An interview withTony Ward: Dietician

Ashwini: Hello and welcome to Brain Injury Bites where we provide help and advice for people after a brain injury. Hi, I'm Ashwini and I'm a Trustee at Headway Warrington. I'm also a Senior Associate Solicitor focusing on catastrophic injury, including brain injury.

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

Ashwini: We're delighted to be joined today by Tony Ward. Tony is a Director at Neuro Rehab Nutrition which is based in Manchester. Although that title is probably quite self-explanatory, Tony, would you like to introduce yourself to our listeners?

Tony Ward: Yeah, sure. Yeah, so I'm Tony Ward. Hi. I’ve been a dietitian now for 19 years. And yeah, so basically, we provide sort of dietetic advice for people that have experienced a traumatic brain injury or spinal injury just to help them support them for the quality of life or what other nutritional issues that they may have as well. So yeah, and it's great to sort of work in this environment and yeah, pleased to be here.

Brooke: What's the main thing that you find that people are lacking in brain injury?

Tony Ward: What, in the way of nutrients?

Brooke: Nutrients, yeah, what nutrients do they topping up or supplementing, maybe?

Tony Ward: Well, it, I think it's more that people are just lacking in probably a lot of different things - there's not one specific. I mean, we always talk about sort of the balance and getting sort of enough sort of food and each sort of nutrition. And you can sometimes find people with brain injury, some eat the same thing all the time and they, you know, a lot don't like the vegetables or the mix. So you can get them sort of lacking in sort of vitamin C, sort of the B vitamins and also vitamin D is a big one.

Brooke: Especially if you live in Manchester.

Tony Ward: Especially if you live in Manchester and coming up to this time of year! I mean, to be honest, I think that's not just for people with brain injury. I think that can be, it's like a chronic, everyone really because we get most of our vitamin D from the sun.

And you know, your skin sort of metabolises that and you absorb it and due to the short days and not going out and a lot of people with brain injury don't go out because they’ve not got the confidence to go out or…

Ashwini: Socially isolated.

Tony Ward: Yeah. And vitamin D can do you know, obviously bone health is the obvious one and but you know, your mood can be affected as well.

Brooke: So should you take vitamin D and calcium together?

Tony Ward: They say vitamin D helps you absorb calcium, but with calcium, that's kind of readily available in a lot of foods like milk, yogurts, cheese. And if you're eating that sort of balance…

Brooke: If you're vegan, you won't get any of that though, will you?

Tony Ward: You can get things through sort of fortified milk alternatives, oat milk, soy milk, almond milk. You know, breads fortified as well and breakfast cereals.

So, you know, but if you are seriously lacking in that sort of food group, you can take supplements to do it. And yeah, if you are not getting enough vitamin D, then, you know, and with calcium… but you'll find most calcium supplements come with vitamin D in it.

Ashwini: Interesting. I mean, yeah, well, I do want to come on to the effect of diet and supplements, but I think just coming back to sort of the importance of diet and nutrition following a brain injury and thinking about what kind of foods or balance can help with promoting brain health, brain recovery getting things firing back the way they should be after a traumatic brain injury.

Tony Ward: In sort of a specific for the brains, you know, omega 3 fatty acids are, you know, a well known sort of role in sort of maintaining the sort of the integrity of your sort of neurons, the membrane. And so that's in things like fish, salmon, mackerel, it's all the fishy fish. So the pilchards, the sardines, so a lot of people can find it difficult to have that. You can get it in thing things like, get some other omegas, fatty acids from olives and olive oil and sort of avocado as well.

But also. antioxidants because you’ve got that oxidative stress and oxidative stress can sort of make it difficult for your brain to heal or as such.

Ashwini: Can you just explain what oxidative stress is for our listeners?

Tony Ward: Right. Okay. So, basically oxidative stress is, it's basically when your body breaks down sort of particles when you're digesting things or you're breaking things down, you can create what we call again, these sort of free radicals and they are like an absolutely crazy molecule that can ping around and it can damage other cells around it. And it's like a car producing carbon monoxide - it's the after sort of things. And basically, so the, the reason the vitamins will kind of grab these damaging sorts of radicals and just, you know, and they kind of like hoover them up, you know. And so it can help them stop preventing sort of damage and we say that is oxidative sort of stress sort of thing.

Brooke: What I've had trouble in the past is I've like acquired knowledge about things like that, but I don't know how to put it into practice. What I think what I need and what people with brain injury need is like, what's the most the simplest way to get those things into your body? What should well, I don't know, I guess I've always wanted to be told what I should eat

Tony Ward: Hmm

Brooke: If somebody just you know, sorted my meals out for me every day. Give me my breakfast, my lunch, my dinner. But obviously you don't do that. And if you try and do these things yourself, what's an easy way to get those things into your body? What should you be concentrating on?

Tony Ward: I mean, some people go towards the supplementation sort of side of things, which we don't sort of advocate straight away. You know, if I'm seeing a client, we always try and get that food and, you know, we may do a meal plan.

Brooke: Yeah

Tony Ward: Everyone's different.

Brooke: Yeah.

Tony Ward: Some people like you say, I want a meal plan, I want to just be told what to eat. The only thing with that is that the occupational therapists, you know, they want you to kind of make your own meals and things. And that's important because that's your quality of life. That's your independent living. And, you know, that's why we work very closely with occupational therapists because, you know, yeah, it's easy to say this is nutritionally what you need, but it's not adding to your quality of life. It's just sort of, here's your meal, eat it, you know, and that means you can get de skilled in certain areas of your life.

Brooke: If you don't use it, lose it kind of thing.

Ashwini: I suppose as well, if you're being told what to eat, you have little investment in the process and so it doesn't, you're probably not buying into the longer-term benefits of nutrition in the same way.

