Tips for New Dietitians, evidence-based practice and guidelines feat. Mike Patterson

Mike Patterson: 0:00

When you look at evidence based practice is sort of looking at the evidence base clinical experience, and also the patient's perspective because you might have the best evidence base in the world for something. And you might have the best clinical experience. But if the patient doesn't want to do also, if it's not suitable to the patient, it's not going to be correct. Anyway.

Aaron Boysen: 0:21

Welcome to the dietetics digest podcast, a podcast that helps you understand more about the different areas of dietetics and nutrition and what others are doing within them. We do this by talking to inspiring and influential individuals that are advancing practice in some way, shape and form. Our mission is to create a resource that helps dieticians to build, grow and share ideas with each other to help advance their practice and the practice of others. I am your host, Aaron Boysen. Hello, Michael Patterson. And thank you for joining us today on dietetics digest podcast. Maybe you could start with introducing yourself who is Michael Patterson

Mike Patterson: 1:01

are a dietitian. I'm currently back in my old role as a clinical dietitian, but our pre Corona and also in about five weeks time on clinical research fellowships and nutrition. So it's got a PhD mixed in there. So I'm employed by Holyoke medical school. As a research fellow, I do a PhD. As part of that sponsored by Yauch cancer research looking at palliative pn venting. gastrostomy is in Manipur, bollock structured palliative intervention in South Korea,

Aaron Boysen: 1:30

what really triggered the interest in that area in particular.

Mike Patterson: 1:33

And so pretty much since I qualified, I knew I wanted to be intestinal failure. So I covered colorectal as part of mercy basement, I did my consolidation on Colorado, what I found really, really interesting. So as soon as I got to my jobs, I got a job in hardware. I did my seed placement, nice shout out to contractor. So luckily, it's been five that was my first rotation, the rotation, so it's been like six or nine months, I've managed to sort of top Marines are doing it, but 18 months. So I got sound a little bit longer. I knew I wanted to sort of delve into piano, I always covered when pn dietitian was off, always picked up new patients if they were busy. And then we started doing a little bit more positive pn as a nutrition team. And then colleague of mine to do their PhD. So she's another fellow at bolier Medical School. And he said obviously PhDs coming up on dbrs cancer research. So it's got been in around this area. So I met with my no supervisor, who's a professor of medicine put the idea to her about investigating parts of pn, Gaston is about function issues, mainly Medicaid. So the Research Centre are currently doing some research looking at sort of patient reported outcomes in malignant bowel obstruction. So they're already looking into that area. And then when I spoke about nutrition and the gastrostomy side of things, she was really interested. So she said to me, and my centre research dietitian, that she wants an army of dietitians. And so

Aaron Boysen: 2:59

should we start the recruitment drive right here?

Mike Patterson: 3:02

Yeah, maybe she just said there's some she has some issues with some of the evidence. So she wants to prove that evidence. So I appreciate and get more dietitians into research. It should be out.

Aaron Boysen: 3:12

So you said you always had interest in the area of intestinal failure. Was that originally from when you first started dietetics? Or did that interest grow throughout your time in dietetics?

Mike Patterson: 3:24

So dietetics is actually a second career for me. So I left school 16 did an apprenticeship. So I was a telecoms engineer for five and a half to six years. It paid very well, it was like there's no thought process to it a lot of time, you just put cables together and really frustrated. So then offering Andriy redundancies with a half decent pair to go with it. So I took that my other half family got pig farm. So I worked on that for a while while thinking about different choices. So I've always been interested in sports nutrition, just from personal perspective, looking for a new career and my sister's a video always always interested in nutrition dietetics so different access costs and different undergrad for sort of German undergrad, maybe go down the smart route. I do the non clinical placements. I did my undergrad at Leeds I did the non clinical soft spots, research placement leads and then when I did my placements, Southland, colorectal got introduced to pn is quite Science Nation without a word from a from a dietetic perspective, you get to play about those numbers a bit must involve a bit more sort of medicine involved with it. So because of that just sort of knew straight away, this is the area I want to work in. Well,

Aaron Boysen: 4:33

thank you. That's really interesting. It's really interesting to hear the thought process you took in choosing where your eventual direction would be. And I think that's really important when we're discussing the next topic because it's really important to understand that everyone's journey is different. However, there are commonalities in which we can support each other in and a few months ago, you put out a tweet, which was sort of around half ranting and half tips for new dieticians. Possibly just starting out in a career in dietetics. So just like that tweet, I want this podcast or maybe a little bit of ranting, but really aimed at those new dieticians and advice for them. So bring us on to one of the first points you mentioned in the tweet. And it resonated with me, because obviously, we go through lots of topics in our degree, we cover lots of different areas. And sometimes things aren't at the forefront of our mind when we graduate, you've got other things on your mind. And going into your first job, you want to make sure you prepared, is there any area that you think New dietitian should brush up on? Or just refresh their knowledge before they get started?

