Sarcopenia, Malnutrition and Physical Activity feat. Stacy Jones RD

Stacey Jones: 0:00

And I think as practitioners as dietitians, we should then be taking more detailed assessment in terms of looking at muscle mass and strength to better inform our decision making and nutrition interventions. And also, if it can help demonstrate effectiveness of dietitians and measure our outcomes, then I think we should be all doing that as well.

Aaron Boysen: 0:18

Welcome to the dietetics digest podcast with your host and dietitian me Aaron Boysen dietetics digest is a podcast created and produced by dieticians for dietitians. We interviewed dieticians from around the world to talk about their journey and their groundbreaking work. This podcast will help inspire you and others to become the best dietitian possible. I'm your host Aaron Boysen. And today we have my guest Stacy Jones. So Stacy Jones is an associate professor and curriculum change lead at Coventry University. Stacy has worked in academia for the past six and a half years and prior to that worked as a specialist community dietitian, as well as a public health specialist dietitian Stacy's undertaking a part time PhD in the area of sarcopenia. Looking at the role dietitians have in preventing and managing sarcopenia in older adults, she's passionate about leading for the profession of dietetics and evidence based practice striving for excellence in patient care taking in a holistic patient centred approach. Stacy is a committee member of the UK BDA older people specialist group, and is also part of the E f ad. As European Federation of associated dieticians, older adults specialist network in her spare time, she enjoys running, cycling, and has more recently taken on open water swimming. In pre COVID time she enjoyed travelling the world and learning about different countries and cultures. Fortunately, she's got a bit more time on our hands, because that's not available. And she's able to join us today. Thank you so much for joining us, Stacey.

Stacey Jones: 1:59

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

Aaron Boysen: 2:02

So obviously, you've got a large background, a lot of interesting areas. So the innovation and the sort of pushing dietetics forward is something that one of the reasons why I really started this podcast interview some really inspiring and insightful people in the area of, of dietetics. And I wanted to discuss a little bit today, a little bit about the area you're working in, what brought you to that, and how your journey has been so far. So if you could just sort of give me an outline of how you got where you currently are and where you currently are.

Stacey Jones: 2:30

My background started with a degree in biology and sports science, and I wasn't really sure what to do as a career. But I knew that I enjoyed learning about the human body and health. And also I was I had a very strong interest in exercise. So that then led me on to learning more about how exercise can actually impact on the human body. And in health and disease. I was particularly interested in the nutritional aspects which led me on to study a postgraduate diploma in dietetics, to train as a dietitian, and when I first started working as a dietitian, I went straight into public health. I then went on to work as a community dietitian in a more clinical area, mainly working with patients who were malnourished, lots of elderly patients and preventing malnutrition, and nutritional support. Whilst while supporting those patients, I felt that there were a lot more that we could do in order to prevent malnutrition and its consequences and also to improve patient important outcomes. So for patients, it was about the ability to be independent carry out activities of daily living improvement in their mental well being their social life, the quality of life and actual physical function. And so as a dietitian, whilst we're very much involved in, in giving advice to support their diet, their dietary intake and improve their dietary intake. I felt that the the measurements that we were taken around weight gain BMI, we're actually not that important to patients. And I felt that there was more that we could be doing in terms of our dietetic assessment and our dietetic involvement. Was there any particular event

Aaron Boysen: 4:07

that sort of led up to that because you said, You obviously, were looking at sort of anthropometric measurements like weight and sort of helping people who have maybe had unintentional weight loss and helping them restore that way, if you have any, any sort of experiences or sort of a collection of experiences that you felt with patients that you felt that you could do more with?

