Tag Archives: oncology dietitian

Does Your Cancer Program Have a Registered Dietitian?

March is National Nutrition Month, the ideal time for ACCCBuzz to spotlight the role a Registered Dietitian Nutritionist (RDN) plays in the delivery of high-quality, patient-centered cancer care.

By Kelay E. Trentham, MS, RDN, CSO

Heartshaped Fruits and Vegetables-smDo you have a Registered Dietitian Nutritionist (RDN) in your cancer center? If not—or if your RDN staffing is limited—you may be interested in what an RDN can do for your patients.

First, Some Background

What does it take to earn the RDN credential? To be a Registered Dietitian Nutritionist, you must first obtain, at a minimum, a bachelor’s degree in Nutrition from an accredited program. Next, you must complete a minimum of 1,200 hours of RDN-supervised practice in various settings including clinical, community, and food service rotations, among others. In the near future, a master’s degree will be the minimum required education, and currently many master’s programs are combined with internships. Finally, you must pass a registration examination before using the RDN credential. In some states, RDNs must also be licensed – which is denoted by the LD (licensed dietitian) or LDN (licensed dietitian nutritionist) credential.

Once you’ve earned the RDN credential , you must complete 75 units of continuing education every five years to maintain it. There are five RDN specialty certifications, one of which is for oncology. The CSO credential indicates that an RDN is also a Board Certified Specialist in Oncology. The CSO credential is earned by passing the CSO specialty examination, which is administered by the Commission on Dietetic Registration. To be eligible to sit for this exam, RDNs must have been practicing for at least two years and must be able to document 2,000 practice hours in oncology within the past five years. The CSO credentialing exam must be retaken every five years.

What Does an RDN Do?

Assessment. At a minimum, the RDN employs the nutrition care process and provides medical nutrition therapy (MNT) to patients deemed at malnutrition risk. The nutrition care process involves nutrition assessment, diagnosis, and intervention, as well as monitoring and evaluation. Nutrition assessment is the evaluation of a patient’s diagnosis and co-morbidities, anthropometrics, laboratory values, nutritional intake, psychosocial, socioeconomic, and cultural factors as well as a physical assessment. During a nutrition-focused physical assessment, the RDN notes changes in muscle and fat tissue, skin, hair, nails, and other physical indicators of macro- or micro-nutrient deficiencies.

Diagnosis. The assessment process leads to nutrition diagnosis: the determination of specific nutrition-related problems to be addressed such as malnutrition, altered gastrointestinal function, or impaired nutrient utilization. RDNs use standardized language for nutrition diagnoses, and indicate the etiology and related symptoms of the stated problem.

Intervention. With the assessment and diagnosis complete, the RDN next determines nutrition interventions to address the identified problems – such as diet modifications, oral nutrition supplementation, or enteral or parenteral nutrition support. Finally, the RDN will regularly monitor patients and evaluate the effectiveness of the interventions. The nutrition care process is ongoing until nutritional problems resolve or stabilize.

Nutrition Matters

Studies show that adult cancer patients with poor nutritional status experience decreased tolerance to cancer treatment, higher hospital admission or readmission rates, increased length of hospital stay, decreased quality of life, and increased mortality. A number of studies recommend that nutrition intervention for cancer patients be provided by an RDN, and others indicate that nutrition education on use of foods to maintain nutritional intake yields better quality of life over simply recommending oral nutrition beverages. Ideally all cancer programs would employ a validated nutrition screening tool, such as the MST or PG-SGA, to identify patients at malnutrition risk and refer those patients to the RDN for medical nutrition therapy. Indeed, the 2013 Oncology Evidence Analysis project of the Academy of Nutrition and Dietetics recommends these very practices: malnutrition risk screening (and rescreening), with referral of those who screen at risk to an RDN for MNT.

Engaging the Patient

In addition to identifying and treating or preventing malnutrition, a primary role for the RDN is the provision of patient education on topics ranging from dietary strategies for side-effect management to the pros and cons of vitamin, mineral or botanical supplement use during treatment to the efficacy (or lack thereof) of popular ”cancer diets.”  RDNs assist the healthcare team in identifying patients who would benefit from enteral or parenteral nutrition support during treatment, and can educate patients regarding the logistics of this therapy. RDNs can provide care coordination and navigation services when nutrition support is an integral part of treatment, for example, for patients with head and neck and esophageal cancers. The RDN may also address nutrition-related long-term and late effects of cancer treatments.  RDNs can play an important outreach role in educating patients and the community about evidence-based diet and lifestyle approaches for cancer prevention and survivorship.

The Bottom Line?