Mike Patterson: 5:40

Yes and no. So I sort of do like to jump into things and just give it a go see what happens. In terms of refreshing, definitely. So I still do it now, especially when you come up with it. So you see a new condition or think about something else. So especially from where I am now with intestinal failure, but going back to pretty much every aspect starts ethics, physiology. So it's the thing that you learned in first year? Well, I certainly did when you do this, like, why am I landed this one and this come foreseer when you've done all your other modules, you've done all your placement, physiology comes a little bit out of your mind. And then for me, when you got back, when you start working, you come back on placement, you start a job full time, physiology becomes that much more important, I think in terms of when you have a good understanding of physiology, it improves your understanding the medicine, so I'm not expecting dietitians to be medics. We're not medics, but having that really good knowledge of physiology really helps improve in terms of your medical knowledge. I think it helps you understand the disease a little bit better. What's actually happening body where you're digesting information is going to help us think Yeah, physiology is probably the big one. I've said it on the on the thread. But in terms of I'm very biassed that gi physiology, you need to know your GI physiology. I don't doesn't care what condition it is, it's probably going to end up in the gut. If it doesn't, obviously, it's intestinal failure. But again, we still need really, really good gi physiology. And I'm

Aaron Boysen: 7:06

running through some of those theoretical topics that may not have been all seem to have been as applicable at the time now that you're working are almost directly applicable to your work.

Mike Patterson: 7:19

Yeah, yeah. So it's just that was going on right in your mind. And just, I always think if you just take a little bit of the backward steps and times, because you probably just want to jump into it. But if you then you know you're assessing the patient and look into their solid medical history. If you actually think a little bit about the physiology can help, what you're then going to want to do with that person is going to inform your plan that little bit more.

Aaron Boysen: 7:41

So how am I understanding physiology inform your plan.

Mike Patterson: 7:44

So it might help you solve a problem, even something like fat malabsorption. If you don't understand where something gets absorbed, or what happens when someone's won't absorb them, if you don't have that good understanding, you might not pick up on it, it might not be something that a medic could pick up on as well. So if someone's having like the atheria medic might not pick up on it. But because as dietitians, we often have the luxury of having a little bit more patient contact times in the medical world, again, something where communication skills come in, but we get to have a bit more of an in depth chat with someone. So you might pick up on some triggers that they're giving you that maybe they've not had a chance to discuss with a medic, if you apply a little bit of physiology to it, you might be able to think, ah, maybe it's something that you can always discuss them with their medics as well. I think if you have a good understanding of physiology, when you're discussing something with a medic as well, it makes it that little bit easier, because you can explain what your thought process is because of x y Zed, and it might just get that point across a little bit more.

Aaron Boysen: 8:40

You mentioned a little bit about communication skills. Is there a way to brush up on those before we start our new jobs?

Mike Patterson: 8:47

I think sometimes from what you do at uni, very, very sort of structured, very formal doesn't always apply necessarily, especially to me in an acute hospital restaurant is quite sick, you're not always going to be able to chair someone with a little pedal following and, you know, if you push up and just think, at least if I can focus on that paraphrasing and summarising I think that's the two big ones I take is that you can actually do that quite easily with someone in acute care. So you might not be able to do everything else, you might not be able to sort of guide someone as much towards a goal. I don't think he can in sort of different areas of dietetics he can sort of it's a little bit harder, I think in an acute setting for someone to come up with that on plan. As much as I think he was at least paraphrasing and summarising what's happening. You're able to sort out plan together a little bit more focusing on that

Aaron Boysen: 9:37

paraphrasing and summarising Why do you think those particular skills are most beneficial in an acute setting?

Mike Patterson: 9:43

I think it just again, this active listener at least it shows to the patient that you're actually listening to them and they get to understand sort of what they've said back and for me as well. It helps me remember what patients said to me. I'm not a big fan of some people are but I'm Not a big fan of sitting there recording things on paper, I find it quite distracting for me. I don't know if the patient does, but for me as well, if I paraphrase throughout, if I summarise at the end or summarise where Mary's appropriate, it helps me remember what that patient said to me. And then I could go back and write whatever notes that tells me I can. I can remember history a little bit better.

Aaron Boysen: 10:21

Yeah, I've noticed that too. And it really resonates with me, because when I summarise or paraphrase something to a patient in hospital, and maybe I've forgotten something, or maybe I didn't have appropriate emphasis on an area that was really important to them, they can reinforce that area, so that I'm aware of what's what's most important to them.

Mike Patterson: 10:42

Yeah, percent.

