Care Partners Compass: Navigating CRC

S2 Ep4 - Chew on This: The Importance of a Dietician on Your Care Team
Care Partner's Compass: Navigating CRC
Elsa Lankford

Elsa 0:01
Welcome to Care Partners Compass Navigating CRC. My name is Elsa Lankford. I am the care partner to my incredible wife, Kristine, who has stage four colorectal cancer. As a disclaimer, this podcast and its content is for entertainment purposes only. The views and opinions expressed by any hosts or guests on this podcast are their own personal opinions. Reference to any specific product or entity does not constitute an endorsement or recommendation. This podcast does not contain medical or legal advice. Please consult your medical professional about any medical questions or concerns.

Lora 0:47
Hello.

Elsa 0:51
If you wouldn't mind introducing yourself so that I can edit that in seamlessly.

Lora 0:57
Of course. So Elsa, thank you for having me. My name is Lora Silver, and I am a registered dietitian specializing in working within oncology and with patients going through cancer. I work Smilow Cancer Hospital, which is the cancer center with Yale New Haven Health. I've been in this position for close to five

------ Deciding to become a dietician ------ 1:23

Lora 1:23
years now.

Elsa 1:24
Oh, wow. So how did you get into this, to this line of work?

Lora 1:28
Well, I studied social work and Spanish and was the first few years after I went to college, I was a little more engaged in community organizations and grant and nonprofit work and that kind of thing. And as a young professional going to work and finding myself and often burning myself out in various jobs, I had a very personal experience around food and nutrition and activity and just know, just got curious about, gosh, the way I eat seems to affect how I feel when I go out for a run or how I sleep. Um, just noticing that connection more for myself as a young adult. And, um, I got more and more curious and up discovering health coaching, the fascinating field. And I think it's a really important role in a healthcare team that not every hospital or medical setting necessarily has, but it's someone who doesn't actually necessarily need a whole lot of medical training and background, but it's really about, you know, helping me as the patient to actually close that gap between knowing what I need to do and actually doing it. And there can be such a gap. So I found health coaching and enjoyed working one-on-one with clients, learned a lot about health education. And again, like just what it takes to understand what motivates us and how to really change our behaviors. So that prompted me to go back into school and ultimately go back to school and study

------ Dietician vs nutritionist - what's the difference? Part 1 ------ 2:49

Lora 2:49
nutrition as part of the training. I know one of things we want to talk about is everyone uses the words nutritionist and dietician interchangeably. What does that even mean? Well, to be a registered dietician, which is what I am, we do have to go through more extensive training and a supervised internship where you, it's similar to a residency for a physician where you circulate through all different areas of a hospital, all different specialties.

------ Oncology and diet ------ 3:15

Lora 3:16
Oncology was one of the areas that really interested me.

3:25
So in some cases, you're getting to work people around food changes in their food and what they're eating and drinking. And then on the other end of the spectrum, you might be working with folks who for a brief period of time may have, may need a feeding tube, may need IV nutrition, which is known as TPN. And there's a whole spectrum in between that. And oncology is one of those areas as a dietician where you get to gain experience and look with people across that spectrum. Um, and it's also a very meaningful area to work in because food,

4:02
food holds such a special place in our lives and our, our relationships to food and eating can be very complicated even before a cancer diagnosis. And so working in this area also gives me the opportunity to really have conversations with people around that and more of an appreciation of that you necessarily get to in other areas.

------ Food and cancer from care partner's perspective ------ 4:27

Elsa 4:28
Yeah, that was interesting. When I woke up this morning, I was just kind of writing down my thoughts about food and cancer. And it's like, I wrote down, from some illnesses, it can nurse you back to health and even in cancer,it can to a good degree and

Lora 4:44
Mm-hmm.

Elsa 4:44
nourishing. And there's an aspect of control that you have some control over your health.

Lora 4:50
Yes.

Elsa 4:51
Which with cancer there's, you know, not a lot of, but then there's definitely the negative connotation about guilt and,

Lora 4:57
Mm-hmm.

Elsa 4:58
and blame. And as a care partner, you know, I eat during stressful times and it's like,

Lora 5:08
Mm-hmm.

Elsa 5:08
so food is really, it is, it is amazing how important it is, but like you said, it's also so, so complicated.

