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Hello and welcome to it. Healthquest series Minors for the coupon That and I'm gonna be manning that shut this evening. I believe our speaker's arrived. Just confirm that in the second box they should help this. There is this self session on nutrition. I apologize for the vague and narrow title I realized after making it that I should have been more specific. But this evening, we hosted by sleep, whereas lean, it's a dietician with the chest for the life of me couldn't exactly remember which trust is attached to currently, so I couldn't put it afterwards. I know it's somewhere in central London, but it's one of them Anyway, Now it's truly through Facebook fighting a picture of her with food. Ah, every section. We put this up, making the most of it Please to take notes, please to ask questions. Please do interact. It really makes it that much more rewarding for you guys there that much more interesting for us on. Then is there any bits you like, or bits you want to know more about please to get in touch and we are more than happy to send you for resources or questions. Since this address. Feel free to, you know, meet with any queries. We also have instagram and a Facebook. Appalling it. Updating these. We have got new glasses take over from the Who has the last exam tomorrow. After which I'm going to be nagging them until they do it. More authority. The 90. Here's where we are currently in terms of our sessions, uh, sessions ending in June. So that's the one of the first, the two. We have injury in nutrition. It's evening without having evening with the nurse on the 30th, which will be a session to discuss all things around the careers. Nothing we also now have our July August September sessions. Sorted is a sort of overview of what we've got. The two in July will be pediatrics and then pain and pain management. And then August was good extent. Dedicate a little bit more towards people who are applying courses, things that this and then back to us and clinical case is it tender? Different is that I will hand over so you have to show your slides and you'll be shale slides. You know I can share my slides. I'm giving a second stops It's in my face. Big giant Freddy, Uh, get us your one and I can do this and swap to be, uh well, that's send life. They get over to you. Can you see in hand Me okay? Yes, I cook. So I just got a blank screen at the moment. Off the slights s o hi, everyone. Thank you so much for joining tonight. As Freddie said, My name is Rob and I on the cardio respiratory dietician at the World Brompton Hair Field Hospitals or them currently on two non clinical sitcom meant rolls to any chest, England and guys and see, um, asses, um, so a little bit of varied. But Freddie had asked me today to talk about the basic self nutrition. So it will be a pretty basic overview, I think, even just putting some of these slides together, it has made me realize how much applied stuff I do as a dietician, as opposed to kind of natural nutritional science, which was very much in the first couple of years of you need so and I thought I would basically start with some kind of public health guidance in kind of try and bring that back a little bit more to the science behind it and then putting into applied on what the dietician does. So I'm hoping that most of you have seen this public health England eat well guide at the moment. So it's the public health recommendation for what someone without any kind of medical history should be ideally following so over kind of guessed a day or a week. The idea is that the play to split into kind of a third of kinda starchy carbohydrates, the third of vegetables portion of protein and a little bit of dairy, and that's on down the updated one. But they did. This is the most updated one with the one before. They actually had these foods stay with the quick, quick, more unhealthy foods within the plate, and they actually moved it from the plate for this one on anything. What was important to mention is water on and fluid. So they say, drink 6 to 8 cups day and up would be mawr in this heat on also because we are looking within the world dietetics of cultural, competent, culturally competent information, some people have ordered the well guide to support those who have vegans or those who are from different ethnic minority backgrounds to support with health inequality. So, yeah, that just gives you a bit of an overview about what is kind of the recommendations. But going into that a little bit more in detail. When we think of nutrition, we tend to think of macro micronutrients on down, and I'm just going to quickly run through a kind of a macro nutrients. So macro nutrients essentially, what the majority of our diet is made up off, and then micronutrients. We do require them, but in smaller amounts. Hence the macron, the micro. So macro nutrients are things like carbohydrates. Proteins but micronutrients include things like vitamins and minerals, which your body still really needs to function. But again, you won't need them in as large of the mouths. So, in terms of carbohydrates, I'm hoping some of you guys might know this anyway from Jesus, See a level. But for every single gram of