July and August

The second half of the year started in a similar fashion to June – just enjoying being in good shape and the very gradual easing of lockdown restrictions and return to some semblance of normality across the UK. This included our ‘Last Man Stands’ cricket season belatedly getting underway, albeit with lots of hand gel, elbow bump wicket celebrations and socially distanced team photos. I developed and delivered ‘introduction to running nutrition’ webinars to local running clubs and had a great response.

We were also able to escape London and get a proper change of scenery for the first time in four months, and my main running highlights of these months were an 18km hard run following Holly on her bike through rural Somerset, and the hilliest run of my life (Strava confirms this: 506m elevation gain) along the Welsh coast, from Tenby to Laugharne. At this stage of the year, 3:50 / km pace felt like a ‘steady’ effort, whereas 3:35 had become my standard tempo pace on the 9km run to work. 2000km for 2020 was chalked up well ahead of schedule, and I was undoubtedly in the running form of my life…if only I’d had a big race to prove it.

September

The month started well, with the closest thing to a race to look forward to in over six months. The Heathside handicap 5km was a safely spaced and well-planned event on the 12^th, and my 16:32 (N.B. the course was short at 4.7km) was good enough for 4^th out of 70-odd club runners.

However, it soon started to unravel. Rather than just take the tube like a normal person, I made the dumb decision to run 22km at 4 min/km pace to deep South London immediately before a full day of keeping wicket in the baking sun for my cricket team (which basically involves leaping around and landing in awkward positions). It could be coincidence, but shortly after that day I started feeling an unusual ache in my hip.

I should then have bailed on our fake club Tuesday intervals slot, but my running ego got in the way and I did the session. Later that week it was pretty obvious I’d been an idiot and overdone it. Again, at this point I could and should have listened to my body and given myself a week or two off, but had committed months ago to a long Bath to Bristol run with a couple of old school friends, also carefully planned around a very rare chance in 2020 to see my dad and granny (outside, obviously). I decided to chance it under the proviso that we kept the pace very easy and chatty. We did, and I survived, somehow, without any pain.

October and November

However, a few days later, it was glaringly obvious that this was a proper injury and I had to sort it out without any further delay. I went down the physio route, and was diagnosed with a stress reaction (the precursor to a stress fracture) and given a structured rehab plan.

So, I didn’t run for two whole weeks (I enjoyed the break more than I expected), then started with 3km at very easy pace. Every 2-3 days I ran again and increased the duration by 10%, keeping the pace very slow. Every other day I took the opportunity to do S&C (far more than I’ve ever done before), and I incorporated a fair bit of cross-training too (swimming and cycling). October saw me cover a grand total of 45km – my lowest monthly total since my running records began many years ago!

Over November, I slowly crept back up to doing my full run commute distance of 9km, and then focussed on chipping away at the pace. I had one minor setback where I veered from the plan and did a bit too much too soon, but other than that I loved sticking to the regimented, incremental structure, and by the end of November I was getting closer to 4 min/km for tempo runs and to 50km weeks.

December

Whereas November had seen slow but steady rises in COVID cases on the ICU, by December, the much anticipated second surge was here. While the numbers on the units are roughly similar to the first surge in spring, the challenges this time are undoubtedly greater, as hospitals are doing everything to keep operations and other services running alongside the direct management of the pandemic itself. On top of this, the frontline workforce is exhausted and massively depleted, with twice-weekly self-testing (a bizarre way to start the day) meaning that the self-isolation statistics are truly eye-watering.

The projections for the coming weeks are getting bleaker almost by the hour, daily death rates are nearly back to 1000, and the country is placed in ever tighter tiers of restrictions…yet the public appreciation or compliance is nothing like it was back in spring. Some are even protesting (maskless, obviously) outside the hospital chanting that it’s a hoax. If you don’t laugh, you cry.

