Serious injury triggers a small army of professionals into action.
Each one plays their part as the patient is carried through the fight against death or permanent damage towards rehab and recovery.

Yet, despite being primed for this battle, one profession is all too often being left out – to the detriment of the brain and spinally injured.

So says Sheri Taylor, a registered dietitian with over 20 years of experience who works with people with serious injuries and neurological conditions.

Beyond the acute care given immediately after an injury, and cases where artificial or tube feeding is required, a dearth of input from dietitians exists, she believes.

Malnutrition and missed opportunities to maximise recovery are two worrying by-products she is witnessing as a result.

Sheri Taylor

“Adequate nutrition and hydration should be fundamental parts of neuro-rehab,” she says. “I find a lot of clients are not even meeting the basic levels required.

“There’s a bit of a mixed bag in the UK in terms of dietetic service provision and how quickly nutritional support is implemented. A lot of trusts have very specific criteria that people have to meet before they are allowed to see a dietitian.

“You need to be quite severely malnourished or overweight – or have a severe medical issue –
before there is any service provision from a dietitian.
I don’t see much in the way of intervening before issues arise.”

The prevalence of malnutrition in UK brain and spinal cord injury centres is poorly evidenced – perhaps a further sign of neglect in this area; but various studies do point to a festering problem generally among the severely injured.

Swedish research shows that 68 per cent of patients with brain injuries who had regained the ability to eat independently, were malnourished within six months of their injury (Krakau, 2007).

Figures suggest spinal injury patients also face a heightened malnutrition risk. One study found that 44 per cent of spinal cord injury cases were at risk of malnourishment when admitted to a spinal injury centre following acute care (Wong et al. 2012).

The research into the UK’s network of spinal injury centres also found that less than a fifth of centres weighed patients at admission.

The remainder said they had no specialised weighing scale on site and therefore were unable to weigh patients until they were mobile.

Eight out of 11 centres said they used some form of nutritional screening tool.
The ratio of dietitians to patients overall, however, was well below that of any other intervening force.

There were 4.8 dietitians serving the 482 beds covered in the data. This 1:100 ratio compared to more than
1:1 for nurses, 1:6 for physios and 1:9 for occupational therapists.

The speed at which tests for malnutrition can be carried out make high levels of undernourishment in brain and spinal injury centres particularly confounding to Taylor.

The standard Malnutrition Universal Screening Tool (MUST) requires only a few pieces of data – the patient’s BMI, how much weight they have lost in the last three to 
six months and whether any conditions or symptoms have stopped them eating for five or more days.

“Those three questions are not even being asked in some centres. Often so much focus is on the high-level factors in the search for answers, such as medication and technology, while some of the basics are being overlooked.

“Surely the basics must be met before we look at more
costly interventions?

“Perhaps it’s assumed that a client has neural fatigue, for example, but are we sure they are not anaemic or dehydrated? It’s worth at least asking these questions to rule things out.”

As a Canadian, Taylor’s career was forged in
a free healthcare system which places much more importance on disease prevention than in the UK, she says.

“A lot of work is done in Canada in ensuring people have adequate levels of calcium and vitamin D, for example, to help maintain their bone mass. This costs a lot less than having to do surgery on someone who breaks 
their hip further down the line.”

Improving nutrition levels at the earliest point benefits both patients and paymasters of public health. In the context of brain injuries, earlier intervention through better food and hydration could be particularly useful in preventing loss of muscle mass.

“We know malnutrition increases the risk
of infection and the length of hospital 
stay. Similarly, obesity increases the risk of chronic diseases and the need for specialist equipment. All of which increase the cost of care over time.

“From a neuro-rehab perspective, a major traumatic injury usually results in serious levels of inflammation in the body. This
kicks your metabolism into a higher gear
for a certain amount of time.

“This increased metabolic rate can actually lead to your muscle mass being broken down quite quickly. This leads to lots of problems down the road, meaning more rehab is ultimately needed to regain that muscle mass.

“Also, while the patient may have higher energy needs, if they are sedated or ventilated, they may have a lesser ability to take food orally.

“So if we can intervene early on and try
to minimise the amount of muscle mass
they lose, that would obviously be very cost-effective.”

Taylor’s work with brain injured clients sees her liaising closely with a wide range of neuro-rehab professions.

“I work with doctors to make sure blood tests are carried out to rule out certain conditions, such as anaemia, which could be affecting the person’s energy levels.

“I also work with them around laxative use, because if we can make certain changes often laxatives are no longer required.”

She also eases the journey for 
neuro-rehab patients from residential 
to community settings.

“I can add, subtract or adjust different nutritional supplements which that person may have been on in a rehab setting, if 
they perhaps have different needs in
the community.”

Speech and language is another area of focus. “The client may have issues with their swallow and may require texture-modified diets, such as a pureed or thickened fluids diet.

“I work closely with the family support team to make sure they have the food
that they enjoy, prepared in a way which is suitable given any swallowing issues they may have.”

