ABSTRACT
Background: Cancer related malnutrition (CRM) is commonly observed yet is associated with poor response to intensive cancer treatments, increased risk of chemotherapy related toxicity, increased risk of post operative complications and also reduced survival times [1]. Research suggests that these negative outcomes can be avoided through early nutritional intervention; hence the importance of identifying those at risk of CRM via prompts nutritional screening [1]. Cancer treatment is often provided within an outpatient setting where nutritional screening procedures are inconsistent [2] and where few nutritional screening tools used have been formally validated in cancer patients [1]. Therefore the aim of this study was to identify reliable indicators of CRM with the potential to be included within an oncology outpatient nutritional screening tool. Methods: The databases Pubmed, Cinahal Plus and Open Grey were systematically searched by a sole researcher. The search procedure included the terms Indicators & Malnutrition along with the following additional search term combinations: Cancer Oncology, Cancer & Outpatients and Oncology & Outpatient. No date restrictions were imposed. Predetermined inclusion exclusion criteria were used. Selected studies underwent quality assessment and data extraction. Quantitative studies that reported on indicators and variables of adult CRM that were deemed suitable for a nutritional screening tool were included. Results: From 217 studies, twelve all of observational methodology met the inclusion criteria; all lacked rigour in sampling. Five studies with a total of 6041 participants indicated unintentional weight loss (UWL) is common in cancer; four had a statistical significance. Six studies reported on body mass index (BMI), two suggested cancer was associated with a low BMI however four suggested that UWL was more prevalent than a low BMI and highlighted limitations of the measurement. Six studies reported on gastrointestinal (GI) cancer, a range of GI cancers were represented; all studies indicated an additional risk of malnutrition in GI cancer. Three studies reported on metastatic disease (MD), all suggested malnutrition and UWL was more prevalent in MD; two reported statistically significant results. Two studies suggested poor performance status (PPS) is associated with poor nutritional status; both studies were comprehensive; one was a large European study the other compared against a control. One study reported symptoms of anorexia and fatigue increased the risk of malnutrition within cancer. Discussion: The overall quality of the research is poor yet this review helps consider the evidence collectively. This review suggests UWL could be a reliable indicator of malnutrition in cancer. In regards to BMI the review suggests relying upon BMI as an indicator of malnutrition is inadequate. This corresponds with other research and the consensus is BMI should only be used in conjunction with other nutritional markers [2]. This review indicates additional risk of malnutrition within GI cancer, MD and PPS. Further evidence is required on the effects of anorexia and fatigue. Conclusion: Although the evidence base is limited by observational study designs and methodological weaknesses, the results indicate UWL maybe a reliable indicator of cancer related malnutrition; BMI may be useful but has limitations within this population. Patients with GI malignancy, MD and PPS seem to have a higher risk of malnutrition.
ABSTRACT
Background: Dietary advice is the first line treatment for type 2 diabetes [1]. There is research evidence that patients with chronic disease often do not adhere to recommended dietary advice, Desroches et al. [2], however there is limited research investigating dietary adherence amongst individuals with diabetes. The aim of this study was therefore to explore the factors associated with dietary adherence in type 2 diabetes mellitus. Methods: An internet-based qualitative research method was chosen, and following an internet search the ‘Diabetes-Stories’ website, containing verbatim transcripts of open interviews exploring patients’ experiences with diabetes, was selected on the basis of the potential to generate data to meet the aim of the study [3]. The most recent interviews were selected (‘1980s+’) and those involving patients with type 2 diabetes only. Each transcript was then searched using the key words ‘diet’, ‘food’, ‘nutrition’ and ‘dietitian’ to identify data which related to the research aim. Eight interview transcripts were consequently obtained, consisting of interviews with four males and four females, and dating from the years 2004-2007. The data were analysed manually by one researcher using Thematic Analysis. Four emergent themes were reviewed and agreed by the research team. Consent for use of the transcripts was obtained from the website principal investigator and all identifiable information was made anonymous. Results: The four emergent themes were dietary advice and participant understanding participant adaptations and adherence, participant struggles and feelings and relations with healthcare professionals. All participants appeared to understand the dietary treatment of type 2 diabetes and social support and education were reported as important in adherence. Most participants were non-adherent at times and not acknowledging the longer term risks and dislike of the recommended diet were significant reasons. Two participants felt they were not treated as individuals by healthcare professionals and one participant felt he was expected to be more enquiring about treatment decisions than he wanted to be. Discussion: Many studies provide evidence that social support and education are associated with increased diabetes treatment adherence, Gomes-Villas Boas et al, [4]; Minet et al, [5], therefore suggesting their importance in dietetic consultations. In addition to this, studies suggest that providing dietary treatment suited to a patient’s personal circumstances, and preferred delivery of information (prescriptive or inclusive), is also likely to increase adherence (Hancock, 2012). Study limitations include the dates of the transcripts used, and the ‘passive’ analysis of secondary data from a single website. Conclusion: This study provides a useful insight into the factors associated with dietary adherence in type 2 diabetes, and more current ‘active’ qualitative studies are therefore needed to strengthen existing evidence and enable appropriate changes.