Stacey Jones: 4:27

Yes, actually, I had a lot of head and neck cancer patients who are on enteral tube feeds and actually still had a life around them still going to work, still wanting to be able to do more and get back to their sort of active lifestyle and with feeling like it was impacting on their their sort of mood and their motivation with the amount of muscle loss that they'd lost in the strength and sort of their ability in terms of their functional ability to actually when it came to the weight gain and that wasn't actually as important and they were asking after asking me things that they could be doing. To help gain some more strength, and particularly around exercise, so that sort of led me to think about, and particularly an older, frail adults who were housebound, maybe had quite a high fear of falling or limited mobility, and that has impacted on their, their social aspect and their ability to go out and meet people and socialise that has a knock on effect on their mental health and well being as well. So for me, it was about could we be doing more for patients, rather than just restoring their weight and reducing malnutrition? And to actually go one step further and enable them to take more control over their life and have that independence. So in terms of muscle mass and muscle gain, what interventions were actually effective in achieving gains in muscle strength and muscle gain and muscle function? Rather than just thinking about the weight gain? And actually, it did? It did cross my mind a few times that were we just increasing people's weight? And therefore what what weight were they actually putting on? Was it fat mass? Or was it actually muscle mass? Because if they were very sedentary, and they weren't actually doing any physical activity, but they were gaining weight, would that just be almost increasing their risk through you know, for other things in terms of increasing their adipose? Sorry, increasing their their fat mass, and not their muscle mass?

Aaron Boysen: 6:20

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

Stacey Jones: 6:27

So this inspired me to think about exploring this area in terms of further research, and that that was what led me really to move into academia. So I moved to come into university, teaching dietetic students, and that career really enabled me to have influence over the future generation of dietitians, thinking about what we learn at university and how that will then go on to impact practice and change practice that was really inspiring and being able to have that impact in terms of the profession. And undertaking a PhD, whilst I was at Coventry University gave me the opportunity to then explore the evidence behind malnutrition, exercise, nutrition, and the links that that had with sarcopenia. Throughout my the journey of my PhD, and this has evolved really into looking at the role of the dietitian in prevention and management of sarcopenia. And more. So what could we be doing in terms of combining that exercise and nutrition approach, which is what the evidence suggests, and exploring the scope and the role of the dietitian, and potentially expanding that role or advancing that role? And to be more effective for the patients at the end of the day?

Aaron Boysen: 7:42

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

Stacey Jones: 8:00

Okay, so sarcopenia has been around for a very long time with various, various definitions. And it was only until recently that we had a consensus and definition for sarcopenia. So in 2010, the European working group for sarcopenia, in older people published the first definition and consensus for sarcopenia. And this has since been updated in 2019, whereby sarcopenia is defined as a disease of muscle failure, failure, rooted in adverse muscle changes associated with ageing, but can occur in early life. So that's the definition from the European working group. And what we're really looking at is the combination of low muscle strength and low muscle mass for a diagnosis of sarcopenia to be confirmed, and then we look at the loss of physical function as an indication of the severity of sarcopenia.

Aaron Boysen: 8:52

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

Stacey Jones: 9:02

That's a great question. And actually, it's about a holistic diagnosis. So we can we can look at muscle strength, muscle mass and physical function, and have more objective measures of those. Some measures are more appropriate in a research setting, and can be quite costly. And we do have some measures that are quite easy and quick to do that would be more suitable in a sort of clinical setting with a patient or in a patient's own home. So in terms of what the European Working Group sarcopenia recommends, for diagnosis, so for muscle strength, they recommend using grip strength in a hand grip dynamometer. So that's actually something that can be done out in the community within a hospital ward, it could be done in the patient's own house. All we need is a hand grip dynamometer to take with us, and it doesn't take very long at all to measure a patient's grip strength and then there are designated cutoff points to then diagnose sarcopenia. So for men, it would be a cutoff of less than 25 In kilogrammes on the hand grip dynamometer for women less than 16 kilogrammes on the hand grip dynamometer. So that's a really simple, quick measurement that we can do to assess muscle strength. And it's a good surrogate measure for upper body strength and lower body strength as well, with a hand grip. There's also something else that we can do, again, in the clinical setting, it's called a sit to stand test. So it's really simple, get our patient sit on a chair comfortably, and we time how long it takes them to stand up and sit down from that chair five times without using their hands in a safe and controlled manner. And that can be an indicator of lower leg strength.

