An interview with Sian Riley: Diatition

Ashwini Kamath: Hello and welcome to Brain injury Bites, where we provide help and advice for people after a brain injury. Hi, I'm Ashwani and I'm a trustee at Headway Warrington. I'm also a senior associate solicitor focusing on catastrophic injury, including brain injury.

Brooke Trotter: My name is Brooke and I've lived with a traumatic brain injury since 2007.

Ashwini Kamath: Brooke and I are joined today by Sian Riley from Red Pepper Nutrition. We're delighted to have you with us, Sian. Sian is a dietician, but I'm going to hand over to you to tell us more about who you are and what you do.

Sian Riley: Thank you very much. Thank you for inviting me here today. Yes, my name's Sian Riley and I'm a dietitian. I specialise in rehabilitation. So mostly brain injury but also see people in rehabilitation after spinal cord injury and orthopaedic injury.

Ashwini Kamath: Obviously, we're here to talk about brain injury rehabilitation. So, we'll be talking to you today about your role in rehabilitating people with brain injury and how dietetics is an important part of that. But perhaps again, you can tell us what kind of input do you have with people who've suffered a traumatic brain injury and at what point do you get involved?

Sian Riley: Good question. So I mean, it's a bit corny, but I kind of feel that nutrition is the foundation of rehabilitation and that's because after a trauma your body's doing a huge amount of healing and in that healing process, it's using up a lot of nutrition because it's the building blocks to that healing process. Quite often a lot of people will start their rehabilitation journey in a state of malnutrition, which means that they're not gonna reach their rehabilitation potential, but also their health is going to be compromised in that. So in terms of when I get involved I usually get involved further on down the rehabilitation journey, but I would love to get involved earlier because I think if we can address nutrition in the earliest stages of rehabilitation then that's going to be really, really beneficial.

Ashwini Kamath: I guess it's quite difficult, isn't it, when there are so many other clinicians involved, so many other therapeutic interventions that perhaps nutrition does take a little bit of a backseat.

Sian Riley: Yes, unfortunately, it does seem to not be prioritised as much. And obviously, in the hospital setting, it does hopefully tend to be prioritised more - the kind of basics of nutrition and sleep as well. But yeah, it tends to be only really addressed when there's an issue and when there's visible issue, but we obviously know that if somebody's not healing optimally, then there'll be a lot going on in the body that's not working as it should. Brooke Trotter: I was going to say about the hospital, you say, do you think it's good, the nutrition in the hospital?

Sian Riley: I think it, I think it could always be better, definitely. I think it's, again, it's not prioritised as much as it should be in hospital. I think particularly when somebody's able to eat their own food - so that kind of hospital catering, I don't think it's prioritised financially in a hospital setting. I think the kind of, the situation in a hospital where people are eating is not great for a meal environment, you know, you've got the sights and sounds and smells of a busy ward and you’re expected to have your meal there, in your bed, so you're not, you're not in the right posture/position to be eaten. And of course the, you know, the catering staff in the hospital having to provide meals for quite a number of people on quite measly budgets a lot of the time. So they're in a really difficult situation. Usually in the very early stages of rehabilitation, if somebody's not able to eat and drink, they might have like nasogastric tubes and there the kind of, the nutrition from the hospital dietitians will be more of a priority. And, you know, the hospital dietitians and the medics are very aware of the increased need for nutrition in that situation.

Brooke Trotter: I was going to say the, well, the nutrition in, available in Salford Royal to buy in like, you know, as an outpatient in the cafe setting now is a lot better than when I was in there. I mean, that was quite a long time ago, it was 15 years ago, but it seems, it seems there's a lot more choice now. I don't know what it's like as a patient, but I assume it's improved quite a bit.

Sian Riley: Yeah, and I think it is that, it's the choice of food, isn't it? And going to a cafe and having that, and it's, we just need to be able to recreate that in the hospital environment.

Brooke Trotter: You said about your posture, what's the best position to eat food in?

Sian Riley: Well, yeah, I suppose a speech and language therapist might have some opinions on that. But I think kind of sat up in a chair, upright. When you're in a bed, you tend to be lying back a bit. So you've not got that kind of same gravity for the swallow. So yeah, it's just making sure you're not slumped in a bed, but also to be changing positions and, you know, kind of getting out of the bed if you're able to, to eat your food is obviously a much more pleasurable eating experience.

Ashwini Kamath: Yeah, and I suppose in hospital, you know, if you're, yeah, if you're spending all your time in bed or most of your time in bed and just, you know, eating becomes functional rather than pleasurable. And so then there's less focus on the value of it in a way. It's just something that needs to be fueling the body.

Sian Riley: Yeah, definitely. And this kind of social element of eating is just really important. Whereas if you're sat in your bed eating your meal, and everybody's sat in their bed, they're not eating together, they're eating yeah, in the same position.

Ashwini Kamath: Thinking specifically about brain injury then, I think we've talked about in previous episodes the, some of the physiological impacts of brain injury and that can have an impact on someone's sense of smell and someone's sense of taste. So perhaps you can talk us through the five senses and just what happens when somebody, the sorts of things you've seen in your role of what happens when somebody has a brain injury, how that impacts on their taste and smell in particular.

Sian Riley: Yeah. So we see quite often after a brain injury and someone might lose their sense of smell, which has a massive impact on their appetite, on their nutrition, but also on how they're feeling, their mental health, their feelings of isolation. So when we talk about smell loss, we talk about anosmia and parosmia, so anosmia is where we lose sense of smell and that can quite often happen in brain injury because the neurons from our brain are going into our nasal cavity and they can sometimes be sheered off after a brain injury and they can regrow. And sometimes when they regrow, like neuro regeneration, they can regrow and form wrong connections.