carbohydrate, this provides four calories of energy. Um, Andi just to kind of break it down. We think I start of carbohydrates in three different groups, so we think about them and starchy foods which is typically known as carbs. That includes things like bread Pastor acceptor a on there, really important the kids, and they provide vitamins, folate, iron and calcium stay, linking it back into the micronutrients. The other big thing, which I think has, I think, has nutritional scientists. We often and we're like beginning to do more research on. But I think has been very much ward for so many years is fiber So again, that's a type of carbohydrate, which your body can't break down and it passes into your large intestine or your colon so it will be found in plant foods. So things like especially like skins of like fruits and vegetables and beings, but nuts and whole grains. And actually the public health recommendation recently changed within the park kind of five years that we should be aiming for 30 g of carbohydrate. Uh, what 30 g of fiber a day on bats based on very good evidence, since just that fiber can reduce your risk of things that colon cancer type two diabetes, stroke and cardiovascular disease on just to give you a little bit of context. Whilst the recommendation is 30 g a day, as a UK population, we tend to eat somewhere between 18 and 20 g a day, so we actually really under it on this nutrient on the last type of carbohydrate we think about is sugar on this? Convey broken into kind of two categories. Free sugars and intrinsic sugars. So intrinsic sugars are kind of the fruits, which naturally occurring within like a whole piece of fruit or occur within like milk. So I think that lactose on those aren't the ones were really like to concerned about. We're more concerned about the free sugars, which you can find things like honey maple syrup or just kind of white sugar brown sugar. On Those are the ones which is associated with kind of type two. Diabetes and obesity on those are the ones we're really looking to kind of reduce as a public health population type perspective on Get Yes. For those of you who might be wondering, free sugars do include things like fruit juices, so it's weird. The phrase pre free sugar used to is quite a new phrase. It used to be called, and there would be it's like non milk extrinsic sugars, so intrinsic means like within something and extrinsic means outside and the way it's kind of Onda way it was kind of categorized is when you think of intrinsic sugars, you think of sugars like within a cell in the plant, or like within a selling a fruit. But if you can imagine that when you juice a fruit, the blender will obviously destroy that cells so the sugar will come out or the cell, and that will be extrinsic. So that is why it's kind of free sugars. I heard that kind of makes sense, but it's just to explain that the reason why I kind of fruit juices like only counts one of your five days because it is technically a free sugar. Um, the other macronutrient want to quickly touch on is protein, which is really important to keep your muscles really strong. And it's a really big part of being clinical dietician. We focus a lot on protein for a lot of different conditions, everything from cancer to respiratory conditions on again for every gram protein it provides four calories off energy on you guys are probably aware that there are 20 minute acids and they are the building blocks of protein, and if you do study dietetics, you will have the fun. You have fun. I lost my work. But you have the enjoy of having Teo remember every single amino acid and draw them. But I've gotten about, um, now generally as a UK population especially, and that's good, say so. She must be is, actually for everyone. We tend to overeat on protein, so we kind of work out for general population protein requirement says A few times you're waiting kilos by 0.75. That's how much protein your body probably requires on down, I think generally fly can average female that ends up being around 45 g a day, and we tend to eat somewhere in the 60 g. So it's not a nutrient word to worry about from a public health perspective on, and then we come onto fats on again. This is quite different to protein on down carbohydrates because for every gram of fat actually provides nine calories, which is obviously more than double what thing other macro nutrients provide. I will say nutrition isn't as nuance like if there's a lot more nutrition is, there's a lot of shades of grey with in nutrition, So it's not quite a simple, is it? Providing for nine. But that's generally a ballpark figure. You're probably aware that they provide essential fatty acids and which is really important to make our brain works essentially. And also they carry around fat soluble vitamins, which is really important to make up with these functions, or a D, E and K on Did you probably have heard of the term saturation unsaturated fats, saturated fats and typically solid in room temperature? And you can probably imagine their chains if you do any kind of chemistry on unsaturated fats, which we think of mono and polyunsaturated fats, which is the ones we typically want more off because we know that saturated fats are linked