Aaron Boysen: 10:37

So 100 measure and sit stand tests are really useful measures. And I've actually noticed that sometimes, occupational therapists will do sit to stand tests, and you can often sort of either both do them and see any differences or or use their measures and use them in your assessment to be able to assess the patient's physical function. But that's, that's great for our work on on award setting with some older adults. And I'm able to do some of these tests. But unfortunately, a lot of dietitians are increasing remote consultations, and that they might have to talk to someone over the phone. And just about using questionnaires like sock F. Do those? Do those hold any weight? Would these be good tools to be able to assess a patient?

Stacey Jones: 11:19

Yeah, the sock f is a validated screening tool for sarcopenia. And it's five simple questions. It's based on a self reported answer from the patient. But it's very quick and very simple to execute in a clinic setting, and even in an on a virtual consultation as well. So you don't need any physical measurements to take. So yet five simple questions, each question is scored either a zero or a one or a two, and then the total score of 10. And anything that scores four or more is a likely indicator that someone may have sarcopenia. That's a really quick and easy screening tool to use. And it's recommended by the European working group for sarcopenia.

Aaron Boysen: 12:00

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

Stacey Jones: 12:07

Yeah, so the gold standard really, for measuring muscle mass would be in a dexa scan or MRI scan, but obviously, they're very expensive and that they're not easy to come by. And you would need to be trained as well in order to carry out those measurements. So we don't routinely use them. bioelectrical impedance is a good measurement. cbia is a good technique in order to look at body composition. So that looks at that can look at body fat percentage, and fat free mass, an easier and more surrogate method, sort of a more practical method to use for dietitians, I think would be to measure the calf circumference. So that's something that's really simple, just need to tape measure. It's not too invasive for patients, and it's a good predictor of muscle mass in terms of older people, and a calf circumference cutoff of less than 31 centimetres would indicate a reduced muscle mass. Why

Aaron Boysen: 12:58

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

Stacey Jones: 13:03

So reduced muscle mass is often seen also with a reduced level of strength and that can affect our physical functioning as well. So some of the consequences of that could be reduced independence to carry out activities of daily living, increased risk of frailty, and reduced quality of life, increased risk of falls and fractures and an increased susceptibility to morbidity and mortality. And overall this this will have an increase a knock on effect on health care costs as well. Obviously, this is around where

Aaron Boysen: 13:34

sort of physical physical functional mobility is often looked at by physiotherapists, maybe occupational therapists and dietitians are often have very weight centric approaches to assessments. And if some and often our screening tools, for example, the most screening tool is used and often that's very, very weight centric assessments or patient use referred to us because of low weight or lots of weight loss. dieticians really have a role in helping to prevent or treat sarcopenia.

Stacey Jones: 14:04

I think we do as dietitians we will be seeing frail, malnourished patient, patients with multiple comorbidities. And all of that will place patients at further risk of sarcopenia. So if they are malnourished, they're likely to be at risk of sarcopenia. I think we have a duty of care to offer a holistic, patient centred approach with patients and patients are at the centre of our care. People come as a whole. So we can't just look at individual problems. We have to look at the whole person and think we have a duty of care to prevent further disease or ill health as well. So if we can have a prevention approach to sarcopenia, then I think we should be looking at how we can be most effective within our role. And I think dieticians have excellent communication skills. We have excellent behaviour change skills as part of our nutritional counselling. So we're able to assess people's motivation help them overcome barriers. We can provide them with education and I'm raising awareness of why something's important. And we can set we can support the patients to set appropriate goals. And all of these are going to be really important when we're talking about physical activity as well as nutrition. And I think, if we're in a position where we've already built up that trust and that rapport with our patients, and we're seeing this population of patients anyway, through our dietary counselling and dietary interventions, then we are in a really good place to then provide that holistic care and offer advice on physical activity or as the care nurse navigator signpost patients to other services. And the evidence actually supports the best approach to prevent or treat sarcopenia is with a combined approach of nutrition and exercise interventions. So I think it's really important to combine the two. So maybe