Ashwini Kamath: Oh, interesting. Yeah.

Brooke Trotter: Is that why you like different foods afterwards?

Sian Riley: It can be. It can also, when the neurons form wrongly, they can produce different smells to what you're expecting. So that's called parosmia and that's when you smell things that aren't there or you're smelling different things from a strong sense of smell.

Ashwini Kamath: Okay. So is it sort of like something might suddenly smell like rubber, which isn't, but yeah.

Sian Riley: Yeah, it's usually a really unpleasant smell. So it might be, I've heard people say things smell like burning rubber, tar, burning toast sometimes which actually it's, it is a positive as in, those neurons are reforming, so it's more likely that your sense of smell will improve over time when that happens, but it's obviously really distressing and it can put people off, it can put people off eating. If your meal's coming towards you and it's smelling to you of burnt tar then that can be really alarming. But it might put people off going to restaurants, going to cafes, because again, they're having that experience.

Ashwini Kamath: And I suppose there's a wider impact to that, both in terms of the social side of it, you know, you lose out on those social experiences because it becomes potentially unbearable, but also from a nutritional point of view, if things smell different to how they should smell or, you know, then someone might sort of stop eating and that can have other negative impacts.

Sian Riley: Yeah, I mean, smell, I mean, it's one of our five senses. So when somebody's down a sense, that's, that's massive and has a huge impact. But our sense of smell is there to stimulate our appetite. So when we're smelling food as it's cooking, it's preparing our body for that food coming. And we're forming a judgment of that food. So we're forming a judgment that it smells good. We want to eat it. It's safe. And that gets our saliva going. That saliva’s going just talking about it! And it also gets our gastric juices going. So we're kind of preparing our body for what's coming. If you don't have that smell, you're not preparing yourself. So you're almost, the food going into your mouth is your first experience of that food. So you're not going to have the same appetite for it.

Brooke Trotter: Do you still get hungry if you can't smell?

Sian Riley: I think you will still get hungry if your body needs food, but I don't think you're going to have that same desire for food that that you do before. So quite often, some of my clients will talk about just not wanting food, getting no enjoyment from food, not having the appetite anymore which can have a huge impact nutritionally because, I was talking before about how. a lot of people will start their rehabilitation journey in a state of malnutrition and then to, you know, to almost needing to catch up on your nutrition and you've got these additional issues that are preventing you from eating. One of the, you know, reasons I love being a dietitian is because I love food and when people aren't enjoying food, I just find that really sad because it should be a huge enjoyment.

Ashwini Kamath: It's, I mean, it's such an intrinsic part of the human experience. It's what binds people, families, cultures, everything. It's, you know, everyone has food in common in a way and it's such a big, talking about, it's a big part of how we socialise and coming back to what you were saying before, if people then don't feel that they want to, because they don't want to go to restaurants or whatever, because it's off putting - the smell of food just is, becomes off putting then psychologically that could be quite detrimental because you're missing out on those social occasions with friends, with family, etc. and it can become quite isolating.

Sian Riley: Definitely, I think, yeah, massive isolation at a part, at a time in their life when you know, having community around you is so important. I think there's a charity called Fifth Sense that look at smell loss after brain injury. The founder of Fifth Sense, Duncan Boak, had a head injury himself and lost his sense of smell so kind of set up the charity to support those in a similar situation. And they did some research looking at the effects of smell loss after head injury. And you know, there was a lot of talk about feeling socially isolated, depression, a dulling of senses that they just felt that they were experiencing life at a lower sensation, I suppose, that they didn't have the same highs, the same lows as before they lost their smell. And yeah, that kind of extra anxiety of going out and being in a social situation where perhaps they couldn't handle the smells that were coming or had less enjoyment of the food and the situation was really quite apparent.

Ashwini Kamath: Well, we'll definitely put a link to the charity there in our show notes and anyone that is suffering with that please do check that out. I just wanted to come back to something that you mentioned about you know, the neurons shearing and potentially malforming which is what causes this change, is it possible for that to almost recalibrate? Can somebody regain a proper sense of smell after those neurons have kind of mismatched?

Sian Riley: Yeah, so there is some research to show that neurons can regenerate and they can reform, which is really encouraging. We quite often, I'd quite often do something like smell training with clients. So again, on the Fifth Sense website, you can see examples of how to do smell training. And you can also buy some little smell training pots from a charity called AbScent as well. And the idea of smell training is that you're encouraging those neuron connections. So you have kind of five pots of smells - so it might be things like flowery petals. Have you seen these?

Brooke Trotter: I've heard of it, I've not done it myself. It's something I've never really had a problem with the smell, but.