My runs back from work this month made me angry, with people hugging and congregating on increasingly busy streets. Following a year of Government U-turns, the rules got relaxed and then tightened again for Christmas, but by this point, depressingly large numbers of the population seemed to think they didn’t really apply to them anyway. It’s fair to say that the pandemic has really brought the best out of some people and the worst out of others. As I write this, I’ve just had to quickly shave off the Christmas beard, as ICU numbers have spiralled to the extent that we now need to staff the New Year’s Day bank holiday as an emergency.

I tried to switch off from the news over my precious Christmas break, and tucked into some beautiful muddy runs around Hampstead Heath, the River Lea and Ally Pally, plus a first fake solo ‘parkrun’ for 9 months on the Finsbury Park course on Christmas morning. At 18:20, I’m nowhere near back at PB pace yet, but it’s something to build on for next year.

But perhaps the most significant run of the year was on Tuesday morning, as I jogged home from receiving my first dose of the COVID-19 vaccine: the light at the end of the tunnel that my ICU colleagues, and no doubt millions of others, will be clinging onto over the next few weeks.

The post 2020: An unforgettable year as a runner…and ICU Dietitian (part 2/2) appeared first on Tom Hollis.

Perhaps a little self-indulgent, but this year has been unforgettable for all the right and mostly wrong reasons, so here’s my month-by-month recap. I’m lucky that running is a constant in my life, and something I can turn to on even the hardest of days, so I’ve based this blog around that.

January:

Starting the year buzzing with optimism but still burdened by my terrible sense of direction, I got lost and missed the start of Whitstable parkrun, but caught up from the back and swore this year was definitely going to be the year I got to my first milestone of 50 parkruns. Nothing was going to get in the way of that…

As part of that burst of parkrun positivity, I finally volunteered at one too (the 500^th at Finsbury Park), and then sneaked a new PB by one second at Burgess Park (17.55).

And this was also the year that I was going to become a better and stronger all-round runner. I showed up for my first proper XC race at Ally Pally in ludicrously muddy conditions. It quickly became apparent that I was the only runner not wearing XC spikes, and I basically slid my way round the hilly course, but I loved it (and promptly purchased some second hand spikes).

Finally, knowing that this is where the PBs are built, I headed back to track Tuesdays with London Heathside and vowed not to miss a single session without good reason this year. Again, surely nothing would stop that…

February:

Some mad storms (Ciara and Dennis, respectively) blew in, so I took to the gym and the treadmill to keep up the workout intensity prior to race season.

I was also doing hill reps at least once per week, did my favourite ‘1 hour gas test’ run to gauge where I am with training (15.78km), and got somewhat obsessed with dietary nitrates, as I went all-in on a literature review as part of my Sports Nutrition Postgrad.

March:

A month of utter madness couldn’t have started better. On the 1^st of March, I took on the Big Half in London and I think it was probably the best racing performance of my life to date. I smashed my PB by well over 2 minutes (1:17:15), and it’s the first time I’ve finished a race with a time I didn’t know I was capable of (and I wasn’t even wearing carbon plated shoes!)

A week after that I took 20 seconds off my parkrun PB (17:35) at the hilly course at Finsbury, then the following Saturday I took a further 6 seconds off that (17:29) and notched up my first ever 1^st place finish at my home town course in Frome. Little did I know then that that would be the last parkrun of the year, and that nearly 10 months later I’ve still been unable to defend my ‘title’.

Meanwhile of course, things were getting really scary in the news, and at work on the ICU. Our unit was starting to fill up with COVID positive patients, and it became apparent that this was the start of a serious pandemic. Nonetheless, Bath Half Marathon refused to cancel on the 15^th or even offer me a refund if I didn’t turn up, despite me explaining why I couldn’t possibly do so given my work. I’d run this race 7 or 8 times previously, but won’t be signing up again.

A week later, the country was in full lockdown. Work got crazier and crazier and life became restricted in so many ways, but one tiny silver lining was my daily run commute home. Over the next few weeks, I felt like I had the wide streets and landmarks of central London to myself, and the sun shone every single day. Truly unforgettable, surreal scenes.

