By Prof. Annie S. Anderson
A few weeks ago the American Cancer Society published a very comprehensive guide to Colorectal cancer survivorship care which includes a detailed section on health promotion. Top of the list is the recommendation that survivors should achieve and maintain a healthy weight. Indeed weight management is considered a priority standard of care. This recommendation arises from evidence on poorer outcomes from patients with excess weight and recognition that cancer treatments worsen the severity of many underlying chronic conditions.
Weight management is best achieved through decreased caloric intake and increased energy expenditure through physical activity, and patients need guidance on both. In our LiveWELL feasibility study (weight management for CRC survivors) participants reported that when they proudly announced to their health care staff that they had achieved weight loss, the response was often one of concern. In a further study of the attitudes and practices of colorectal clinicians (medical and nursing staff) it was clear that dealing with obesity was seen as tricky – with too little evidence, too little time and skills, and a threat of spoiling the relationship between the patient and the clinician all presented as barriers. Our most recent study (TreatWELL), which offered lifestyle advice from diagnosis to after the end of all treatments, we also found little understanding, support or referral opportunities from healthcare staff. For overweight or obese patients who had lost weight, the general view was that they should be encouraged to “return to normal” and all patients should be encouraged to eat to appetite (even if that meant energy dense, low nutrient creamy cakes, desserts and sugary drinks). Indeed, the general guidelines produced by the dietetic department encouraged pies, biscuits and other high energy foods.
Once upon a time when patients were diagnosed with late stage disease, unintentional weight loss required considerable dietetic skills and nursing know how to avoid further weight loss and indeed to build up the patient after surgery. These concepts have continued, and in our TreatWELL study we wondered if we could turn these around to present weight management in a more positive light.
Many clinical staff are familiar with guidance to promote physical activity, often seen as something positive to offer patients and an opportunity for patients to gain some control over their management. Achieving an active lifestyle and breaking up sedentary time are both important contributors to health and well-being; but they have little impact on weight management without attention to dietary intake. For the overweight, reducing weight is likely to have a greater effect than activity alone. The reality, however, is that many health care staff feel uncomfortable about raising the issue of body weight, particularly if they feel that this might provoke guilt (e.g. the perception that their obesity has caused the cancer) or that it is yet another clinical demand on patients who have been through much discomfort already.
Our approach to the challenge of introducing the topic of obesity to patients is to focus on re-building a healthy body; highlighting the need to maintain (where abilities permit) and improve muscle mass (identified by improved function) whilst also reducing body stores of fat (identified by fat loss) so that overall body composition is maximised, and bodies resistant to further disease are built. This approach moves the emphasis from appearance to internal composition, and should help to improve self-esteem as two important body parameters improve. This approach may also be less likely to induce guilt by offering a different paradigm to that of “slimming”.
A further dimension of lifestyle that requires to be explained to patients is made up of the dual messages of Be Physically Active AND Avoid Inactivity. The two are related but need to be addressed separately. For example, we found that patients appreciated a walking plan (with a pedometer) to increase physical activity, but in addition we provided tips for breaking up sitting time (e.g standing whilst taking phone calls, walk round the room when television adverts are on). There is an increasing evidence base on the importance of breaking up sitting time (even in people who are very fit) which includes data from patients with colorectal cancer.
NHS staff have also noted that there are few resources on weight management for colorectal cancer survivors on weight management but Bowel Cancer UK do produce a useful leaflet that provides an excellent starting point.
Cancer survivorship is a growing field as we see more people diagnosed earlier and better treatments. Let’s make sure that those of us working in cancer rehabilitation find ways to optimise guidance and support and re-think some of the old approaches about diet and feeding.
Professor Annie S. Anderson BSc PD PhD FRCP
Ninewells Hospital and Medical School, University of Dundee