrition, and nutritionalsupport. Whilst while supporting
those patients, I felt thatthere were a lot more that
we could do in order to preventmalnutrition and its
consequences and also toimprove patient important
outcomes. So for patients,it was about the ability to

(03:32):
be independent carry outactivities of daily living
improvement in their mentalwell being their social
life, the quality of lifeand actual physical
function. And so as a dietitian,whilst we're very much
involved in, in giving adviceto support their diet,
their dietary intake andimprove their dietary intake.

(03:52):
I felt that the the measurementsthat we were taken around
weight gain BMI, we'reactually not that important
to patients.
And I felt that there was morethat we could be doing in
terms of our dieteticassessment and our dietetic
involvement.
Was there any particular event

that sort of led up to that because
you said, You obviously, werelooking at sort of
anthropometric measurementslike weight and sort of helping
people who have maybe hadunintentional weight loss and
helping them restore thatway, if you have any, any
sort of experiences or sort of acollection of experiences
that you felt with patientsthat you felt that you could
do more with?

Yes, actually, I had a lot of head
and neck cancer patients whoare on enteral tube feeds and
actually still had a lifearound them still going to
work, still wanting to beable to do more and get back to
their sort of activelifestyle and with feeling
like it was impacting ontheir their sort of mood
and their motivation withthe amount of muscle loss

(04:48):
that they'd lost in thestrength and sort of their
ability in terms of theirfunctional ability to
actually when it came to theweight gain and that wasn't
actually as important andthey were asking after asking me
things that they could bedoing. To help gain some more
strength, and particularlyaround exercise, so that sort of
led me to think about, andparticularly an older, frail

(05:09):
adults who were housebound,maybe had quite a high fear of
falling or limited mobility, andthat has impacted on
their, their social aspectand their ability to go
out and meet people andsocialise that has a knock on
effect on their mental healthand well being as well. So for
me, it was about could webe doing more for patients,
rather than just restoringtheir weight and reducing

(05:31):
malnutrition?
And to actually go one stepfurther and enable them to
take more control overtheir life and have that
independence.
So in terms of muscle mass andmuscle gain, what interventions
were actually effective inachieving gains in muscle
strength and muscle gain andmuscle function?
Rather than just thinkingabout the weight gain?

(05:51):
And actually, it did? It didcross my mind a few times that
were we just increasing people'sweight? And therefore what
what weight were they actuallyputting on? Was it fat mass? Or
was it actually muscle mass?
Because if they were verysedentary, and they weren't
actually doing any physicalactivity, but they were
gaining weight, would that justbe almost increasing their risk
through you know, for otherthings in terms of increasing

(06:14):
their adipose?
Sorry, increasingtheir their fat mass, and not
their muscle mass?

And what did that lead you? When was the next
step after you sort of had thisrealisation?
What was the next step inyour life that led you to
where you are now.

So this inspired me to think about exploring
this area in terms of furtherresearch, and that that was
what led me really to moveinto academia.
So I moved to come intouniversity, teaching dietetic
students, and that careerreally enabled me to have
influence over the futuregeneration of dietitians,

(06:48):
thinking about what we learnat university and how that
will then go on to impactpractice and change practice
that was really inspiring andbeing able to have that
impact in terms of theprofession. And undertaking a
PhD, whilst I was at CoventryUniversity gave me the
opportunity to then explorethe evidence behind
malnutrition, exercise,nutrition, and the links that

(07:13):
that had with sarcopenia.
Throughout my the journey ofmy PhD, and this has
evolved really into looking atthe role of the dietitian in
prevention and management ofsarcopenia. And more. So what
could we be doing in termsof combining that exercise
and nutrition approach, whichis what the evidence
suggests, and exploring thescope and the role of the

(07:33):
dietitian, and potentiallyexpanding that role or
advancing that role? And to bemore effective for the
patients at the end of the day?

Yeah, I think that'd be really, really
interesting to cover. And youwrote a paper on this topic
about getting dietitians alittle bit more involved with
exercise and talking aboutthat with patient cohorts, but
maybe for the, for thelisteners that may be not as
familiar with it. What issarcopenia? And how would it?
How would you How would youknow if you saw a patient with
sarcopenia?