Aaron Boysen: 15:48

we could start a little bit with those nutritional interventions. So a dietitian may be collecting sort of weight markers and seeing a person's weight go up. Now, you're saying they should collect some maybe 100 measure a set to stand measure? How are they going to use that measure in their assessment? How, how might they change their plan to optimise for muscle growth rather than just weight weight increase.

Stacey Jones: 16:10

So the more measurements that we can take will help him form a proper, more thorough assessment of the patient so that we can tailor our interventions more appropriately. And we can also then measure how effective those interventions that have been by taking more measurements. So just taking weight or BMI doesn't necessarily tell us we might say that their weight has gone up or their BMI has improved. But actually, that doesn't tell us whether that's an improvement in muscle mass or strength or whether that's had actually any impact on some of the patient important outcomes. So the more measurements we can take, the better and more more detailed and nutritional diagnosis and plan can be.

Aaron Boysen: 16:52

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

Stacey Jones: 16:57

so as dietitians, nutrition is our bread and butter so when we're thinking about recommendations for older adults, it's really important to consider their protein intake and their protein requirements. So it's been identified that the Recommended Dietary allowance for protein of nought point eight grammes per kilogramme is insufficient to meet the protein requirements for sustaining muscle mass in older adults. So the SPN guidance on clinical nutrition and hydration in geriatrics recommends that protein intake should be at least one gramme per kilogramme per day in older adults and further recommendations. So based on the protein age study, recommend that for older adults over 65 years old, we should be considering daily protein intake in at least in the range of one to 1.2 grammes per kilogramme of protein per day, and even higher, so 1.2 to 1.5 in those undertaken exercise or those with chronic disease. And obviously, caution should be taken with anybody with possible or existing renal impairment. And now I've heard

Aaron Boysen: 18:02

from so often when new guidance comes out, and they recommend sort of protein intakes of 1.5 dietitians might look at that and go, how on earth are we going to reach that with some of our patients who already struggle to meet x x previous guideline? Is there anything that like you have any tips or any advice or anything you can work towards? Because that's often the main sort of stumbling block I find in Firstly, even dieticians believing that it's possible, let alone the patients

Stacey Jones: 18:33

it is and actually in this particular age brief, older adults may have things that have impacted on their appetites, they may have a poor appetite, they might have early satiety and not be able to eat large portions of food get full very quickly. And for very, various reasons and many reasons. appetite can be poor, in older adults in nutrition intake can actually be quite poor, and they may struggle to meet their their nutritional requirements. And actually, what we know about older adults is not only does the protein intake need to be slightly higher, there's a blunting effect. So in older adults, we see that we actually need higher amounts of protein to actually trigger the muscle protein synthesis. So thinking about how much protein is actually needed at each meal time is important as well. And the guidelines do recommend aiming for at least 20 grammes of protein in each meal, which can be quite difficult to achieve when you've got somebody that maybe has a really poor appetite or is limited in sort of their food choices or their ability to cook and prepare meals themselves. As a dietitian, we should be using our individual dietary counselling skills. So we're actually looking at the patient looking at their food preferences, their current intake and where possible using a food based food first approach. So for example, looking at food fortification, so an example of that is adding four tablespoons of skimmed milk powder to a pint of milk can add an additional 20 grammes of protein To that pint of milk, so we can be advised on food first approaches encouraging high protein snacks encouraging protein foods with each meal, and considering oral nutritional supplementation where appropriate. But definitely taking the food first approach to counsel. Older adults want to provide that advice for older adults on some of the higher protein foods that they could include at mealtime. So milky drinks, and things like eggs with male it's quite a soft, easy protein food to manage. If they're sort of not overly keen on eating meat or finding the meat hard to chew, for example, they're looking at food 45 the foods that they are having going to meals they are having to make them as nourish nourishing as possible.