April

I grew an FFP3-ready moustache (i.e. medical grade face mask), initially as a bit of a joke, but 8 months later it’s just become my permanent 2020 look (albeit accompanied by a temporary Christmas beard as I write this). It was either that or full on clean shaven…no thanks.

Early in the month, I attempted but couldn’t sustain a decent pace for what would end up being my longest run of the year (28km). I started to realise that the stress and emotion of work was taking its toll and that I shouldn’t take it or my physical or mental health for granted. It became impossible to switch off from the news, especially as it made its way closer and closer to home. It’s no secret that the Prime Minister himself was on our ICU, and the hospital site was awash with media and security. It was intense.

So, I slowed 90% of my runs right down and switched others out for glorious walks through beautiful North London residential streets with Holly, and just used it as my time to try to switch off and zone out. It helped, to an extent, and I then allowed myself to really let loose once per week for a 5km time trial at the weekend. I definitely don’t regard these as official PBs, but took great satisfaction in building up to them as if they were races, and managed 17:15, 16:54 and 17:07 in consecutive weeks.

May

I managed to get my 6^th and final piece of sports nutrition coursework in on time, just. This was a mammoth ‘Sportfolio’ case study with an athlete that had proved to be a useful distraction from the day job, but I could not have been happier when I pressed ‘submit’. The feedback a week or two later was the best I’ve ever received across my whole academic life, and it just confirmed how much I love working in sports nutrition. Since then I’ve officially launched Tom Hollis Performance Nutrition, and have enjoyed every second helping like-minded endurance athletes and plant-based clients reach their potential.

Other than that, May was really just a month to keep things ticking over. The ICU was still unrecognisable in size and appearance as we tried to treat the huge number of COVID patients (many of them long-stayers at this stage), and at least a dozen redeployed dietitians were still part of our now sizeable ICU dietetic team. We kept up team morale with daily 5 minute exercises (obviously I loved this) and weekly international shared lunches on Fridays (a rare chance for people to use their creativity in an otherwise boring year), and I used those Friday mornings to blitz a tempo run to work to make the most of the ensuing onslaught of global carbs.

The weather remained beautiful throughout May, and I kept the pace low but the mileage up. I passed 1000km for 2020 early in the month, and pretty much every evening I ran (slowly) to the park to hang out with Holly and Harvey (our part-time dog). It wasn’t all bad.

June

The Black Lives Matter movement was in full swing, and at least twice I got caught up in BLM protests as I stupidly planned to jog home through Whitehall. Things finally started to calm down on ICU though, at least in terms of COVID. The temperature also started to drop, so I decided to use this as my opportunity to ramp things up again with my running; I got back to regular tempo runs, some rare double run commutes, solo interval sessions on the track, and hill reps at least once a week.

With the Sports Nutrition Postgrad successfully completed, I now had some free time at the weekends, and needed a new routine. I started doing much-missed Sunday long(ish) runs again, finishing up at Starbucks for my free NHS coffee and Aldi in time for the NHS only opening hours. For once in our careers, my colleagues and I were made to feel pretty special and appreciated in those weeks, and the cherry on top for me was a free pair of Brooks Glycerin 17s that arrived through my door. They’ve been my comfy run commute go-to shoe ever since.

As for those long runs, I found myself in surprisingly good shape, and despite keeping things controlled and steady, notched up the following:

7^th: 21.1km at 3:53/km pace

14^th: 22.1km at 3:56

21^st: 18.5km at 3:56

27^th: 21.1km at 3:55

It was around this time that Tuesday club sessions restarted on the track, but due to distancing and time restrictions, I joined a little group of Heathsiders in doing our own replica sessions instead. It felt great running with others of the same level for the first time in months, and also made me realise that all that consistent run commuting (slow or otherwise) had added up to leave me fitter than I’d ever been.

The post 2020: An unforgettable year as a runner…and ICU dietitian (part 1/2) appeared first on Tom Hollis.