Okay, so sarcopenia has been around
for a very long time withvarious, various definitions.
And it was only until recentlythat we had a consensus and
definition for sarcopenia. Soin 2010, the European
working group for sarcopenia,in older people published the
first definition andconsensus for sarcopenia. And

(08:21):
this has since been updated in2019, whereby sarcopenia is
defined as a disease ofmuscle failure, failure, rooted
in adverse muscle changesassociated with ageing, but can
occur in early life. So that'sthe definition from the European
working group.
And what we're really lookingat is the combination of
low muscle strength andlow muscle mass for a diagnosis

(08:44):
of sarcopenia to beconfirmed, and then we look at
the loss of physicalfunction as an indication of
the severity of sarcopenia.

How do you How would you know, say, a clinic
setting or an award settingHoward, how to dietitian be
able to recognise thatin a patient?
Would you just say are they'repretty weak?
They look pretty weak?

That's a great question. And actually, it's
about a holistic diagnosis. Sowe can we can look at muscle
strength, muscle mass andphysical function, and have more
objective measures ofthose. Some measures are more
appropriate in a researchsetting, and can be quite
costly. And we do have somemeasures that are quite easy
and quick to do that would bemore suitable in a sort of

(09:23):
clinical setting with apatient or in a patient's own
home. So in terms of whatthe European Working Group
sarcopenia recommends, fordiagnosis, so for muscle
strength, they recommend usinggrip strength in a hand grip
dynamometer. So that's actuallysomething that can be done out
in the community within ahospital ward, it could be
done in the patient's ownhouse. All we need is a hand

(09:45):
grip dynamometer totake with us, and it doesn't
take very long at all tomeasure a patient's grip
strength and then there aredesignated cutoff points to then
diagnose sarcopenia. Sofor men, it would be a
cutoff of less than 25 Inkilogrammes on the hand grip
dynamometer for women less than16 kilogrammes on the hand grip

(10:05):
dynamometer. So that's a reallysimple, quick measurement
that we can do to assess musclestrength. And it's a good
surrogate measure for upper bodystrength and lower body
strength as well, with ahand grip.
There's also something elsethat we can do, again, in the
clinical setting, it'scalled a sit to stand test. So
it's really simple, get ourpatient sit on a chair
comfortably, and we time howlong it takes them to stand

(10:28):
up and sit down from that chairfive times without using
their hands in a safe andcontrolled manner. And
that can be an indicator oflower leg strength.

So 100 measure and sit stand tests are really
useful measures. AndI've actually noticed that
sometimes, occupationaltherapists will do sit to stand
tests, and you can often sortof either both do them and see
any differences or or use theirmeasures and use them in
your assessment to be able toassess the patient's physical
function. But that's, that'sgreat for our work on on

(10:58):
award setting with some olderadults. And I'm able to do some
of these tests.
But unfortunately, a lot ofdietitians are increasing remote
consultations, and that theymight have to talk to someone
over the phone.
And just about usingquestionnaires like sock F. Do
those? Do those hold anyweight? Would these be good
tools to be able to assessa patient?

Yeah, the sock f is a validated
screening tool for sarcopenia.
And it's five simplequestions. It's based on a self
reported answer from thepatient. But it's very quick
and very simple to execute in aclinic setting, and even in an
on a virtual consultation aswell. So you don't need any
physical measurements totake. So yet five simple

(11:40):
questions, each question isscored either a zero or a one
or a two, and then the totalscore of 10.
And anything that scoresfour or more is a likely
indicator that someone may havesarcopenia.
That's a really quick and easyscreening tool to use. And it's
recommended by the Europeanworking group for sarcopenia.

Could you describe a little bit more
about how we measure musclemass and sort of the index
and sort of the consequences ofpoor muscle function?