Malnutrition impacts patient outcomes, cost of care, and importantly, your patients’ quality of life. Nutrition care is a crucial component of the provision of not just adequate, but of high-quality, patient-centered cancer care. The RDN is your nutrition expert and should be an integral part of the multidisciplinary care of patients undergoing treatment in your cancer program.

ACCC member Kelay E. Trentham, MS, RDN, CSO, is 2016-2017 Chair, Oncology Nutrition Dietetic Practice Group of the Academy of Nutrition and Dietetics. She is Oncology Dietitian at the MultiCare Regional Cancer Center in Tacoma, Washington.


Tele-Health Technology Connects Patients with Nutrition Services

by Nicole Esco, MPA, RD, LDN

Innovator Seal16singularAfter receiving a cancer diagnosis, patients suddenly face a schedule full of appointments. Not only can this be overwhelming, the schedule can also leave patients feeling that there is little room for additional, potentially beneficial appointments such as a consultation with an oncology dietitian. Even when patients want to schedule a visit with the dietitian, transportation is often a barrier and a source of additional stress for patients unable to drive or with limited support at home. Those living in rural communities may have to travel a significant distance just to receive their treatments, and as care providers we want to limit the burden on our patients.

At Baton Rouge General Medical Center Pennington Cancer Center in Baton Rouge, Louisiana, all patients receiving radiation therapy have access to the services of a registered dietitian for individual nutrition consultations, follow-up care, and referrals to community resources. Some patients will encounter challenges with eating during treatment, and the dietitian can ensure that these patients have the tools to manage any side effects that may interfere with eating well, adequate hydration, and maintaining a healthy weight.

Registered dietitians apply evidenced-based nutritional intervention to improve patient outcomes. For example, patients at high nutritional risk (those with cancers of the head and neck, stomach, pancreas, and lung, and patients receiving tube feeding/IV nutrition) need weekly follow-up since they are at greater risk for eating difficulties, dehydration, and/or maintaining a healthy weight due to treatment side effects.  But the fact is that scheduling a separate appointment with the dietitian in addition to their daily treatment schedule and other medical appointments is challenging for these patients. At Pennington Cancer Center our focus is on providing patients with comprehensive care with as little disruption to their schedules as possible.

Delivering Care Close to Home

In 2014, Pennington Cancer Center expanded its radiation oncology services, adding a third center located in Zachary, Louisiana, 16 miles north of our Baton Rouge clinics. This new clinic serves the surrounding rural communities in Louisiana and Southern Mississippi –areas where patients previously had to travel significant distances to receive radiation treatment.

Pennington Cancer Center is committed to ensuring that nutrition services are available to all patients undergoing radiation treatments. Our challenge: finding a way to make these services convenient for patients and efficient for staff scheduling.  As a result, we explored various telemedicine solutions. One challenge was finding a telemedicine option that was both HIPAA-compliant and easy for staff to use. We wanted a program that provided secure data transmission, safeguarding patient information. Our IT team was integral in helping us to implement an effective telemedicine program and ensure the security of video conferencing.

Today, we offer patients virtual nutrition counseling sessions conveniently scheduled when they are already at the radiation center for their daily treatment appointment.  Scheduling these sessions in conjunction with their treatment schedule eliminates the need for additional appointments or having to arrange transportation to other clinics for an in-person visit. These virtual sessions provide patients with the same nutrition information and resources that they would receive if they were meeting with the dietitian face-to-face.

During these virtual sessions, the dietitian’s role is to engage the patient and help build rapport. Video conferencing is a new concept for a lot of our patients, and some are more comfortable initially than others. On the other hand, some patients are very comfortable and open up immediately. Watch our short video to learn more.

Pennington Cancer Center’s initiative Tele-Health Technology Connects Patients with Nutrition Services is being recognized with a 2016 ACCC Innovator Award. Join us at the ACCC 33rd National Oncology Conference in October and learn more about how we implemented this patient-centered service.

Guest blogger ACCC member Nicole Esco, MPA, RD, LDN, is the registered dietitian in the Radiation Oncology Center, Pennington Cancer Center Baton Rouge, LA.



Improving Patient Outcomes with Nutrition Services—What a Dietitian Can Do for Your Cancer Center

March is National Nutrition Month. ACCCBuzz has invited guest blogger Colleen Gill, MS, RD, CSO, to share her perspectives on the value dietitian services can bring to cancer care services. Ms. Gill is a clinical dietitian with the University of Colorado Cancer Center. She is also serves on the ACCC Board of Trustees.

Red appleBy Colleen Gill, MS, RD, CSO

Although 90 percent of cancer treatment occurs in clinics, dietitian services have not been universally available in the outpatient setting. While for inpatients some level of coverage for dietitian services exists, the focus is rarely on issues patients encounter after discharge from the hospital and while undergoing anticancer treatment.

