On Friday 24th May we were pleased to welcome our local Macmillan Dietician, Ashley Davis, to The Living Tree for what proved to be a lively & useful debate on the role of dietetics in helping those living with cancer.
He started by outlining the historical development of his role – set up at Dorset County Hospital in 2005 with 3 years of funding from Macmillan to develop a service which prioritised nutritional support for adults throughout their cancer journey. This became focused mainly on looking at how to support DCH patients with a variety of cancers (excluding peri-operative nutrition for Upper Gastrointestinal cancer surgery – stomach, oesophageal – whose surgical treatment had relocated to Bournemouth) through their chemotherapy, optimising protein & calorie intake to enable them to get through treatment.
His role has evolved in recent years, such that he is now employed by DCH & no longer deals exclusively with cancer patients. He is supported by a team of dieticians, & other clinical colleagues whose knowledge of dietetics has been up skilled enabling them to give appropriate nutritional advice when needed. Ideally advice should be individualised to each person’s needs, & these needs change over time depending on their treatment stage. Initial assessment is aided by the use of the Malnutrition Universal Screening Tool which calculates malnutrition risk based on BMI, unplanned weight loss in the previous 3-6 months, current acute illness & consequent inability to have adequate nutrition over next 5 days. Guidelines recommend referral to a dietician if high risk, with provision of first-line information & support by all those involved in clinical care.
Few of the Living Tree members present at the meeting remembered being offered any form of malnutrition risk screening or support during their own cancer treatment, & one example was given where the person concerned had been given different dietary advice by different professionals, raising the concern that an agreed plan had not been communicated amongst colleagues. Ashley agreed that is is vitally important for all clinical staff to recognise personalised dietary needs, & accepted that there is a frustrating amount of conflicting information making it hard for patients to know which dietary advice to follow.
This led on to a discussion of people’s concerns over their own experiences where they felt the quality of nutritional care could be improved. It was felt by many that healthier food & drink options need to be offered on the chemo unit – healthy wholemeal sandwiches or snacks with a selection of non-dairy & gluten-free alternatives, decaffeinated & herbal hot drinks (green tea!!!) It should also be possible to adapt hospital catering for those who need “little & often”. Ashley explained that ideally the catering department should visit anyone having chemo who has specific dietary needs to look at menu options with them. He went on to highlight the quality of food prepared in the DCH kitchens, which is cooked from fresh ingredients on the premises (unlike most hospitals which buy in bulk orders of cookchill or cook-freeze prepared meals).
Several members commented on the poor quality of food offered on the isolation unit at Poole Hospital (some had resorted to bringing in supermarket micro-wave meals).
We spent some time discussing the difficulty accessing skilled expert dietary advice on the management of pelvic radiation syndrome. Those affected felt that the devastating effects of this condition on quality of life were not dealt with adequately. Many had the impression that the importance of diet as a whole when learning to look after yourself better with any cancer had not been fully recognised by the professionals involved in their care.
We touched on the amount of training in nutrition provided for student doctors & nurses (very little!) – and Dietician students may spend only 1-2 weeks rotating through Oncology during their 28 weeks of clinical placements. So even qualified dieticians may not necessarily have a lot of experience helping those with cancer. In future it is hoped that all new clinical staff appointed to work at DCH will benefit from some nutrition education as part of their induction training.
The subject moved on to the soya debate – conflicting reports of benefits or hazards for those with hormonal dependent cancers (breast & prostate). Ashley informed us that the latest evidence has been collated & led to a recent report published by the American Institute of Cancer Research, stating that soya is safe in breast cancer – 1- 2 daily portions of, for example, 1 glass of soya milk, or a small soya yoghurt. Many people choose to go dairy-free due to concerns over the use of chemicals by the farming industry which have the potential to get into cow’s milk – Ashley commented that there are perfectly good alternatives to dairy (provided they have adequate amounts of vitamins, phosphorus, calcium etc).
We then asked if Ashley could list his top 10 super foods! He prefers to think of “super diets”! The greater the number & variety of colourful fruit, veg, herbs & spices the better! The wider the range, the less chance of missing out on any particular vital nutrients. The USA advocates “8 a day” compared to the “5 a day” in the UK. The Eatwell Plate includes a predominance of plant based foods amongst the 5 food groups. Caution should be taken against mega-dosing with dietary supplements & vitamins – excess of these can be harmful (eg. Diarrhoea with excess vitamin C, & pro-oxidant effects of excess anti-oxidants taken during chemo).
Finally we touched on current developments in improving nutritional care for cancer patients at DCH – there is now a Nutritional Link Nurse forming part of the nursing team on each ward, who can help if anyone is found to have particular problems. In addition, DCH is a pilot site testing out a new national Holistic Needs Assessment tool, whereby newly referred patients complete an electronic questionnaire covering any concerns related to their cancer, prior to seeing their oncologist or surgeon, in order that potential problems (including dietary concerns) can be flagged up at the outset & be included in care planning.
Two further points which were discussed & need to be mentioned:-
Firstly, it is possible for patients to self-refer to the Dietician service, although ideally this should be done by the patient’s GP or hospital specialist or oncology team.
Secondly, we stressed the point that every cancer patient should be offered an opportunity to discuss individual dietary needs, especially following treatment when the agenda shifts to one of keeping well & reducing the chance of relapse. Ashley agreed that long-term survivorship needed to be addressed in more detail. It is noteworthy that as part of the national Survivorship initiative, a Dorset-wide collaboration between DCH and Bournemouth Hospital and University had recently delivered Nutrition Master classes for a range of healthcare professionals. The aim being to raise confidence, awareness and knowledge of frontline staff so they can better support their patients with sound evidenced-based dietary advice.
Throughout the afternoon, Ashley very patiently listened to our concerns & answered our questions. We are very grateful for his input & hope we did not give him too much of a hard time!