Yeah, so the gold standard really, for measuring
muscle mass would be in adexa scan or MRI scan, but
obviously, they're veryexpensive and that they're
not easy to come by. Andyou would need to be trained
as well in order to carryout those measurements.
So we don't routinely use them.
bioelectrical impedance is agood measurement.
cbia is a good technique inorder to look at body
composition. So that looks atthat can look at body fat

(12:30):
percentage, and fat free mass,an easier and more surrogate
method, sort of a more practicalmethod to use for dietitians,
I think would be to measurethe calf circumference.
So that's somethingthat's really simple, just
need to tape measure. It'snot too invasive for
patients, and it's a goodpredictor of muscle mass in

(12:50):
terms of older people, and acalf circumference
cutoff of less than 31centimetres would indicate
a reduced muscle mass.
Why

do you Why is it an issue when someone has
very little muscle mass ora low level of muscle.

So reduced muscle mass is often seen also with
a reduced level of strength andthat can affect our physical
functioning as well. So someof the consequences of
that could be reducedindependence to carry out
activities of daily living,increased risk of frailty, and
reduced quality of life,increased risk of falls and
fractures and an increasedsusceptibility to morbidity

(13:26):
and mortality.
And overall this this willhave an increase a
knock on effect on health carecosts as well.
Obviously, this is around where

sort of physical physical functional mobility is
often looked at byphysiotherapists, maybe
occupational therapists anddietitians are often have very
weight centric approaches toassessments.
And if some and often ourscreening tools, for
example, the most screeningtool is used and often
that's very, very weight centricassessments or patient use

(13:56):
referred to us because of lowweight or lots of weight loss.
dieticians really have arole in helping to prevent or
treat sarcopenia.

I think we do as dietitians we will be seeing
frail, malnourished patient,patients with multiple
comorbidities.
And all of that will placepatients at further risk of
sarcopenia. So if they aremalnourished, they're likely
to be at risk of sarcopenia.
I think we have a duty of careto offer a holistic,
patient centred approach withpatients and patients are at

(14:25):
the centre of our care.
People come as a whole. So wecan't just look at individual
problems. We have to look atthe whole person and
think we have a duty of care toprevent further disease or ill
health as well.
So if we can have a preventionapproach to sarcopenia,
then I think we should belooking at how we can be most
effective within our role. And Ithink dieticians have excellent

(14:48):
communication skills. We haveexcellent behaviour
change skills as part of ournutritional counselling. So
we're able to assess people'smotivation help them overcome
barriers. We can providethem with education and
I'm raising awareness ofwhy something's important. And
we can set we can support thepatients to set appropriate
goals. And all of these aregoing to be really

(15:09):
important when we're talkingabout physical activity as
well as nutrition. AndI think, if we're in a
position where we've alreadybuilt up that trust and that
rapport with our patients,and we're seeing this
population of patientsanyway, through our dietary
counselling and dietaryinterventions, then we are in
a really good place to thenprovide that holistic care
and offer advice on physicalactivity or as the care nurse

(15:32):
navigator signpost patients toother services.
And the evidence actuallysupports the best approach
to prevent or treatsarcopenia is with a combined
approach of nutrition andexercise interventions.
So I think it's reallyimportant to combine the
two. So maybe

we could start a little bit with those
nutritional interventions.
So a dietitian may becollecting sort of weight
markers and seeing aperson's weight go up. Now,
you're saying they shouldcollect some maybe 100
measure a set to standmeasure? How are they going
to use that measure in theirassessment?
How, how might they changetheir plan to optimise for
muscle growth rather thanjust weight weight increase.

So the more measurements that we can
take will help him form aproper, more thorough
assessment of the patient sothat we can tailor our
interventions moreappropriately.
And we can also then measurehow effective those
interventions that have beenby taking more measurements.
So just taking weight or BMIdoesn't necessarily tell us we

(16:31):
might say that their weighthas gone up or their BMI has
improved. But actually, thatdoesn't tell us whether that's
an improvement in muscle massor strength or whether that's
had actually any impact onsome of the patient important
outcomes. So the moremeasurements we can take, the
better and more more detailedand nutritional diagnosis and

(16:51):
plan can be.