Aaron Boysen: 20:44

So let's move on to sort of talked a little bit about nutritional interventions. Now let's talk about exercise. Now, do dietitians even have a role in talking about exercise? I mean, isn't that the physiotherapist job on a the professionals in the area? We're not I don't think I received any training on it in university. I said exercise is good. resistance training is good to build muscle mass, but I wasn't given any sort of specifics that I would feel comfortable talking about it with a patient. Is it really all wrong?

Stacey Jones: 21:10

That's an interesting question. I think it goes back really to thinking about our role as a holistic practitioner. So my research that I've been carrying out was to seek out the attitudes and views of dietitians and physio therapists and for the concept of dietitians, offering prescribed exercise alongside nutritional counselling and older people. And actually, it's almost a continuum of what do we mean by prescribing exercise. So it can be really basic, and it could be a very first line approach and just given out the sort of really simple move more messages, and the government recommendations for exercise, and that could then progress on to more prescriptive exercise where we're actually giving more specific exercise advice, setting goals with patients and reviewing those patients. So what when we say prescribing exercise, it comes down to I think everyone's individual interpretation of what we mean by that and perception of what we mean by prescribing exercise. For me, if we're talking about holistic care, and making every contact can then we should be considering encouraging basic physical activity in all patients as part of our holistic advice as dietitians just like we would expect to the professionals to offer first line advice on nutrition, so be it healthy eating for the general population, or basic food fortification advice for those at risk of malnutrition. So I think everybody has a duty of care to talk about diet and exercise in the context of achieving general health outcomes. So simple government advice for the general population of 150 minutes of physical activity each week for older adults, in particular, ensuring that they carry out at least two days of strength training, and also the simple move more messages. So just reducing sedentary behaviour, encouraging someone to get up out of their chair every half an hour or every hour. So it can be very low risk, simple advice that we would, you know, be expected to give to anybody. And if you think about if we're in a clinic with somebody that was overweight, and we're talking about obesity, I'm sure it would be second nature to talk about exercise as part of that weight loss strategy. And it goes hand in hand with with diet and exercise. So why are we not talking about that with older people and older adults, when we come to talk about strength and muscle mass?

Aaron Boysen: 23:22

Do you think there's sometimes when we say things like strength training, it can be quite the words are quite charged, like most people, when you talk about that they view are the glissant for a gym membership, they've got to talk to the guy at the gym, he's got to tell me about how to do all these different equipment, use all these different equipments for six times I've joined about six different times and cancel my membership multiple times. And also it's COVID and increased risks. jever feel like sometimes that that phrasing needs to be altered a little bit in a consultation with with patients and further explanation needs to be given? And if so, what explanation would you would you offer to a patient

Stacey Jones: 23:58

definitely I think even the term exercise can mean different things to different peoples, though, we tend to use maybe the terminology of physical activity as it sounds less threatening to somebody, particularly for older adult, the thought of exercise May, you know get in thinking about going to a gym or having to run a marathon. And actually it doesn't mean that it's any type of physical activity that will get your heart racing a little bit that will increase your breathing rate will make you work a little bit with a bit of effort. So yeah, I think the terminology that we use when we're talking about exercise is important and maybe using the terms moving more or keeping active or physically active is much less threatening than the terms exercise. And I think you're completely right when we talk about strength training or resistance training, it can be quite intimidating for a lot of people and even some dieticians who think well, you know, that's that's a very specialist area, but actually what we mean by resistance and strength training is just working against the force or resistance and For some older people in terms of their exercise capacity, that could mean using their own bodyweight as resistance. So just getting up and down out of a chair, or raising upon to your tiptoes and coming back down again, could be enough to stimulate a sort of strength response. It doesn't have to be, you know, huge heavyweights. But it is important that it's sufficient, sufficient intensity of exercise that can produce those strength gains. So it's about sort of, again, tailoring that advice to the individual and looking at what their what their baseline is, and what their sort of capabilities and capacity after exercise, and then building slowly and gradually on that just so that they can start to see some improvement.