Despite having promised to myself in 2013 that my life in academia was finally over, having qualified as a Registered Dietitian, there I was in the classroom again, ready for Exercise Physiology – the first module of my Applied Sports Nutrition postgrad.

Most of the students on my side of the course had a nutrition background of some description (while the other side had a sports background), including a sprinkling of dietitians with differing levels of clinical experience. I was the only one coming from a critical care (ICU) background though, and this caused a few eyebrows to raise. At least two or three of my new coursemates asked ‘why would an ICU dietitian be interested in sports nutrition’ or stated that ‘you couldn’t pick two more different ends of the dietetic spectrum’. I knew that this wasn’t the case, but I could also see why someone who didn’t work in critical care might make these assumptions…and no doubt there are others visiting my website who will be thinking the same. So these conversations stayed with me, and I’ve been meaning to write this blog ever since.

I make no secret of the fact that I specialise in critical care and endurance sports nutrition (plus plant-based nutrition, but I’ve covered that in lots of other blogs so won’t mention here), and I feel lucky to have found two areas of nutrition that I feel so passionate about. Importantly though, there are huge areas of overlap that mean that, far from being totally separate entities, a greater understanding in one really benefits my practice in the other.

1. Precision nutrition

ICU is all about numbers, data, and precision – or at least the pursuit of precision – and this is certainly part of the appeal. This is true for everything from biochemistry to ventilation settings, and certainly for nutrition too. Patients are generally fed via enteral feeding tube or intravenously, and every ml of delivered nutrition is documented. That’s not to say that how we set our nutrition targets is without some controversy, nor that feeding always goes to plan (there are always interruptions and unexpected breaks in feed), but as long as everything is accurately documented and analysed, we can monitor and react to those individual nutritional ‘balances’ (comparing feed prescription to delivery), as we seek to optimise that patient’s nutritional status.

The same can be said for sports nutrition. As with ICU, there may never be absolute consensus on how we calculate athletes’ nutrition requirements, but as the evidence base continues to grow (and it’s my job to stay on top of this), there is now undoubtedly greater precision and specificity in the guidelines. Through electronic food diaries, we can then quantitively track a client’s progress against these targets and be extremely precise in our recommendations. In my experience, this is what clients want, and it’s great to be able to provide this with confidence.

2. Periodisation

In a similar vein to the point above, there is a broad acceptance that nutrition advice on critical care needs to be periodised, adjusting for different stages in a patient’s journey from early acute illness (where substrate utilisation is impaired) through to the late acute and then chronic and rehab phases, when physiology and metabolism shifts dramatically.

A major outstanding question in critical care nutrition is how to recognise the flow between these different phases. Fortunately, this is not a problem in sports nutrition, where the evidence and guidelines allow for nutrition advice to be neatly periodised around far more clearly defined phases, both on a ‘macro’ level in terms of training seasons and race build-ups, but also on a ‘micro’ level, in terms of key nutrient intake windows around individual sessions and rest days: essential to getting the best adaptation from all that hard work in training.

3. Body under stress

I mentioned earlier the acute phase of critical illness and how this impacts on nutrition. Critical illness puts a huge amount of stress on the body, and, certainly in its earliest stages at least, induces a hypoxic and catabolic state where the metabolism of glucose, fatty acids and amino acids is all likely to significantly altered.

The same is true in sports, of course, where we push ourselves to the limit and induce physiological stress, albeit deliberately! We deprive our working muscles of adequate oxygen to respire aerobically, tipping us into and beyond our anaerobic or lactate thresholds. We also need to remember that exercise alone (whether resistance or cardio) is catabolic, and it only becomes an anabolic (i.e. muscle-building) process when combined with adequate nutrition. I’ve often come across statements such as ‘one day on ICU is like running a marathon’, and this is all rooted in the massive overlap here in terms of stress on the body.

I look out for rising blood lactate, electrolyte depletion and reduced oxygen saturation in all my ICU patients. It’s no coincidence that these are all also key elements  of exercise physiology and performance nutrition!