with increased risk of things like increased cholesterol in our blood, which is not very good. So it was just a quick thing about when you think of the word dietician. What do you typically been cough on? Typically, whenever I tell some, um, a dietician, I get told or well, can you help me lose weight on? Actually, what we do is is a lot more, but I read than that so generally is a whole. We work with lots of different clinical conditions, so it can vary anything from, um, tube feeding. So putting a tube in someone Sorry. Uh huh. Putting a tube in someone if they're unable to swallow that could be achieving that. Tell me or it could be achieved, which goes in the nose and down to their tummy. Um, all the way through to If you have something wrong with your kidneys, you might not be able to have certain nutrients, things like potassium. And you might be rejecting things like sodium on doing like phosphate all the way through to If you got really rare metabolic diseases and your body doesn't break down, I should know certain types of protein. For example. It's how you can avoid that protein within your diet while still trying to get all the nutrients on. We tend to typically work in a multidisciplinary team, so we don't just work on a road with other dieticians. We work with doctors, nurses, other allied health care. Professional was people that physio off patient therapist so way really work with a hole group of dynamic individuals. The course is mainly about kind of. We tend to bridge the gap between scientific research within food and nutrition, and then we kind of support our patients by giving practical guidance with that. And as I mentioned, we work with lots of different feeding options. So all rel feeding and special diets enteral feeding, which I was mentioning before, which is kind of feeding into the stomach and also parenteral feeding, which is feeding into the vein. So 30 asked me to talk a little bit about kind of malnutrition, so because we tend to do a lot of it in hospital, I was I don't know why there's popped up already, but I was going to ask you, like what? When you think of malnutrition, what you typically think, because I think there are a lot of misconceptions and lots of people have. This image of malnutrition is something they see on the TV screen, but actually the definition is really broad. So it's a state of nutrition, weather's deficiency, or excess and energy, protein and other forms of nutrients which cause adverse effects on body foreman function. So typically, we think of malnutrition in two different ways, under nutrition and over nutrition on go over nutrition is things like people who might be obese and let me to lose weight on Under nutrition are people who are either not eating real well, have lost quite a lot of weight or have a low body mass index, which is your weight against your height. Typically, though, I will say in the hospital the million thing we fix on his under nutrition and over nutrition, we tend to focus on within, like a community setting, say more like working with GPS and working within a community clinics again just for you guys to think about what do you think costs the NHS more? And I know these fingers are a little bit old, but under control. You're not over nutrition. So ah, lot of people are quite surprised to hear that under nutrition actually cost, then itches a lot more than over nutrition on. I would ask you to reflect on kind of what do you see more in the media being spoken about? On Interestingly, I know this data is old, but this did actually include Type two diabetes as well. So it's just to re highlight that there is actually something which is causing a lot mawr, I guess, damage in terms of cost to be any chest, but also is, ah, not not debilitating to patients. And that is kind of under nutrition. And you might be sitting there thinking okay, but, like, Why is it so expensive on? The reason it's really expensive is because if you become malnourished and lose a lot of weight and lose a lot of muscle, you're more likely to get things like respiratory failure. And if you get respiratory, well, you're more like a different hospital, so hospital stays really expensive. You're more likely to pick up things like an infection. So and things like a pneumonia if you got anything like a pressure ulcer off a wound. If you don't have good nutrition, it won't heal on again. So that will be kind of uncovering the costs off, nursing, having to come out and check the rooms and trying and address it as best as they come without the nutrition, there's a bidirectional link between depression, um, malnutrition. So if you're depressed, you are more likely to become malnourished because you're more you're less likely to kind of eat what you can and eat kind of the correct nutrition, but also, if your manners you'll see more like you become depressed because you don't have enough energy to really kind of support your brain functioning. Um, the other thing, just to mention, is something like hypothermia as well. I'm so I work in a specialist heart and lung, um, center. And you might be asking about How does malnutrition actually happened? Like, why do these patients news wait to the point where they picking up infections