Sian Riley: Right. So, yeah. So yeah, you have these pots of… so it might be things like rose petals and eucalyptus as that Olbas oil type smell and you would kind of smell them as a training if you like. And the idea is that you rate your smell of them at the start. And I think you're supposed to do it weekly or even daily to kind of get those neuropathways back formed. It's quite you know, is it, we call it training and it's really useful I think. One, because it identifies where your smell loss is at, at the moment. So quite often we talk about or clients will talk about not having any smell and actually when you do smell training with them, they will have something. So I think that's kind of really encouraging when they can identify something there. And the smell bit of our brain is very closely linked to memory. So sometimes even talking about a memory associated to a smell can just help those neuropathways reform. So for instance, with the eucalyptus. I've had a client who, it reminded her of her grandmother's hankies. It was the smell of Olbas oil. So she would think about that memory while smelling it and it's kind of getting all those pathways reformed if we can. But also I find smell training is really useful to do it with family and friends because if you're smelling things and you're discussing that smell and, or discussing the lack of smell, I think that's really something tangible that family can understand because quite often when someone's lost their sense of smell, it's just dismissed and not talked about and the impact's not talked about. So to have that experience with family where, you know, oh really, you can't smell that? Gosh, it's so strong. You know, at least they’re kind of understanding where that person's come from.

Ashwini Kamath: It's interesting what you're saying there about a person who, for them, that smell reminded them of their grandma's hanky. Because obviously, when we're dealing with a brain injured cohort, you've got also memory issues. So, and smell is quite often linked with memory. You know, you smell something, it takes you back to a particular time, a particular point, person, whatever. So I wonder whether that additional complication, the sort of impact on memory…

Sian Riley: It kind of dampens the memory, doesn't it? Because they're not making those links again to past events and I think it dampens the emotion. So, you know, we don't think of smell being an emotional, or to produce an emotional response in us, but actually that smell of Olbas oil on your grandma's hankies is a very emotional response, isn't it? Emotional memory. So yeah, so I think smell training is definitely worth doing. And it's something that I very much recommend to a lot of my clients who’ve lost their smell.

Ashwini Kamath: And do you find by and large that people do report more positive outcomes?

Sian Riley: Yeah, I mean, I think the science, the research behind improvements after, in your smell after brain injury isn't as positive as perhaps improvements in smell after say a viral infection. So something like, you know, a lot of people lost their sense of smell after COVID in the first wave. If you've lost your sense of smell from a viral infection, there's better research to say that that'll come back. With brain injury, it's less likely to, but I still think it's worth trying because even a tiny improvement could make a massive difference for somebody's quality of life. And again, if you've got that parosmia, where your neurons are reforming incorrectly, that is a positive sign that the neurons are reforming. They've just got to find the right place.

Ashwini Kamath: Just moving to taste then, because, you know, we've talked about the loss of smell, but there's also the loss of taste and talk to us about the impact of that on people who are recovering from brain injury.

Sian Riley: Yeah. So we've talked quite a bit about the kind of like. the smell of food kind of stimulating our appetite, but once it's in your mouth the smell is also really important. So when we talk about the taste of food, actually quite often what we're talking about really is the flavour of food. And the flavour of food is made up from the smell and it, but it's also made up from our taste buds on our tongue. And actually our taste buds on our tongue, we've only got five basic tastes. And those basic tastes are sweet, sour, salty, bitter, and umami. And when we talk about losing our sense of taste, actually, we've still got our sense of taste. But we've lost our sense of smell. So we've, so the flavour of food is very different. So it tastes different, but it's actually the flavor.

Ashwini Kamath: Yeah, I suppose it's a bit like when you have a cold or something and you just can't taste food the same way.

Sian Riley: Yeah, definitely. And if you want to kind of understand how smell affects taste, I've done a, like a jelly bean experiment in the past. So basically it's very simple. You eat jelly beans. It's great! But you just pinch your nose, close your eyes so you can't see the colour of the jelly beans and just eat them and see if you can guess the flavour. And it's really interesting because things like sour and bitter, you can usually taste. So if you're having a lemon flavoured jelly bean, you'll usually be able to identify that it's lemon. I had a coffee-flavoured jelly bean and all I could taste was the sweetness. And then I let go of my nose and the overwhelming coffeeness came. So you can kind of see that for somebody. without their sense of smell, every jelly bean will taste the same, very sweet, perhaps a little bit sour, but mostly just very sweet. They're not getting those individual flavours coming through. So for somebody eating a meal, they might be tasting the salt, they might be tasting the sugar you know, maybe bitter and sour, which we can use to our advantage. But generally, the food will taste a lot blander than it did before the accident. So I think you were mentioning Brooke about food tasting different after your accident?

Brooke Trotter: Yeah, it did, but I didn't, I don't think it lasted that long. What's umami?

Sian Riley: Oh yeah, so…

Ashwini Kamath: A bit like your sort of… It's that, the only way I can describe it is kind of that kind of like soy saucey kind of. Yeah. I think, is miso part of the umami food group, like if you've ever had like miso soup? So it's something that just kind of makes you go…

Sian Riley: So I think it's Japanese for delicious, and it's, I describe it as it's, it's quite a meaty taste. It's a very delicious taste, so it's got a really nice feel, if you like, in your mouth. And quite satisfying. So things like soya sauce, even tomato ketchup, I think is a very umami. Yeah. Fish sauce, Worcestershire sauce, which I can never say. Brooke Trotter: Fish sauce is disgusting!

Sian Riley: But it kind of needs to be, yeah, if its used right, it's kind of bringing out that umami. Things like meats, fish, eggs and yeah, they're, mushroom is also really high in umami. So I think mushrooms is the one that I can recognise more because I think something like mushrooms taste very meaty, but they're just a vegetable. They're just mushrooms, but you can have something like mushroom soup and it'll taste very kind of satisfying.

Ashwini Kamath: I think it's probably also why it's used in a lot of vegan alternatives to meat.