ABSTRACT
Background: There is an increase in dietary related long term conditions with insufficient numbers of dietitians to see all the patients requiring dietary advice. Previous research has highlighted that dietitians are uncertain as to the ability of healthcare professionals (HCPs) to give nutritional advice and that aspects such as training need improvements to increase the effectiveness of advice Doherty et al., [1]. The aim of this study is to expand on this research by identifying the HCPs dietitians commonly work with, whether dietitians think it is suitable for these HCPs to give nutritional advice and the role of dietitians in facilitating HCPs giving advice and any barriers to this role. Methods: An online questionnaire using the Bristol Online Survey Programme was developed. The participants were registered NHS dietitians in the Eastern Region. Verbal permission for the dietitians to participate was gained through their dietetic managers via a telephone call. Subsequent information and the questionnaire’s link was then e-mailed to participants via their dietetic manager. In total 300 dietitians were recruited. The data collected was then analysed using descriptive statistics and categorisation into key themes, Dey [2] & LoBiondo-Wood and Haber [3]. Ethics: Ethics approval was gained from the University of Hertfordshire’s Health and Emergency Professions Ethics Committee. Results: 84 dietitians responded (28% of those recruited), working in different dietetic settings alongside a wide range of HCPs, with the top 3 HCPs, the dietitians worked with, being diabetes nurses (69% respondents), General Practitioners, GPs, (64% respondents) and Speech and Language Therapists (66% respondents). Also, through the use of the “other” option, dietitians added addition HCPs such as health visitors, community carers, education programme leads (1% respondents). Overall, 91.7% of dietitians believed that HCPs giving advice is beneficial. The qualitative data gained highlighted two main themes; “HCPs involvement in first-line advice” and “implications of incorrect advice”. Discussion: Overall dietitians were positive about other HCPs providing first line nutritional advice. However concerns were raised with regards to incorrect advice being given by HCPs, due to barriers for dietitians in facilitating support such as limited time for training and high turnover of staff members. Dietitians were concern as incorrect, non-upto- date information given to patients could have a negative impact on patients Hankey, Eley, Leslie, Hunter and Lean, [3]. The dietitians’ classification of HCPs was also unclear. The original HCP list was composed using the HCPC register with the addition of doctors and nurses; however some participants classed other advisory sources such as health programme trainers as HCPs. This questions whether dietitians are aware of all potential advisory sources giving nutritional advice and also questions whether these sources have appropriate nutritional training. Conclusion: Overall, Dietitians believe that HCPs are beneficial when giving out first-line nutritional advice but were concerned with HCPs giving out more in-depth, complex advice. The dietitians’ definition of an HCP was also unclear, questioning whether dietitians are aware of all sources of nutritional advice. This is therefore a potential area that could be explored through further research.
ABSTRACT
Background: Strict adherence to a gluten free diet is the only treatment for coeliac disease. Over the past two decades, there has been a societal shift into less home cooking and eating at restaurants has become an important means of social participation [1] creating significant difficulties for people with coeliac disease. This research aimed to explore the issues that people with coeliac disease need to contend with when dining out, their coping mechanisms and the key aspects that facilitate a normal social life through the analysis of online message board postings. Method: A qualitative approach to the research was selected. Data were collected from The Coeliac, DH and Gluten Free Message Board between November 2012 and January 2013. Posts pertaining to the experiences of eating out on a gluten free diet were identified and analysed retrospectively using thematic analysis. Data were anonymised for confidentiality. Results: The emergent themes examined positive and negative dining experiences, coping mechanisms, informational support/expert knowledge, relationships/spouses and emotional stress. The posts suggested an appreciation of the support of Coeliac UK and the ability to dine out now, with mainstream restaurants offering gluten free choices Negative dining experiences occurred when staff demonstrated a lack of knowledge regarding gluten intolerance, were inhospitable or where illness had resulted from being served food containing gluten. Partners of people with coeliac disease reported stress from these negative consequences. People with coeliac disease experienced guilt, shame, anxiety and fear of being a social nuisance. Positive coping strategies included calling restaurants in advance to check that they are willing to cater for someone with coeliac disease. Discussion: However, despite the coping strategies that people with coeliac disease deploy, the negative dining experiences may lead to a lack of trust and the belief that they will be unable to dine out safely. In support, Coeliac UK [2] found that 22% of sufferers are unable to trust restaurant staff to prepare safe uncontaminated gluten free food. Restaurants may not prioritise education and training initiatives in safe practices in the provision of gluten free meals to diners with coeliac disease. This can place a greater burden on people with coeliac disease in utilising assertiveness skills to ensure their food is safe. Conclusion: Being able to eat the same food as others promotes feelings of unity, which enables greater social participation and potentially increased wellbeing. Restaurants are becoming more aware and adaptive to diners with coeliac disease but there is a need for an increased focus on ensuring safe practices in the provision of gluten free meals.