Is there anything that dietitians could do to
optimise for that musclegrowth? Is there anything
that we could watch out for

so as dietitians, nutrition is our bread and
butter so when we're thinkingabout recommendations for older
adults, it's really important toconsider their protein intake
and their protein requirements.
So it's been identified thatthe Recommended Dietary
allowance for protein ofnought point eight grammes
per kilogramme is insufficientto meet the protein requirements

(17:19):
for sustaining muscle mass inolder adults.
So the SPN guidance on clinicalnutrition and hydration in
geriatrics recommends thatprotein intake should be at
least one gramme perkilogramme per day in older
adults and furtherrecommendations.
So based on the protein agestudy, recommend that for older
adults over 65 years old, weshould be considering

(17:41):
daily protein intake in atleast in the range of one to
1.2 grammes per kilogramme ofprotein per day, and even
higher, so 1.2 to 1.5 in thoseundertaken exercise or
those with chronic disease. Andobviously, caution should
be taken with anybody withpossible or existing renal

(18:01):
impairment. And now I've heard

from so often when new guidance comes out, and
they recommend sort of proteinintakes of 1.5 dietitians
might look at that and go,how on earth are we going to
reach that with some of ourpatients who already struggle to
meet x x previous guideline? Isthere anything that like you
have any tips or any adviceor anything you can work

(18:24):
towards?
Because that's often the mainsort of stumbling block
I find in Firstly, evendieticians believing that
it's possible, let alone thepatients

it is and actually in this particular age
brief, older adults may havethings that have impacted
on their appetites, theymay have a poor appetite, they
might have early satietyand not be able to eat large
portions of food get fullvery quickly.
And for very, various reasonsand many reasons.
appetite can be poor, in olderadults in nutrition intake can

(18:55):
actually be quite poor, andthey may struggle to meet their
their nutritional requirements.
And actually, what we knowabout older adults is not
only does the protein intakeneed to be slightly
higher, there's a bluntingeffect. So in older adults,
we see that we actually needhigher amounts of protein to
actually trigger themuscle protein synthesis. So

(19:17):
thinking about how muchprotein is actually needed
at each meal time isimportant as well. And the
guidelines do recommendaiming for at least 20
grammes of protein in eachmeal, which can be quite
difficult to achieve whenyou've got somebody that
maybe has a really poorappetite or is limited in sort
of their food choices ortheir ability to cook and
prepare meals themselves. Asa dietitian, we should be using

(19:39):
our individual dietarycounselling skills. So
we're actually looking at thepatient looking at their food
preferences, their currentintake and where possible
using a food based foodfirst approach.
So for example, looking at foodfortification, so an example
of that is adding fourtablespoons of skimmed milk
powder to a pint of milkcan add an additional 20
grammes of protein To thatpint of milk, so we can be

(20:02):
advised on food first approachesencouraging high protein snacks
encouraging protein foodswith each meal, and considering
oral nutritional supplementationwhere appropriate.
But definitely taking the foodfirst approach to counsel.
Older adults want to providethat advice for older adults on
some of the higher proteinfoods that they could include

(20:24):
at mealtime. So milky drinks,and things like eggs with male
it's quite a soft, easyprotein food to manage. If
they're sort of not overly keenon eating meat or finding the
meat hard to chew, for example,they're looking at food 45 the
foods that they are havinggoing to meals they are having
to make them as nourishnourishing as possible.

So let's move on to sort of talked a little
bit about nutritionalinterventions.
Now let's talk about exercise.
Now, do dietitians evenhave a role in talking about
exercise? I mean, isn't that thephysiotherapist job on a the
professionals in the area?
We're not I don't think Ireceived any training on it
in university.
I said exercise is good.
resistance training isgood to build muscle mass,

(21:04):
but I wasn't given any sortof specifics that I would feel
comfortable talking aboutit with a patient. Is it
really all wrong?