Aaron Boysen: 10:43

So we talked a little bit about communication with patients. But I want to take you back to what we were discussing earlier. It's a little bit our knowing physiology helps us discuss things with the MDT so that doctors, physios, nurses, Speech, Language therapists, occupational therapists, and other members of the MDT, do you have any tips on communicating with them? I remember when I was a newly qualified dietitian, because I felt quite new. And I felt that my knowledge wasn't fully developed. And I also felt like when people said, build rapport, it meant, Hey, did you see the football game on Sunday night, and I'm just terrible at those sorts of conversations.

Mike Patterson: 11:24

And I'm the same as you are for small talk, not a big one for small talk, in terms of, I think it is different depending on who you're talking to, as I said before, like with medics, I tend to find a good way that they sort of respect to that a little bit more, but to sort of get to know that a little bit more, if you know, your patient story, get really, really, really good at knowing your patient story. So you know, eight year old guy admitted with this history of this, this is currently happening on this treatment devices. This is this is this is happening. So this is why I think I should do this. So I think for a consultant, he might have 20 3040 patients on the ward days looking after that, if you say our current issue about Mr. Smith, Mr. Smith, if you can sound Can I just ask you about Mr. Smith, we lost the story, it's gonna make it a little bit easier for him. And I think that's a good way to get chatting. If you know your patient story, it makes it easier to chat with medics and then you know, a bit more likely to just chat randomly or ask you about a patient. And the same thing I I find that like the physios speech and language, or the therapist goes back to the fact that I think as dietitians we have that little bit more time with patients, we get to know them a little bit more often patients will tell you certain personal things. So dog or cat by variable R, and I found a good way to sort of break the ice for the physios or speech language is talking about patient bring something like that, like the little sort of finer details and stories that the patient tells you, and probably told the other therapist that story, basically, I just find it's a good way to get chatting about it. Also, this is can really be helped for a lot of people, but I think being male and being being a dietitian is a bit of a novelty. So I think that honestly helps people noticing you because first of all, just being the male dietician, I, I've often been that the only male dietician where I've worked. So it's like, it's the male world. So you get to know people because because of that I've worked

Aaron Boysen: 13:23

in a hospital where I have that novelty factor. But currently where I work, there's actually quite a few male dieticians in the office, I think there's about five in our cute team. So I think by now that novelty factor is unfortunately worn off. In fact, saying that one of our new dietetic assistant started, and she mentioned that she didn't realise how female dominated dietetics was because there was so many males in the office.

Mike Patterson: 13:53

That novelty value. And they also think in terms of when you're a new band five, that probably is brand new f1, there's going to be brand new, brand new speech and language therapists all probably feel very similar. And I do tend to find like newer punk fives, newer therapists, newer doctors do tend to just end up chatting, I think similar age similar experiences tend to find a new start chapter. Also rotation, I think help as well. So if you know you're on a set reward for six 912 months, you do get to understand a little bit more they get to know you. And that really helped.

Aaron Boysen: 14:25

I think by being there for a longer amount of time. It makes it easier for people to invest in a relationship, because you know how long it's going to last?

Mike Patterson: 14:34

Yeah, like I always found if I'm going on to a new Ward and an Old Covenant, it's always good to go have a chat with water stuff, it's going to be there water while the charge less. It's there one so don't just introduce yourself, however awkward it may be and just say I'm going to be here for the next 912 months.

Aaron Boysen: 14:51

So you've been there yourself. You've been a newly qualified been five dietitian and now your F 10, a phrase highly specialist dietitian.

Mike Patterson: 15:00

Knock on it.

Aaron Boysen: 15:01

So you've seen it from both sides. If you were giving advice or if you were sort of looking back, is there any advice you would give to yourself as a newly qualified band, five dietitian,

Mike Patterson: 15:12

quite a few things. So going back to that point last, and I don't think we need to be mad, but I wish I just understood medicine that little bit better when it first came out. And I think probably is something that you pick up with experience. And as I said, going back to the physiology, having good knowledge of physiology, biochemistry will help do a refresher on that. So I think in terms of I wish we just had that little bit better knowledge of medicine, I just think it really, really helps in terms of getting you understand, and especially sort of when you first read medical notes of that, but the right thing, and I actually do them constantly on Google, like what does that mean? What does that mean? What does that mean? But again, it probably just comes with experience, again, this point and massively biassed towards but research skills. We do do research as an undergrad, as opposed to graph, but I think it could be improved that little bit more. Especially it's not like a critical thinking skills. I think for me, when you improve your critical thinking skill to problem solving becomes that much better matches think it allows you to break things down a little bit more. So yeah, having my personal perspective is that every dietitian would have to do some sort of research for a lot of people might not like it. But I just think it's really, really important as as a profession that we have a really good knowledge and understanding

Aaron Boysen: 16:32

of research methodology. So in your mind, what would the benefit of those research skills be?