4. Rehab and recovery

As ICU medical management improves, so do patient survival rates. And with this being the case, in recent years there has been an ever-increasing emphasis on achieving far more than just ‘survival’. Post Intensive Care Syndrome (PICS) is a dreadful but all-too-common combination of cognitive, psychological and physical impairments that persist for months, if not years, after ICU. One benefit of the current pandemic has been the increased media attention (and clinical funding) that post-ICU has received, but the reality is that this is not an issue specific to COVID-19.

We have the most fantastic post-ICU MDT recovery clinic at my hospital, where patients have access to a consultant, nurse, physio, occupational therapist, psychologist, pharmacist, and of course, a dietitian – me! I feel very privileged to be able to guide these incredibly vulnerable patients through their rehabilitation and recovery, as they deal with a bewildering mix of symptoms and changes in appetite, intake and body composition.

The language overlap with sports nutrition in terms of ‘rehab’, ‘recovery’, and ‘muscle wasting’ is immediately obvious, and in fact, this is another area where the evidence base in critical care rehab nutrition lags behind and actually borrows from the comparably well-defined guidance for sports and performance nutrition. Logic suggests, for example, that the ‘muscle full effect’ of protein dosing and timing that is so well described in performance nutrition should also apply to the rehabilitating post-ICU patient. I do therefore often adopt a similar strategy in my post-ICU clinic, but the reality is we don’t yet have the data in this population to confirm the theory. Watch this space, hopefully…

The other benefit of working in the post-ICU clinic is that I get to actually speak to my patients (!), many of whom have no idea that my colleagues and I were also providing their nutritional care when they were sedated, mechanically ventilated and tube-fed on the ICU a few months earlier. Given that all of my sports clients are awake (hopefully), it’s probably no bad thing that I’ve been keeping up my clinic skills, not least negotiating goals that work around individual patient lifestyles and schedules.

5. Holistic physiology

Working on a mixed medical and surgical ICU means that every patient that comes through the door is completely different, and critical care dietitians, perhaps more than any other, need to be experts on the body as a whole. Organ systems don’t fail in isolation; a patient might have respiratory, kidney and GI failure simultaneously, for example, and each of these has nutritional implications that we interpret and respond to. It’s sometimes incredibly complicated and may mean prioritising one component over another, but coming from a biology background, I relish the opportunity to think so holistically.

Once again, this really benefits my work in sports nutrition, where it’s all about different organ systems working together. Of course, there are the fundamental and overlapping roles of the working muscles, lungs and heart. But we also need to consider, for example, the complex relationship between exercise and the GI tract, and the massive impact of the central nervous system on performance. All of these can be influenced by or impact on an athlete’s nutrition and hydration strategy, and this is what usually occupies my mind when I’m running (genuinely!), and certainly when I’m advising clients.

Hopefully I’ve managed to convince you that, far from being alien ends of the nutrition spectrum, there is a HUGE overlap between the wonderful worlds of critical care and sports nutrition, and that expertise in one massively benefits the other.

The post Where ICU meets sports nutrition appeared first on Tom Hollis.

But it’s not just the watching that floats my boat. If I go more than a couple of days without going for a decent run or some serious physical exertion (ideally with a competitive element), I get very crabby.

So that’s most of my spare time covered, but my day job is of course centred around nutrition, and primarily the dietetic management of incredibly sick patients on ICU. I love the role, and as I move well into my second year of doing it, it’s certainly a case of the more you know, the more you become aware of the massive gaps in your (and the collective) knowledge base. But that’s fine by me – I would hate to feel like I wasn’t learning something new each day, and I’m in the right place to help unravel the complexities of critical care nutrition.

Anyway, it recently occurred to me that I should also be doing more to combine my twin passions of sport and nutrition. I’ve had a flurry of questions come my way this year from friends and fellow runners (in the build up to the marathon, particularly) about multiple aspects of sports nutrition, and it is something I really enjoy discussing. I’ve covered plenty of sport and exercise nutrition in previous degrees, but now it’s something I’m planning to formalise, with recognition by way of the Sport and Exercise Nutrition Register (www.senr.org.uk), giving me the opportunity to work with more people who love sport and exercise (nearly) as much as me.