Aaron Boysen: 25:43

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

Stacey Jones: 26:03

definitely and there are exercise programmes out there, such as a tygo, which is a balanced based exercise programme. And so we could be signposting people on to these exercise programmes that are run in the community and through exercise referral schemes. I think talking to your local physio therapists see they see if they have any resources that have already been produced that they deem suitable for dietitians to be given out to patients as first line advice. So it could be chair based exercises, it could be a leaflet or a website where people can follow exercises. A lot of these exercises are going to be done in their own home unsupervised. So it's about balancing that risk really, and I think talking to your your physiotherapist, is the best way to go forward to to find out if they've already got some resources that they would be happy for you to give out to patients or signpost patients to

Aaron Boysen: 26:55

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

Stacey Jones: 27:01

Yes, so as part of my research, I recently carried out some interviews with exercise professionals and physio therapists. They were people that were working already in the context of older people within the community. And it was really to find out what their thoughts and their perceptions and their attitudes were to the prospect of dietitians potentially giving out exercise or physical activity advice to older adults alongside nutritional counselling in the context of sarcopenia management. Actually, I was I was quite surprised and pleasantly surprised by the enthusiasm of physiotherapists and exercise professionals to want to work with dieticians. And to hear that dietitians are actually interested in this area and they see it as being important. And they can see how exercise and nutrition are linked. They were very keen actually that that you can't really have effective exercise without being sort of meeting nutritional requirements and having a good nutritional status. So actually the to compliment each other in a both really important so there were very much positive views of physiotherapists that dieticians should be given out to basic move more messages. And if that could happen as part of the making every contact count and holistic advice that we're giving out, they could only see a benefit in that, and particularly in terms of low risk activities, like chair based activities, or, or general, you know, getting up out of a chair and moving around more and in doing what the patient feels they're able to do was quite low risk, but they were very keen to actually work more closely with dieticians, because they actually see that some of the patients they're seeing maybe malnourished or, you know, not taking in sufficient amounts of protein, or a good diet. And actually that has a negative impact then on the amount of exercise that they're able to do and the sort of outcomes they're able to achieve with the patient. So I think there was sort of a mutual respect of how exercise and diet are both so important and how dietitians and physiotherapists should be working more closely together with patients to achieve our goals at the end of the day, because we're both both trying to achieve the same outcomes with patients and that is to improve their quality of life and their overall health status

Aaron Boysen: 29:15

just out of interest. If you could go back and be a community dietitian again, how would you What would you do differently? And how would you How would you work with a physiotherapist there,

Stacey Jones: 29:24

I think actually learning about more more about each other's roles. So having that opportunity maybe to shadow each other. So for the dietitians to go and spend some time with physio therapists, and likewise for physios to kind of spend some time with a dietitian so that there's a deeper understanding of the role of each I think providing training so using the resources that we've got within departments and the specialist knowledge we've got a so if you can provide some enhanced training for each of us as a bit of a trade off in in training so that the dietitians Can you know, provide training to physiotherapist in order to give that first line advice And ensure that the advice they're given is consistent with the messages that have come in from the dieticians and vice versa. So the physiotherapist can provide training for dietitians on providing that first line advice and, you know, agreement on when to refer to the other profession. So maybe having some agreed pathways of these are the patients that are appropriate to have that first line advice. And this is when to refer on. And better communication really is what I got from both the dieticians and the physiotherapist through my research is that if they're more aware that there's input from both professions, and they can work together, so when the dietitian goes to see their patient, they can maybe ask how they're getting on with their exercises that have been prescribed by the physio. And likewise, when the physio goes to see the patient, they can ask about how they're getting on with the dietary advice, and making sure that they're eating appropriately, to help with their exercise, that those reinforce messages and hearing it from different professional professionals, time and time again, may actually help motivate the patient and improve compliance and adherence to the advice. So actually, they there is benefit in both professions, talking about diet and exercise. So the patient can see the link between the two. And can see the important.

