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Just waiting for it to load to know. I think it's loading for the live but always have technical issues. Ok. We are live now. Hello, everyone. Thank you very much for joining us today. We have Rachel Stewart here who is one who is an oncology dietician. And we, she will be speaking about her role as a dietician, especially oncology, dietician, Rachel. Would you like to introduce yourself? Perfect. Thank you so much. Um Yeah. So, um like I said, I'm, I'm an Oncology dietician based um in Nine Wells Hospital, um which is NHS Tayside in the northeast of Scotland. Um So I'm just going to introduce the role of the dietician today. Um And I'll talk a little bit more specifically about um oncology diets as well. Are we good to go then? Perfect. Thank you. Um So you can see, I've put my HC PC number in there and that's there for a reason because um I'm going to talk about sort of registration post process and how you actually become a dietician. Um So, so that I don't normally put that in my presentations, but it's there today. So, um first of all, we're going to talk about what is a dietician? Um So you'll see the logo up there on the top, right? Um So that is a campaign by the British Dietetic Association, um which is just sort of a logo um just to sort of promote the profession and um to encourage people to find a good sources of information in terms of nutrition and particularly dietetics. Um So, dietitians are the only nutrition professionals that are regulated by law. Um And we are registered with the Health and Care Professions Council. So you saw my, my number there um before and that helps to protect the public. Um And the term dietitian or registered dietician and you might see it shortened to RD um is a protected title by law. So, um only dieticians who have completed the relevant courses can um use that title, um, the British Dieted Association, um which we call the BD A and you might hear me saying that um is our professional body. Um But they also hold our trade union and so a lot of people use them for that. Um Just to sort of clarify as well. So you might hear the term nutritionist, um and that can be used um quite often, but nutritionist is not a protected title. So, um, any of you, any of the public could call themselves a nutritionist. Um And it doesn't really mean anything. Um But you do, we do have nutritionists who are qualified and to provide information particularly about um food and healthy eating. Um and there is a voluntary register, um and a qualified nutritionist can use that register. Um and they can sort of have an abbreviation as well. Um You might hear other terms such as nutritional therapists, um or diet or nutrition experts or there's lots of different combinations that people might use. Um But these are generally based on alternative or complementary medicines. Um and that there are registration bodies which take these, but they're self regulated. And it, it really is quite confusing for the public to be able to find good sources of information because it, it can appear very legitimate. And often we do have people certainly locally, even recently, we've had patients who have attended nutritional therapists, um or unqualified nutritionists and being given advice um regarding their cancer. Um and, and their, their diet and then they, they appear to us having lost significant amount of weight or cutting out food groups for, for no reason whatsoever. Um So it really is um, a tricky battle and there's, there's sometimes not much we can do um because there is no protection in law, unfortunately, just to sort of touch on how um you become a dietician. So for myself, I studied in Robert Gordon's University in Aberdeen and that was a four year undergraduate course. Um There is two year postgraduate courses available as well. Um And um, you have to have a Life sciences degree in order to, to join that course, there are now um dietetic degree apprenticeships. Um This is a new thing. I've, I've never actually seen it in, in action yet. Uh But when I had to look for it, there are two universities in England who are providing this. So you can work as a dietetic support worker in the clinical setting and be supported through the degree as an apprenticeship, which is really interesting and, and I'll be interested to see anyone who comes through that process. Um All of those um routes to becoming a dietician include clinical placements in the NHS. Um Those normally consist of 2, 12 week placements and a shorter placement. Um and those can be in various areas, um specialities within the NHS. It really just depends on, on where you end up and then just to touch on what dietitians actually do. So this really summarizes it. Um So basically we interpret the science of nutrition. Um and our aim there is to improve health um or to, to treat diseases and conditions. Um It might also be thinking about sort of sports nutrition. Um and it could be to sort of improve performance in those areas area in terms of areas of practice. Um There are lots of different areas of practice as you can see. I just named some of them. So there's the first column on the left there and those are the ones that I think are the most common where you'll find dietitians most often and, and bias because oncology is at the top of the list. Um, but those are the areas. So we have critical care and dieticians and Neurosciences. And it really depends on the center as to whether they would have a die, a dedicated dietician and un dedicated funding as to, to what would be provided. Um, diabetes is a large area where there's, there's a lot of dieticians employed and, and it could be in gestational diabetes type one, type two in lots of different ways. Um Also weight management and bariatrics is, is a place where you'll find a lot of dietitians and in every board and every