Mike Patterson: 16:37

Because in terms of I think a lot of the times the way that huge generalisation is that sort of be quite happy to offer guideline below, right. That's what the guideline says, This is what I'll do. Whereas I think if you have that little bit better knowledge of research methodology know how to find an interesting, perfect because the evidence base is constantly evolving in nutrition and dietetics. There's a lot of areas where there isn't a great evidence base. But if you just have that little bit more of a reshot skill, you might be able to find something or even if it's something quite small, like a case study or a little case series of patients, you might then be able to apply something like that to your practice, is that there's not really an evidence base, but I found this, this and this. So I'm going to try this in my practice. And as long as it's safe, that's what you're causing no harm you can sell, why are you doing that? Well, I found this and some people have had a bit of success, there's no evidence that can go off anywhere. So I might as well try this, and then that'll monitor it, and go from there. And again, methodology, I think it's something that's really, really important in terms of like when you read in the paper, and most people read an abstract that might go to the results. Because this site will go through the methodology fast, obviously, because of the methodology, see whether it's good or bad, and you can go from there, then you can look at the results in the discussion. So my supervisor said to me, pretty much when looking at purpose, just look at the methodology and the discussion. So the methodology will tell you whether what they've done is good or bad. And the discussion is, they should hopefully tell you what they've done good or bad, and what is good. What about it's bad topic. So having that good understanding the methodology, social media really helps.

Aaron Boysen: 18:09

Thank you. That was actually first pointed out to me when I was on non clinical placement, I was working with some PhD students, they had a journal club, a couple of lunch times a week, and they invited me along to it. And that was one of the tips they gave me to really understand the quality of the research that was reading the methods was the most important area. And I think from then on, it was really eye opening to me when I read research to sort of the results can be quite appealing. But it is the methods make or break an article from research,

Mike Patterson: 18:41

especially sort of who have done the research on it really, really helps. So you might find like someone might be caught in set guideline. But then when you actually look at the guideline, it might be our the evidence base is based on 18 year old males who have got a normal BMI, and you've got a female who's BMI 14 from here, but you're following that guideline, because it's so generic white, if you've got a good standard methodology and look at the guidelines says that, but when actually look, it's not relevant to my patient population whatsoever. And if you don't have that sort of critical thinking skills, you might spell the guidelines as that. Whereas if you have that little bit of delving into papers and thinking, Well, you know, or even if this sort of papers that are very similar to your patient population, you might say, well, there's not really much of an evidence base, but this pair back looked at a patient population group are very similar. So I'm going to sort of use that as a basis angle from that, I think sort of evidence based practice is looking at best available evidence. So if you can then work out what is the best available evidence, you can sort of go from there. Thank you. I

Aaron Boysen: 19:46

think that's so important to understand, not only the guideline, actually what that guideline is based on because it can really inform our practice. And I think there's lots of talk about guidelines are just guidelines, but how can you really Understand the guideline enough to use it as a guideline, if you don't understand what underpins it, if you don't understand the strength of the evidence, the limitations of that evidence in your patient cohort, I mean, if you don't actually understand the guidance, there's only two ways to follow it. Follow it with exactness or whimsically break it comes from Yeah, you almost need to know the rules. In order to break the rules effectively, you need to know what the guidelines is based on to know that it doesn't fit your patient population, because if you don't know you're based on sort of whimsical feelings, and not based on evidence,

Mike Patterson: 20:35

yeah, definitely. And when you look at evidence based practice is sort of looking at the evidence base clinical experience, and also the patient's perspective, because you might have the best evidence base in the world for something. And you might have the best clinical experience. But if the patient doesn't want to do also, it's not suitable to the attention, it's not going to be going anywhere. Even when you look at these best practices, then three things, you need the best available evidence, whatever that may be, you're not always going to get an amazing RCT that tells you this, you need to sort of see what from your clinical experience, whether you've tried something before, what your patient population, whether you've seen sort of something similar in this patient population group before, and also what, what the patient wants to do. Thank you.

Aaron Boysen: 21:18

I think that's really important things that we'll discuss there. Now in your Twitter thread you also mention about anthropometric measurements that are not weight, what measurements were you referring to? And how are they useful?