It's just, you're just literally being spoon fed in a way rather than sort of looking at your diet, your nutrition and kind of going, okay, this is what I'm going to choose. I'm making this choice because I need to introduce more protein or more carbohydrates or more vegetables or whatever into my diet because you know, or I've done this today and I'm particularly tired, so I need a bit more of that.

Tony Ward: Definitely. I mean, it's, you know, if we, if you go to someone and say, right, you're eating like this today, this is on the menu. He's like, well, I don't feel like that. I don't feel like eating like that today. You know, you got to give people that autonomy to make them decisions of what they like to eat, but then be educated, you know to say, well I can't have fish and chips from the chippy every day. Or I can't have a pizza every day or a takeaway. You know, if you give them that understanding of why they need that nutrition and it's going to help them with their rehab, and give them the options, more options, then yeah, they can probably pick and be more invested in it.

Because, like you say, you know, if they're saying, yeah, just give me what I need to eat, that's not investing and it's that's not what they, you know… they're probably not going to sort of initiate anything that, you know, you advise because they're not fully invested in it.

Ashwini: Yeah. And I suppose it's not helping them with their rehabilitation aims because, as you say, it's about promoting independence and you've got people like the occupational therapist as part of the team who are trying to do that.

I suppose there might be times when it is necessary to say, right, you need to eat this, you need to focus on this, or whatever, but it can't be a longer-term solution. So yeah, I guess you probably have to make that judgment call as to when it's appropriate to tell people that this is what you need, as opposed to these are the things that will contain these nutrients, these things that you need to nourish your body, and off you go and, you know, figure out what you want to do with it.

Tony Ward: Definitely. I mean, it's, you know, all the whole thing of rehab is to get them to point that they can be as independent as possible to live their life how they want to live it. And you know, if we’re taking the part of like giving them the food that they should be eating and saying just right off you go to eat it, then they're never going to move forward, you know, in that choice and given that independence because a dietitian can't be involved forever, you know. They can’t just say, right, I'm bored of the meals now, give me something else, you know, you've got to be able to say I've had enough of this one, let’s…

Brooke: You need to know what's in it and what you're getting from it, don't you?

Tony Ward: Yeah, yeah.

Ashwini: And it's part of that empowerment, I guess.

Brooke: Yeah, I do think you can be given too much at once, though. You know, like you can be given too much information at once, but…

Ashwini: Yeah. And how does that work then? Because you'll be part of a multidisciplinary team and we've spoken with previous guests about, you know, their role within the MDT, as we call it. So, at what point would you come in and do you, are you there as a regular participant in that multidisciplinary team, or do you sort of pop in and out? How does that work?

Tony Ward: So it all depends, again, it depends on the sort of client. We find it's getting better, but we find that we get brought in later on usually when they've put on a lot of weight or the opposite, they’re sort of losing the weight or they’re struggling, or they suddenly develop diabetes or another sort of comorbidities. And so, a specific example, if they put on weight and then it's affecting the physiotherapy and the rehab. So we've come in and say, right, okay, you know, you needs to try and lose a bit of weight or you’ve got diabetes, you need to get the sugars down and so then we come in then.

But ideally when people leave the hospital, you know, that's when they've got to have that nutrition involvement because it is the basis, it is the foundation of your health.

Ashwini: Yeah.

Tony Ward: And you need to fuel that rehab.

Ashwini: Yeah, I suppose it's a bit like the adage prevention is better than cure. Yes. If you're meeting somebody after they've already you know, put the weight on or had a dramatic weight loss and they're poorly nourished, then you're almost firefighting that and trying to make some gains. Whereas if you're sort of bedding in good principles from the beginning, then you probably going to have better outcomes.

Tony Ward: Definitely, definitely. And it's a lot harder. Everyone knows it's a lot harder to lose that weight than it is to sort of put on that weight. And, you know, and it's easier for dietitians to come in and, you know, to prevent that weight gain. I find that there's a lot of clients and it's difficult to get that weight loss because the activities down on some people, but they’re eating the same amount of food and that's what a lot of people do - they say, well, I'm eating the same that I ate before the accident. And I say, yeah, but your body and your life is totally different. And you're not burning them calories as much as you were, you know, your brain's not firing the certain muscles as much. So your diet has to be different from day one.

Brooke: Getting older as well. Yeah.

Tony Ward: Yeah, yeah, metabolism getting lower.

So to have that at the start, you know, prepares them because people are going to create habits and they're going to get into sort of routines and if you can angle them routines early on...

Brooke: Getting the right routines early, yeah.

Tony Ward: Then their rehab is going to take off, it's going be great. You know, it's going be a lot, lot easier or it's going be not easier, it's going to be a lot smoother because you're not going to get to the speed bump of maybe they've put on all this weight and now they're going to struggle with that physio and they can't stand up as much or as long to do prepping their food because they struggle with their weight. So yeah, it's earlier the better.

With the MDT, we work with occupational therapists quite a lot regards to the cooking and, you know, the facilities and such. We also work with the speech and language a lot regards to if they have swallowing difficulties.

Ashwini: Oh of course, yes.

Tony Ward: You know, then we can help provide meals and advice regards puree, because pureeing and overcooking foods to get that puree, can lose nutrients.

Ashwini: Yes, yes. And I suppose because you're not masticating, you're not breaking down the food in the same way, so you're probably losing something from that process as well. It's a bit like, well, people sort of say it's better to eat fruit rather than juice because of the way the body's absorbing and digesting.

Tony Ward: Definitely, it's the kind of especially if you're diabetic is juice, you know, you’ve probably got four three or four apples in one juice. And you know, when you eat an apple, yeah, it's got the one amount of sugar and it's dealing with that sugar. But then you're missing out on all the fibre and everything like that.

