Karen Collins, MS, RDN, CDN, FAND and Michelle Bratton, RDN, CSO

Interviews by Araceli Carranza, a dietetic intern in the Individualized Self Study Program at California State University, San Bernardino. I am intrigued by the science behind cancer and treatment and how dietitians can help. Exciting yet daunting, I was asked to interview two incredible oncology dietitians to get a better understanding of what they do working in this area of dietetics.

Karen Collins, MS, RDN, CDN, FAND

Blog: Smart Bytes®

Twitter: @KarenCollinsRD

Facebook: @KarenCollinsNutrition

LinkedIn: @KarenCollinsRD

Araceli Carranza: You have done extensive work specific to diet and cancer prevention, what advice can you share with RDNs who may want to work in oncology yet are not sure they can compartmentalize patient engagement and counseling with their own personal feelings?

Karen Collins: I think that anytime an RDN works with people, it means that he/she sees people who have significant health, family or personal challenges. Oncology is not the only field where we work with people who are vulnerable, scared, and at real risk.  I don’t think we want to totally shut off or compartmentalize our feelings – that’s the source of the compassion in our care, and it’s what can make this work so incredibly meaningful and rewarding. The key is to remember that you are there with a job to do, and so you focus on doing what you can to support and help each patient, delivering evidence-based care with compassion and professionalism. For personal reasons, an individual RDN might find a particular area of nutrition (oncology or something else) or patient population that touches a particular “soft spot”. Then they need to decide if that would make working in that area especially rewarding, or too emotionally overwhelming to be able to function as professionally as they want to.

Sometimes, though, a new patient group is only overwhelming on first exposure. As you focus less on your feelings and more on each patient as a person with needs you are there to address, something that initially seemed overwhelming becomes your “new normal”. Also, keep in mind that oncology nutrition care involves patients who vary widely in prognosis. The number of cancer survivors is increasing every year! Oncology RDNs work with some patients who are terminal, providing important care and input to families as part of hospice, for example. But this work also includes TPN, tube feedings, and oral supplements for people who are having trouble meeting needs due to surgery or during certain types of treatment. And with improved outcomes of treatment, survivorship care is becoming an important role for oncology RDNs. This especially calls on combining nutrition for reducing cancer risk with nutrition for overall health (including lower CVD risk and management of diabetes) along with dealing with any long-term side effects of cancer or its treatment.

AC: Given that there is a wide range of diet recommendations to help fight cancer or prevent cancer how do you funnel all that information into a simple meal plan or usable recommendations?

KC: First, it’s important to be clear that not all “recommendations” provide an equally sound basis for making dietary choices. Whether we’re talking to fellow health professionals or to patients, it’s helpful to emphasize the importance of knowing how various recommendations they see were formulated. The recommendations on cancer prevention in the Third Expert Report from the American Institute for Cancer Research (AICR) and World Cancer Research Fund (WCRF) are considered the gold standard. They have been developed based on an evaluation of all available research that meets criteria for the strongest evidence. These can be accessed at: https://www.aicr.org/reduce-your-cancer-risk/recommendations-for-cancer-prevention/

Translating those recommendations into practical choices for meals for individuals is where the art and science of nutrition come into play. Priorities may need to be adjusted based on someone’s other health concerns. And for people in the midst of or following cancer treatment, different types of cancer and treatments can require different strategies – for example, ways to avoid excess calories or provide much more concentrated calories and protein; food textures and ingredients (fat, fiber, spices) that don’t irritate mouth, throat, or other parts of the digestive tract; and flavor profiles that work with taste changes. And then we need to look at practical issues, such as interest and ability to shop, cook, and prepare food; and family and cultural food preferences. 

AC: There are two clashing cultures in the news today, diet culture vs dining-out culture, with the growing rate of chronic diseases and cancer what advice do you give to people who want to be successful in both maintaining healthy eating habits and keeping their social life?

KC: First, I’d contend that as RDNs, we deliver an important message: You don’t have to choose between these two extremes. Healthy eating at its best is not about rigid rules and a perfectionistic view of eating. A dining-out culture does not have to mean tossing all care about one’s health to the wind. Without embracing a “diet mentality”, it’s reasonable to look for places to go that offer some healthful options that are delicious and offered in an atmosphere you enjoy. For example, you can look for options to include more vegetables, look for whole grains, watch for bean-based main and side dishes. And avoid over-consuming in response to large portions or messages suggesting that every time you eat out it’s a celebration that means it’s time to overdo. Simply watching beverage choices – avoiding or limiting alcohol and sugar-sweetened beverages -- is a great start when considering how you can maintain a social life and still live a healthy lifestyle.

AC: Please share a favorite recipe.