Lora 5:19
Yeah

------ How can we make it easier to get dieticians on the care team? ------ 5:19

Elsa 5:20
So why, and you, you got into this a little bit, but I've noticed with a lot of people that like their care team is all doctors, especially in colorectal cancer. It seems like having a nutritionist or a dietitian would be so important. I don't want steal your thunder. Do you, could you talk a little about, I mean, I'm assuming that you agree that you think it's important. So what can we do about this? Do people even know to ask?

Lora 5:52
Yeah. Lots of thoughts. So

5:57
in, no matter what state you're in, actually, You should be able to access a dietitian through your cancer center, but a lot of times they're not available on site or in person, so it may be something that's only available by request and then also as a telehealth or by phone service. Because in some cases you may have a dietitian that's there on site or is part of that team working with your same doctors, or in other cases, a cancer center might partner a contract with some other service that arranges for dietitian services for you, basically. But to be as part of like the, uh, accreditation of cancer centers across the country, we do need to provide access to a registered dietitian, which is wonderful. And you're right that it's not, not enough of us know about it and know to ask and know to offer it. And there's a lot of issues with that. I can also share and maybe we can include it in the show notes or something. There are some services that again are offered in certain regions or some, in some cases are offered across the country where no matter where you're getting your care, this is something that can be accessed separate and free. So if you have, it's great, it's ideal to go through your cancer center first, because then your dietitian is working hand in hand with your doctors, right? They can, they can consult about your case. And I think that's really important, but if that's not available, then there are a couple options across the country that we can connect people to so that you can access that.

------ Why is there an extra step? Why not by default? ------ 7:36

Lora 7:36
As far as why it's like this,

7:40
it's probably a longer, more complicated answer, and I probably don't even know all the contributing factors to it. Unfortunately, it goes to more, you know, root causes and healthcare system issues that we need to address. There are certain kinds of nutrition care that are, uh, covered by major insurances and reimbursable or reimbursed. And right now medical nutrition therapy for oncology for cancer care is not one of those is not actually covered. And so the, the, the only, the major advantage that I can see of this current situation is that it means we're not usually billing for these services. So the benefit to the patients and families is that they don't have to, there's usually no cost associated with it, whether they have insurance or not.

Elsa 8:36
Okay.

Lora 8:38
That's a benefit, but there are other trade-offs to that as a system goes. So it's really, it's really unfortunate that we're in a situation, right? That like where you're saying it doesn't feel evident and obvious and always visible that a dietitian can be a part of the care team.

8:58

Elsa 8:59
yeah.

Lora 8:59
So

------ Dietician vs nutritionist pt 2 ------ 8:59

Lora 8:59
I'll take a step back and, and answer the, the question about, you know, what's this difference? I hear nutritionist, I hear dietitian. So a registered dietitian is a special type of nutritionist, and it means that it's a person that has more specialized medical training and preparation to work in hospitals and to work with more complex diagnoses and to provide what's called medical nutrition therapy. So when I think of working with someone with a diagnosed cancer, regardless of the type of cancer, but especially with colorectal cancer and the typical treatments and surgeries and the nature of that process. I recommend working with a registered dietitian because we have that specialized training to really work with it. The term nutritionist can be used regardless of someone's training or education.

Elsa 9:58
Oh, wow.

Lora 9:59
So it's one of those titles or terms that can vary wildly from state to state. So there are some people that are, uh, offering nutrition services and, and refer to themselves as nutritionists and are fabulous and have done lots of their own training and education to do it, but it's not required in order for them to use the term nutritionist. So that's why you, how you kind of have to be careful, especially when you're online and following people, right. And someone calls himself a nutritionist, get curious and dig deeper and understand what was their training? What are their credentials? What did it take for them to get that title? A registered dietitian, on the other hand, you can trust that that term, it's a legal, you know, it's a, there's a legal definition to it.

Elsa 10:48
Yeah. Like an accreditation kind of thing. Okay. Yeah.

Lora 10:52
Exactly.

Elsa 10:52
I had zero idea about that. I, I did not. Okay.

Lora 10:56
We have a marketing problem. It's true.

Elsa 11:00
Yes. Yes. Most definitely. My goodness.