Brooke: Can you answer a question for me? Is sugar from… is sugar, sugar? Like there’s fructose which is sugar from fruit, is that healthier than say, I don't know, a chocolate bar sugar or is sugar, sugar?

Tony Ward: Sugar is sugar. The way you get that sugar can be a healthier way in different ways.

So fructose is basically kind of two molecules, two different molecules. And you've got a glucose, not getting into the science thing, but it's going to have the same effect on your body. It's the same amount of calories, sugar is sugar, whether it's from sugar cane, a chocolate bar, a sweet, fruit and that, but it's the natural sugars that you want.

Brooke: Yeah, I suppose if it's coming with fibre from an apple rather than the cream and fat from a Cadbury’s bar of chocolate.

Tony Ward: Definitely. So it's not refined. So refined is a big word in like, you know, confectionaries and ready made meals and such. And they just have a, kind of have a lot of rubbish in them and it's added sugar that is, is the sort of, the bad thing.

Brooke: The thing with no added sugar that you see on…

Tony Ward: Yeah, but it's like if you're having a piece of fruit or rather if it's got the same amount of sugar as the chocolate bar, I'd rather you have a piece of fruit because you're getting the vitamins, the fibre, it'll fill you up, you're not getting the fat from the chocolate and things.

So sugar is sugar. So like they say, honey, and some will say, well, what about brown sugar? You know, and all this, like it all has the same amount of calories, it all has the same effect on your blood sugars. But yeah, I'd rather you have a piece of fruit because you're getting everything else.

Brooke: Everything else that comes with it. Thank you.

Ashwini: Yeah.

Coming back to what you were saying then about, you know being involved early on rather than later down the line, and I guess that could even start within a hospital setting while somebody is still a patient. But I guess there, you might also be faced with challenges over the, you know, the fact that that person's got a lack of control over what their diet and nutrition is whilst they're in hospital you know, depending on which hospital you're in.

I don't know, Brooke, what your experience was like, whether your hospital food was good or not, but also, you know, you'll get family members bringing things in because they want to do something, they want to feel useful and, you know, give some home comforts or whatever and, and so yeah, and it's not as though that person can just get up and make their own meals - it's all being brought to them. So, do you come across challenges then?

Tony Ward: As soon as you've had that brain injury, there's a nutritional challenge. You know, there's a health, you know… Your metabolism can go up, you know, by 40 to 200%.

Ashwini: Wow.

Tony Ward: So, you know, your brain injury, you know, has a huge effect. And so that, for instance, if you generally have 2000 calories, for example, for a normal diet, just to kind of keep the healthy weight, that means you’ll either be having to have 2800 or 4000 calories. And also, your body having a brain injury you're kind of hyper catabolic. So basically, you know, you’re burning lots of protein, you need that protein to kind of heal.

Brooke: I was going to say is the demand on your brain first - nutrition to heal it.

Tony Ward: Yes. So it's, you know, you're, it's like when you, you know, you get that temperature, when you get that flu, it's your body fighting that infection.

Your body's trying to heal. It's gone through trauma. You know, when you even cut your finger, it can get red and sore. It's that response. So, you're trying to prevent losing too much protein. And it's really hard to, you're kind of really minimising the effects of it. It's so difficult to prevent it.

Brooke: Does that just mean you're more hungry then?

Tony Ward: The thing is though, we're at the stage where you're in probably ICU.

Brooke: Right, OK.

Tony Ward: These are the days… But it can last from weeks to a year, this catabolic state.

Brooke: So I was thinking it was like, there was a point when you, when your nutritional needs slow down and then you carry on eating that amount and then you put it on the weight.

Tony Ward: This is the timeline with it, and it's really interesting with sort of a brain injury, the timeline from the brain injury you have, you've gone through hyper metabolic, hyper catabolic, you lose a ton of weight, you lose cause you're immobile, you're using your muscle… your biggest protein storage in your body is your muscles, so you're using your protein to kind of heal and then that slows down that - that metabolic rate slowly slows down. And then within the hospital, we're trying to get that weight back on and we can do that through tube feeding or you know, supplements, food fortification.

And then you kind of come out of the other end, out of hospital and you’re probably less mobile. But then we're still packing in them calories to get that weight up. It's a different weight. It's because sometimes it, you know, it can be fat, you know, more fat weight and, you know, not the muscle mass.

Because you have some people saying, Oh, I used to do bodybuilding. And I used to, you know, I used to be really muscular. Now they're the same weight. But a different shape.

Brooke: Yeah. Yeah.

Tony Ward: You know, you've got that little belly.

Brooke: That's nice to have that explained actually, because I went down to 7 stone 9. And then I went, I went up to, I think it was about 13 now, but I was about 13 and a half I went to. But I exercise more now, so I was a different shape.

Tony Ward: Yeah, definitely. And it's trying to kind of make sure when they've come out of the certain point in this timeline, this nutritional timeline with sort of brain injury that knowing when to say, okay, let's start getting that sort of healthy nutrition, let's get that healthy eating.

So you're not going to be living the same life we were trying to get this, you know, in the way of physical activity and such - some may do, it's you know, we need to make sure you're eating what's right for you now, not like, oh, I used to like eat that before.

Ashwini: Yeah, yeah, yeah. Because if you used to go running all the time and now you're not, then your needs are different.

You mentioned about the loss of muscle mass and the change of body shape. Is that sarcopenia obesity?

Tony Ward: It can be, yes. So sarcopenia obesity is kind of a phrase we brought into the elderly, when they sort of get, you know, they’re not as active and you know, they're not using muscles and you generally, you're still eating the same calories. So like, if you don't use it, you lose it - the muscles, but then the calories is the fact that they're putting on the fat mass. So yeah, sarcopenia is basically muscle wastage and the obesity is putting them extra calories on.

