Before You Meet with a Dietitian, Listen to This

 Meeting with a dietitian and not sure what to expect? Or maybe you’ve had an experience that didn’t feel helpful. In this episode, we discuss why oncology nutrition appointments can sometimes fall short and how to make the most of your time with a dietitian. Plus, practical tips to help you prepare for your next visit and get the support you actually need. 

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SPEAKER_00 0:17

Welcome back to the Cancer Nutrition HQ Podcast. I'm your host, Crystal Zuniga. And as you may know, I'm an oncology dietitian and I've had the opportunity to support thousands of patients during and after cancer. And I have seen firsthand how valuable nutrition care can be. Unfortunately, I have also heard from far too many cancer survivors that they had a hard time finding a dietitian, or one that they had seen wasn't helpful. Appointments felt rushed, the information felt generic, or the dietitian didn't really understand their specific situation. Why do some people walk away from nutrition appointments feeling incredibly supported while others feel disappointed or like it wasn't helpful? I want to help explain some of the reasons that can happen. Not to make excuses, but because I think understanding will help you advocate for yourself more effectively. And I think this is actually a really good time for me to talk about this because I am currently not accepting new patients. So just know that this is not self-promotion. Instead, think of this as your behind-the-scenes guide. We're going to talk about what dietitians in oncology settings are working against and then the practical stuff. How to walk into your dietitian appointment ready to get the most out of every single minute. So why might some nutrition appointments feel unhelpful? Well, let's start with the reality of access to nutrition care. There are simply not enough oncology dietitians. A recent survey of cancer centers in the US reported a ratio of one dietitian for every 2,300 patients. One. Cancer centers are not required to have a dietitian on staff. Many oncology nutrition services are not adequately reimbursed by insurance or not reimbursed at all. Medicare, which covers a large portion of cancer patients, does not cover medical nutrition therapy for cancer. Because insurance reimbursement of nutrition services is limited, many hospitals and cancer centers are providing nutrition services as a complementary add-on, absorbing the cost themselves. While that's great for your wallet, it limits how many dietitians they employ and nutrition appointment availability and duration. Dieticians end up getting spread thin, and often the system only allows them to see patients who have already hit a crisis point. So if you feel like your dietitian didn't have enough time with you, honestly, they probably didn't. If you are able to see a registered dietitian privately, I strongly encourage you to explore that option so that you can get the level of care that you may need. I think another source of disappointment is that expectations around nutrition have become distorted. There's a lot of misunderstanding around what dietitians do and what medical nutrition therapy is. And this mismatch between what patients think is important versus what the dietitians know is important can result in disappointment. Maybe you expected a very advanced or highly personalized supplement protocol and menu plan. And instead, the dietitian is talking about calories and protein. But a good dietitian is going to pull you back to that foundation, and I need you to understand why. If you are not meeting your basic calorie and protein needs, then nothing else matters. I know that sounds harsh, but it's the clinical reality. If your body is in a state of malnutrition, your immune system can't rebuild, your muscles can't support themselves, and your treatment is more likely to be interrupted. If you are losing weight, your body does not care about extra vitamin C or that turmeric supplement. It's like, what do you want me to do with this? We have to stop the house from burning down before we can talk about what color to paint the walls. That foundation, adequate energy and protein, is the only way we prevent that functional decline that makes cancer treatment so difficult. Trust the process of building the foundation first. I think sometimes patients imagine that we have a perfect nutrition protocol for every diagnosis, every stage, every treatment combination, and we don't, although I'm holding out hope that one day we will. Also, some cancers are rare enough that we simply do not have any nutrition research in that exact cancer population. In those cases, dietitians are doing their best to extrapolate from related evidence and apply clinical principles. That doesn't mean they can't help you, but it does mean that the conversation may be more general than you hoped. A lot of oncology nutrition is applying evidence, clinical reasoning, symptom management, and prioritization. Social media and grifters have convinced people that cancer nutrition is some hyperspecific supplement or anti-cancer food or rigid dietary protocol. Real nutrition support can look very unglamorous. It looks like helping someone maintain their weight, helping someone poop, helping someone eat despite numerous side effects, helping someone get more plants in their diet to have a more well-balanced diet. This isn't what gets people excited, but these foundations are what help with supporting quality of life and treatment outcomes. Now, another reason it might not have felt helpful is that sometimes the