Sian Riley: So kind of, yeah, definitely. I think the other really interesting thing about umami, so our taste buds are there to get nutrition in. It wants you to, you know, your tongue wants you to enjoy the food, so you're getting that nutrition in. And umami foods tend to be very high in glutamate and amino acid which make up protein. So it's your body trying to get that nutritious protein foods in. So when we've lost our sense of smell, we really need to be using our basic tastes as much as possible to make food more interesting and to get that taste from it as much as possible. So using umami rich foods is a really good way of getting that in.

Brooke Trotter: So everybody obviously has a different, everybody has a different brain, don't they? Is that, is that why people like different foods because of the different structures in the brain?

Sian Riley: I think so. I think, yeah, all our brains are very unique, aren't they? And it, you know, we don't know how other people taste food.

Brooke Trotter: You have a marmite brain or a non-marmite brain!

Ashwini Kamath: I suppose there's all sorts of factors in there. It's like, there's a bit of a nature-nurture thing there as well. You know, if you're brought up in a particular cultural environment and, your food, sort of your staple foods are this, then, you know, it's why certain people always go for spicy or not, for example.

Sian Riley: Yeah, I mean, I think you know, our smell and our taste is there to prevent us eating foods that are dangerous to us. So if we've been brought up on, say, spicy foods you know, lots of herbs and spices, we'll have been brought up knowing that those foods are safe and that they tend to be the foods we'll go for, really. And that can be quite alarming for someone after the loss of smell because they, don't know what foods are safe anymore and it can kind of increase their anxiety.

Ashwini Kamath: Well, that actually brings me nicely to risk factors after brain injury and the impact on smell and taste. So you've mentioned that, yeah, you know, not knowing whether something's safe or not, but I suppose there's some very basic safety issues around a lack of smell, lack of taste. Do you want to sort of explain some of those to our audience?

Sian Riley: So I think, you know, how many times do you sniff a bottle of milk before you put it in your cup of tea? So things like that are really important that we need to know if we use smell to decide if the food's gone off. Quite often, if you don't have that, then you're relying on things like you know, use-by dates and sell-by dates, which recently a lot of the big supermarkets have actually taken the use-by dates and sell-by days off their products to reduce food waste. I completely understand their reasoning for it but for somebody after a brain injury and after losing their sense of smell, that can be really impactful in a safety point of view. And also well, even with a use-by date and a sell-by date, you don't know how that food's been stored. So you know, your milk could have been left out on the side, so if you're just following a use-by date, it's not always appropriate. So yeah, from a food safety point of view, you're a sense down, so you can only really see if the food looks off rather than smelling it. And there's also kind of issues from kind of fire point of view, gas leaks, burning food. Yeah, there are a lot of safety risks there as well. There's also, you know, rather than safety risk, there's a risk to health as well because we've still got the basic taste and we talked about sweet and salty being those basic tastes. Quite often what we can do is end up relying on those tastes more. So if a food tastes salty, it doesn't taste bland and you can taste that, you might add more salt to your food after a brain injury, which will then impact on things like cardiovascular disease, blood pressure. Yeah. And also, you know, a very common one is to add more sugar to your food. And I completely understand why, because you want to eat a food and you want it to taste exactly the same as it did before. So if you find a sweet food that you can taste and it tastes familiar to you, you're going to go for that. So it might be that somebody you know, adds more sugar to their tea because actually it tastes like they remember it. But it can obviously cause…

Ashwini Kamath: Well it's impacting on the calorific input and other issues around, yeah.

Ashwini Kamath:So how do you then work with people, so with your clients then, what sort of things do you do with them?

Sian Riley: Yeah. So quite often I might be asked to do an assessment of someone's nutritional needs. So I would have a look at the, I always start where somebody's at because I feel that we eat the way we eat for a reason and to come in and completely change the way someone eats rarely works. So I always kind of find out what they're eating at the moment, why they're eating it, who they're eating it with who cooks for them, who shops and we work from there. So if somebody's meeting their nutritional needs, then, you know, I've got the opinion of, if it ain't broke, don't fix it, you know, carry on. And sometimes people just like that reassurance to know that they're doing everything great. Otherwise, if they're not meeting their nutritional needs and there's a priority list there, if you like, of what things can we tweak so that they're meeting their nutritional needs, but still maintaining their independence and still maintaining the way that they're eating for the reasons that they eat.

Ashwini Kamath: Working with people post brain injury and, you know, you've talked about obviously looking at the way that they eat and what works for them. Can you perhaps come up with some sort of tips in terms of how to promote good nutrition that is also obviously helpful towards brain recovery and just general health but that can be interesting that can stimulate senses, stimulate imagination and make it a more pleasurable experience, even if, you know, they are sort of compensating for deficits in smell and taste.

Sian Riley: Yeah.

Brooke Trotter: That's, sorry, that's, I was gonna say, that's something that's really, I've wanted help with is nutrition because I just don't know apart from you have a little bit of protein, a little bit of carbs and…

Ashwini Kamath: And loads of vegetables!

Brooke Trotter: Yeah, loads of vegetables. Yeah, which is the standard British plate, however it's called, but

Sian Riley: Yeah, balanced plate. Yeah, it's I mean, I think the main thing is to focus on nutrition. I think quite often we see food very negatively. We see food as calories and we see food as bad and fat and actually our bodies need a huge amount of nutrition and particularly after any kind of traumatic injury. So kind of seeing food as goodness and nutrition and enjoying food. I think that that's one of the most important things is that food should be enjoyed. And I think we have so much emotion linked with food that's negative. So guilt - we should be doing better. So nutrition… Got to be good yeah, rewarding myself, treating myself, all of that. Whereas actually, we need to see food as nutrition and important and the priority and enjoy it. So, the balanced plate, you know, so we'll talk about, you know, third of a plate protein, of third of your plate starchy carbs and third of your plate vegetables is a really good way of kind of making sure you're getting all that nutrition in. But then I think it's also mindfully eating. So, yeah, so it's kind of, so it's enjoying your food.