That's an interesting question. I
think it goes back really tothinking about our role as a
holistic practitioner.
So my research that I've beencarrying out was to seek out
the attitudes and views ofdietitians and physio
therapists and for the conceptof dietitians, offering
prescribed exercise alongsidenutritional counselling and
older people.
And actually, it's almost acontinuum of what do we mean

(21:33):
by prescribing exercise. So itcan be really basic, and it
could be a very first lineapproach and just given out
the sort of really simplemove more messages, and
the government recommendationsfor exercise, and that could
then progress on to moreprescriptive exercise where
we're actually giving morespecific exercise
advice, setting goals withpatients and reviewing those

(21:54):
patients. So what when wesay prescribing exercise, it
comes down to I think everyone'sindividual interpretation
of what we mean by that andperception of what we mean by
prescribing exercise. Forme, if we're talking about
holistic care, and makingevery contact can then we
should be consideringencouraging basic physical
activity in all patients aspart of our holistic advice

(22:16):
as dietitians just like wewould expect to the
professionals to offer firstline advice on nutrition, so
be it healthy eating for thegeneral population, or
basic food fortificationadvice for those at risk of
malnutrition.
So I think everybody has aduty of care to talk about diet
and exercise in the context ofachieving general health
outcomes. So simple governmentadvice for the general

(22:39):
population of 150 minutes ofphysical activity each
week for older adults, inparticular, ensuring that
they carry out at least twodays of strength training, and
also the simple move moremessages. So just reducing
sedentary behaviour, encouragingsomeone to get up out of their
chair every half an hour orevery hour. So it can be very
low risk, simple advicethat we would, you know, be

(23:01):
expected to give toanybody. And if you think about
if we're in a clinic withsomebody that was overweight,
and we're talking aboutobesity, I'm sure it would
be second nature to talkabout exercise as part of that
weight loss strategy. Andit goes hand in hand with with
diet and exercise. Sowhy are we not talking about
that with older people andolder adults, when we come to
talk about strength andmuscle mass?

Do you think there's sometimes when
we say things like strengthtraining, it can be quite
the words are quite charged,like most people, when
you talk about that they vieware the glissant for a
gym membership, they've got totalk to the guy at the gym,
he's got to tell me abouthow to do all these different
equipment, use all thesedifferent equipments for
six times I've joined aboutsix different times and
cancel my membershipmultiple times.

(23:43):
And also it's COVID andincreased risks. jever feel like
sometimes that that phrasingneeds to be altered a
little bit in a consultationwith with patients and further
explanation needs to begiven? And if so, what
explanation would you wouldyou offer to a patient

definitely I think even the term
exercise can mean differentthings to different peoples,
though, we tend to use maybethe terminology of physical
activity as it sounds lessthreatening to somebody,
particularly for olderadult, the thought of
exercise May, you know get inthinking about going to a gym
or having to run a marathon.
And actually it doesn't meanthat it's any type of physical

(24:19):
activity that will get yourheart racing a little bit that
will increase your breathingrate will make you work a
little bit with a bit ofeffort. So yeah, I think
the terminology that we usewhen we're talking about
exercise is important andmaybe using the terms moving
more or keeping active orphysically active is much less
threatening than the termsexercise. And I think you're

(24:41):
completely right when wetalk about strength training or
resistance training, itcan be quite intimidating
for a lot of people and evensome dieticians who think well,
you know, that's that's avery specialist area, but
actually what we mean byresistance and strength
training is just workingagainst the force or
resistance and For some olderpeople in terms of their

(25:02):
exercise capacity, thatcould mean using their own
bodyweight as resistance. Sojust getting up and down out of
a chair, or raising upon toyour tiptoes and coming back
down again, could be enoughto stimulate a sort of strength
response. It doesn't have tobe, you know, huge heavyweights.
But it is important that it'ssufficient, sufficient

(25:25):
intensity of exercise thatcan produce those strength
gains. So it's about sort of,again, tailoring that
advice to the individual andlooking at what their what
their baseline is, and whattheir sort of capabilities
and capacity after exercise,and then building slowly
and gradually on that just sothat they can start to see some
improvement.