trust. Um and again, the funding can vary as to what that looks like in terms of in Scotland, though we have a lot of funding for weight management and for the, the strategy. So, and there is, there are a lot of weight management dietitians in this board. I'm also on general surgical boards. You'll find dietitians there and respiratory learning disabilities and mental health, eating disorders, pediatrics. And then all the specialities within pediatrics. And actually, that could include metabolics. I've not written that in, but that should be there. Um Metabolic dietetics is quite specialist area um in terms of managing conditions like um PKU um and other metabolic diseases and renal dietetics is, is well established as well. And of course gastroenterology and then working with older people and they call them in the middle are the ones that I think are less often. And, and there's not as much recognition in some of these areas. Um So, um maternal and um that shouldn't say, and so I should say fertility. And so in maternal and fertility dietetics is just sort of starting to take off a little bit more recently. And there's specialist groups that have been established in the past couple of years. Um So this is an area that's quite interesting and there's no new courses that dieticians can apply to and go on. And that mainly happens in private practice. I've not heard of any um die die sort of NHS funding for that also within pride, prescribing support. And that's somewhere that um has become more common in the past sort of five years or so I would say, and that's mostly because everyone wants to save money. Um So dieticians are employed in prescribing support particularly for oral nutritional supplements. So, um they will work mostly in primary care to develop formularies um and to maintain a contract, a contract um with the nutritional supplement companies. So that's an area that is really um more recently, there are more dieticians working in those areas also within HIV care. Um cystic fibrosis, food allergies within the catering departments. That's both NHS and, and outside the NHS and also within palliative care. The call, the column on the right hand, side. Um, those are the ones that I would say are mostly in private practice are dieticians who are freelance. Um, so freelance dieticians might have their own clinics or work for private hospitals. Um, and there also are sports nutritionist and they have a specific register that they go on to. So you might have, um, a sports dietician who, who specializes in sports nutrition and they, um, they, they have to go to undergo rigorous training um also within food services. So that might be things like food product development and um especially specializing in allergies and labeling of products. Um Dietitians might also work in government advisory in developing policies, um particularly around public health. They might work in child to sector within the media, comment to non recent studies or um within newspapers and um online and they might work within medical companies, particularly for nutritional supplements, as I mentioned, um or also for things like pancreatic enzymes. Um They might work for the Ministry of Defense um and sort of a workplace health um in the area. Um and then they also might work in education. So in terms of higher education, universities and colleges, so you can see that it's quite, um can be quite a varied role and it's not something that I can summarize very well. Um But there are so many areas and so many things that dieticians can do with a degree, but you will find them in NHS more often. Um but private practice um is becoming more common and I'm seeing more people talking about working in private practice and there's a lot of support from the British Die Association in order to establish that as well. Um I quite like this little infographic. Um So this is um produced by the British Diet Association as well. And um this just shows us dieticians feel that we're quite holistic. Um And we like to think so anyway. Um So this just gives a sort of summary of what a dietician might be thinking about. And we have these posters up in our clinical areas a lot. Um So, as you could imagine the way that food and nutrition affects your health is influenced by your, your background and your upbringing, um your current situation, your your beliefs, um you know, your existing diseases. So, um we find that we're, we're taking to account lots of different aspects of health as, as most health professionals are. So, um but this is sort of a nice little infographic just to demonstrate that as well. Um So next, I'm just going to talk a little bit about oncology dietetics because that's the area that I work in and it's the area that I'm passionate about and I've been working in oncology for about four years now. Total. Um So it's the majority of um my, since I've been started working um oncology, dieticians might assess patients before their cancer treatment. Um during their cancer treatment or after and, and not necessarily treatment actually just during diagnosis because some people might not be receiving treatment. Um but, but definitely in all stages, um the funding as I mentioned for other specialties in dietetics really depends on the board and, and the trust. And so before I worked in Bradford, and the funding was totally different for um on college dietetics to compared to NHS Tayside where I work now. And so it really, really depends. Um But you will find that predominantly there is dedicated funding for Upper G I Cancers and HPV Cancers and the head and neck cancers as well. So the areas where um nutrition is affected the most um within those cohorts. Um But yeah, it really really does depend. Um in Scotland, we have um QPS that we um should adhere to for the upper G I Cancers. So that dedicates um time and resources. Um Although it