Ashwini Kamath: Being present with it and noticing what you're eating.

Sian Riley: Exactly. So being involved in every aspect of your nutrition is really important. So, you know, if you can be involved in the shopping, the meal planning so that you're choosing what you are going to eat, that's all really important.

Ashwini Kamath: And I guess coming back to what we were talking about, about. People in hospital, they're not involved in that because it's being prepared for them. It's being brought to them. It's taken away. All you're doing is literally hand to mouth eating it. So it's just a job, really. Yeah. Whereas if you are involved in the preparation, but that in itself, we know, certainly I know from working with clients post brain injury, and this is where we have occupational therapists involved, is that sometimes that sequencing of meal preparation, planning, organising, preparing can also be compromised because of their injury.

Sian Riley: Absolutely. Yeah. And it's trying to make sure it's graded and that it's achievable for people because you know, if they're completely exhausted by cooking a meal, they're not going to have any appetite to then eat it. So it might be about preparing a meal in the morning. You know, quite often we use slow cookers, yeah, so that actually when you're more tired later on in the day, you've got a meal that you've been involved in. I think it's, you know, meal planning is really important from that point of view because it takes away all the many decisions then in the week, I mean, they say we make 200 decisions a day about food. So that might be what we eat, where we eat who we eat with, how much we eat. So for somebody after a brain injury, that's a huge amount of choices to be making.

Ashwini Kamath: It's quite a cognitively overloading process.

Sian Riley: Hugely. So it's having that balance of making sure somebody has the choice and involvement, but not overloading.

Ashwini Kamath: Yeah, and I guess meal planning again can be an important part of someone's rehabilitation journey because again, it feeds into that sort of the OT's role, the occupational therapist's role of helping someone with, you know, regain their planning skills.

Sian Riley: Yeah, definitely. So, you know, it needs to be done, managed very carefully to make sure that the person is in the centre of that whole process. Did you have any support with that Brooke when you left hospital?

Brooke Trotter: I think one of the big things when you come out of hospital is like so much is done for you when you're in hospital and you have to come back and you think you're gonna be totally fine when you come out. But then when you come out, you've got all these decisions to make that were made for you when you're in hospital. When I had the accident, I was living in Manchester as a student. When I was discharged, I went back to my parents' house in back in Scarborough, where I'm from, which is like, you know, you do all these things… I'd been travelling around the world and then I'd gone to, I'd moved to Manchester at uni, you know, you're trying to get your independence and then you kind of, all the way back to step one, back at mum and dad's house. I guess a lot of them decisions were still made for me. I've got, you know, I have got a good family like that, which I'm, you know, immensely grateful for. But, you know, you do want to be independent as well. But I don't think I think 15 years on, I still struggle with decision-making like that. You know, I still go by the - I don't always do it - but I still go by the things that the OTs taught me, which was meal planning, you know, meal planning for the week. And then you look at what ingredients you need and then buy the right ingredients for that. I'm not saying I'm perfect at that, but I do use some of the...

Ashwini Kamath: That's good though. That's still like, you know, 15 years on, you're still using those techniques consistently.

Brooke Trotter: I find I'm still like, I'm sort of realising how good they were at the time, sort of realising like, you know, you realise something that, you know, that's a good idea to only buy what you need. Yeah, I was told that 15 years ago, but you just, I just think with, well, my experience of brain injury, anyway, I only take things on when I'm sort of ready to take them on. I, you can, it's like, they'll, you can lead a horse to water, but you can't make it drink, isn't it? You can tell them what you, you could tell them what you want, but you know, there's, I was very, I was always very good at pretending I understood, but I'll, yeah, it didn't take, it didn't want to.

Ashwini Kamath: But I suppose if you're invested in something, you've seen the benefit of meal planning, so you do it and you do it consistently. And again, coming back to what I was saying before that, you know, food is such an intrinsic part of the human experience. So, in a way, I think there's a lot, there's a good chance of investment in the kind of rehabilitation that you're providing. So you must see quite a lot of sort of success in what you do.

Sian Riley: Yeah, I mean, you know, it's such a privilege, isn't it, to be part of the rehabilitation journey for people. But yeah, I think if you can, if you can get in at the right time, you can see real improvements. And I think people are quite, nervous about seeing a dietitian. I think they quite often feel that, ‘Oh, she's going to judge me. She's going to take this away from me.’ And I love just seeing the look on somebody's face as they realise that I'm not there to do that. And actually, you start building up that relationship and that rapport with somebody and you know, it is just making achievable changes, one that, that improves someone's nutrition, but also improves their independence and their choice within food because that's really important and, you know, the social side of food is. Quite often someone will say ‘Don't take away my pub night!’ And it's like, I absolutely will not. That's really important. We keep that in because, you know, we just get so much out of the social side of food. And I think it's, you know, I love working with the multidisciplinary team because we're seeing the bigger picture of rehab and, you know, you can get somebody's nutrition perfect, which I think is impossible, but if the rest of their rehabilitation isn't prioritised as well, then it's just not going to work. So, you know, seeing the bigger picture for someone and seeing you know, how they interact socially and with the family and just making that work for them is really important.