In 2012, the American College of Surgeons Commission on Cancer (ACOS CoC) added a standard to address nutrition (Eligibility Requirement 12), stating: “a policy or procedure is in place to access nutrition services either on site or by referral.” This is a step in the right direction; however, the process is left up to each center, which can result in token efforts without administrative endorsement of supportive oncology services.

Over the past five years, staffing surveys have found that many more cancer centers have added nutrition services and, more significantly, have noted improved patient and staff satisfaction that has led to hiring of additional dietitians. A study is currently being funded by the Institutes of Medicine (IOM) to identify optimal staffing based on patient need rather than current practice. The IOM Planning Committee on Assessing Nutrition Care in Outpatient Oncology is hosting a one-day workshop on Monday, March 14, which will be open for the public to watch as a webcast. Event details and registration information is available here.

The Role of Nutrition Support for Patients with Cancer

Discussion of the role of nutrition support for cancer patients has a long history. In 1980, DeWys and colleagues published ECOG data showing that weight loss was associated with poor outcomes in cancer patients. In 1998, Andreyev and colleagues identified increased toxicities and shorter treatment duration as outcomes of weight loss, and noted this resolved with stabilization of weight. Since then research has found that nutrition support helps manage symptoms, improving intake and thus stabilizing weight, nutrition and hydration status, normalizing bowel patterns. This keeps patients on treatment pathways without interruptions related to failure to thrive and hospital admissions for dehydration. Across the continuum of cancer care, nutrition support is associated with improved quality of life (QOL), better maintenance of muscle mass and functional status, and improved tolerance of treatment with better outcomes. Eating also allows patients to sustain social connections, while minimizing conflicts around eating that can arise from family concerns and pressures.

Five Basic Steps for Starting a Nutrition Program

For cancer programs interested in starting a nutrition program, five basic steps include:

  1. Screening.
  • Criteria are now well defined* and include assessment of any losses in muscle mass and evaluation of the rate of weight loss. Interestingly, obesity is actually a predictor of higher rates of malnutrition, though with delayed recognition.

*Consensus papers on the assessment of malnutrition were published in ASPEN and the Journal of Nutrition and Dietetics in 2012. In 2013, Jensen, Compher, Sullivan and Mullin followed with a summary of strategies to implement a multidisciplinary team approach to identifying patients at risk.

  • Screening should be done at least monthly, as therapies can and do change over time and create new barriers to eating. Identifying and addressing changes and new symptoms proactively will lessen their impact and the likelihood the patient will become malnourished.
  • In a recent review of screening tools (Skipper A, et al., 2012), the Malnutrition Screening Tool (MST), which uses unintentional weight loss and reduced appetite, was found to have the greatest validity and reliability. In some cancer centers, screening is implemented with a simple question that includes these factors; the screening question is added to the list that the medical assistant reviews with the patient at each visit. For example, asking patients: “Are you experiencing any difficulties with eating that limit your ability to maintain your weight?”
  1. Initiation of interventions in patients at nutrition risk, by diagnosis, weight/muscle loss.
  1. Staff and patient education activities.
  • Identifying or creating materials needed to address symptom management issues
  • Educating staff where appropriate, i.e., enzyme dosing for malabsorption, bowel regimens, TPN monitoring/support
  • Support group lectures
  • Supervising nutrition rotations for local internship programs, medical school electives
  1. Involvement in outreach activities that increase the visibility of nutrition support services.
  • For example, through outreach activities with Living Beyond Breast Cancer, Lymphoma and Leukemia Society, or similar support groups
  • Community lectures on complementary/integrative nutrition topics. Sample topics might include:  Limiting the adoption of extremely restrictive diets that are not evidenced based; helping patients integrate nutrition without creating a new stress in their lives; and addressing issues such as supplementation, weight management, and exercise.
  • Cooking classes
  • PR requests from local media
  1. Hiring carefully. Find candidates with a passion for oncology and a desire to make a difference. A registered dietitian nutritionist (RD/RDN) with 2,000 hours of oncology experience can take a certification exam to become a board certified specialist in oncology (CSO).

Here are some resources to help get you started:

American Institute on Cancer Research: www.aicr.org

  • The plate model as a visual guide for a healthy diet
  • Continuous Update Reports on specific cancers and diet
  • Symptom management materials:  HEAL Well: A Cancer Nutrition Guide

Association of Community Cancer Centers: Cancer Nutrition Provider Resources

The Oncology Nutrition Dietetic Practice Group of the Academy of Nutrition and Dietetics;      FAQs www.oncologynutrition.org/erfc/healthy-nutrition-now/foods/  Materials to address questions on juicing, sugar and cancer, soy, etc.

ACS Nutrition and Physical Activity Guidelines for Cancer Survivors, 2012.