So, that’s the short-ish term plan (alongside good old intensive care of course). And there was me thinking my days of academia were behind me…watch this space and wish me luck!

The post Sports nutrition (and combining passions) appeared first on Tom Hollis.

For this reason, we often need to bypass the digestive system completely, supplying nutrients directly to the bloodstream instead. This is called parenteral nutrition, which is a delicate art, requiring different degrees of personalisation depending on the complexities of each patient. It has been a privilege becoming an expert in this very technical field.

Then, in the new year, I moved to another NHS trust with a huge reputation for research and clinical excellence, in my new role as Senior Specialist Critical Care Dietitian at Guy’s and St Thomas’. I’m still, unashamedly, at the stage where I get a cheap thrill from my new surroundings (hard not to be when my run to work ends with a view across the Thames to the Houses of Parliament…hence the slightly blurry sunrise picture above), but my first goal has been getting to grips with my new clinical environment. The Intensive Care Unit (ICU) is unlike anywhere else in the hospital, and needs to be treated very differently as a dietitian. Patients are sicker, often requiring multiple forms of artificial organ support and with rapidly fluctuating clinical pictures. The different way in which we estimate nutritional requirements on ICU reflects this, and needless to say, the majority of our patients are not able to ‘eat’ in the traditional sense.

Although I’ve not been an ICU specialist for very long at all, another thing that has been immediately obvious has been the huge emphasis on research, and crucially, acknowledgement of the gaps in the research. The importance of properly nourishing these patients is not in doubt, but the optimal means of doing so remains a  rapidly evolving (and at times, very contentious) area. It is exciting to be a part of it and I look forward to expanding my knowledge!

The post Introduction to Intensive Care appeared first on Tom Hollis.

So, just to clarify a few points…

The ‘anti-dieting’ thing is really just my response to the standard media message that ‘diets’ are a short-term, quick-fix towards health goals, as implied by the phrase ‘going on a diet’. Of course the true meaning of the word ‘diet’, i.e. what people eat every day, is of huge interest to a dietitian.

In health (or at least relative good health), a sensible approach to diet and nutrition is usually all that is required. I’m not saying this is always straightforward to achieve, and there is always a degree of personalisation involved, but it does irk me when people try to overcomplicate and confuse things.

But beyond this, there is the truly complex world of clinical nutrition, where the provision of micro and macronutrients must be carefully manipulated in order treat specific diseases and conditions. Since this is usually of less relevance to the general public, I have chosen not to write too much about it, but occasionally, clinical dietetics finds its way into the public conscience.

One such example is the ketogenic diet, as typified by a recent Guardian article, which looked at the potential role of this diet in achieving weight loss.

Essentially, the ketogenic diet is a high fat and low carbohydrate approach, with fats converted to ketone bodies, which then replace glucose as a major energy substrate for the brain. It is by deliberately achieving a state of ‘ketosis’, whereby the level of ketone bodies in the blood increases, that the ketogenic diet has proven to be of huge clinical significance in treating epilepsy in children, and this is also the reason why this dietary approach continues to attract research with regard to the treatment of brain tumours.

While this Guardian article does touch on the origins, essentials and mechanisms of the ketogenic diet (as well as briefly mentioning, rightly, that it can be a challenging one to follow), I have one major bugbear here. Why pretend that the article is about weight loss, when almost all of the text refers to its role in epilepsy? I just think it’s a lazy method of trying to attract more readers.

Above all though, it’s interesting to see proper clinical nutrition mentioned at all in a major newspaper, and of course I particularly enjoyed the recognition at the end of the piece (albeit from Hollywood film director, Jim Abrahams), that the diet ‘requires a trained Dietitian.’ Too true, Jim.

The post Ketogenic diet appeared first on Tom Hollis.