Ashwini Kamath: Yeah. And I suppose, you know, as part of that, you're working with the multidisciplinary team, there'll be a lot of work around, say, routine. And that's probably quite important, I imagine, from a nutritional point of view, making sure that people are eating at those regular intervals, whatever, whether it's your three meals a day or less but more often kind of approach.

Sian Riley: Yeah, because, I mean, I said before that, you know, our bodies need a huge amount of nutrition. Well, we have to be quite regulated with that. If we're missing a meal or two even a day, that's a huge chunk of nutrition we're not getting in. So it's trying to keep that routine, which quite often, you know, people do thrive with a routine and a structure.

Ashwini Kamath: Yeah, we definitely, I think we talked about that in season one about the importance of structure and routine.

Sian Riley: Yeah, definitely. And it's also, you know, again, it's that positive… seeing nutrition positively. And that, you know, your body, your body needs this. It's not just about calories because quite often I will have that is that clients will talk to me about, ‘Oh, I'm missing this meal because you know, I'm trying to be good’ It's like, no, you know…

Ashwini Kamath: I guess that's a lot of incorrect messaging around calories and macro nutrition.

Sian Riley: Yeah. And just, I suppose the negatives around health, so when I'm, you know, in rehabilitation, I really want to look after someone's muscle, lean muscle mass, because that's really important when often people in hospital will lose a lot of lean muscle mass because of inactivity, but also because their body's doing so much in the healing process that it's burning off that muscle. So, you know, when I'm looking at somebody's weight, I'm not just looking at the number on the scale - I'm looking at, right, where's the body composition. So I'm looking at how much muscle mass they've got. Your bone health is a really important thing that most people don't think about until they're too late. But I kind of feel that's my job to think about your bones. So, you know, it's and it's just really important because if you're losing your muscle mass, you're losing your strength, you're losing your mobility.

Ashwini Kamath: Which can impact on other areas of rehabilitation.

Brooke Trotter: Do you get a lot of people lying to you at first, because the first thing I would think of if I'm seeing a nutritionist, like, right, I better tell here that I'm eating something that I'm not eating.

Sian Riley: No, actually, I don't. I think people are quite strangely too honest. I think they like to, sometimes people, I think, like to shock, but I think. I think most of my clients would kind of say, there's no point in me lying to you, I know that, I need to be honest. And I always kind of say, yeah, that's great because I need to start where you're at. And if I don't know where you're at, it's really difficult. So no, you usually have some very funny conversations about, you know, and I'm human as well. I might know it, but do I do it? Probably not all of the time! Do as I say, don't do as I do! And it's, you know, we all lead busy lives and particularly in rehabilitation. And I do believe that food has got to fit in with your life, not the other way around. And sometimes that's the problem I see is people trying to be too perfect with their nutrition and then of course, you know, the failure from that.

Ashwini Kamath: I did a course in mindful eating a while ago and yeah, it was really interesting the sort of the messaging around it you know, as well as, you know, what we were saying before about being present and being involved in the process, planning it, enjoying it, you know, noticing what you're eating and so on. It was also just taking away that guilt. So it's okay if you, if you overindulge, accept it, acknowledge it, accept it. Think about why, you know, is it because I was feeling emotional? Is it because I was actually hungry? Is it because something, you know, whatever it is, is going on, accept it and move on and it's not necessarily the whole, you know, the diet starts again on Monday kind of thing. It's like, it's happened, move on.

Sian Riley: Because it's, you know it's a lifestyle, isn't it? It's a way of being and, you know, making those small changes. And I always think, you know, in that example that you giving, I always say, well, I hope you enjoyed it. Because, you know, if you are going to eat a chocolate bar and you eat it full of guilt, you know, enjoy it! And you know, if you don't want to eat it tomorrow, that's fine. But if we have this guilt, all that does is it makes us feel like we've failed, it puts shame on us and we're more likely to do it again.

Ashwini Kamath: Yeah. And I think from a rehab perspective, that could potentially set somebody back further as well in their journey because then it's like, Oh, well, what's the point, you know, yeah, and whereas it's important to kind of keep pushing forwards and it's, it's okay, just, you know, let's talk about it, let's understand and let's move through.

Sian Riley: Yeah, and there can be a massive grief for people after brain injury as well. And, you know, particularly some of my clients might be really into sport before their injury, massive part of their identity that they're a sports person and their nutrition would have matched quite often their sport. So then after their brain injury to not be able to do the sport to the same level is a huge grief. And then also not be able to match their nutrition because that was their identity. So it's trying to kind of help people to understand that, that in rehabilitation, the nutrition you need is very similar to a sports person. You know, you're needing all that nutrition and you're needing to feed yourself and look after yourself and, you know, there are a lot of similarities as well.

Ashwini Kamath: Are there any other sort of tips that you would give in terms of helping people to cope with, you know, changes, alterations to their smell and taste after brain injury, for example, in terms of what they would do with food?

Sian Riley: Yeah, so I think so I will, we'll put a link too, on the show notes, to a little booklet here, which you can't see because I'm showing it! Which i's a booklet that two, myself and another dietitian from Red Pepper Nutrition have, has written called The Five Basic Tastes and Why They Matter to Us. So, in there, there's lots of tips about how to make the most of your taste. Kind of practical tips about using herbs and spices. And there's also a bit in there about the trigeminal nerve, which I don’t think we've talked about. So this is actually a kind of a pain receptor if you like. So things like hot food or spicy food tends to... And the trigeminal nerve we can really use after smell loss. I think some people after smell loss really like spicy food because it's giving them that feedback, that sensation. Some people find it too overpowering. So it's just trying to work with the individual and how they like to use it, but also things like using hot and cold food, maybe mixing them together is a good way of things.