11:08
Yes. Somebody needs to get on that. Yeah. Yeah.

Lora 11:11
Yeah. Yeah. And then to make it even more complicated, you know, there is, so most of the dieticians that you'd work with in a cancer center or a cancer hospital either have this extra credential or are probably working toward it. And it's called a certified specialist in oncology or CSO. And that just ensures that the dietician you're working with has a more well-rounded training and exposure to many different diagnoses under the umbrella of cancer. So that's an important designation to look for, too, when you're seeking out a dietician.

Elsa 11:47
Okay. Oh, that's super helpful. That's super helpful. What I'm much more aware of is colorectal

------ General nutrition tips for CRC ------ 11:54

Elsa 11:54
cancer. If we could maybe talk very generally about when somebody's diagnosed, do you have some general tips for the different kind of stages of cancer in terms of when they're about to be doing treatment, getting ready for surgery? That type of thing. Just general thoughts about Yeah.

Lora 12:20
So, you know, what we do as dieticians is really work on aspects that should improve the quality of your life. I would say it's quality of nutrition is so closely tied to

------ Ideally meet with a dietician even before you start treatment ------ 12:34

Lora 12:34
quality of life, right? So when you're just starting out with treatment, and even frankly, even before you start treatment, and you're just navigating the initial visits and the workup process, right? And it can be quite overwhelming. stressful and

12:50
there can be a lot of emotions happening and it can you can have anxiety and nerves can we could be a real issue in that part even before any treatments were started right even in that setting it can be helpful to have the support of nutrition services and to meet with a dietitian because that to me is where you know when we're going through a stressful period in our lives we eat differently we reach for different foods we crave different things

13:20
our schedules might be completely upended and disrupted so even then it can help to meet with a dietitian and get some tips and tricks to help make sure we're covering our bases and eating enough to really fuel and nourish ourselves and and all of

------ Diet during cancer treatments ------ 13:33

Lora 13:33
that when we're going through cancer treatments one of the most important things is to maintain our muscle mass it helps us to feel strong as we're going through treatment but when we look at research on cancer treatments and this applies for chemotherapy radiation surgery all of those when people are able to maintain their muscle mass going through those treatments they're able to tolerate and weather the side effects of those treatments better they really tend to have fewer side effects and better outcomes and a lot of the better outcomes are because they're able to tolerate the full dose of treatment as prescribed so if your radiation oncologist prescribes a certain number of sessions if your medical oncologist prescribes a certain number you know wants you to get through six cycles of a particular chemotherapy regimen as dietitians we're here to make sure that you get through that as comfortably and as effectively as possible and that you don't have to experience delays or holes in your treatment because of side effects if I'm struggling too much with diarrhea for example which is a common side effect of so many chemotherapies I might have to hold or delay my treatment or potentially switch gears to a different regimen right so

------ Good balanced nutrition is so important ------ 14:51

Lora 14:50
that even though the chemotherapy is causing the diarrhea what I'm eating is not necessarily the root cause of the diarrhea there definitely are some foods that can make that worse and aggravated or there's some foods that can really help but make it better in addition to the other medications they give so I think in the earlier stages when you may not be facing treatment side effects but you are facing the stress of the diagnosis and the stress of the workout process and medical visits and all of that I think some good basic

15:22
like balanced principles of balanced nutrition would come into play and they can sound a little boring but they're very effective which is one eating fruits and vegetables

Elsa 15:36
it's not gonna be

Lora 15:37
news to anybody I promise but but I'm telling you there are really protective

15:44
compounds in fruits and vegetables they really are protective for our immune system and so it makes a difference when you're including those on a regular basis in your daily and weekly rotation if you're including those as a regular part of your diet it's really a protective thing to do for yourself and for your immune system and that gives you a good foundation going into whatever's nice and when I say like regular fruits and vegetables I'm thinking you know trying for you know trying to make sure you're at least two or three servings of fruit a day and at least two or three servings of vegetables a day

16:21
number of servings of fruits and vegetables and which foods are the very best, but really at the end of the day, the more variety, the better, and the more colorful plant, you know, fruits and vegetables that you, that agree with you and that you feel good when you eat and that you like, the better, but really, fruits and vegetables during that early stage, it's important, and that matters. Good for all of us for a variety of reasons, for a variety of chronic conditions, but there's a lot of protective compounds in there that help for this.