timing of the appointment isn't optimal. Some centers have everyone see a dietitian automatically, which is great in theory, but it means some people are seen when they're asymptomatic and don't need individualized support yet. Or they feel so overwhelmed with a diagnosis and initial planning that their brain simply cannot absorb nutrition information at that moment. Other times, patients aren't referred to a dietitian until very late in their disease trajectory. And at that point, the nutritional challenges aren't something we can reverse, but rather something we're trying to slow down. So if someone says, well, I met with a dietitian and it didn't help, there are many possible reasons behind that. Maybe the referral came too late. Maybe the dietitian didn't have enough time with you. Maybe the patient wasn't ready to receive that information or didn't even really understand why they were referred in the first place. Maybe expectations are mismatched. Maybe there genuinely wasn't a strong connection. There are many layers to this. So if your dietitian appointment wasn't what you needed, please don't let one disappointing experience stop you from trying again. Try to find another provider you may better align with. Okay, now let's shift into the practical side. So how do you actually get the most out of the appointment? Your dietitian has limited time with you, but here's how you can show up prepared to make the most of that time. Bring specific questions, not just what should I eat? That question is way too broad. Think about what's actually impacting your eating right now. What symptoms are giving the most trouble and making it difficult to eat? Ask for advice about that. Or maybe you want to learn more about how certain foods or diets can support you. I'm gonna throw this in here that a pet peeve of mine are questions like, what about mushrooms? What do you think about X diet? Because I usually follow up with, well, what about it? Is there a specific function, benefit, harm you're interested in understanding? Be more specific. Some questions that you could ask like, how can I get more protein if meat tastes bad right now? How do I manage this constipation from these pain meds? Are there any concerns with the supplements I'm taking or are interested in taking? What should I prioritize right now? I'm overwhelmed. What can I do to help reduce my fatigue? My white blood cell counts are dropping. How can I support my immune system? Specific questions help us give more useful answers. Oh, and definitely write down your questions before you go in. You don't want a chemo brain moment to get in the way. Next, know your medications and supplements. If your dietitian isn't already integrated into your healthcare system and doesn't have access to your medical record, bring a complete medication and supplement list. And I mean complete, because saying I take magnesium doesn't really tell me enough. What kind? What dose? Same even goes for things like protein powders. Patients will say, I'm taking a protein powder. Okay, which one? There are hundreds of protein powders on the market. I need to see the label. I need to know the brand. You may just see a source of protein, but as a dietitian, I see the potential source of nutrients or bioactive compounds that might interfere with your treatments, non-nutritive sweeteners that could help explain some of your GI symptoms, and a range of protein and energy content. These details matter in getting an accurate and complete assessment of your intake and potential risk of diet medication interactions. These details might feel like annoying homework, but I cannot assess your intake accurately if I don't know what's actually in the products that you're using. Another thing that can really help is having some awareness of what you've actually been eating. Not to judge yourself or obsess over tracking, but if you tell me, well, I'm eating fine or I'm eating normally, that can mean completely different things to different people. One person's fine may be 600 calories. Another person's fine may actually be enough for them. So write down what you've been eating. Even a rough food log for a few days, including portion sizes as best as you can estimate, time of day, can be incredibly helpful. And if your intake varies a lot, that's okay too. Just say that. Tell your dietitian, my intake is all over the place right now. Here's what a typical day looks like when I'm feeling okay, and here's what happens when I'm not. That is still good information. Your food logs help to identify nutrient gaps, the distribution of energy and nutrients throughout the day, hydration issues, inconsistent intake, symptom patterns. We can't know without a real-world look at your plate. There are times where I literally have patients take pictures of their meals. And don't be shy. Please be honest about symptoms. You don't need to downplay them. You are not complaining. I need to know these things. Be ready to talk about the unglamorous things like your bowel movements and urination habits. And I'm asking the details, frequency of bowel movements, color of the urine, any changes in them. Not to embarrass you, but to learn more about what's going on inside. I will say I appreciate when patients just go all in on the details without me asking. I'm like, yes, they know this is important, and I don't have to pry it out of them with awkward questions. Another thing I highly recommend is bringing a caregiver or support person if possible, especially if they're helping with food prep, grocery shopping, or meal planning. They can benefit from the sessions just as much as you because