Vegetarian Chili

(A lot of ingredients, but an easy-fix, inexpensive and delicious way to enjoy vegetables and pulses) 

• 2 cloves garlic, minced

• 1-2 Tbsp. olive oil

• ¾ cup celery, chopped

• ¾ cup green or red bell pepper, chopped

• 1 cup onion, chopped

• 1 28-ounce can chopped tomatoes (preferably no salt added)

• 2 15-ounce cans red kidney beans, drained and rinsed in a sieve or colander

• ¼ cup raisins

• 1 Tbsp. red wine vinegar

• 1 ½ - 2 tsp. chili powder

• 1 tsp. dried basil (or 1 Tbsp. fresh)

• 1 tsp. dried oregano leaves

• ¾ tsp. ground cumin

• ½ tsp. cinnamon

• 1/8 tsp. ground black pepper (or to taste)

• Bottled hot pepper sauce (optional)

• Plain low-fat yogurt, regular or Greek style (optional topping)

 Directions:

Mince garlic and let it sit while you prepare other ingredients so that the active form of their potentially protective compounds can form. Heat olive oil in Dutch oven or large pot. Add celery, green or red pepper and onion; cook until tender but not brown. Add minced garlic to brown slightly without allowing it to burn. Stir in undrained tomatoes, raisins, vinegar, and spices. Bring to boil, then reduce heat and simmer about 15-20 minutes. Stir in kidney beans and heat through. Flavor as desired with more ground pepper and hot pepper sauce; top each serving with a dollop of plain lowfat yogurt (if desired).

Makes 4 bowls (1 ¼ cups each)

Tip: Dishes like this often taste even better after they sit overnight. You may want to make extra for lunch or a super-quick meal later in the week.

Michelle Bratton, RDN, CSO

Clinical Nutritionist

University of Arizona Cancer Center

Tucson, AZ

Michelle.Bratton@bannerhealth.com

Araceli Carranza: Why did you enter this area of dietetics and how long have you been a Certified Specialist in Oncology Nutrition (CSO)?

Michelle Bratton: I have been a CSO for 11 years.  When I first started at the Cancer Center I thought it was very important to get my certification so I started studying and as soon as I logged the required patient care hours I sat for the exam.   My first job as an RD (a looong time ago) was in a large teaching hospital and I was responsible for the oncology and renal unit.  I disliked counseling patients on the renal diet because while it is so important, unfortunately it is also very restrictive.  I hated going through the list of foods they could not eat.  Personally, I love food and I love to eat so I felt bad being the food police.  But when I was working with those cancer patients it was all about encouraging them to eat.  Back then, and still today, the priority for patients in active treatment is adequate calories and protein to maintain functional status so that they can tolerate treatment.   Then when I returned to oncology 20+ years later the emphasis, I believe, is still maximizing the good nutrients, which for some patients may be kcal and protein, but for survivors it may be the phytonutrients in plant foods.  Overall I find it a pretty positive food message. 

AC: Given that oncology is an emotional time for patients and family, how do you build a rapport with them?

MB: I think it is essential to be empathetic and perceptive to the patient and their family.  I also think it is very helpful that I work in an outpatient setting so I often see patients more than once.  That allows me to build a relationship with patients.  I have become a better listener since I started working here and that helps build rapport. 

AC: What latest cancer research are you excited for?

MB: Oh my, there are several things.  The concept of fasting during chemotherapy is very interesting.  I have had a couple of patients who have done it and did not have the problems that one might expect but we need studies.  Also, one of the studies we are doing here is the LIVES trial.  It is trying to discern if after primary treatment for ovarian cancer, following a plant-based diet and adhering to exercise recommendations can reduce the risk of recurrence or the time to recurrence. 

AC: In your clinical opinion how do you manage other comorbidities when a patient is actively undergoing chemotherapy or radiation therapy?

MB: I assume you mean specific to nutritional needs.  I would say that NO ONE is better at assessing nutritional needs with consideration of a patient’s medical history than RD’s.   Often times though, other nutrition issues, such as the need for a diabetic diet, are not a high priority.  Since a decrease in appetite and intake can accompany cancer, strict limits on nutrients, such as carbohydrates or sodium, may not be necessary. 

AC: What nutritional recommendation do you give patients who are in remission?

MB: It depends on the type of cancer they were diagnosed with.  The role of nutrition in influencing risk of cancer diagnosis, and possibly recurrence, varies by the type of cancer.  Overall I recommend a plant-based diet.  When I say a plant-based diet I mean an abundance of plant foods and less animal foods.  It does NOT mean a strict vegan diet.  This is important because some vegans refer to their way of eating as “plant based.”   While a vegan diet is usually very healthy I do not think the literature supports the need for avoidance of all animal foods to reduce cancer risk.   We can enjoy a wide variety of foods.