Mike Patterson: 21:30

So they were obviously that is a really useful tool to start off with. And I think either iron software is really useful, but where it can be manipulated, so much. So outside of clinical practice, I tie box, so I used to sort of compete a little bit, but now I just do coaching, I work with some athletes that currently, so merely MMA fighters, and work on procedures. So in terms of professionally, you can find people who lose 6789 kilos in a week overnight, so weight can be manipulated that easy. So basically put someone on a really, really low carbohydrate diet, dehydration them a little bit. So you've lost the glycogen stores, you've lost the water attached to that, under the hydrated. So has someone lost seven kilos overnight on just the hydrated and it can be similar in terms of clinical perspective. So and this is feed for a couple of days, not the right IVs to correct it may have lost four kilos, but might not have lost four kilos because they're just really, really dry. So if you have a good on Sunday biochemistry, look at a blood sample, I have not lost four kilos that just really dry. And the other end of the spectrum, there's so many conditions that we look at where there's going to be some aspect of fluid retention. So renal patients, that's number of real patients are going to be fluid overloaded. One of the reasons for dialysis, heart failure patients going to be massively fluid overload. If you look at liver patients that might have 1516 1718 kilos worth of the sizes in there, even from my side of things and surgical patients, vast majority of surgical patients get some fluid retention after surgery. Well, the first thing I got taught as a surgical dietitian is after surgery, make sure you look at the legs, make sure you say is right for the squeeze your ankles, because more often than not, they're going to have somebody on the legs, you might have a lot of squeezing their ankle, right? Yeah, that's probably this is why we're it's often not the greatest because there's so many different conditions where you can get fluid retention, you might get excited, and it's just going to mask what's happening. So some of them really, really easy ones a minute params confirms triceps skinfold, calf circumference, grip strength, they're all relatively cheap, pretty convenient. They're not to sort of invest if I know some universities do do isaaq accreditation. This is another thing that I wish I was taught more citations. I wish that every university made sure that every dietitian that came out uni had isaaq Would you mind

Aaron Boysen: 23:49

explaining what isaaq is for those who maybe aren't aware.

Mike Patterson: 23:53

So the International Society for the advancement that kind of anthropometry so because the level three you can teach, but the level one does various measurements I would do to get my eyes at training in the middle of nowhere, but obviously there is a small pandemic happening. So as a level one you do satin bone calf measurements and set muscle thicknesses and also callipers. So it's just a way that you can assess them on body composition rather than just checking something to where you can then assess for things like muscle mass with the bone gas, trying to look at sort of what's more skeletal structure is mostly the callipers to look at. And it's just much easier method. So I think sort of you know, it'd be great if we could decks all our patients on the same deck same the same hydration tricks every time Not gonna happen. Probably not ethical to have access to everyone. But things like that are much easier, much more practical method of just getting an idea of what someone's body composition is actually doing. And I think in terms of grip strength especially it's going to give you a look Get more functional data as well. So I found on through really good conversations with medics as well. So going back to the intestinal failure side of things, I had a guy with a high output stone that was on max meds to district him, and his weight was massively fluctuating. So it didn't actually look like he was losing weight. So he was a tradesman. So expect them to have a pretty good grip strength, reasonable muscle mass. So I was discussing it with the medics and saying, look, this is what happening. I think it's worth just fluctuating because we still molossia Friday, the medics are a little bit unsure did full answer on it, it showed in terms of prescriptions was, you know, much less than what it should have been for a guy his age and also in terms of from just mid upper arms conference cast conference showed that he didn't have the muscle mass you'd expect for a guy his age to adapt to the medics and said, Look, this is what's happening. He's going down. This is not what we'd expect for this guy, especially being a tradesman, he's probably using his hands quite a bit. And then the decision made was to start him on piano, ready to reverse the surgery. So he ended up on the end for about three and a half, four months, to start utilising the fact that his weight was fluctuating so much looking at using the bloodspot to use an anthro, I was able to convince the medics that he was needing further nutritional support. And the patient was actually really against me. And at first, he was just like, No, I don't want to do it. And then after we started him on it, and once he got in his former regime, yeah, absolutely love that stuff. Because like a new book, er, because he got so much better. The fact that he was better nourished. And you know, pretty much the reasons that I did was because I could prove to her that he was malnourished. It was fortunate to work.

Aaron Boysen: 26:33

Thank you. That's really interesting. I mean, I knew about Isaak, but I just thought it was marketed towards Oh, it was made for more sports professionals or people working in sports medicine, and I sort of thought it was maybe impractical in clinical practice. And but I guess I'm wrong.

Mike Patterson: 26:53

Yeah, I think sort of, it's marketed that a little bit more towards sports, you got think first, a lot sports are probably going to be doing more body composition assessments, we would do it. But I just think in terms of their teaching methods to take a correct measurement. So especially sort of like, error can be huge between the same people doing it, and also sort of taking the right measurement. So you know, if you take a measurement, a couple of centimetres different on the are, the measurement might be massively different. So if you get taught the correct technique to do it, even stuff, like taking capsules, mid upper arm taking callipers, I just think it's really, really applicable. And because there's so many conditions, as I say, Why Where is useful, but at the same time, doesn't matter of limitations. If you can do some pretty easy, quick answer. I think it just makes an assessment so much more comprehensive, I think it helps from a patient perspective as well. If you're showing that their strengths increase, then you can show it to them that their nutrition interventions work and that you're getting some functional outcomes is really important for patients, especially if they can't see any changes in the way because it's been masked by deema, or look or sighted.

