Dr. Skye Marshall: Wellness, Health & Beyond in a World of Dietetics & Nutrition

Felicity Cohen: Welcome to the Wellness Warriors Podcast. My name is Felicity Cohen. I’m the CEO of WeightLoss Solutions Australia. In this series of podcasts, I’m really excited to introduce you to a range of wellness experts and health professionals, as well as bariatric patients that have been through a surgical pathway over a number of years. I hope you enjoy the series.

Welcome to the Wellness Warriors Podcast. Today, I have great pleasure in introducing you to Dr. Skye Marshall, please make Skye welcome.  Thank you so much for coming in today.

Dr. Skye Marshall: Of course. Thanks for inviting me.

Felicity Cohen: So, lots to talk about. So I guess first of all, let’s go back to when you actually decided to become involved in the world of being a dietician.
That was your first career pathway and first choice, when you started studying. Where did that come from and what did you actually anticipate at that point in time that you were going to be doing?

Dr. Skye Marshall: It was definitely a bit of a curve ball. My whole family are artists. So, I thought I would end up in that, you know, career pathway as well.

My Pa and my sister are painters, my mum owned a craft shop and, still does. And everyone just does artistic, things and pursued artistic careers. And in high school, I was really drawn to photography, using the dark room and everything, which is a little bit sciency. Cause you have to use all the chemicals and, and be really careful about how you produce the film and that sort of thing. But I also really got hooked on nutrition because, studying nutrition and food science in high school, it was almost like I didn’t have to study. I didn’t need to learn. I didn’t have to try to understand whenever anything was explained. I just got it. And I think that’s just because I was just so naturally interested in it.

And so at the end of high school, I just wasn’t sure what career path to go, you know, nutrition or photography. And I applied to a photographic schools, submitted a portfolio and got accepted, but then I took a two year gap to try and make that decision and become an adult and earn some money and that sort of thing.

And in the end I chose nutrition because I thought it might have a more regular and stable income, which is true, probably. Hopefully. So, yeah, I mean, I had no idea what a dietician was. I hadn’t been exposed to that, growing up in the country, I grew up in a macadamia farm. Everyone was farmers or artists around me. But I just thought it would be, you know, why not try it? So I had to learn science and do a lot of catch up in the first few years, chemistry and all that sort of thing. But I just got so interested in it, and so I feel like I did make the right choice and I always thought, “Oh, you can do photography on the side”.

But I think if you want to do something, you need to be fully committed to it. If you want to do something well, having a split interest. Makes it hard. I think it just means ultimately those skills I got in high school mean that I take better photos of my dogs and my kid.

Felicity Cohen: That’s a good thing.

Dr. Skye Marshall: Yeah, that’s true.

Felicity Cohen: Yeah. Okay. So that was where the passion came from. And I agree, you know, you’ve got to be driven by your passion. and it’s really interesting to note, you know, where that actually came from and when something does clicks and you know that that’s your pathway, you just go on it. And for me, I’m celebrating now 20 years having been in this business and I find it really hard to believe.

Sometimes I have to pinch myself because that time has just gone so, so quickly. And I think obviously when you love something and you feel passionate about your contribution to what you’re doing and how that develops over time, that, you yeah, that’s definitely the way you choose your path.

Dr. Skye Marshall: Exactly. Yeah.

Felicity Cohen: So post dietetic study, then what, where did you go from there?

Dr. Skye Marshall: Yeah. So, to study, I needed to move to Newcastle or any major city. So I ended up in Newcastle, but I was really keen to move back home. And in fact, the New South Wales government was offering scholarships if you undertook your study to become health professional, and then move back to your rural area, because they’re desperate for allied health and health workers in rural New South Wales.

So, I was awarded a scholarship, which was great. So, I was also really lucky enough to have done my clinical placements during my study back at home in Lismore. So, I knew everyone there. I was just basically walked straight into, straight into a private practice in a medical center. And, you know, when you’re rural, you’re kind of everything.

So I was the private practice dietician in the medical center. I was the hospital dietician. I was the dietician driving around to see veterans out on their farms, all around the place and also then the community health dietician. So I had really, really broad experience across all of dietetics, which is fantastic. But it, you really do miss the team environment. I think working closely with other people and learning from them. So that was quite hard not to have that as a new graduate.

Felicity Cohen: So from Lismore then where?

Dr. Skye Marshall: After doing that and working in private practice for a few years, I guess I got a little bit, I guess, a little bit bored because the patients that you tended to see was had a lot of repetition in them and I’m someone who needs sort of a long-term goal to work towards.

And I think that I just in a sort of personality that doesn’t work really well with just seeing client after client, because my main concern was like, okay, well I’m seeing a new patient walk in the door every hour and some of them will come back and I’ll see them again, but especially in the hospital setting, once they go home, I have no idea what happens to them. And looking at our guidelines in nutrition and dietetics, in fact, there was almost no research to show, if a patient comes into hospital and you treat them for malnutrition because they’re not eating very well, once they go home, what happens? Everyone there is saying, “Oh, I’m fine. I’m fine. I just want to get home. And I’ll be okay once I get home”.