Aaron Boysen: 31:12

Yeah, definitely I remember, I was reading, maybe it was a it was sort of reflection from a dietitian in relation to it was in relation to ICU nutrition, but it was talking about this, this idea of sort of extending roles of different professions. And it was about the overlapping nature of roles and how that helps with things like communication, working better for a team. And I think that's, it's an area where I, I think there is room for improvement if you if you agree in this sort of the assessments that we do and how we manage patients and also communicate with the MDT as a whole, in order to ensure that patients don't just gain fat mass, but also gain muscle mass,

Stacey Jones: 31:53

definitely I think MDT working is the key really is that we're all working together, at the end of the day, the patient should be at the centre of the care. And we are all working together to achieve the same goals. And I think when it comes to actual capacity, versus demand of patients out there, so if we think about how many older adults are out there that are having this general decline in muscle mass and muscle strength, maybe they're more, you know, they're becoming more sedentary, less physically active, maybe their diet isn't to the same quality as what it used to be, are factors affecting their dietary intake. And so they're sort of gradually on this decline of reduced muscle mass reduce strength reduce function, they may not be picked up by any healthcare professionals, dietitians or physiotherapist, so that there are so many people out there that would benefit from this holistic advice and even the early intervention and sort of preventative approach advice. So I think we don't have the capacity for all of those patients who are malnourished or frail to be seen a physiotherapist and we don't necessarily have the capacity there for all of those patients who are seeing physio therapists to have access to a dietitian either. So I think the more we can be doing to to make smarter use of their capacity in order to benefit patients. Yeah,

Aaron Boysen: 33:14

whereas acute settings are restricted by the amount of hospital beds that you've got, community services can be infinitely expanded. incidently sort of grow like almost like you could serve more people. And I think as we learn more about the impact of nutrition, and we learn more about sort of at risk kaski BMI is for older adults Coronavirus below 23 is at risk not dangerous to be around the trip malnourished button. So that risk BMI.

Stacey Jones: 33:41

Well, yeah, so the glim criteria, which is the global leaders in malnutrition, recently released some new criteria for diagnosis of malnutrition. And it it actually refers to the BMI cut offs for older adults. So adults over 70 years have a slightly higher BMI. So anybody with a BMI of under 22 would be classed as at risk of malnutrition in the over 70 category. So actually, it is a little bit advantageous to have to carry that little bit more weight in older age. But what we do need to be careful of is is what is that makeup of the weight? And is it Are they is that weight and BMI, actually masking? What might be a loss of muscle mass and a loss of muscle strength. And actually, it's been masked by this increase in fat mass. So yeah, the more the more measurements we can take, the better our understanding will be if that patient's nutritional status in general.

Aaron Boysen: 34:39

So what role does the most screening tool have then is is that is that still useful screening tool? Or do you think it needs to be revalidated on screen screening tools that involve but not must in particular, but all screening tools that involve BMI and older adults does it need revalidating to really be able to screen effectively because by that chord you might already get a patient that's quite quite severely malnourished, according to the glim criteria arrive to clinic, and Wouldn't it be better to have early intervention in those patients?