Aaron Boysen: 28:01

Thank you so much. I think that's so important, especially over the last couple of months for myself, it's really illustrated the limitations of weight, but also, BMI and BMI in the context of a lot of our screening tools, has very crucial to acknowledge limitations that are prevalent. That brings me on to another topic recently due to coronavirus, and a lot more patients being an ICU. And having prolonged periods of time on non invasive ventilators, they might have lose a dramatic amount of weight, but maybe not have a reduced BMI. What's the dietitians role in helping those patients? So basically, you've done an assessment and you found out that this patient is healthy or even overweight or obese BMI, but has a dramatic amount of muscle mass loss due to recent weight loss? How would you approach that

Mike Patterson: 28:57

those patients so like, yeah, sarcopenic base is quite an interesting one in terms of they've got to really, really poor health outcomes there that if they're going to have high adiposity, that's not going to be a great outcome for them. But also the fact if they're gonna have low muscle mass, it's really going to impact them. So the first thing I do is I speak to the physios and see what they're up to. So we know in terms of gaining muscle mass, the biggest driver is going to be some form of resistance exercise. resistance exercise doesn't mean that they're going to have to be hitting the gym five days a week, you know, so just means at least some resistance for them. And in terms of nutrition, I think it's sort of quite an interesting one, because you're gonna have to try and address a couple of different things. So you're going to try to have to address the fact that have probably been having an energy surplus, so you're going to maybe want to look at reducing their caloric intake, kind of want to put them in an energy deficit. And alongside that, you're going to have to address the protein intake. So we know in terms of building battery mass, you can build up the mass when you're in a deficit. Especially for someone who's sort of like quite a novice when it comes to resistance training. But again, this is where I think sports dieticians, sports nutritionist sports dieticians and a general clinical dietitian are probably disagree what a high protein diet is since a Chappie called Josie Antonio, who's the editor for journal of the National Society of sports nutrition. So he's done quite a bit of research on really high protein intake. So you're looking at three, three and a half to four and a half grammes per keto. So he sort of argues that he plus a high protein diet is something over two grammes, tequila, and I probably sit on that side of the fence with him, but high protein diet is probably something either two grammes per kilo so there's some work done by Brad Schoenfeld and on Aragon, so they said to maximise the anabolic effects of protein, you need to be looking at both doses. So four meals a minimum of four meals, a point four grammes per Keilar up to ARDS point 1.55 grammes. So for these patients, you're going to be looking at trying to get 1.6 to 2.2 grammes of protein and ideally split all the four even meals. So this is the whole thing I said on my tonight about looking at stimulating muscle protein synthesis. So this again, was sarcopenia. As a guy, Professor protein says to Philips, how much that's covered. So anyone who's got an interest in nutrition support, who's got an interest in sarcopenia, we need to look at the lack of stupidity. So there's a dietician. So she's an Irish dietitian, still a doctor. And so she did some work few years ago, looking at protein distributions. As I think historically, if you looked at probably a sort of typical British diet, you've been looking at sort of quite a skewed proteintech, generally pretty rubbish and breakfast time, maybe a little bit more than than lunch, probably the big hair protein on a meal. So I think aiming a little bit towards sort of those evenly distributed protein patterns, a good idea, especially for a sarcopenia patient, so for their sarcopenic obesity, they're looking at creating some sort of calorie deficit, to reduce the fat mass, you need to make sure they're going to get some sort of resistance training. So speaking with physios and see what videos can do, and then looking at sort of optimising the protein intake, try to find a bit of a nice, even distribution of a sort of at least three to four meals and trying to hit that once the 2.2 grammes, Sue Phillips has actually published something really, really recently looking at nutritional supplements in sarcopenia. Not it's not purely sarcopenic, obesity, so the big ones created. So great things got really, really, really good evidence. So some of the things that we're looking at that the sack kapena is created between D and omega three. So that's I've looked at some of their supplements. So there's some things that people can look into as well.

Aaron Boysen: 32:40

Oh, that's really interesting, actually. So say I had a patient that was a step down from ICU, and he has experienced a massive amount of muscle loss during his time in ICU, and covid. Lows on there, he was on for a prolonged period of time, would you recommend creatine monohydrate to those kind of patients,

Mike Patterson: 33:01

I think it's definitely something worth discussing with a patient. I'm not saying that every single sarcopenic obesity patient needs to be creative. Some people would probably disagree that APR needs to be created. I do know a few people have that viewpoint, but it's just something worth considering. So if you're really trying to optimise that patient, if you've if you've managed to sort of get them into a good eating pattern, where you probably think they are losing a little bit of fat mass, again, this is where answers can be really important, not just looking at the way because you want to make sure that they're gaining some muscle tissue. So if you sort of got them in there, they have an energy deficit, making sure that they're getting a good amount of protein going in. I think creatine is definitely something that you can discuss with a patient. I'm not saying for every single patient, especially in terms of portability, the convenience, you know, you have to take everything into account, but it's definitely worth worth looking at. And I think that's something that I think in terms of supplements from an acute side of things, it's very much pushed towards do there are clinical nutritional supplements Is that fun to use. And, and it's something I talk about when my patients quite a bit. It's our commercial available sports nutrition supplement can be proven ingredients that can be relatively cheap ish.