and they're having to come in to hospital? Big thing is kind of weight loss and poor appetite or anorexia. So if you pick up on infection or you've got a lung disease, it's quite normal that inflammation can cause a poor appetite. So typically, what happens is it sends off site a kinds, and that will send signals to your brain, dampening down your appetite and telling your body not to have an appetite. So if you don't have an appetite, your more likely to eat less and then you'll lose weight. A psychological state is really important, so with our patients with long term chronic conditions, it's it's really hard. It's it's a really, really tough thing on. So again, like I was saying before, if you are depressed, you're more likely to get money fishing because nutrition is the least of your concerns. Wound healing. So we often see a lot of surgical patients on do again. If they've had, like, a massive surgery, something like a heart lung transplant thing. Like they they'll need extra energy and protein in order to heal on day. Sometimes they're acclimates to be really, really high, and so it could be really hard to meet them so they can risk getting a nourished taste changes, which is something you probably have heard quite a bit from Cove it. But we also see it in, for example, a lot of respiratory patients or cancer patients as well, especially if you're on chemotherapy and if it could really very everything from kind of bland to metallic. And so it's thinking about how we can work with the patients to support getting the most nutrition in them. Whilst working around that taste changes gastro symptoms, so giant issues absolutely love their gastro symptoms and love asking about bowel so. But it's not really important things like diarrhea and constipation, because If you've got loose stools, you're going to lose all your nutrition. But also, if you're constipated, that's good. You can just imagine everything kind of blocking up, and that's going to impact your appetite and you're just not going to feel hungry. But also things like bloating again really difficult, like a really tricky symptom for people to have on its how best we can support that. A swell I'm ventilations. There are a lot of our patients also have, like face masks and oxygen tanks. On that, um, abbreviation. They're sore. A shin put that is, and sounds with shortness of breath or short of breath s. So that's a medical. If you've ever seen medical next, you'll see that coming up quite a bit. But if you're again, breathless is really hard to coordinate your swallow and you're eating, um, and also in terms of ventilation, A said. If you've got a face marks based masks toe support your breathing, it's really hard to eat things as simple as like dry mouth can really impact. How much you eat are Lastly, I think this is gonna be an ever growing area. Is fatigue and mood and security so again living where the chronic condition is really tough. But as you can probably see, what's on the rise of the moment is food and security say people who are actually in jobs are not unable to you afford food, and I think it I think that's just gonna worsen over the next year. So that's something we really need to report all of our patients with on sign post wherever we can. Um, so in terms of what we do to support to these patients, so we typically work with them on. Look at symptom control. Is that all of those symptoms? I just said on the previous slide. We look at what we can do to help. So there are lots of different diet tree things which can help, for example, a dry mouth and things like having ice keeps things like it's quite a holistic piece of work, but like like having a lemon and chewing on soft mints or gum that helps produce saliva. So we do a lot of some to control both holistically whilst working in the with the medical team so we might get some anti sickness prescribed. We also worked really closely with our chefs on. We try and make sure the food is really nourishing. And so we call that food fortification, and we could put you take something called the Food First approach, which is where we try and optimize someone's nutritional intake by a food alone. So that could be through extra nursing drinks, things like milkshakes or juice drinks just to help bump up calories and protein on. We also offer or nutritional supplements, which are kind of like that. They tend to be milk or juice based drinks, which you can kind of get from the pharmacy, or the GP can prescribe them a swell on. They just provide a lot of macro micronutrient. So if you're unable to eat, you can at least get your macron like creatures through these drinks and quickly set this point any one. Whoever works in the hospital make friends with the dietician because they know what the snacks are the best person to make friends with ever. Yeah, we definitely do. We, um, like a big part of our role is I'm working with the catering team, so whenever they're they're, like trying and you menu or something, we like to get to try everything, and it just sounds from that. There is a lot of lot of work which goes in behind, so a lot of the work can be like how much calories and protein like the hospital menu provides and how we can work with Occasion team