doesn't really directly translate into funding. Um but it does help keep us accountable um for screening all patients with um diagnosed with esophageal or gastric cancer, um screening them for malnutrition. And then if they're at high risk of malnutrition, they have to be seen with by a dietician um before their first treatment. So, um that helps to keep us accountable, but it's really the only um CPI that we have in Scotland is for upper G I cancers. Um Our referrals for oncology, dietetics, generally most places it will be based on screening for malnutrition. Um and seeing those that are at high risk of, I'm going to talk about that a little bit more. Um So just to, to touch on um malnutrition. So, um we might see patients in order to prevent predicted malnutrition and to diagnose malnutrition and to treat malnutrition. And we know that um nutrition is an independent factor, an independent predictive factor for short survival within cancer patients. Um and it's estimated to occur within 50 to 80% of cancer patients. And that's quite a wide range there. Um But there is a lot of evidence to show this. Um we know that mostly um patients will lose muscle mass. Um and this can coexist with obesity. So often we find that we get referrals a lot for patients who have low BMI S um but not so much for patients um who are obese, but they might actually um be malnourished, but it's harder to identify. Um there's more and more recognition for sarcopenia. Um now, which translates to um poverty of the flesh. Um and sarcopenia is defined when this weight loss, this loss of muscle mass negatively influences physical function and strength. Um So now we've got more screening in place um or available at least um to help to identify sarcopenia and including scope obesity so that we make sure that we're not missing out large numbers of patients. So just to touch on the types of screening. Um you might have heard of malnutrition. Um universal screening tool must and for short, and this is implemented in most hospitals across the UK. And every, every patient who's admitted to hospital in the UK should be screened for malnutrition. And normally this is the tool that's used. And so there's three steps to the tool. It's first looking at BMI um second, it looks at weight loss and um there's an option for acute disease score or for per intake. So no intake for five days or more. And then those are calculated and then normally that dictates whether there would be a referral to dietetics and to implement sort of food first techniques as well. Um saying that man, the must tool is not validated to be used in oncology, but it is what is used mostly. And recently, the Scottish Rehabilitation Group for Cancer um decided to continue to use the must tool and not to use other tools and that, that might be more helpful. So we're kind of staying still a bit because must has um been rolled out and is, is well used across across the nation. Um We plan in NHS Tayside as part of a pilot with our um nutritional supplement provider um to use must, but in combination with another screening tool for, for sarcopenia that's called saf um This tool looks at um measures for sarcopenia which includes strength um assistance in walking, rising from a chair and climbing stairs and falls. So there's um markers for those things and they are added up to the score, which indicates whether someone um is likely to be scope or not. So, we are going to use that in combination with must in order to receive referrals. Um but then also to diagnose sarcopenia as well. Um Just a a couple of references to guidelines and evidence, obviously in the areas across diet ethics, there is um lots and lots of resources and evidence and guidelines available for the different specialities. All they wanted to do just now was to point out the ones that I I feel that we use the most. Um and that are the most established um nice has guidelines for nutrition support in adults which covers um oral nutrition, but also enteral and parenteral nutrition. And those guidelines are quite, quite old. Now, they actually haven't been updated recently at all. And we also have the guidelines. So this is the European Society for Parenteral and Enteral Nutrition and they have guidelines for the clinical nutrition and cancer. And this also gives us um guidance on and nutrient provision within cancer patients. So estimate nutritional requirements. Um the provision of parenteral and enteral nutrition. It also gives guidance on um the use of medications such as prokinetic or antiemetics. Um and it also gives guidance and on palliative care and end of life and the provision of food or enteral nutrition at the end of life um and the appropriateness. So, um it is quite a comprehensive guideline and then also one that I use most often um is the there's BMJ guidelines for um the management of pancreatic endocrine insufficiency. Um and those ones are, are really useful and very practical in terms of managing pancreatic enzymes um in pancreatic cancer patients or in, in chronic pancreatitis as well. Um we often use well, most dieticians it should be implemented across, across the profession is developing dietetic diagnosis and and first we establish the problem and the main problem that we use the most or that we see the most in cancer patients is malnutrition or predicted malnutrition. If we know that they're going to be going under gonna undertaking a treatment, um maybe such as chemo radiotherapy for head and neck cancer. Um also unintentional weight loss, impaired nutri utilization from um malabsorption um and also acquired swallowing difficulty. Um Our aims can vary for our patients. Um It might be to maintain or to improve the nutritional status. Um but it also might be to minimize losses. Um We might be looking to improve quality of life often particularly in the um HPV cancers um where our patients