But are they okay? And is the advice that I gave them helpful? I don’t know. So, I was lucky enough to do a bit of research in my degree doing, choosing honors. And then, I just started talking to some colleagues thinking, I think I want to do some research around this so that we know if the advice we’re giving is actually making a difference in the long term once patients do go home from hospital. 

So I just contacted Professor Liz Isenring, she was at the University Queensland at the time. She had quite a good reputation for doing research in the sort of hospital space. So I contacted her and said, “Oh, I might want to do some research”.

And I sent her my CV. So she called me and basically convinced me to do a PhD, which seems so big and like, you know, full on. And I never thought I could do anything like that, but under the right guidance and mentorship, I guess four years later, I had a PhD.

Felicity Cohen: Fantastic. And then obviously that’s exposed you into a much bigger, broader world, and a space where now you’re actively involved in so many different, projects that are research related. So your career pathway has taken quite significant turn. and so at the moment you’re involved in multiple streams of research as a supervisor conducting research and all over the place. So tell us a little bit about what that looks like for you.

Dr. Skye Marshall: Yeah, I guess that’s true. Some people choose a really narrow field to doing research and, then they’ll stay on that and develop a really strong track record over 10 or 20 years in that one specific topic. But I, I find that I just get really excited about learning something new. I mean, so often we’ll have conversations with colleagues and we’ll talk about.
“Oh, I wonder, you know, I wonder why that happened and it happened.”, or “I wonder why this patient went so well and this patient didn’t”, or “I wonder what we could do to make this treatment a bit better”. 

And I just thought, “Oh, maybe we could do a research topic”. So, bariatrics was something I had, had no experienced in. We don’t really do that in rural Australia. People usually come to metropolitan areas to receive that service.

So when the topic came up, when you contacted Bond University for bariatric, for a study in bariatrics, it was something that I was just like, “Oh, okay. I know nothing about that. Maybe I probably should know something about that.”. And then doing a lot of reading into that. I just realized it, again, it’s another space where, a lot of what is done is based on the health professionals judgment, and there’s so much scope for research. So we’ve got a better idea about when a patient comes in to have bariatric surgery, what might their outcomes look like? And you know, what are the risks associated with it and what are the diverse, benefits that they get from that as well?

Felicity Cohen: So let’s just dive into what you do, what your role is here and how you connected here at WeightLoss Solutions Australia. So, I just want to talk a little bit about the ENvISaGE Study, which is our study exploring the endoscopic sleeve gastroplasty. And, I see that as being quite, groundbreaking because unfortunately in Australia at the moment, the landscape is actually preventing a lot of clinics on focusing on endoscopic sleeve gastroplasty procedures for multiple reasons.

So there’s a lot of political agenda, that’s kind of obviously infiltrating choice around procedures. My greatest belief is that, you know, this is a procedure that is growing exponentially worldwide. The growth in the endoscopic space is huge. And what we can offer patients with an endoscopic procedure, I think is really important to explore.

You know, if you can offer a patient a procedure that is non-surgical and it’s the right procedure for the right patient, and it’s going to be give them good long-term potential outcomes from a weight lost perspective and a health outcome perspective, then we should actually be looking at doing this more and more frequently and growing that space.

So that’s the first thing that comes to my mind when looking at endoscopic procedures overall. It’s quite an exciting space, obviously, you know, no cutting, and no, disection of the anatomy, shorter hospital stays, all these things come into play when we’re looking at an endoscopic type procedure. 

And then obviously patient outcomes are really critical when we’re considering this. But sadly, in Australia it hasn’t been widely taken up. The procedure at the moment, doesn’t have a Medicare scheduled item number, which means that it’s expensive and difficult for patients to access. So for me as an advocate for the patient, and always wanting to look for best potential solutions to support any patient for weight loss, you know, whether they’re overweight or morbidly obese, I think it’s, for me, it’s absolutely critical.

And it’s part of the, the moral fiber of where I come from sitting in this seat 20 years post working in bariatrics, that we need to look to the future. So I get really excited when we’re looking at a new procedure that has so much merit and internationally, you can see when we’ve been overseas and seen in Spain, how much more this is taking off in other parts to the world.

So, my hope is that, you know, this will be enough to be groundbreaking. And to break down some of those barriers around acceptance of endoscopic procedures and specifically the endoscopic sleeve gastroplasty and that it becomes a more popular procedure eventually over time. So, so that’s a big picture where I’m coming from when it, when we’re looking at endoscopic sleeves.

And it’s changed obviously over the last couple of years, but it’s a really exciting project and fabulous to watch. Patient demand is growing all the time as well for that, for the ESG, you know, it’s becoming more and more sought after, and you can understand why from a patient position. Why wouldn’t you want to go for that? If it is right for you. You know, the world of bariatrics, obviously over 20 years from a medical technology perspective has vastly changed, grown and developed. So I’ve actually witnessed that right from the outset, when we only had gastric bands to offer patients the laparoscopic adjust, laparoscopic adjustable gastric band. That was all we could offer patients 20 years ago. So the growth change and overall evolution in this space has been massive. So, yeah, I’d love to hear what your thoughts are on the ESG and the study and how the study looks for you.