to optimize that because there are certain standards and it could be really hard to meet, so a lot of work does go into it. But then, when we do get the free food, especially in the NHS, mean love free food, it is great. Um, I was also just going to say, kind of like I was mentioning before a lot of what we do, especially if you work in certain areas based like stroke or critical care. When I worked in critical care, a lot of people say Oh, but like, What are you doing as a dietician on when someone is breathing through a machine? Obviously they're unable to eat and drink because they've got a machine potentially in their mouth, so that's supporting them to breathe. So we need to think of other ways to feed them in order to for them to get any questions they can heal well, so this is called a nasogastric tube, and this is a short term tubes and you would only have use in a short term situation, and you pass it through the nose and it go into the tummy, and then you would feed through that on. Do also for longer term situations in particular, no degenerative diseases. Things like MND, for example. What can happen is your swallowing can deteriorate on, so it can be quite distressing for people to swallow and have any nutritional medications through their mouth on. So what you could do is bypass the whole system by putting a feeding tube into their stomach. And you can put all their nutrition hydration on medication through the tube. And we also do you do a bit off what's called Parenteral nutritionist. Well, I didn't have a picture of it, but it is just nutrition through the vein. Um, Andi tend to use that if the stomach isn't working very well, so potentially. For example, if someone has cancer of the stomach and it we couldn't feed through it, we would put the nutrition directly into like a vein here, which goes into the heart and nutrition could go around again. The the reason Some people might also, Why don't we do this more often off? What's the indication? The reason we don't use these things. These are quite invasive nutrition techniques on. For example, nutrition through the vein has lots of risks of infection. So that's why it's like a very, very, very last resort and also, you know, to get this feeding tube. It's called a gastrostomy in the stomach. It's it's ultimately kind of a small surgery, so it's just to kind of keep those things in mind. Um, one of the things we do, especially I'm going kind of back to you. Weight management and what I was talking about in terms of kind of over nutrition on when we're trying to support our patients to lose weight is we look at trying to implement back positive nutritional messages. So I think something which could be very confusing for a lot of people is that when you look a kind of public health messaging, it can be quite conflicting as we get a lot of feedback being like Oh, but I am I supposed to avoid salt, sugar, fat like all of them, like, What am I supposed to eat on? So a lot of our work is quite holistic in this regard and can just be about like me building relationships with weight, kind of people's relationships with food on. So a lot of our reinforcement messages can be things like positive nutritional measures such as eating the rainbow on, obviously going more in depth into their diet to see exactly what could be changed, what they're managing, what is a good diet and what what they expect as well. Um, on d I think this is nearly my last like, But I think what we should also want to say is that when we look at weight management and someone trying to lose weight, so a big piece of work that we also look at again quite honest ically is looking at satiety so interestingly. And that's kind of the sensation of feeling full. So out of all the macro nutrients, I was saying, because it kind of that carbohydrates, protein protein is actually the most satiating macro nutrients. That means that, um, if you have a good good amount of protein, that will help you to feel full of the longer, um, and so typically, it's about how we can support patients to almost manipulate their diet, to improve these four features, to support them losing weight because I'm going a bit of a soapbox. But one of the things that people don't understand about kind of weight loss and weight management is that our body evolutionary is kind of working against us. So our body, because if you think back in like the caveman days where you didn't have a constant supply of food, your body would be constantly clinging onto any kind of fat or muscle that your body has, because it was really detrimental for you to lose weight. And so it's a really hard process because your body is actually working against you. So when you're trying to lose weight, your that's not normal for your body. Your body is thinking I need to cling onto the weight I can because it's it's worried, and it thinks it's in starvation mode. It thinks it's not going to get another meal for, like years. So yeah, we work with kind of manipulate and see whether we can increase protein opposite to a safe amount because protein can also detrimental Effect your kidneys if it's enlarged volumes on increasing fiber. I mean, I think everyone needs to do that. But again, even more important