Yeah, I remember. I was at an event
once and this exercisephysiologist was talking and
he recommended a website andif you're familiar with
it called moving medicine, yes,yes, I've heard that. Things
like that when someone needs abit more of a bit more
guidance in the idea of whatexercises they could do. And
it gives them things like bedexercises, Chair exercises,
things like that useful

definitely and there are exercise
programmes out there, such asa tygo, which is a balanced
based exercise programme. Andso we could be signposting
people on to these exerciseprogrammes that are run in the
community and through exercisereferral schemes. I
think talking to your localphysio therapists see
they see if they have anyresources that have already

(26:24):
been produced that they deemsuitable for dietitians to
be given out to patients asfirst line advice. So it
could be chair basedexercises, it could be a
leaflet or a website wherepeople can follow exercises. A
lot of these exercises aregoing to be done in their
own home unsupervised.
So it's about balancing thatrisk really, and I think
talking to your yourphysiotherapist, is the best way

(26:47):
to go forward to to find outif they've already got
some resources that they wouldbe happy for you to give out
to patients or signpostpatients to

we've talked a lot about dieticians, perceptions,
but what a physiotherapistthink about dietitians given out
exercise information.

Yes, so as part of my research, I recently
carried out some interviewswith exercise professionals
and physio therapists.
They were people thatwere working already in the
context of older peoplewithin the community. And
it was really to find outwhat their thoughts and their
perceptions and their attitudeswere to the prospect of
dietitians potentiallygiving out exercise or physical

(27:24):
activity advice to older adultsalongside nutritional
counselling in the context ofsarcopenia management.
Actually, I was I was quitesurprised and pleasantly
surprised by the enthusiasm ofphysiotherapists and exercise
professionals to want to workwith dieticians. And
to hear that dietitians areactually interested in
this area and they see it asbeing important. And

(27:46):
they can see how exerciseand nutrition are linked.
They were very keen actuallythat that you can't really
have effective exercisewithout being sort of meeting
nutritional requirementsand having a good nutritional
status. So actually the tocompliment each other in a both
really important sothere were very much positive

(28:07):
views of physiotherapiststhat dieticians should be given
out to basic move moremessages. And if that could
happen as part of the makingevery contact count and
holistic advice that we'regiving out, they could only
see a benefit in that, andparticularly in terms of low
risk activities, like chairbased activities, or,
or general, you know, gettingup out of a chair and

(28:28):
moving around more and indoing what the patient feels
they're able to do was quitelow risk, but they were very
keen to actually workmore closely with dieticians,
because they actually seethat some of the patients
they're seeing maybemalnourished or, you know,
not taking in sufficientamounts of protein, or a
good diet. And actually thathas a negative impact then on

(28:48):
the amount of exercise thatthey're able to do and the sort
of outcomes they're able toachieve with the patient. So
I think there was sort of amutual respect of how exercise
and diet are both soimportant and how dietitians and
physiotherapists should beworking more closely
together with patients toachieve our goals at the
end of the day, because we'reboth both trying to achieve the

(29:09):
same outcomes with patientsand that is to improve their
quality of life and theiroverall health status

just out of interest. If you could go
back and be a communitydietitian again, how
would you What would you dodifferently?
And how would you How wouldyou work with a physiotherapist
there,

I think actually learning about more more about
each other's roles. Sohaving that opportunity
maybe to shadow each other. Sofor the dietitians to
go and spend some time withphysio therapists, and
likewise for physios to kindof spend some time with a
dietitian so that there's adeeper understanding
of the role of each I thinkproviding training so using the
resources that we've got withindepartments and the specialist

(29:46):
knowledge we've got a so if youcan provide some enhanced
training for each of us as abit of a trade off in in
training so that thedietitians Can you know, provide
training to physiotherapistin order to give that first
line advice And ensure that theadvice they're given is
consistent with the messagesthat have come in from the
dieticians and vice versa. Sothe physiotherapist can provide

(30:08):
training for dietitians onproviding that first line
advice and, you know, agreementon when to refer to the other
profession. So maybe havingsome agreed pathways of
these are the patients thatare appropriate to have that
first line advice. Andthis is when to refer on. And
better communicationreally is what I got from both
the dieticians and thephysiotherapist through my

(30:29):
research is that if they'remore aware that there's input
from both professions,and they can work together,
so when the dietitian goesto see their patient, they
can maybe ask how they'regetting on with their exercises
that have been prescribed bythe physio. And likewise, when
the physio goes to see thepatient, they can ask about
how they're getting on withthe dietary advice, and
making sure that they're eatingappropriately, to help with

(30:51):
their exercise, that thosereinforce messages and
hearing it from differentprofessional professionals,
time and time again, mayactually help motivate the
patient and improvecompliance and adherence to
the advice. So actually, theythere is benefit in both
professions, talking aboutdiet and exercise. So
the patient can see the linkbetween the two. And can see the

(31:11):
important.