Dr. Skye Marshall: Yeah, okay. So the ENvISaGE Study, was lucky enough to be funded by the Commonwealth of Australia Grant called the Innovation Connections Grant, which is to support research that involves industry like WLSA, the medical practice as an industry partner.

So we’ve received two years of funding. And in the first year we asked any patient who is having the sleeve, the laparoscopic sleeve, or the ESG and they lived kind of locally to the Gold Coast area, if they wanted to participate in the study, which would involve filling out two surveys every six months and also getting a DEXA scan. So what we did is we looked at not only what their weight was, but also their body position using the DEXA scan.

Which means we can look at how much bone, they have how much muscle they have and how much fat they have in each of the different body compartments. But we also looked at other outcomes, including their medical status, things like cholesterol, blood pressure, risk of diabetes, that sort of thing, and their quality of life specifically related to being in a bigger body.

In addition, we also looked at like, gastrointestinal symptoms, like, you know, where they’re getting reflux, bloating and having just a bit of uncomfortableness through that whole digestive system. So we looked at those outcomes before they had each procedure at six months, and then again at 12 months. So right now we’re almost finished collecting all the six month data and we’ve started collecting some of the 12 months. But the thing that I really like about the ENvISaGE Study is that it’s not so focused on weight loss as on health. So, I know like weight loss is one of the most “Googled” terms.

It’s, it’s in the name here, and probably a lot of the patients and even some health professionals and, and society in general is so weight focused. But really, what we want to do is improve people’s health, not just their weight. So the weight is, can be related to improving health, but just because someone has a, you know, a greater weight loss with one procedure versus another doesn’t mean that the benefit they have on their health is necessarily greater.

So, what we’re doing is we’re having a little look at yes, what is the change in weight over that six and 12 months? But how does the body composition change? So sometimes what I have noticed is that patients think that they’ve put on weight when they come to do the DEXA scans or that their weight hasn’t changed at all.

And what we’ve found is that they’ve improved their muscle mass, but their fat mass has continued to decrease specifically in the high risk areas, which is around the neck and around this abdominal area there, which can increase risk of sleep apnea or chronic disease. But also we’re looking at, you know, how has quality of life improved?

And if quality of life has improved a lot, then it doesn’t necessarily matter whether it was 18 kilos or 22 kilos that was lost. What you want to do is have a better quality of life and be able to enjoy life and participate more in it. So I think that is what’s really good about the ENvISaGE Study and it’s looking at those two procedures and I mean, my hypothesis is that there’re gonna be quite the same and related to those, those outcomes around health and quality of life. But I don’t know yet. And humans are quite flawed at judgment. I think we can have, we can think that we’re seeing something, but we need those numbers to back it up. So it would be really interesting to get those numbers in a few more months.

Felicity Cohen: I mean, definitely your interpretation around the study and the benefits from a health perspective, reflect my philosophy in relation to why we do what we do here, because it is absolutely a hundred percent first and foremost it’s health outcomes.

So reducing medical co-morbidity that are associated with weight. We’re not focused on how much weight a patient’s going to lose at 12 months. What we’re looking at is where is that patient going to be five, 10 and 30 years out. And for me, that’s so many different things. That’s reducing their risk of multiple medical comorbidities for the future.

It’s dealing with whatever they have right here and now, any medications that they’re on. And then of course, all of the quality of life issues, the mental health, issues that are associated. So for us, it’s a lot more about that bigger health and wellness kind of story, and the multidisciplinary team in this space is so critical to driving those long-term outcomes.

So the end result for us is about what do we want our patients to be achieving, where do we want them to be in 30 years? Well, we don’t want them to be in nursing homes we want to avoid the endocrinologist, the cardiologist, and every other specialist that we possibly can, and definitely quality of life outcomes for us, key, it’s number one.

And, and that’s the story that we’re seeing come through. So in this podcast stories, series. We’re talking to patients who had surgery, for example, one who had surgery in 2002. And we talked about the story and where she’s at now, 18 years later. So the longevity of outcomes as well, is really so important. So yeah, the procedure, obviously for each individual is really important, but the bigger picture is health and wellness. And the podcast that we’re talking on today is all about wellness. which is what we’re mostly concerned about. So one of the other studies I wanted to chat to you about briefly is Project GRIT.

So Project GRIT is, childhood obesity prevention study, and GRIT stands for Growth, Resilience, Insights, and Thrive. You know, that it has lots of different potential opportunities to explore how we can prove the health in our, younger youth and adolescent population and how we can, you know, hopefully assist and help prevent in that group of patients, potential weight, risk issues for them down the track as they become adults. So tell me a little bit about what you think about Project GRIT and where we’re up to now.