When Taylor first began working with neuro-rehab clients, she spent a week living on a pureed diet to learn the nuances of making food enjoyable despite a lack of texture.

Today she remains on something of a crusade against unappetising mush.

“I worked as a locum in the NHS for a few years and repeatedly saw people with swallowing problems being given very limited diets that seem to revolve around mashed potato, yoghurt and supplements.

“But it doesn’t have to be this limited.
People are often stuck for ideas and don’t know how to make adjustments. But food is a huge part of someone’s quality of life and shouldn’t be restricted unnecessarily.”

Nutrition’s impact on muscle mass and
bone density make dietitians highly 
relevant to physiotherapy too.

Specific interventions include helping to alleviate constipation, which may have a detrimental effect on spasticity levels.

Issues such as chronic diarrhoea or IBS can also prevent clients accessing therapy that could help them, like hydrotherapy. There is also a psychological element to Taylor’s work.

She works with neuropsychologists in
cases where agitation levels may be exacerbated by some underlying problem such as abdominal pain or bloating.

She also provides input to occupational therapists as they work to get clients preparing food independently.

An area which Taylor says requires more involvement of dietitians is in cases where best interest decision-making is relevant.

“Support teams are very good at encouraging people to make their own decisions. But if somebody is repeatedly making bad food choices, such as continually asking for fast food, for example, there is often still some reluctance [to allow] a dietitian to step in and help to make best interest decisions where appropriate.”

More generally, Taylor is focused on challenging perceptions about the link between nutrition and recovery among neuro-rehab professionals.

“I go to a lot of neuro-rehab conferences 
and people often ask me what a dietitian 
has to do with brain injuries. People are often fascinated when I tell them the many ways a dietitian can help, but they usually admit it had never crossed their mind to

work with someone like me.”

Taylor hopes emerging evidence about 
links between nutrition and recovery
will raise the profile of dietitians in neuro-rehab.

“There is a lot of research being done on
the impact of nutrition on neuro-rehab and recovery, in areas such as inflammation, brain functioning and mood.

“Hopefully in the next few years we will see more guidance or even set recommendations, like ‘every brain injury case needs omega 3’ for example. We’re very close, but not quite there yet. Certainly, there is tremendous potential for this.”

A breakthrough on this front may come
via a seemingly unlikely source – the American forces.

“The United States military is investing serious amounts of money into this exact area. They are trying to gain as much information as possible on when we need 
to intervene and with what dose in order to either prevent problems or to speed up the brain’s recovery as much as possible.”

One such study by the US Department of Defense is an investigation into links between omega-3 fatty acids, mainly found in fish oil, and suicide prevention.

A more famous example came 13 years ago when its research arm, the Defense Advanced Research Projects Agency (DARPA) called on the science community to create the optimum food for soldiers in battle.

Biochemists responded with the invention of a substance which generates energy from ketones – molecules formed by the breakdown of fat – instead of carbs fat
or protein.

The product is far from being widely used by members of the public, but is
currently being hyped as an entirely new category of fuel for humans.

Long before the next generation of scientifically pimped super foods fill supermarket shelves, however, Taylor has
a much simpler vision; for everyone in rehab to receive basic levels of nutrition and hydration.

“Adequate nutrition and hydration affects every single part of how your body and brain function. It affects energy levels, muscle mass, bone density, skin integrity, and should be a cornerstone of rehabilitation.
It is absolutely fundamental to it,”
she says.

 


 

Legal view: Dietary decisions for people who lack capacity, by Sintons’ Kathryn Riddell

The Mental Capacity Act 2005 (MCA) provides a legal framework enabling decisions to be taken on behalf of persons who lack capacity.

Five key principles underpin the MCA. Firstly, a person is assumed to have capacity to make a decision unless assessed otherwise. Secondly, all practical steps must be taken to enable a person to make their own decisions.

Thirdly, incapacity must not be assumed simply because someone makes an unwise decision. Fourthly, all decisions made on behalf of a person who lacks capacity must be taken in their ‘best interests’.

Finally, when a ‘best interests’ decision is taken, regard must be given to whether the purpose can be achieved in a less restrictive way. Where there is concern that a patient is making bad dietary choices, potentially detrimental to their health, the first question to ask is whether they have capacity to make those choices.

The test for capacity is set out in the MCA. Remember, incapacity cannot be assumed just because a person makes unwise dietary choices.

If the patient does lack capacity to make healthy dietary decisions, then those caring for him/
her are empowered by the MCA to make dietary decisions in their ‘best interests’.

The MCA stresses the importance of ascertaining the wishes of the incapacitated person and consulting with other interested parties – including relevant health professionals.

Ultimately, an assessment of ‘best interests’ involves a careful weighing up of ‘pros and cons’ in order to reach
a decision which achieves its purpose while simultaneously causing the least infringement of the rights and freedoms of the person who lacks capacity.

Helpful guidance can be found in the MCA Code of Practice (available online by searching on the gov.uk website).

Kathryn Riddell is a partner and medico-legal specialist at law firm Sintons, based in Newcastle upon Tyne.