Stacey Jones: 35:09

Yeah. So there are many screening tools out there that validated and you know, well used. And that screening tools serve a purpose to try and identify those patients who may be at risk in order to signpost them to appropriate interventions and referrals to appropriate professionals. So the most screening tool is widely used. And it's, you know, it's a validated tool. But I think the limitations are that it is only looking at BMI and weight change. And actually, now we know that, you know, there is more to it than that. And sarcopenia is really important. So looking at measures of muscle mass and body composition, the glim criteria isn't a screening tool, it's a diagnosis tool. So actually, within the limit, it still advises that use screening tools as a first line approach, and then using the glim criteria to then further assess that risk of malnutrition. So that Yeah, the glim is a really good tool, I think we should all be starting to use that within our practice, because it looks at not just BMI, but it also looks at muscle mass as well. And and then we can be using things like the sock f tool, which is a really simple screening tool questionnaire type tool to look at sarcopenia risk, and I think as practitioners as dietitians, we should then be taking more detailed assessment in terms of looking at muscle mass and strength to better inform our decision making and nutritional interventions. And also, if it can help demonstrate effectiveness of dietitians and measure our outcomes, then I think we should be all doing that as

Aaron Boysen: 36:41

well. Definitely. And I've started to use things like sock f handgrip a lot more in in patients on the ward, but also in clinic. And I found them be really helpful not only for me to gauge the patient's progress, and me to get a rough assessment of how much sort of obviously it's not direct. But if obviously the handgrip goes up in the weights going up at sort of a steady rate, you can sort of infer that they're probably gaining muscle mass from that assessment. But also, I found it motivates people quite a lot, especially the handgrip, they go, Oh, once you told me I was below average, I got very upset by that. So I went home. I got I did everything you said and I've worked I've worked for me, I've been working really hard hope it's good to me. And they show improvement. But it's whereas the way is a bit like it usually works better with with with males, and that's probably due to the way society sort of conditioned males to have the appearance of being strong and things like that. But I think the deaf that you can see that the patient isn't doesn't really care about the weight. But they care about these sort of other measures that the activities of daily living. And when we take that into our assessment and inform the patient about our assessment process, I found my myself it really helps the patient understand the importance of nutrition and also as a motivating tool to enable them to achieve the goals that they desire. Instead of just saying this Oh, aim is to increase weight or optimise nutritional status by stabilising weight. Often Often patients don't care as much as we do about measures like that.

Stacey Jones: 38:15

Definitely, I think something like handgrip can be a real motivating tool for patients that, you know, maybe they're not seeing their weight go up. But they're seeing that they've got an improved grip strength, then that can be a motivating factor to say that it is making a difference. And that's probably more important than the actual weight gain itself. Yeah, and it's very simple and quick and easy to use.

Aaron Boysen: 38:36

Thank you. Thank you so much for joining me today on this podcast is dietetics digest podcast, and all of the show notes will be available. And we'll put references to anything discussed. So the Global Leadership Initiative and malnutrition, we'll put references there. And there's a few, a few ones that I want to share and a few other tools like an explanation of what the SOC f tool is. And also references to some of the research that Stacy has been doing on her PhD. I'll also put social media information for Stacy the one she wants to direct you to, so you can keep up to date with her work and keep informed with the exciting new things she's learning and everything she sort of her her musings on Twitter as well. So you can keep up to date with those. I don't know if you wanted to include anything else in the show notes or is that quite comprehensive?

Stacey Jones: 39:26

Yeah, I can provide you with some say for example, the European working group for sarcopenia. I can provide that that documents have mentioned that I've mentioned the glim criteria. And I've mentioned the the aspirin guidelines, I can provide references for those as well. Perfect. Thank you.

Aaron Boysen: 39:41

Thank you so much. Thank you so much for your time. And hopefully you can get back to your travelling soon and fingers crossed

Stacey Jones: 39:50

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

Aaron Boysen: 39:54

you. Thank you for joining us this episode of The dietetics digest podcast. To share your thoughts in today's episode, please visit our social media. Our main channels are Instagram and Twitter. Also, if you enjoyed the podcast Why not leave us a review on Apple podcasts or a podcast host of your choice or consider telling a friend about the podcast. Finally, make sure that you subscribe and follow the podcast so that you can stay up to date with our latest episodes.