So you can associate it with people with head injuries. They're not as active, they're not doing, you know, they're eating more calories. Because you get a lot of people that comfort eating, you know. So yeah, sarcopenia obesity is sort of kind of a new phrase. It's not been out for too long. And so that can cause an issue going forward because you're getting heavier, but your muscle power and strength is still the same, you know, not as strong, and then obviously, then rehab can be difficult.

Ashwini: So how do you mitigate against that?

Tony Ward: It's kind of prevention, you know. So it's very hard to kind of get that weight off once it's on, because they are not as active, you know, for someone who hasn't got a physical issue of doing some activity, we'll go for walks, we'll go for runs, we'll try and keep active to mitigate the food that we eat. But someone that's had a traumatic brain injury may not be able to do that. So, you know, once they've come out of the sort the NHS, say, then you know, then it's carrying on that sort of nutritional support or that education so they can be able to make them sort of changes, and yeah, and to prevent that and you know, you want to make sure they're getting enough protein so they're not using their protein stores, their muscles. You want to make sure they've got enough energy so they're not feeling fatigued so they can do their physiotherapy, but not too much.

Ashwini: Yeah.

Tony Ward: You know it's getting that sort of balance.

Ashwini: I feel like you are probably balancing many spinning plates at once.

Tony Ward: Yeah, it's crazy. And you've got all that, you know, if we had no emotion around food, then you say, eat that, eat that like a machine, like, and we just do it, that would be great. But then you're dealing with, you know, mood, you're dealing with, you know, the foods that they like, you know, sometimes it's the only thing they've got to make a choice on.

Ashwini: Yeah. Yeah. Yeah.

Tony Ward: And it's, that's why, you know, in neuro nutrition, we try and make sure that it's bespoke, we co create with the client what they, you know, what they want to eat and try to adapt it, but slowly and too much to soon, you know, so they don't feel like you're taking anything away from them.

Brooke: You hear things like I don’t know, for instance like you hear protein, you need protein for muscles, and then you can focus on that, or some things that I've done in the past is focus on like protein, like you just end up eating like a, you know, whole chicken from the rotisserie and stuff like that, and then you realise and you're not, you know, you're not getting your carbohydrates, and you just feel terrible, so, yeah. I understand, I now understand the need for like a balanced diet.

Tony Ward: Definitely. That happens a lot with the protein. I mean, I've treated people that have done weights before, you know, they used to go to the gym a lot before the accident, you know, the injury, and then they go back home and say ‘oh, I’m taking protein shakes’, you know, and I’ve said, well, the thing is that you've got to do the exercise. Protein shakes are really for athletes that are training two, three times a day.

Brooke: Extra, extra protein.

Tony Ward: Yeah, they're not getting enough in their diet, but we generally do as a layman sort of person, we'll get enough if we have a balanced diet. And we only can process a certain amount of protein in one go. So it's…

Brooke: So what happens to the excess protein then?

Tony Ward: You burn it down into calories and then…

Brooke: Does it get stored as fat eventually?

Tony Ward: Yeah.

Brooke: Right, okay.

Ashwini: I guess as well though, I mean, it's an interesting point you raised there about, you know, you think you've got to have protein so you go and eat a whole rotisserie chicken. Whilst I think we see this across the board and not just within, you know, the brain injury population, but you know, fad dieting, etc. And it's like, oh, this is the latest craze, everyone must have like avocados, almond milk or whatever it is. So yeah, and I've definitely seen it with protein as well. But then when you introduce that within someone who might have rigidity of thinking as part of their kind of ongoing issues following a brain injury, that can be even harder, I guess, that can present more challenges in terms of trying to get away from, you know, that very fixated one track, I must have this and this is how I'm going to have it.

And I guess that again is where you have to work with the other therapist and clinicians within the multidisciplinary team, maybe looking at the neuropsychological aspects of that, as well as the occupational therapy. How does your role come into that? You know, how do you work with the other therapists to sort of move away from that rigid approach?

Tony Ward: We work with sort of physiotherapists, we work with you know, saying how we could help to fuel their sort of, their sort of rehab and we give messages to clients when to eat certain foods and if the whole team speak the same language, you know, when they're doing their therapy, cause you know, we don't go in as much as say an occupational therapist who may go in twice a week, physio two to three times a week. They can give that message.

Ashwini: So it's constant reinforcement and consistency.

Tony Ward: Yeah. And you know, we do a lot of training with support workers and you know, with psychotherapists we can talk about sort of emotional eating and work on that sort of rigidity of thinking as such.

Like for instance, the protein, you know. Well, actually no, let me use a different example, vitamins and supplements.

Ashwini: Okay.

Tony Ward: I have one client that just thinks, okay I need this to get my blood sugar down, I need to lose weight so gets a fat metaboliser and he's, you know, I need to buy this from Holland and Barrett and you know, yeah, that's it.

And they come back and they can spend, you know, 50 to 60 pounds at a time on a ton of vitamins and supplements. And they think it's giving them the best, but, you know, one who's probably a thousand percent over what they require. One, they'll pee it out, but they can get toxicity of different things. And yeah, and it's, sometimes it may, you know, it can maybe affect their sort of medications or what they're on.

But it's unnecessary. It may be, you know, some supplements may be necessary, like a vitamin D, if it's low, you know, that the research is out there, that it's important, but you know, fat metabolisers and, you know, all these different sort of green tea, you know, supplements and really high strength vitamins can be dangerous.

Brooke: I can imagine one, sorry, the one, the things like that, I ended up taking, buying loads of stuff from Holland & Barrett and I was taking like six pills on the morning. Yeah. But yeah, I suppose they’ve got to be spread out throughout the day has it? Rather than just taking it all in one go and then overwhelming your body with it.