Yeah, definitely I remember, I was reading, maybe
it was a it was sort ofreflection from a dietitian in
relation to it was in relationto ICU nutrition, but
it was talking about this,this idea of sort of
extending roles of differentprofessions.
And it was about the overlappingnature of roles and how that
helps with things likecommunication, working better

(31:33):
for a team. And I think that's,it's an area where I, I
think there is room forimprovement if you if you
agree in this sort of theassessments that we do and
how we manage patients and alsocommunicate with the MDT as
a whole, in order to ensurethat patients don't just gain
fat mass, but also gainmuscle mass,

definitely I think MDT working is the
key really is that we're allworking together, at
the end of the day, thepatient should be at the
centre of the care. And weare all working together to
achieve the same goals. AndI think when it comes to actual
capacity, versus demandof patients out there, so if we
think about how many olderadults are out there that are

(32:13):
having this general declinein muscle mass and muscle
strength, maybe they're more,you know, they're becoming more
sedentary, less physicallyactive, maybe their diet
isn't to the same quality aswhat it used to be, are factors
affecting their dietary intake.
And so they're sort ofgradually on this decline of
reduced muscle mass reducestrength reduce function, they

(32:35):
may not be picked up byany healthcare professionals,
dietitians or physiotherapist,so that there are so many
people out there thatwould benefit from this
holistic advice and even theearly intervention and sort of
preventative approachadvice. So I think we don't
have the capacity forall of those patients who are
malnourished or frail to beseen a physiotherapist

(32:58):
and we don't necessarilyhave the capacity there
for all of those patientswho are seeing physio
therapists to have access toa dietitian either. So I
think the more we can be doingto to make smarter use of
their capacity in order tobenefit patients. Yeah,

whereas acute settings are restricted
by the amount of hospitalbeds that you've got, community
services can be infinitelyexpanded.
incidently sort of grow likealmost like you could serve
more people.
And I think as we learn moreabout the impact of
nutrition, and we learn moreabout sort of at risk kaski
BMI is for older adultsCoronavirus below 23 is at

(33:36):
risk not dangerous to bearound the trip malnourished
button. So that risk BMI.

Well, yeah, so the glim criteria, which is the
global leaders in malnutrition,recently released some
new criteria for diagnosis ofmalnutrition.
And it it actually refersto the BMI cut offs for older
adults. So adults over 70years have a slightly higher
BMI. So anybody with a BMI ofunder 22 would be classed as

(34:04):
at risk of malnutrition inthe over 70 category. So
actually, it is a little bitadvantageous to have to carry
that little bit more weight inolder age. But what we do need
to be careful of is is whatis that makeup of the weight?
And is it Are they is thatweight and BMI, actually
masking? What might be a lossof muscle mass and a loss of

(34:26):
muscle strength. Andactually, it's been masked by
this increase in fat mass. Soyeah, the more the more
measurements we can take, thebetter our understanding
will be if that patient'snutritional status in general.

So what role does the most screening tool
have then is is that is thatstill useful screening tool?
Or do you think it needs to berevalidated on screen
screening tools that involvebut not must in particular, but
all screening tools thatinvolve BMI and older adults
does it need revalidating toreally be able to screen
effectively because by thatchord you might already get a

(35:01):
patient that's quite quiteseverely malnourished,
according to the glimcriteria arrive to clinic, and
Wouldn't it be better to haveearly intervention in
those patients?

Yeah.
So there are many screeningtools out there that validated
and you know, well used. Andthat screening tools serve a
purpose to try and identifythose patients who may be at
risk in order to signpostthem to appropriate
interventions and referralsto appropriate professionals.
So the most screening toolis widely used.
And it's, you know, it's avalidated tool.