------ Protein needs during cancer ------ 16:51

Lora 16:52
and then I also think about protein. You may not need crazy high amounts of protein,

17:00
but we do want to make sure that you're getting enough protein to maintain your muscle mass and to maintain your weight. It's not great if you're about to go into surgery or you're about to start a treatment regimen and you are in a, you're going through a phase where you've been

17:24
unintentionally losing weight without trying. Or if you've been losing a lot of muscle mass recently, right? And struggling with a lot of weakness and fatigue and really not eating well, it's not a great foundation going into treatments. There's a lot of different ways that you can think about how to get enough protein. Meeting with the dietician can really help to personalize the goals for that, right? So, uh, QX, and a quick way to do it can be to take your weight in pounds and divide that in half. And the number you're left with is about the number of grams of protein that you should aim for for a whole day. So for example, if I weigh 150 pounds, divide that by two and I get 75. So I'm looking at a goal of about 75 grams of protein a day. Some people might benefit from more depending on how active they are or if certain treatments have started and that can increase your needs a little bit, but that's a really good start.

------ Before surgery ------ 18:21

Lora 18:22
And then the other thing, especially thinking about surgery. So I work with a lot of folks going through, you know, before and after major surgery for their cancer. And when I think about giving yourself a good foundation going into that, I think about actually practicing some of the eating habits and some of the tips now before my surgery that I know I'm going to have to do after the surgery. So for example, if I'm heading into surgery and I know, and they've told me that I'm not going to have much of an appetite and I'm going to feel full very quickly when I eat. So right now I might be able to get away with two or three square meals a day and I'm fine. I don't really snack much in between, but they tell me after the surgery, I'm really not going to have much of an appetite and you're not going to be able to eat full meals. You're going to have to snack throughout the day. You're going to have to have smaller meals, but eat more often. It's actually a really good idea to practice that now, even if I don't feel like I need it right now. When we, when you practice that ahead of time, it helps you to identify what your obstacles are going to be because everyone's different. But for some of us, just the idea of snacking in between can feel so unfamiliar. And depending on what our lifestyles and schedules are like and what our family they're like, it can help you to identify some of the obstacles that are going to come up after surgery and help you work through those and chat about it with the dietitian. Now chat about it with your healthcare team now, so that you can come up with solutions so that you feel so that you're actually more prepared to follow through with that after surgery. Another thing that's true, I think with all, with a lot of these GI related surgery, is that, you know, chewing your food really well and pacing yourself at meals tends to make everything about eating more comfortable and pleasant after surgery. But if you ask a, you know, it's very common for a lot of us to start down our meals and not chew enough.

20:29
Yeah. A lot of us do not chew well enough. Easier said than done. But if that's, if that's, if you know that that's something you really have never had to think about before and are not familiar with, it can help so much to practice that habit now before your surgery, before you actually need to. Cause otherwise it can be kind of too much to be practicing all of these new habits for the first time and be dealing with the post op or post surgery fatigue and possibly some pain and possibly some side effects. It's a lot. Right.

------ Getting the care partner involved in thinking about diet before surgery ------ 21:02

Elsa 21:03
And for, I'm just thinking from a care partner's point of view, also those, those could be helpful tips for, a care partner to, to help their loved one, get into that frame of mind as well.

Lora 21:17
Yes. Yes. Yeah. And if you can, if you can stand it, actually practicing it along with them

Elsa 21:23
Yes.

Lora 21:23
because we're very social.

Elsa 21:25
That's true.

Lora 21:26
You know, and we really do, we mirror each other, right? Like, if we're sitting down and the person beside us is putting their fork down between each bite to help themselves to more, that, like, seeing that can actually help me do the same. If I'm watching someone do that, you know, you don't want to make yourself crazy doing stuff like that, but, but sometimes it's just making it more, you know, doing, making changes and trying on new habits as a team, as a family, can really help.

Elsa 21:51
Yeah. I

Lora 21:51
be a

Elsa 21:52
can

Lora 21:52
supportive thing.

Elsa 21:53
I think that chewing more can, there's a lot of benefit to that for care partners as well. I see that, uh, yes.