for people who are trying to lose weight, because again, it can really help you feel full of for longer swapping your facts to you. Healthy fats. That does help with the tighty, but also it more likely also helps with your blood profiles. They're making sure that your cholesterol is low on fluid again, like I think it's one of the nutrients that we often don't consider enough. But a lot of the times when you're hungry, sometimes you actually just thirsty on D in making sure you have enough fluid throughout the day can support what kind of weight management. Um, I think this is my last slide, but I think it was just to mention like the nutritional journey isn't always a light bulb moment for everyone on, and it's the way I kind of like to describe it to patients is it's kind of like a string of fairly lights where you kind of in terms of like recovery from nutrition, Mountie traditional, any like even weight management. Your your kind of just waiting with the kind of every single light bulb to flick on. And eventually you'll have that whole string of light bulbs when you eventually reach your goal. But it's not something which is gonna happen straight away, and it is a lot of work. So, um yeah, I think it's just to mention that it's a lot of burden, like a really big bird and for our patients on. We're mindful of that, and it's just her support managing expectations. And so I think that's it for me. I didn't want to keep it too long, so I wanted to make sure that there were Times Square. If you do you have any questions, I'd be happy to take them. Thank you, but I up to start with a question, actually, because the thing is quite interesting, one that we I think a lot people, a lot of a lot comes up about it. I think online, that's what What were your something some of the fat diets that are out there when people are trying to lose weight through a little bit? You know, you know, things like that can start it. It's things like the like this, like fasting diets, those things, like people who go vegan fiddles to lose weight, etcetera. Do any of them sort of hold credit to you or do you think they will? So I think it's quite a difficult thing. And I think one of the big things that with the dietician is like being dieticians. We always think about personalization. Um, interestingly, the nice guidelines do stay that essentially weight loss is so hard that, especially initially, it kind of says any kind of die or any kind of way that you can leave white, Um, is okay in the short term on so wasp. But I got I think this is The thing about nutrition is there's like 50 shades of gray. It's it's quite a nuanced area. So if I had a patient who who was coming in and has, for example, lots of cardio metabolic risks, so risks to the like heart on, they really need to lose weight. And they were very keen that at least for the short term, they want to try a really low calorie diet. I would look at supporting them safely with that or the short term thinking about that, they need to consider their nutrition in the longer term. The caveat with that is that if, for example, it's a patient who we see like obesity, if you are obese, you're unable to you and have a heart or lung transplant. If those patients lose weight really, really quickly, they're more likely to lose their muscle. And that's linked with worse clinical outcomes. So I wouldn't be recommend like they actually need really sensible weight loss. Um, but general population, I think if you're working with the dietician, you probably look at something you want to try in the short term, see if it works, and then I get evaluated again very shortly and then see how that works and then look at reintroducing, um, a more sustainable diet. I think so. Rosy just to say around that it's quite a interesting world because there were conversations with in the nutrition world about whether expectations around weight loss. So is it. How realistic is it for people who are an obese PMI to be going to a normal weight of bm eyes that really something we should be aiming for on There are increasing bits of evidence of kind of quitting quit. What is used to be known is that your your dieting so losing like 5 to 10% of your body weight. But regaining that that there's increasing amounts of evidence to suggest that that actually does have benefits for your heart and does seem to have benefits for your health on. So if the Amos just to, like lose weight, gain weight, lose weight, gain weight because that does seem to have benefits for your health, then if it's a short term diet, yeah, as long as it's nothing ridiculous around, say, for outrageous. I think in the short term, especially if you're working with a dietician who would help to guide you to make sure it's a safe, it's possible. Yeah, it's It's okay. That's a good question here, which is dieticians help deal with eating disorders, and what does that entail? And what sort of advice do you have on that base? Yes, so we do. That was actually my previous roll a couple of years ago in like mental health, So we work in a lot different types of mental health. So everything from psychosis, eating disorders Yes, we play an incredibly key role in eating disorders. Even sort of start a Shins are a big so