Brooke Trotter: Stimulating the sense.

Sian Riley: Yeah. Stimulating the senses.

Brooke Trotter: It's made me think of sticky toffee pudding and ice cream!

Sian Riley: Oh yeah,

Ashwini Kamath: Yeah, yeah,

Sian Riley: Yeah. So it's that, you know, you might not be getting the full flavour of that, but if you’re getting the senses from the, yeah, the hot and cold is really useful. So it's just kind of, it's using all your other senses, which is basically mindful eating isn't it? Different textures, sometimes crunchy food might be, you know, it's got a very different mouthfeel, hasn't it? And it's just using those senses. You know, we talked about looking at our food. Yeah. Just a really simple thing. Eating the rainbow. Yeah. Eating the rainbow is something that us dietitians are always harping on about. Is eating a whole range of colours because we get different nutrients from different coloured fruits and vegetables. But you know if you are just being given a food and you're just eating it like it's a task, then you're not seeing what's there. So it's just really kind of visually seeing what's there.

Ashwini Kamath: I suppose not eating in front of the TV either, which, you know, I suppose that goes for everybody really, again, as part of mindful eating, actually noticing it, but particularly post brain injury, you know, when attention can be easily distractible and again, just removing more sort of cognitive or you know, stimuli and being able to focus on the one thing.

Sian Riley: Yeah, definitely. It's just trying to be present in that, isn't it? Which is, you know, we all do it. We've all eaten a meal where we've literally got to the end of the meal and thought who's eaten that because we haven't been aware of it. And then, you know, it takes time for our stomach to tell our brain it's full. And that's why it's really important that we're satisfied after a meal because if we're trying to restrict all the time, we're not going to be satisfied and we're just going to eat more and that's, you know, that's human nature. So it's just really important to be enjoying what you're eating and feeling satisfied after you've eating. Which is quite often why we talk about half a plate of vegetables, not just because of it's the goodness of the vitamins and minerals, it's also because they will fill you up and you have to be full after a meal. Otherwise, we all just raid the fridge again. So it's just trying to, yeah, fill us up and get that satisfaction and get that enjoyment of food.

Ashwini Kamath: And getting the good nutrients in as well. I suppose one other thing that we haven't really touched on as yet which is linked to nutrition and what we're talking about in terms of your guilt, et cetera, but body image can be, I imagine quite, well, can be very impacted after brain injury. And we we've talked in previous episodes about, you know, losing one's sense of identity, self and so on. But, you know, given that body image can also be linked to our diets and how we look, and that can change quite drastically post brain injury with, for example, as you said, like loss of muscle mass or people putting on weight. So how do you work with clients around that?

Brooke Trotter: People follow fad diets as well. Myself, I've done that plenty of times, like for instance, eating no carbs and just proteins. And that lasts about two days and it just feels so unbearable. Or you do it for a few days and you notice yourself feeling like really low energy and then you have a good meal and you feel so much better.

Sian Riley: Yeah. And I think the fad diets probably come from just trying to get help for the body issues, isn't it? So the two are very much linked. And I think the first thing is recognising that there's a massive change to somebody's identity and a massive grieving process. And, you know, I always think of you know, the going to work dressed one way, and then you might come home from hospital a few months later in jogging bottoms, you know, and it's, and looking in that same mirror and just seeing a completely different person looking back at you and, you know, you just can't imagine the trauma involved in that. And I think it's just recognising and identifying the grief that's in there. And it might be someone, you know, I’ve worked with sports people who, you know, very fit and active and then they might put on a bit of weight and to everyone else, it's not much, but to them, it's huge.

Brooke Trotter: If you've trained and you've got a, you know, you're on the scales, not every day, but if you do keep an eye on your weight, you will notice it. And then you start to look for it in photos and stuff and it's, and then, you know, add to that the getting older thing and it's, it's just, yeah, it's just, it's, it's horrible. And it's it's something that, yeah, I guess I've, I've dealt with.

Sian Riley: Yeah, and it's, it's kind of listening to people on that level, isn't it? It might not seem much to the charts or it might not seem much to you as a health professional or to family but actually it might mean a huge amount to them that they, they get back to where they, they were. I talk a lot about strength rather than weight because, you know, I want all my clients to be stronger. I want to look after their lean body mass and their bone health and, and, and get them stronger. And I think that can take the pressure off sometimes because there is a massive change in your body composition after an injury and that's through, you know, no, no faults of, of their own. And that they can become, you know, huge, huge, huge guilt around that and shame around that. But it's just working with someone to make those changes, to get back to where they want to be and not just what, you know, we feel that health is. But yeah, I think it's, I think being aware of eating disorders and disordered eating after a traumatic injury is really important.

Ashwini Kamath: Can you just explain what disordered eating is?