22:05
Yeah, well, that's cool. And what about,

------ Survivorship and diet ------ 22:08

Elsa 22:09
what about survivorship for for people that are

22:17
maybe they're done with treatment or they're getting to maintenance treatment? It seems like that's still helpful to have a dietician to be able to talk to.

Lora 22:28
Yeah, I think so. There's a lot of, and again, a lot of, I know where I am. We have some programming and services available where we can help put together, just like you said, maintenance or survivorship plans for you.

22:43
Fortunately, a lot of the nutrition advice that applies for prevention of cancer also applies for reducing risk of recurrence. And for those survivorship, uh, uh, recommendations and guidelines. What's good in that if you've already learned or you've already been familiar with some of the, the nutrition tips for preventing cancer, it's really the same lifestyle habits and eating practices. So for example, getting, you know, having a diet that's overall, overall good emphasis on fruits and vegetables and whole grains and getting protein from plant-based foods. Those recommendations are pretty solid. It's interesting. You know, on one hand, there's always research ongoing in the area of nutrition and cancer. There's still so much we don't know and that we have to learn. And at the same time, there are some basic findings that we are coming back to again and again and do seem to be pretty strong base of evidence for that. And lots of compelling findings there, but they're very basic. I think a lot of times they're not as well publicized. They're not as attractive to fit into headlines. I mean, the whole fruits and vegetables thing. There's really, there's a lot of power and solid research to suggest that the more serving the day that we're getting of fruits and vegetables, there's significant protection against cancer and a variety of other chronic conditions. It's still not a guarantee. There's a lot of factors that go into a diagnosis of cancer. Unfortunately, I wish we knew a lot. There's a lot we're still figuring out about that.

Elsa 24:22
Yeah.

Lora 24:24
But there is still good evidence for it as far as protecting us from the initial diagnosis of cancer and then also reducing risk of recurrence.

------ Finding trusted sources for diet and cancer info ------ 24:33

Elsa 24:40
As a dietitian, what are reliable sources of information that a regular person could use? Definitely sold people and getting a dietitian on the care team. That's like, that's checked off.

24:56
But, like, people mean well, but it can be really misleading, it seems.

Lora 25:03
Yes, yes, yes. There's a lot of misinformation and myths. And, yeah, I think it can be very scary and complex. It's a big topic. It's a big problem, I think, in this area. My favorite resources to recommend, number one, would be the American Institute for Cancer Research. It goes by the acronym AICR. So their website is AICR. org. And they are a wealth of information when it comes to nutrition and cancer. So they have areas where you can dive in. And perhaps as a care partner, you might have a little more bandwidth to dive into that research, right? And really look at some of that more detailed information in the latest studies. But they also have higher level pages that you can go to. And, for example, if I want to know more about oats, are oats good for my type of cancer? Or is it a good food or a bad food? They have parts of their website where you can look up the therapeutic benefits of specific foods. And you can get quick answers. And everything is actually based on evidence. And I think it's a really good, understandable website for all of us to be using.

26:23
So the American Institute for Cancer Research, they also share lots of good recipes and meal ideas. So anything that combines actual recipes with the science, I'm always a fan of, right? Because we're always looking for that. Yeah. So I like that resource. And then I also like, especially if you're going through treatments or recovering from a big surgery, there's another website called cook for your life.

Elsa 26:50
Hmm.

Lora 26:51
And this is much more recipe focused, but you can filter and search recipes by a lot of different things. So for example, you can look for recipes that are good for that are good if I'm experiencing nausea and diarrhea. And it will filter all the recipes and show me specific beverage ideas, snack ideas,

Elsa 27:14
meal ideas. Wow.

Lora 27:14
Better recommend it to help me manage that. Yeah.

Elsa 27:17
I'm four years in and I have not used either of these resources. I feel, boy, okay.

27:27
I'm learning.

Lora 27:29
Always learning.

Elsa 27:31
I learned so much from Laura that there's actually enough to do a second episode. on nutrition and cancer. And in that episode, we're going to talk about specific foods that can be helpful, including about inflammation. So I hope that you join us for that episode as well.

Intro Outro 28:00
Thank you for joining me for this episode of Care Partners Compass: Navigating CRC.

28:11
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28:35
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28:37
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