(35:32):
But I think the limitations arethat it is only looking at BMI
and weight change. Andactually, now we know that,
you know, there is more to itthan that. And sarcopenia is
really important. So looking atmeasures of muscle mass and body
composition, the glimcriteria isn't a screening
tool, it's a diagnosis tool.
So actually, within thelimit, it still advises that

(35:55):
use screening tools as afirst line approach, and
then using the glim criteriato then further assess that
risk of malnutrition.
So that Yeah, the glim is areally good tool, I think
we should all be starting touse that within our practice,
because it looks at notjust BMI, but it also looks
at muscle mass as well. Andand then we can be using things

(36:15):
like the sock f tool, which isa really simple screening tool
questionnaire type tool tolook at sarcopenia risk, and I
think as practitionersas dietitians, we should then
be taking more detailedassessment in terms of
looking at muscle mass andstrength to better inform
our decision making andnutritional interventions.
And also, if it can helpdemonstrate effectiveness

(36:37):
of dietitians and measure ouroutcomes, then I think we
should be all doing that as

well.
Definitely. And I've started touse things like sock f handgrip
a lot more in in patients onthe ward, but also in clinic.
And I found them be reallyhelpful not only for me to
gauge the patient'sprogress, and me to get a rough
assessment of how much sortof obviously it's not
direct. But if obviously thehandgrip goes up in the
weights going up at sort of asteady rate, you can sort of

(37:02):
infer that they're probablygaining muscle mass from that
assessment. But also, I foundit motivates people quite a
lot, especially the handgrip,they go, Oh, once you told
me I was below average, I gotvery upset by that. So I went
home. I got I did everythingyou said and I've worked
I've worked for me, I've beenworking really hard hope it's

(37:23):
good to me. And they showimprovement.
But it's whereas the wayis a bit like it usually
works better with with withmales, and that's probably
due to the way society sort ofconditioned males to have
the appearance of being strongand things like that. But I
think the deaf that you cansee that the patient isn't
doesn't really care about theweight. But they care about

(37:44):
these sort of other measuresthat the activities of
daily living.
And when we take that intoour assessment and inform the
patient about our assessmentprocess, I found my myself
it really helps the patientunderstand the importance of
nutrition and also as amotivating tool to enable them
to achieve the goals that theydesire. Instead of just saying

(38:05):
this Oh, aim is to increaseweight or optimise nutritional
status by stabilisingweight. Often Often patients
don't care as much as we doabout measures like that.

Definitely, I think something like
handgrip can be a realmotivating tool for patients
that, you know, maybe they'renot seeing their weight go
up. But they're seeing thatthey've got an improved grip
strength, then that can be amotivating factor to say
that it is making adifference. And that's probably
more important than the actualweight gain itself. Yeah,
and it's very simple andquick and easy to use.

Thank you. Thank you so much for
joining me today on thispodcast is dietetics
digest podcast, and all of theshow notes will be available.
And we'll put references toanything discussed. So
the Global LeadershipInitiative and malnutrition,
we'll put references there. Andthere's a few, a few ones that
I want to share and a few othertools like an explanation of

(38:56):
what the SOC f tool is. Andalso references to some of the
research that Stacy has beendoing on her PhD. I'll also
put social media information forStacy the one she wants to
direct you to, so you can keepup to date with her work and
keep informed with theexciting new things she's
learning and everything shesort of her her musings on

(39:18):
Twitter as well. So youcan keep up to date with
those. I don't know if youwanted to include anything else
in the show notes or isthat quite comprehensive?

Yeah, I can provide you with some
say for example, the Europeanworking group for sarcopenia.
I can provide that thatdocuments have mentioned that
I've mentioned the glimcriteria. And I've mentioned
the the aspirin guidelines, Ican provide references for
those as well.
Perfect. Thank you.

Thank you so much.
Thank you so much for yourtime. And hopefully you
can get back to your travellingsoon and fingers crossed

this cross for all of us. But yes, thank you very
much for having me. I reallyit's been really delightful to
talk to

you.
Thank you for joining us thisepisode of The dietetics
digest podcast.
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.css-14f5ked{margin:0;word-break:break-word;display:-webkit-box;-webkit-box-orient:vertical;box-orient:vertical;-webkit-line-clamp:2;overflow:hidden;}Sarcopenia, Malnutrition and Physical Activity feat. Stacy Jones RD