Sian Riley: Yeah. So, I mean, disordered eating is really it's not a diagnosed eating disorder but you could get disordered eating that somebody's taken control of their eating to such an extent that it's actually producing negative health consequences or.. so, you know, you could call yo-yo dieting disordered eating. It could be you know, going on fad diets, skipping meals. It's just when I suppose your eating pattern isn't, isn't optimal, but it's causing other problems and we do, do see that quite a lot and it's just people trying to get the help they need. So they're trying to control. I mean, food is one of the few things you can control. So, you know, it's trying to get that control back of food, and sometimes it can lead to suboptimal eating and even health issues. And we do see it a lot after a traumatic injury because, because of the trauma they've been through and trying to just regain some of that control around eating.

Ashwini Kamath: Yeah, yeah, I mean, that is a huge thing because after injury, you lose so much control, you know, you have so much input, people telling you what to do, people doing things to you.

Brooke Trotter: You want to prove that you're independent, don’t you, and that you’re still the same person.

Ashwini Kamath: Yeah. Yeah. And also, yeah, just not, I don't know, things that you took for granted before being able to do suddenly for whatever reason and for reasons that you might not understand or have insight into, that control is lost. So I can totally see why food is something that you think, Oh, well, at least I know what I'm putting in my mouth, you know, or not.

Sian Riley: Yeah. And yeah, quite often we will see people after traumatic injury, starving themselves as a way of reducing their weight because that's the message they're hearing. You weight too much. You need to get your weight down. Well, how do I do that? Well, I remember that you cut your calories. You cut your, so that's, that's the way I'll do it. So it's a really, it's a really difficult one, but I think if you, if it's recognised, first of all, then that's really important.

Ashwini Kamath: Yeah. And I mean, it's one of these topics that you could go on forever about because there's such a link with psychological issues as well, and you know, why somebody's putting on weight and, you know, what's, what's the root cause. And I think without getting on any kind of soapbox, you know, it's perhaps something that within the NHS isn't necessarily explored as much that the messages you have to get your weight down, but how much work is going into the why are you, why is this like this? And actually, how healthy are you anyway? What's your lifestyle like? Yeah, I think it's. Because, I don't mean to get, don't get me started on BMI.

Sian Riley: Yeah. Well, it's taking our eyes off the scales as a society. You know, we do just. It's looking at people's health and that's irrespective of what they weigh that, you know, people are more than a number and quite often, you know, you'll hear of people saying I want to get back to the weight I was when I got married, but actually that's not healthy. You know, it's about embracing who we are at different life stages and at different life stages, we will be different weights and, but we can still be healthy within those weights. But I think, you know, unfortunately as a society, we do praise the weight loss of a couple of pounds but we don't praise the health changes quite so much. So it's kind of, yeah, it's just seeing past the scales. Throw the scales away! Throw the scales away.

Ashwini Kamath: Yeah, throw the scales away! And I think, you know, especially someone going through the rehabilitation journey where there's so many people suddenly in their lives, like looking at this aspect, looking at that aspect, it just seems to be one more thing. And so, yeah, if we can reduce the pressure, you know, you've got to get those numbers down and actually let's look at your lifestyle. Let's look at how to make you healthy, strong and how the benefit of doing those things on other aspects of your rehabilitation journey. Surely that's more important than just ticking the numbers down.

Sian Riley: Yeah, it's looking at the bigger picture of rehabilitation and working with everybody within that quite a massive team.

Ashwini Kamath: Yeah, and I think that's it, you know, that's the importance of working within a multidisciplinary team rather than in isolation. So you can all work together to achieve those goals and in different ways.

Sian Riley: And, you know, thinking long term, quite a lot of my clients, I'll come in, spend a certain amount of time with them and then back off, which is the right thing to do. But I need to make sure that I'm, that my involvement has helped their health long-term.. There's no point in just coming in, perhaps achieving some weight loss for a certain amount of time and then going and that weight loss regains. One of my, you know, one of my goals when we are trying to get weight loss is that whatever weight you lose, we want that to stay off. Because, you know, that's more important to health because then you're maintaining your lean muscle mass and you're maintaining those changes.

Ashwini Kamath: Yeah, and it's the consistent maintenance of those changes, a bit like Brooke's consistent meal planning. Invest in it, see the benefit and keep going at that.

Sian Riley: Yeah, and you mentioned the psychologists before, the psychology of food is just so important. We rarely eat because, you know, we're hungry or because, you know, nutritionally, I need to get this in. We eat for so many other reasons and the psychological side of that, especially after such a massive trauma is huge. And I love working with the neuropsychologist as well.

Ashwini Kamath: It's absolutely fascinating.

Sian Riley: It is.

Ashwini Kamath: I mean, that's been really, really interesting. And as I say, it's probably one of those subjects we could go on forever, but we are trying to keep these things bite-sized! So I'd like to say thank you very much for joining us today. That's been so valuable and I'm sure our listeners will really enjoy it too. And as mentioned before we will put links to Fifth Sense and AbScent on the show notes, as well as your leaflet on the five basic tastes and why they matter to us. And we'll also be putting your details on our show notes as well. But perhaps if you want to just give your contact details now, in case anyone wants to get in touch.

Sian Riley: Yeah, no problem. If this is of interest and you want to learn some more, there are some kind of articles on our website as well. So that's www.redpeppernutrition.com. And if you want to contact myself directly then my email is Sian, which is spelt S.I.A.N. - sian@redpeppernutrition.com

Ashwini Kamath: Lovely. Thank you. Thank you, . Well, thank you very much again for coming in to talk to us.

Sian Riley: Thank you.

Ashwini Kamath: Please don't forget to follow, subscribe and share our content. If you do have any suggestions for topics that you'd like us to cover, why not drop us a line at hi@braininjurybites.co.uk