Tony Ward: Well, the thing is though, you don't need to take them at all. If you are, you know, having that sort of breakfast, you know, if you're having like, let's say a breakfast cereal and it's fortified vitamins, you've got the fibre, you, you know, you get or a yogurt with some protein and then you're having sort of a lunch, you know, a sandwich or, a soup and a sandwich or salad, whatever, you know, with a protein source and some carbohydrates and then a meal and maybe snacks in between, then you, that's, you know, you probably, hopefully you get everything that you want.

But the thing is, you have all them supplements, your you know, your pee will probably be the most expensive pee there it is! Because you're just peeing out, you know, it's like you take, you know, multivitamins, you know, strong multivitamins, your urine's like bright orange. Berocca, and you're like, what's going on? So yeah, you probably don't use it, you’ll just pee it out.

Ashwini: So it is there then any kind of useful role for supplements?

Tony Ward: Definitely. I mean, there is, you know, if you are Iron deficient, you know, so it's important that, you know, sort of fatigue and that, you know, you can take an iron tablet to help bring you back up to normal levels.

Brooke: Or a pint of Guinness.

Tony Ward: They say, wasn't it like 15 or 20 pints of Guinness is like equivalent to having a, you know, a small piece of meat or something like that in the way of iron content. It’s something like that, that's not, that's not official, The thing is about iron, it's like, it depends on the bioavailability, you know, how you absorb things.

But yeah, and the vitamin D aspect is a difficulty. And if you're not eating enough, if you really don't like fruit or you really don't like vegetables, then maybe something like a bog, standard multivitamin vitamin will help to kind of tide you over until we get them into a more of a balanced diet. So it's more of a bring them people back up to a level if they're, if they're low.

Ashwini: Like a healthy little push.

Tony Ward: Yeah. Yeah.

Brooke: I get these things from Aldi and they're adult multi vitamins, but they're in like a chewy, like a chew, like gummies, fruit gums, yeah. And I just eat them all in one go!

Tony Ward: So, yeah.

Brooke: So that's not doing any damage, I'm just peeing them out?

Tony Ward: Well yeah, I wouldn't do it. Yeah. Having too much, you don't want too much, you know, vitamins. Some can be sort of, without going to the science thing, can be sort of toxic for you.

Brooke: So one day I'll get like 20,000 percent and then the next day I'll get a little bit.

Tony Ward: Yeah. When you said about spreading it out, that's when you need to spread it out. Right. The one a day – do what it says on the tin, but yeah, or don’t gummy ones.

Brooke: Shouldn't make them so nice then, should they!

Tony Ward: Vitamins are not sweets!

Ashwini: I know, but they do taste like sweet. I have one for like hair and nails and yeah, they are like sweets!

Ashwini: I guess one thing that, you know, especially in this day and age with social media, the way it is, Instagram, et cetera, you get so many people peddling so many different things about nutrition and miracle foods and, you know, try this, do this. And it's hard to know what information out there is sound advice, what's based on science, what's based on fact, as opposed to what is just a bit of a fad or there may be a kernel of truth in it, but actually you'd need so much more of this and all the other things around it. I suppose, the advice would be don't be taken in by what you read online, but it must be very difficult for people to differentiate what's good advice and what's not. So how would you advise people in terms of where to find good information?

Tony Ward: The British Dietetics Association, they do good food fact sheets. And actually it's the BDA, but if you put BDA in the thing, it'll come up with a British Dental Association. But make sure you put British Dietetic Association, you know, they have the food fact sheets, which is very good. That their sort of website. The Nutritional Society it's sort of generally quite good. And if you have got a dietitian it’s you know, it's to listen to your dietitian.

So, I mean, it's interesting how you say how you can be influenced. I remember I was seeing sort of one client and their support worker goes, Oh, I go on this milkshake diet and it's really good and they just latched onto that. And then that's it - they're on the milkshake diet. They're not listening to the dietitian because we’re probably saying stuff that they don't really want to hear in some aspects.

Brooke: That's the human thing that you said, the path of least resistance. Yeah. Yeah. Yeah. And what was that? What was that juice thing? That was probably about 10 years ago now. Everyone was on that juice diet.

Tony Ward: There's all sorts of sort of fad diets, you know. But then if, you know, you're taking out off complete food groups, you know, don't eat gluten, don't eat dairy, you know…

Ashwini: And I guess there's a lot of misinformation around as well, like with gluten as to what a gluten intolerance actually is or, you know, is it something to do with gluten itself or is it that people are overdoing it on certain types of food of which gluten forms part but isn't necessarily the key issue. So yeah, it must be quite challenging, I guess also just trying to dispel certain myths.

Tony Ward: Definitely. And other sort of websites are good, like the NHS website's good. But as we spoke just before doing this, YouTube are bringing out a sort of health YouTube and the people that are on that health YouTube, I think it's a ribbon or search, they are vetted, the content's looked at, it's scrutinised. So it's good evidence-based because they are registered by the doctors, you know, who the doctors are registered with, the nurses, and such, allied health professionals. So that's a good source and that's a growing sort of area.

Brooke: That's good that they're vetted because you get all sorts on YouTube. You get some 19 year old personal trainer telling you what you need to eat and stuff.

Tony Ward: Definitely. And it's, you kind of get what's interesting is that you get all these sort of personalised nutrition and these companies, especially with this, the this new drug, Ozempic and all this like that they, you know, you buy,

Brooke: What is it?

Tony Ward: It's basically, it's… You can have it as a tablet or an injection and it creates a hormone. It's a hormone that helps to reduce your appetite and also increase your insulin as well, so it can help you to lose weight. But then you get these companies that are selling this package and you look at the, Oh, we give nutritional advice and then you go and check out the person who's giving nutritional advice. He goes, Oh, I used to be… I'm a personal trainer, I've done a nutrition, this, I mean, they probably know this stuff, but they're not vetted, you know, they haven’t got their own health professional council.