are um for palliative treatment, either chemotherapy or not for any, any um anticancer treatment. And then we might be looking to improve their quality of life. Um We might be looking to normalize bowel or stoma function. Again, that might be because of pancreatic enzymes or it might be manipulation of the diet. Um and we might also be looking to help improve um various symptoms, um just a couple of common symptoms and side effects and, and this isn't really very comprehensive at all. But, and these are the main ones that we might be seeing patients um who, who have these, all of these are none of these are one. So anorexia, so, suppression of the appetite is, is really, really common. Um And I'll talk about sort of interventions as well, but we, we li closely with the MDT and that might be discussing medication changes um or even thinking about um the use of steroids and in order to promote the appetite, um constipation and diarrhea, um reflux dysphagia, um taste or smell changes. Um mucositis, mood changes and fatigue can all affect um eating and drinking. Um And, and just to see as well, these symptoms might be caused by cancer treatment, but they might um be um as a result of the tumor itself. Um just to quickly talk about a couple of interventions. So, um often in these cancer patients, we might be talking about high calorie or protein diet advice. Um and we might be recommend a vitamin or mineral supplementation or modified texture diet. We're closely looking at patients who have enteral and parenteral nutrition, managing them as in patients and outpatients. And that might be including the the tube care Um we might be looking at pancreatic enzyme replacement and the starting of those or adjusting those. Um We might also be discussing with the MT about checking micronutrient profiles and testing fecal elastic, for example, or electrolytes. And we might also be discussing um exercise recommendations too. And this is to summarize what a week might look like. And it's just some examples about seeing inpatient outpatient telephone calls and MDT clinics, triaging referrals and responding to queries. Um also might include things like developing resources, um reviewing policies, local policies or national policies, um attending team meetings and regional or national groups. Um and just to see as well, some dieticians now have supplementary prescribing rights and which is becoming more common and we don't have dieticians are not able to have independent prescribing rights. Um But we can have supplementary um which some members of my team have got now. And also our, our jobs will include other things that are not just clinical dietetics. So, supervising staff, student training um for myself, we did the Quality and diversity Champion Network and also my CPD and that is the end of my presentation. Um If anyone has any questions, then I'll be happy to take them. I have a list of references at the end there just of some guidelines and um papers that I mentioned. Thank you. Thank you very much Rachel. That was a really, really informative slide. Very good presentation. Thank you so much. I learned so much from your presentation. Thank you more pi for a dietician than I, I was aware of. Obviously I'm not very, you know, knowledgeable in this area, but it's very interesting. Thank you. I, I think it's interesting too in it. Yeah, I think it's, it's so variable as well, you know. Um, and, you know, a dietician who works in a different area would have a, a totally different presentation. Um, which, um, is good, good, I suppose. Um, yeah. Yeah, it's very interesting. I do have a question. Um, what is, what is the biggest struggle that you think on your day to day job being an oncology dietician? I think that would depend on the day you catch me on. Um, but, but sometimes, um, probably it can be hard to see, um, the, the benefit there in them. Um, because a lot of the time, especially in my case load, it's a lot of upper G I and H PB and outcomes for those patients generally are not so good. And, um, so it can be hard to see that and what we're not very good at doing, I think as a whole profession, to be honest is monitoring outcomes or especially in oncology. It can be quite hard to measure outcomes. Um, but, but it's not like that majority of the time, but I think for me that's probably, um, quite difficult. Um, and, and sort of being underfunded, but everyone would say that, I think in every area. Yeah. And what do you think is something that um that obviously this is more, most of the audience will be either like health professionals or physicians or something that physicians can help in, to help your role and your job easier in helping, you know, to do your job in monitoring their nutrition. And, yeah, malnutrition, I think just having a good relationship with the other members of the NDT, not just dietitians in general. I, I'm quite lucky that in the department that I work in that we have a really good working relationship and um you know, the medical team, the nursing team, other allied health professionals know who we are. Um And I think we're fairly well established now. Um So they know just to contact us if there's any queries and I prefer that than sort of making guesses or if there's patients getting discharged, not knowing about it. You know, we, we tend to be able to find out these things. So I think just communication just being sort of open and, and getting to know the team. Ok. Sounds good. Thank you so much. Is there anyone else you have questions for Rachel? You can type in the chat box if there's any, if not, we can be happy to email you if anybody has any questions that Yeah, of course. So we're ok. Absolutely. Ok. Thank you very much for your time, Rachel and thank you so much for volunteering to do this. It was a really, really good session. Thank you for having me. Thank you. Bye bye.