typically within the NHS. Um, it's just that you would like again funding so theater chest tends to They do have outpatient eating sorters, but there's impatient, even soldiers, and there's quite stringent cutoff so on. It's very much weight slash body mass index based, um so typically each and sort of dieticians within the NHS tend to see those who are really quite unwell on are really quite a low body mass index. In that case, we work very closely with doctors like real itchy like side on side with doctors and psychiatrists in it. So what we look at is the first thing we do is we support to manage something called reach feeding syndrome. So when your body has been starved for a really, really, really long time, if you suddenly give that patient lots of nutrition, they're essentially the electrolytes in their body and their blood will go out of sync on Do will drop and it can cause your heart to stop it in its it can be fatal. And so we work really closely with the doctors to get their blood's monitored every single day. Onda we slowly build up their nutrition. We also support in multi disciplinary team discussions around Danu Trish in in Terms in the context of Like, how, um well they are if they need to be sectioned whether how risky their nutrition is. Um, there was some people say that if you are very minor shin, your very low body mass index that your unit you don't have enough energy or nutrition in your body for your brain to actually kind of think and make decisions and have capacity. So we will support with doctors to run to look at that. But it's very much that's quite a doctor led thing on. Then we trying to go. She ate nutritional plan. So and that could be really tricky because I'm it's. It's about supporting kind of patients on giving them a sense of autonomy around their nutrition, which is such a big thing for them. So it is really tricky, so it could be looking at what foods they currently eat and what we can get more off to support their recovery. In extreme cases, you know, we will do the plan for their artificial nutrition. So if someone is sectioned and they are really a risk of dying in some hospitals, you you do have to risk, obviously not the dietician. The masses and the doctors will have to restrain them, put a nasogastric tube down them, and then feed them through that So we will do the feeding regime. But, um, that's quite I feel like this is like a lot of the NHS, even sort of work. It tends to be quite risky. Maurine kind of the private sector, just Oh, but you know, you do kind of work walk more with patients in terms of supporting um supporting like a healing relationship with food on again, looking at kind of safe of foods and unsafe of foods to kind of prevent them getting to that stage on. It's a lot around kind of relationship building report holding also looking at what again is around in their environment socially as well on do you would still would be linking with their GP and doctors. But yeah, it's quite different, depending on the risk of the patient and does anything else with that ready. I was just gonna ask to extend slowly. That's hopefully that you told me about the eating to sorta side that you had a mental health. But what about other mental health conditions? So see, if you see in things like psychosis that she's feeding there. Yes, they they actually have the opposite problem. So then mental health, especially like patients with psychosis. They tend to get pretty on these drugs called AH Lands Opinion or clozapine on it. It's really far is, actually, it's it's actually pretty heartbreaking. What happens is they get, they become psychotic and they need these medications in order to keep this I christen to control a huge side effect off these drugs is weight gain and just having an absolute huge, huge appetite on, say, what's really, really it's not really sorry. What happens if we put them on these drugs cause they need. They need them to keep them and your health under control on they end up gaining loads of weight. Becoming really obese on what's really sad is that they no, all of them, but a lot of thumb. If they've got severe mental illness that's actually in alleged bit like you're ineligible for bariatric surgery. So, um, it's It's quite a challenging situation where, yeah, these patients need to be on these drugs, which is literally not their fault, and it's literally causing their appetite to increase, then that you're getting loads of late of weight. And then should they let you get to see where they need the actual surgery? We can't put you give it to them, so we would be looking at weight management. A lot of them get diabetes. They get hyper cholesterol. In years, they get high cholesterol, so we typically tend to work same kind of weight management. I think we tend to work a lot more with the occupational therapist and physiotherapists because you kind of need a big multi disciplinary approach on. We also do sometimes work with the doctors to see whether medications can be changed, because sometimes it's about stepping someone down from Coloscopy into The Lancet. Peen on that drug is not as weight inducing as a so it's yet again a very big part of MDT working. But yeah, that's kind of the work we would