Ashwini: Yeah, in the same way that dieticians do.

Tony Ward: Yeah. Yeah.

Brooke: And I found from personal experience, like messing about with your food and like, what's it called? The protein, like Atkins diet. I went on that for a while and you do lose weight on that, but I found myself so tired. And like, I've got, I’m someone that's suffered particularly badly with fatigue and it's just like, if you don't get a correct nutrition and when you've got fatigue, you find that like, it crosses over into everything, so like your thinking slows down and you just struggle to get through life basically and all that's just for what someone told me on YouTube.

Ashwini: Water weight there rather than…

Brooke: Yeah, yeah.

Tony Ward: Possibly and everything, you know, like I say, everyone's different, you know, when we say a balanced diet, it's not, you know, your balanced diet may be different to someone else's.

Ashwini: Yeah.

Tony Ward: It's trying to find out what's right for that person. And it's not just the balance of nutrition and the nutrients, it’s the balance within their life, you know, what they're doing, you know, are they really active or are they not so active or are they're going out and doing, you know, how are we going to fit it within their lifestyle?

Ashwini: Yeah.

Tony Ward: You know, it's getting the whole holistic.

Ashwini: Absolutely. And you used a term before, you talked about the emotional aspect and I think that's it. Food is such an emotional thing, you know, it's intrinsic to our culture, it's intrinsic to how we socialise you know, people come together for meals.

It's got a huge emotional value attached to it. So when you were saying before, you know, we're not just robots, we don't just eat like, you know, put food in, there's so much more attached to it. And that can be, I guess, very difficult again, after an injury, because you've already been through so much and, you know, you're trying to get back that control in your life, but also people around you trying to sort of help you feel better in any way that they can.

And you’re probably also grieving, mourning the sort of person that you've lost or other people again might be doing that. You know, because like Brooke, you've said, you know, Brooke after injury is very different to Brooke pre injury and there is a grieving process that goes with that, but that can be quite difficult.

And then, you know, you mentioned about emotional eating and I guess it comes to the point of trying to encourage people to eat mindfully and intuitively. You know, why are you eating this? Is it to nourish your body? Is it to nourish your soul? Is it because you're stressed about something, you're anxious about something and sort of understanding why you're doing what you're doing in the first place?

Tony Ward: That's where it's good when you work with these sort of psychotherapists, you know, that you know, working with them to find what the actual sort of, you know, reason behind a behavior.

Ashwini: Yeah.

Tony Ward: And yeah. Especially in the early days, you know one client who's you know, in a wheelchair really struggling with his weight and he can't get out and you know, so what does he do? He's bored. He's got no activities, unable to do stuff. So his emotional thing is to go and eat and then that has that compounding effect.

Brooke: Something else, you know, socialising involves, you know, going for meals and stuff as well. I don't think socialising is something you ever want to let slip from your life because, you know, you're doing it less anyway, and you find it harder to talk to people. And it's just, I think isolating yourself is one of the worst things you can do after a head injury.

Tony Ward: Yeah, and that's what people do, feel very isolated. And yeah, and some of them turn to something like food.

Ashwini: So coming back to what we were talking about before, and it's something that we touched on, but then I think we sort of went off on a different tangent, we started talking about different foods and nutrients that can promote brain health and recovery. So you mentioned about the omega three fatty acids and the antioxidants.

I mean, are there other sort of nutrients or specific foods that would help people with you know, with promoting that healthy nutrition and recovery?

Tony Ward: Okay, so yeah, so we've got the sort of the fatty fish that we call it, the fishy fish, the omega 3s is sort of crucial. They're also, you've got the sort of the green leafy veg you know.

But, to be honest, everyone says your health is always green leafy veg, it is really, really good. You know, you got some things like sort of spinach, you got kale, you got cabbage, spring greens… I always remember spring greens in my Nan’s Sunday lunch... And they’ve got sort of all the sort of antioxidants and vitamin Ks in there and such.

Also sort of berries. So they’ve got something called flavonoids and lots of antioxidants again, what we talked about, you know, the stress to prevent that oxidative stress, to get hold of them sort of free radicals that from, you know, reduce inflammation. And so these are like sort of blueberries, blackberries and you know, but sort of generally the berry fruits.

Also sort of, you know, eggs are a good source of nutrition, you know, they’ve got sort of choline and they’re good for sort of new neurotransmitters.

And in small amounts, for giving people a treat, dark chocolate is a nice sort of thing, a nice square of dark chocolate.

Brooke: Should it be more than 70%?

Tony Ward: Well, yeah, it depends on how you like it, but yeah, more than 70%. But I'm not saying everyone go out and eat dark chocolate. I'm a bit worried now. But it is, you know, it's nice to have a sort of square every so often. But it's more talking about the flavonoids, the antioxidants that are in these sort of foods that sort of kind of help.

And there's also tumeric, people talk about tumeric, so I know, you know, we talk about sort of misinformation and that, but turmeric. Again, it can create a sort of an inflammatory sort of effect. It's called curcuma.

Ashwini: Curacum. Curcum. Curcum. Curcum. Curcum. What was it?

Curcuma.

Tony Ward: Oh, yeah. I know what you mean. It's one of these words. That's in turmeric. But, you know, you need to eat a lot of it, you know. So a nice healthy curry is not going to, you know, do you sort of any harm with sort of tumeric. So yeah, it's, you can get a lot sort of different things, but if you have all them sort of foods in a sort of a balanced diet, so just go through a quick day, you know, you've got your blueberries, your blackberries and the berries in your porridge or your yogurt in the morning. You've got your green leafy veg in the evening with your meal or a salad in the lunch, the spinach with maybe some salmon or some sardines or a boiled egg you know, an egg sandwich. So you can fit these in to your diet quite easily.

