A Day in the Life of an Oncology Dietitian

Michele Szafranski, an Oncology Dietitian, answers pressing questions about illness and nutrition. 

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The medical nutrition sector attracts people who care about people

Michele Szafranski initially studied and worked in Social Work, but always had a love for working with people in the hospital. Her passion for empowering vulnerable people is clear in the way she speaks about her lead role as Registered Dietitian at Levine Cancer Institute which she has held for seven years now. She is close with her family – including a 9-year-old son and her parents who live locally. 

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What do you enjoy most about your role?

What I have always enjoyed most about my role is being involved with patients at the most vulnerable part of their lives.  I love developing trust with patients by helping them pick a few small goals that we can achieve together to show them they do have some control over their situation. As my role has changed over the years I enjoy being at the forefront of developing programs for our patients and marketing our services to new markets. 

What does a typical day for you look like?

Most of my teammates aim to see roughly eight patients per day, but sometimes as many as 16 on a busy clinic day!  In most of our clinics, the dietitians work closely with Social Workers and the Nurse Navigators to identify patient needs. In my role as manager, I work with the Supportive Oncology team to develop collaborative projects, work on research, and develop metrics to ensure we are meeting patient needs.  As Levine Cancer Institute has grown in recent years, we have worked to develop strategic plans to ensure that when new sites or clinics are added we have the staffing to manage those patients ahead of time.

What are the most common nutritional issues in your cancer patients?

Poor appetite, taste changes, and changes in bowel habits are the most common problems we deal with.  The dietitians can spend up to an hour with patients to really get to the source of the patient’s problems. For instance, if we can tell dry mouth is causing their taste changes, we can provide them with very specific tricks and tips to address the root of the problem. Often these problems start before diagnosis and patients lose significant weight before we see them. Early identification is key to helping our nutritional interventions work.

Many of our patients experience early satiety as well, and medications may change how well their stomachs empty. Chronic constipation is common and can make patients feel like they can’t take another bite.

 

 

 

What types of nutritional therapies do you most commonly use with your patients?

We look at what side effects they are having and try to address them very specifically.  If someone has a poor appetite we will give tips on increasing calorie and protein intake to help every bite count - often recommending Oral Nutrition Supplements or high-calorie snacks to replace the calories patients are missing at meals.  We address hydration a lot as almost no one is drinking enough fluids, so we discuss ways to increase fluid intake with high moisture foods and high calorie/protein drinks, as well as creative ways to make water more palatable.

For patients with taste changes, we may look at the type of change (metallic, flat, salty) and then provide tips to overcome that particular flavour sensitivity. However, many of our surgical patients will require feeding tubes to get them through their treatments. We work closely with them to make sure they are tolerating these feedings and adjusting the formula, rate, and total volume as needed to make sure they get their full-calorie and protein needs met. 

In your palliative care patients, what is most important from a nutritional, and also a holistic perspective?

In our palliative clinic, patients are often struggling with pain management. This can lead to chronic constipation.  Constipation can really become a quality of life issue for our patients, and sometimes an issue they are reluctant to discuss. We try to make it a safe space to talk to the dietitians about all those digestive issues they might be embarrassed to talk about.  For all of our patients, nutrition is a great way to empower them in their own care- often chemotherapy, radiation, and surgery feel very outside their control. Giving them tips to manage their own nutritional status gives them the power to be equal partners in their care and helps them feel like they are doing everything they can to take care of themselves.  Seeing nutrition as part of their treatment plans really helps patients feel like they aren’t just along for the ride.

Prior to treatment (and during), we are really working to keep patients nourished to withstand the treatments and the side effects.  After treatment we are working on that “new normal”, helping patients to maximize their nutrition and manage their risk through healthier eating, which may be challenging as taste changes or bowel habits can be slow to resolve.  Sometimes the real work begins after treatment, helping patients find healthy choices they enjoy and can use to develop a new lifestyle. 

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How do people experience Oral Nutritional Supplements?

I find cancer patients are open to trying just about anything. We often provide them with samples of a variety of ONS so they can try to find one that suits their tastes without them breaking the bank to purchase a variety.  Patients respond well to recipes using ONS, often they find one they tolerate well, but maybe they get tired of a sweet flavour and benefit from using the product in a savoury recipe.

Consistency and frequent follow up is key to improving compliance with patients. If you can build on just a single improvement they have made it gives them a pattern of success and makes them feel like they can take on bigger and more impactful changes.  

Patients love recipes

Using familiar techniques and ingredients can feel like a safe choice until they gain the confidence to try more complicated recipes with new ingredients.

Many cookbooks for cancer patients and their care partners (including the one I co-authored) contain recipes organized according to the side effect they are designed to treat and using the healthy eating guidelines promoted by organizations like the AICR and ACS. Cookbooks for patients should have simple recipes with limited ingredients and steps as to not overwhelm patients who might already be fatigued.  Caregivers should be prepared to freeze single portion containers of leftovers that are clearly labelled and easy to reheat. 

What is the biggest misconception in nutritional cancer care?

I think the biggest misconception and challenge in nutrition for cancer patients right now is the perception that weight loss is good in our overweight patients. Often patients are pleased with their weight loss and don’t fully disclose to their care team how much weight they have lost. Often patients do not realize that this weight loss impacts their ability to withstand treatment and can even impact how well the treatment works. Early intervention can help patients understand the importance of weight maintenance during treatment so it gives us the chance to maximize how well the treatments work. 

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