they also need to understand what symptoms are happening, what the goals are, realistic strategies to try, what's most important to prioritize with your nutrition. Another bonus is that you'll have an extra set of ears listening in or even taking notes. When you are overwhelmed or exhausted, you may not remember half of what was discussed. It is your appointment, so you typically don't need to ask to bring others with you. I've had appointments with the whole family listening in or zooming in from all over the country. I think it's fantastic to see that level of caregiver involvement and support, and they are welcome as long as a patient wants them to be there. Now, not everything will be covered in one session. No matter how much time you get with a dietitian, don't expect to get everything covered in one appointment. We are going to prioritize the most urgent issue first. If someone is severely malnourished and losing weight, I'm not spending time discussing the benefits of fiber or phytochemicals. That doesn't mean those topics don't matter. I'm just triaging. And nutrition recommendations typically evolve throughout treatment. Priorities can rapidly change. So what was talked about in the first appointment may not apply a few months or even a few weeks down the line. So this is important to manage expectations. Nutrition support, like all good medical care, is a process. The most critical priorities get addressed first. The rest gets built up over time. If there are follow-up appointments available, use them. If you have questions after your appointment, reach out through whatever communication channels are available to you. And finally, and I think most importantly, you still have to implement the plan. We have evidence that working with a registered dietitian during cancer treatment makes a meaningful difference in quality of life and the ability to complete treatment. But that evidence is based on the assumption that patients are active participants in their care. As a recent colleague on Instagram told me, dietitians don't have pixie dust. Although that would be pretty cool. And I'd start with using it on our broken health insurance system, but I digress. This is a partnership. You have to move from being a recipient of information to being a partner in your care. You can have the best evidence-based, personalized nutrition plan in the world, but if you aren't ready to implement the changes, the session doesn't help you, and frankly, it was a waste of time. Nutrition care is a collaboration. Patients who tend to do the best are often the ones who ask questions, communicate openly, try the strategies, and report back with what worked and didn't work. Stay engaged throughout the entire process. I understand that implementation is hard and that food might be the last thing you want to deal with on top of everything else. But your dietitian should understand that too and meet you where you're at to develop realistic strategies that you can actually do. Now, if you're a dietitian listening to this, I want to speak directly to you for just a moment and everyone else you can listen in too. I know how hard this work is. You are stretched thin, the caseload is overwhelming, and you are trying to help people who are facing some of the most difficult times of their lives. If someone hasn't told you lately, you are awesome and thank you for your work. To help you feel a little bit more productive in your meetings, I do have a couple of suggestions, which you may already be doing. Leave every patient with one to two specific, actionable things they're going to do before your next appointment. Not a handout, not a general instruction to just try to eat some more protein, something concrete. For example, instead of you need to get more calories in, you could try. Before we talk next, I want you to try adding two tablespoons of nut butter to your breakfast smoothie every day. Or this week, I want you to keep a simple log of what you eat for a couple of days so we can look at it together in the next appointment. We need to go beyond education and help them turn that into action. When patients leave with a specific action, they leave with agency. They leave feeling like there's something they can actually do. And when they come back, having done the thing, that's a win and it builds trust and momentum to keep your work moving forward. Your relationship is not just about providing information. Patients remember how you made them feel. Your interaction with a patient can either build trust or degrade trust in the profession and healthcare system. They may not have had many experiences with healthcare providers, and it takes a lot of courage and vulnerability to divulge personal information to a complete stranger, even if that information is needed to help them. Don't take that trust for granted. Honor and respect it and keep doing the best you can. Now, to sum this up, nutrition care is incredibly valuable and your investment in this process matters. Show up prepared. Be honest about what's hard. Ask the questions you're actually worried about. Bring your supplement and medication list and your food log. Let a nutrition expert help you figure out how to fuel your body through one of the hardest things it's ever been through. You deserve that support. And there are people who are trained to give it to you. If you found this episode helpful, share it with someone who's going through treatment or with a caregiver who's trying to support them. I want this information to reach the people who really need it. As always, thank you for listening and remember to eat your fruits and veggies.