do around that. Thank you that, but I don't see any other questions come through If anyone has any questions, do you prove to shed them? I just got last one last one for you, which I think what? What would be your general advice to anyone? Let's say Doctor, nurse, paramedic, anyone the, uh, the world. What? What do you like? Big things to look out for with patients in terms of mallet over and under nutrition of your bed down patients, Your general patients in hospital? Yeah, you big it's yes. So I think, um, it's interesting. So this is like this really good study, and it's actually in the lung Constipation's and a lot of lung cancer patients when they get seen by dietician. Typically, they tend to being kind of the terminal phase on in the study was saying about how what these patients really wanted was just their weight loss to be acknowledged on. Typically those. I think what people forget is that there's so many social links and, like cultural links with nutrition and food. So you know, for me personally, when I'm happy, I eat and older take away. When I'm sad, I eat in order to take away. When I got on friends, I go out to eat like that's literally like it's so ingrained within our society. Onda um, it's really hard for people. Teo be in a situation where they have no enjoyment from food. It was really hard for, um, carries and family members to watch their loved one not eat. And the other thing to mention with that is that food or something that family members and carriers can feel like they can play a part in and always feel like they can have some level of care towards. So that relationship could be quite tricky as well, where someone is trying to help their loved one eat, but they just don't have an appetite. So bring that back to your question. I think it's just about asking, like about If you feel like someone has lost weight, just ask them whether they have lost weight and potentially ask them what their story is behind that because typically again, because nutrition of food is just ingrained so much into our lives, there's typically like a really big story about it and the story that they want to share, and they just wanted to kind of be acknowledged. So definitely if you're thinking so If you're worried about someone's nutrition, they're not eating. I'm checking with their weight and checking with the mess. Um, I think over nutrition in terms of like a hospital. That's not something we really focus on too much. But I guess the question you could always ask is just whether they would want weight management advice and support on discharge and add it to the discharge. Ask The doctor started to this discharge summary because it's not important right now. But that's not to say that using weight within the community when the comfort of there in home won't help them to prevent another hospital admission on won't help their health. So, yeah, I think those are the two things which are important every year article and one aspect from way back. When I used to work in a ward that was mild, make sure said to me was, Patients tend to get very reduced appetite in hospital, partly because actually, we get so used to a nature around. When we eat, we go to a special room, we get food together. We eat it in the special room. We come back the whole ceremony around. But in the hospital bed. You don't leave that bed. That bed is where you sleep That way, This way you live. That bed is where you eat. That bed is where you might go to the bathroom. If you have to use bed pans and the like, it's become really dehumanizing. It really easy. Wouldn't you know, to crush his appetite? So I think making it ceremony about it, what we will do is, um, told to, um yeah, it was a just check with everything's in reach, like something which is, like, really nice is just to ask. Ask what they want a cup of tea and make it check with their like waters and reach asking They want a packet. This get to make sure it's open or check on their bedside to see what their food. Because, ah, lot of you could just be really inaccessible to patients. I just can't reach it. Or they have just not been able to open their jelly or ice cream or biscuits. And just no one has, like, thought about it. So yeah, I guess just also looking at the environment around them. A swell Yeah, very, really good. Um, okay. With that. If no one else any questions, guess we'll give it. We'll call it there. As for every week, if anyone has questions later on. Pleased if you were going to email them to us with more than happy to answer the massive massive Thank you for coming on this evening. Right? So I know you had another nightmare evening trying to get home in time for this. Come. But if no one else has cracked, give them another 2030 seconds because often little of a delay, we speak, and then it takes about 30 seconds. People actually hear it. Um, but we've never queries questions. Of course, that thank you. As always up it sort of on the of metal channel off of this stuff in your starch. The cording police do nebulized hope of one's enjoying this ridiculous heat wave. Well, those in the UK, obviously it's like everywhere else. Um, but yeah. Stay cool. All right. Thanks. Thank you for having me. Thanks, guys. Fine. All right,