Ashwini: I guess as well that you probably want to try and eat seasonally as well so that you're getting the right things at the right time when they're at their best. I mean you know, your blueberries, for example, if you're eating them in January, they're probably, are they going to be as good for you as if you're eating locally produced blueberries in the summer?

Tony Ward: I can't give you a definitive answer on that. But all I say is that once something's been picked and it's sitting around, it can, within the environment, it can start losing certain nutrients. That's why actually frozen… I was going to ask actually,

Ashwini: I was going to ask actually, would you recommend frozen?

Tony Ward: Yeah, because usually they pick, they process in a good way, you know, just chopping up, they're not adding anything to it. And then they freeze it pretty much, sometimes in that that same day. Whereas if it's fresh, well, how fresh, I mean it could be a week down the line and it's been sitting in there, depending on the environment, it can lose vitamins and nutrients. So, you know, and I will say frozen is great, especially if you forget to eat things and it goes moldy and saving money, especially in this day and age with, you know, with the prices of everything.

Ashwini: Yeah, yeah. Invest in a decent sized freezer!

Tony Ward: Definitely.

Brooke: Yeah, that's one thing I don't have, my freezer's tiny.

Tony Ward: Oh, right. You got one of them little small ones at the top.

Brooke: No, it's not that small, but it's just jam packed with stuff.

Tony Ward: Yeah. And it's, so it's like, for instance, like the mixed berries, you may take it out the night before and you can put them on your porridge or your yogurt. And you can get these steam bags of sort of vegetables and such. But, yeah, if they’re sitting around a long time, and they’re looking a bit old and wrinkly on the old shelf, I’d probably wait to get a bit more fresh.

Brooke: In a typical plate, what should people look for to put on the plate?

Tony Ward: All right, so there is I would say is the go to thing - way of plating up some food and that would be sort of half your plate vegetables, quarter your plate your meat or your protein source, or whether it's beans and pulses, whether you're vegetarian or vegan, and then you starch, your carbohydrates.

So if you've got salmon, you got good omega threes, you got some salad, it's got some spinach in there and then you've got a sweet potato, or a baked potato. There, you know, and that's perfect. You know, in the sort of a balance, you know, you've got your greens, you've got your carbohydrates, you've got your protein, you've got your healthy fats, but you know, you mix and match. You can get some cooked veg, you can get different carbohydrates. You can be very creative with… air fryer is a great to be creative with, with potatoes.

But in the way of sort of specific foods you know, it's, probiotics. So getting that, so yogurts, getting sort of the healthy bacteria in your stomach because you, they have this, you know, starting to get more and more information out there that you have that sort of brain and gut sort of gut brain connection, they call it.

Brooke: What do they call it? Yakult - them little drinks. Are they good them?

Tony Ward: Yeah, they can be. I mean, if you eat again, always going back is like a good sort of healthy diet. So you got some sort of yogurts and eating vegetables and oats because fibre is what the bacteria feed off, you know, which is good. But yeah, if you want to kind of top it up or make sure you’ve got a good… you can do Yakult for two weeks.

Brooke: Not as a permanent thing then?

Tony Ward: Well, no, so, you know, if you, I mean, if you’re sort of having a yoghurt, I mean, like Danone and things like that, or a yoghurt drink, or you can do sort of Yakult if you want. If you don't like yoghurt, if you’re not having them of foods.

Brooke: Just trying to simplify it, because that's one of the things I've struggled with is, you know, you get all this information, but then what, you know, what rigidly should I stick to so like you want to get your…

Ashwini: But does it need to be rigid?

Brooke: Well, I think it does for people with head injuries because they're easily confused. Well, I have been easily confused anyway. So not necessarily rigid, just simplified. What, you know, what do you definitely need?

Tony Ward: Well, if you, I mean, I'd say if you have like sort of, you know, yogurt, there's lots of different brands out there. That sort of let's say probiotic on them sort of foods that you can eat as part of your balanced diet. Again, I wouldn't go out and buy lots of supplements. You know, Yakult is a borderline sort of type of that. You can get things like a yogurt drink, a Danone, which you can use as equivalent to a yogurt. I'm saying yogurt a lot!

But it's to kind of create a good… but with that, you're going to have to have the, you know, your vegetables, your… the fibre is important, you know, one, especially for your bowel health.

Brooke: Do you have as many colors on your plate as you can?

Tony Ward: Eat the rainbow. They say that the different colours have the different types of vitamins, you know, and so yeah, it's try and get as, you know, not all green leafy veg, you know.

Ashwini: And definitely not all beige.

Tony Ward: No, yes. That's yeah, the fried food, the, you know, that's all the beige.

Brooke: Well, every now and again you need some beige food, don't you? Because …

Tony Ward: Every now and again you need to, you know…

Brooke: That's for your mental health thing

Tony Ward: Yeah, it's, you know, you need something that you enjoy. Okay. It's just, you know, it's just not every day, you know, or every other day.

Ashwini: I guess, it always comes back to that sort of the very non sexy sort of everything in moderation, you know, combination of a healthy balanced diet and exercise and that is the key to good health overall.

But it's so difficult. I think in this day and age, when people want, like we were saying before about the quick wins, the fads and stuff, it can be quite difficult to keep trying to push that message of actually, you know, just stick with something longer term that is healthy and balanced and intuitive and mindful and the results will come over time. I think, you know, we're in a such a fast paced society now that we want it all now.