Aaron Boysen: 34:16

And in fact, they might have less calories and a similar amount of protein, which is useful in this patient cohort.

Mike Patterson: 34:21

Yeah, definitely. And I think that's all set for an underweight patient or sarcopenia. You know, sometimes a whey protein shake with a bit of a cream in that might test, some nutritional support.

Aaron Boysen: 34:35

There's lots of different nutritional supplements out there and take some preferences may vary. I personally actually quite like most nutritional supplements, but I think the point is clear that there's lots of evidence out there for supplements like creatine In fact, more than some products, some ingredients that are used in clinical nutritional supplements HMB comes to mind.

Mike Patterson: 34:56

So with the HMP As I mentioned before about Philips, so if anyone wants to talk HMP, have a chat with Prof. Phillips and see what he thinks of HIV. And again, this is a very, very knowledgeable gentleman who's does get the protein props. So he does a lot with with with muscle tissue. HMB. Yeah, we'll leave it at that.

Aaron Boysen: 35:22

So, onto another topic, you've talked a little bit about your experience outside of dietetics. With, with fighters, I think it was MMA fighters and sports nutrition more generally, is there anything you've learned from outside of the normal diastatic sphere that's helped you during your clinical work?

Mike Patterson: 35:43

Yeah, so a lot of it is, a lot of it does come back to sort of sports nutrition is probably a little bit more at the forefront when it comes to optimising muscle mass. And the really interesting thing is that a lot of sports nutritionists, when you actually look at they their work, they don't just work with athletes, a lot of the research that they do is with clinical populations. So I think sort of just getting to know different researchers and different ideas. And it's just opened me up to a lot of really knowledgeable people who are by background, sports nutritionist, but do a lot of stuff that's very, very clinically relevant. So again, I say we're fighters. And one of the things that we do with biters in terms of Alan MC, where is put them on a low residue diet. So again, low residue doesn't really have a definition, no one can really say what low residue is what is residue, and you've got its moral fibre diet. Again, it's a little bit more in terms of it's a little bit more theoretical, whereas the team Liverpool, john Moore's are actually looking at this. So they're going to do some trials, in terms of what we're different actually happens with a low residue, low fibre diet, and so it's something that they use with their so there's a chap called Colin Evans, who does a lot with professional fighters. So he's looking into it. And I think it'd be quite interesting in terms of what they find with the low residue or the low fibre diet in terms of what happens with these sort of the wear of people's stalls and what happens with it, because it's going to be quite applicable to what we do with stoma patients. We tell a high output stoma patient, you need to follow a low fibre low residue diet because it's going to reduce the output from your stoma and some things that they're going to do with these patients. Yes, the physiology is going to be slightly different, slightly different, but it'll be quite interesting to see sort of what's coming out in terms of a dry or wet wet from there still and what will happen actually, in terms of the stoma patient, something's out there the links between sports and clinical, probably flossing, and people think

Aaron Boysen: 37:45

definitely, especially with that example, you just shared. So in the thread also, you talked a little bit about weight management. Now many dietitians might think I'm not in weight management, so why would I need to know about it, but you think every dietitian should know about it?

Mike Patterson: 37:59

Why. So this goes to the trusted dietitian, dietitians are the experts. I like to think that you would trust dietitians, we are the experts in a lot of areas, but I think people use that as sort of We Are the be all and end all of nutrition is a protected title. And I think a lot of nutritionists, sports nutrition, when it came to the real nitty gritty of Clinical Nutrition would be absolutely clueless, the wonder what the doing. So this is why we are protected because we do have that knowledge is very, very critical. But I think to be sort of seen as an expert, I don't like that word for an expert to me, you have to be so who would Mr. Ridley the unshackled you know, these, these really good researchers cover Australia, I would say they are experts, they have a thesis, they are experts, the stuff that they're publishing is brilliant, brilliant, knowledgeable. But I think as a dietitian, you need to have a good understanding of the basics. So this was put into me from Lindsey King and Helen white, which I'm sure you'll be aware of if you went to Leeds. So what they said to me is, as a dietitian to Joe public are gonna want you to know, the random questions on this new diets out what's your thoughts on it? What's the best thing for web management? Are my son plays football, he runs all these 10 cares? What does he need to do? So these are quite like random questions that the general public gonna want you to know about. So if you say trust a decision, we are the expert, you're gonna have to have a basic knowledge of what the current evidence is for pretty basic super sports nutrition, what the current evidence is for weight management is low carb best, this high carb rest, you know, we're getting to that debate because the goal though is if you have that new, good understanding of the basic knowledge, I'm not expecting ICU dietitian to have the best web management knowledge in the world and run, you know, tier three tier four clinic or if they have a good understanding of Oh, yeah, that review came out recently to say that actually, if calories are controlled brought in equal, no weight loss is better than that. I just think that helps the profession that little bit more gains that a little bit more respect in terms of from the other sort of areas of nutrition is yet where the experts on really, really clinical side of things. But we do have a good foundation of general nutrition stuff that maybe is a bit more public health.