Tony Ward: And that's what you get with yo yo dieting. You get that quick fix. The Atkins diet, Brooke as you said, and then you lose it and then it's not sustainable. You want a sustainable food that you enjoy and you know what you can swap in and out. You know, you know. And to have, to sort of have that consistency, that sort of…

Brooke: You end up having dreams about bread.

Tony Ward: Sorry, what was that?

Brooke: On the Atkins diet I used to have dreams about bread. Buttered bread…

Ashwini: I think though, that's the thing that if you say to somebody you can't have that, then you only want it more. And I found this when I started going down a very sort of mindful eating journey. The minute I stopped saying, right, I can't have this, I can't have that. It almost became, it became a non-issue. It's like, I don't, actually, I don't really feel like that. So, I'm not going to have that. But it's not because anyone's saying you can't have it , it's just I don't need it, don't want it. You know, and it works, but it's a longer-term approach.

Tony Ward: Definitely. And that's where as dietitians we work with our clients is, you know, we try and still keep in the foods that they do enjoy.

I mean, I had one client that was so scared to see me because they thought I was going to take a takeaway away from him. What I said was, no, you know, we, you know, we just fitted in the grand scheme of things that you still can enjoy them types of food. Okay, his portion sizes may be a bit different and such, but and you know, you can have the foods that you enjoy, but in a healthier way, it's really…

Ashwini: Do you have any sort of what I’d term success stories from your practice where you kind of feel like, yeah, you know what, I've really made a difference, or I've helped that person really kind of turn around their patterns.

Tony Ward: Definitely. Yeah. I mean, we've you know, I've had one sort of client that's struggled for years to kind of get his blood sugars under control, his weight under control. And it took a while, as you say, to implement things. And so, but we got his blood sugars under control, his weight sort of stable.

And he's, you know, he's enjoying it in a different… you know, we have someone go in and cook with him regularly, so he's trying all these different meals and he's enjoying it. And this is a gentleman that I was saying earlier that, you know, he ate fish and chips. Literally, I think he ate out 12 times a week.

Ashwini: Wow.

Tony Ward: And you know, not always fish and chips, but for at least four of them were fish and chips. And, you know, it's taken a good few years but now he's only eating it a couple of times a week. He's actually cooking food for himself and he's made sort of sandwich and, you know, which is more sustainable financially as well. And another client who I think she lost over a stone within sort of six months because we helped her to create her own meal plan with the support workers. So we created it. And also she's, they’ve got celiac as well. So it's helping to kind of do that, to kind of keep the sort of the celiac disease under control. And obviously the symptoms from that, the quality of life has improved. They're out more, so they're doing more exercise. And yeah, so, yeah, I've got loads, but it can be challenging.

Brooke: Something that's really helped me in the past is MyFitnessPal.

Tony Ward: Yes.

Brooke: Where you're like, you're putting everything that you eat into this app on your phone and it's not the app that's doing it, but what it does is it makes you aware of what you're eating because sometimes I just graze and stuff and if you, if you put everything in there, it gives you… one, it makes you more aware of it and two, it, you know, tells you, you know how much protein you get how much carbohydrates and and stuff like that. So…

Tony Ward: It can be sometimes even just on a piece of paper, or you know because sometimes people… if you put in MyFitnessPal, they don't know what calories are, they don't know what protein is, it's all a bit much. But because you've got that understanding prior to brain injury and, you know, even just writing down and saying, well, I didn't, you don't remember, you know, someone says what you ate yesterday, I'm like, I can't remember. But you miss out, well I had that chocolate bar there, or I had that sneaky packet of crisps, or you know, how much of that, Oh, I had four meals yesterday instead of three, you know, you can actually see what you actually eat. And remember, you know, years ago, you had this Gillian McKeith and they put everything on your table.

Ashwini: Oh, good Lord. That woman.

Tony Ward: It was just crazy. You’d see it, but yeah, she was just, she was scary.

Brooke: You got to remember to scan it in as well, though. If you're cheating on the app,you're on a cheat yourself.

Tony Ward: And that's what a lot of people, you know, I think it's psychological behind it is that people block out some stuff that they may have eaten.

Ashwini: Or it's human nature as well to sort of almost lie about it because they feel shame or they feel like they're letting you down or they know that they're perhaps letting themselves down in some way and…

Tony Ward: I had one client that is just adamant that, you know, I don't eat much at all, you know, they carry on putting on that weight. So it's like trying to get into the graps of why, you know, when or where and how is you get them sort of calories in. So it's always like a game of chess as well. Not a game of chess, but I mean, trying to puzzle, trying to work things out for different people.

Ashwini: Yeah, I feel like your role is not, it's not just limited in a way to dietetics and nutrition. I think there is very much a psychological element in there as well.

Tony Ward: And that's why we're just so grateful for the MDT. You know, working with sort of great professionals and, you know. But again, it's a great environment to do that.

Ashwini: Yeah. Well, that's been really fascinating. Thank you so much.

But before we go we will put your details on the show notes for this episode, but perhaps if you'd like to just give people your details now, so that if they want to get in contact with you to discuss your services or have any questions - over to you.

Tony Ward: Sure. So yeah, I'm Tony Ward. I'm the Director of Neuro Rehab Nutrition. The website is pretty much neurorehabnutrition.co.uk. You can contact us through, there's an info tab there and my email is what my business is. So it's tony@neurorehabnutrition.co.uk. So, you know, if you’ve got any questions or you want to sort of ask anything, just, you know, give us a call.

Ashwini: Brilliant. Thank you. Well, thank you so much again for that and we'll see if we can also find some fact sheets off the websites that you recommended that we can put on the episode notes as well to help people if they're looking for information on nutrition and quality good nutrition from recommended sources.

So yes, we can do that, but thank you very much again for coming to join us.

Tony Ward: An absolute pleasure.

Ashwini: 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.