Aaron Boysen: 40:20

Yeah, exactly. So it's knowing the answer to the questions Joe public want to know, because they're not going to ask you about more clinical questions.

Mike Patterson: 40:29

What I don't what do I What do I feed the beast patient on the fields on the unit? Well, they might do is fasting better than keto? Is keto, about Weight Watchers? You know, these are the sorts of things that someone's going to ask you. So it's just sort of having that decent foundational knowledge to say, well, x, y, and Zed. You know, this is probably not better than this, because of this.

Aaron Boysen: 40:52

So how does the dietitian get all this knowledge? I mean, there's so much information out there. And they're working days only, maybe half eight to half, or,

Mike Patterson: 41:02

yeah, it is you have to be a massive nerd lightweight, just pretty much read all this stuff. So there's a few different things. And I'd say. So one thing that I gained massive amounts of knowledge from this is hopeless, something I'll be doing his podcast. So I commuted from home to Leeds and for my undergrad. So that was four years. And then I did post grad courses at noon yoplait. So that was another two years. So I've got six years worth of commutes there. So probably one of the best podcasts out there in terms of the nutrition is sigma. So Danny Landon's podcast is unbelievable. And the things he has on there is not just sports, nutrition, he has a lot of clinical stuff. And I found them really, really useful. And the thing with that is a researcher might talk about something. And then they'll usually put up their website, their social profiling, you can follow him on that. And they'll probably put on their social media, their research, they'll post on there, they might retweet someone else's research in that area. So you can follow them that way. If you're like me, you stalk researchers and research get and you see constantly get email updates from when they're publishing, it's a good idea to find out who the experts are in your area. So I mentioned before about a little bit later, in Australia, obviously, Danny bear in the UK, and then the chaplain as well from us. So Paul academicals, and Santa Vishnu, Vishnu, Denise's from Duke. And so these are sort of experts from the quick care side of things, if you follow them on social media, or even if you want to pop that out onto research get for me. So in terms of politic pn, there's a few people looking at it. So team down at UCL, the dietician called leave keen, who's doing quite a bit with some of the consultants down there from Manchester, Salford, there's a lady called AnnMarie sailboats who's doing a lot politic. And so there are people I saw start to see what's coming out from that side of things. Interesting crit care as well. So that's why I named names, I follow them. So social medias grant research get so researchgate is basically like a reset social media is where people just put what they've published on their social media places to follow people on that, as your country get old debts what they publish, and podcasts again, I think they're sort of three really useful things to find information, you do have to be a bit of a nerd, like me, you're not going to get this done between the hours of eight and four. When you're seeing patients you've got nuts to write up, you're probably not going to get all the same and obviously get solid like cn magazine, video digest and things which do have snippets in but I just don't think they probably got to the dat as much as you'd find from social media. And the thing with social media is social media has its own peer review as well. So someone will publish a paper and some might comment on that maybe didn't do this right or really like the way that they've done this so you can get people's other researchers feedback on that paper straight away.

Aaron Boysen: 43:56

Exactly. So we can follow the people on social media for their research. Can we follow you on social media and catch up with your research?

Mike Patterson: 44:03

Yeah, so although I just post gets follow other people for that reset.

Aaron Boysen: 44:12

So everyone wants to follow you on social media, they can get some entertaining gifts. Thank you so much for being on the dietetics digest podcast.

Mike Patterson: 44:28

Some guests.

Aaron Boysen: 44:29

Thank you everybody for listening to the dietetics digest podcast references and links to everything discussed in this episode will be in the show notes and join us another time for the episode of The dietetics digest podcast. Thanks for joining me this week on dietetics digest, make sure to visit my website a dietetics digest comm where you can listen to the podcast or why not consider subscribing on Apple podcasts stitcher smart radio Spotify or basically just ask Alexa, and you'll never miss a show. And while you're at it, if you found this show valuable, you could do one of two things. Firstly, if you could leave a review on the podcast that you're listening to, maybe the apple podcast or Stitcher smart radio, and you could tell a friend about the podcast that would be really helpful to help grow the podcast. Thank you so much for the support, and have a lovely week day, wherever you are.