Psychosocial Factors in Dietary Change in Cancer Patients - Essay Example

Psychosocial Factors in Dietary Change in Cancer Patients Cancer patients experience a high occurrence of psychosocial distress that varies by circumstances, with younger patients, women, and those from ethnic minorities, from households with lower income, and those with a longer duration of illness reporting the greatest stress (Carlson, 2004). Such distress needs to be addressed when working with a patient on a dietary program to insure the best adherence to nutritional modifications. This perspective becomes more relevant with each passing year as more effective cancer medical treatments make cancer increasingly a chronic, rather than a terminal, illness. Thus patient responses have become more important in moderating patients stress and adjustment to the disease. People don’t die of disease, says Norman Shealy, they die of depression. The way people deal with their illness greatly influences physical and emotional well being. Several variables impact how people handle their illness. These include stress, coping styles, self-efficacy, social supports, motivation, attitudes, and illness representations. The key to influencing the patient’s nutrition status is by understanding how the practitioner can influence these behaviors. This paper discusses the various psychosocial behaviors, and ways the practitioner can use this knowledge to design patient nutritional intervention strategies. Evaluating Psychosocial Factors To address the psychosocial aspects of illness and how these might impact the patient’s diet the practitioner needs to evaluate the patient’s illness behavior, quality of life and current level of coping. Helpful evaluation tools include: Illness Behavior Questionnaire, European Organization for Research and Treatment for Cancer Quality of Life Questionnaire, and the Coping Strategies Questionnaire. Transtheoretical model (TTM) As is common knowledge, most nutritional intervention programs, even when initially successful, ultimately fail. Part of the problem rests on a one-size-fits-all approach. The transtheoretical model (TTM), also called “stages of change” model, posits that people move through a series of stages in modifying diet and that the practitioner needs to suggest stage appropriate strategies and expect stage appropriate outcomes (Prochaska et al, 1997). These stages are: Precontemplation – no intention to change behavior in the near future Contemplation – aware of problem and considering change in the near future Preparation - planning to change behavior in the near future Action – recently altered behavior Maintenance – sustaining change with a more relaxed effort Within these stages of change, TTM addresses three conceptual frameworks: decisional balance – the pros and cons of change; self-efficacy or how much a person feels they can control what happens to them; and processes of change which encompasses the activities a patient employs towards change. In the early stages, the person is contemplating the advantages and disadvantages of change. For instance, were a cancer patient to go on an organic raw food diet, this might enhance their health but would impact them socially in that they would not be eating emotion-laden food or sharing the same food in family meals. To get to the later stages, a person must begin to outweigh the disadvantages in favor of increased health. As such, the practitioner must provide much education regarding the advantages of change and, to not overwhelm the patient, start with small dietary changes (Glanz et al, 1997). Support systems at the preparation and action stages are crucial help to buffer the vicissitudes of change and it would be a good idea for the patient to get involved with a support group of other cancer patients dealing with dietary change (Kristal, 1999). Likewise, in the early stages, self-efficacy is low and outward directed. The person does not yet have confidence that their actions will significantly impact outcome. The practitioner and support groups must continually boost the person’s self-efficacy through strategies such as reassurance and cognitive reframing to prevent relapses. As the person moves through the stages, they begin to see benefits from the diet and begin to feel more empowered in being able to fight the disease. Relapses become less likely and activities to reach their goal increase and reflect this more positive attitude as they move into maintenance. At this point, relapse is unlikely and the focus is on providing dietary messages that reinforce balance, variety, and moderation. Moving a person through the stages of changes requires detailed knowledge of the psychosocial dynamics of the cancer patient. Psychosocial Dynamics of Behavioral Change and Diet Stress The issue of cancer and diet is complex and fraught with pitfalls. Living with a serious, perhaps deadly illness is extremely stressful and creates enormous anxiety. Stress in turn greatly impacts digestion and digestion is intimately tied with our emotions. Our gut is our “second brain” (Gerson, 1998). Containing over 30 hormones, many of which also act as neurotransmitters, the chemical messengers of mind and emotions, the gut directly “talks” with the central nervous system. Serotonin for instance, the neurotransmitter that governs mood is concentrated in the gut. This makes the gut highly sensitive to turbulence and anxiety and digestive disorders, like irritable bowel and spastic colon, go hand in hand (Heller, 2006). Further, when anxious, our body goes into flight/fight and, to conserve energy, digestion and other bodily functions slows and we don’t digest our food well. The poorly digested food ferments and plays tricks on the brain, and we get sleepy and lethargic, or jumpy and anxious which would make it more difficult for the cancer patient to cope. Further, chronic stress uses up valuable vitamins and minerals and exhausts the system, making coping with or recovering from cancer and its interventions more problematic. And stress throws off your sugar level, which can eventually lead to problems like hypoglycemia (low blood sugar) and sugar cravings. Drugs, radiation and chemotherapy further deplete the digestive system and cause a multitude of gastrointestinal problems that interfere with digestion including: yeast overgrowth, food sensitivities, leaky gut, acid reflux, irritable bowel syndrome, hypoglycemia, malabsorption. These GI diseases themselves produce symptoms that interfere with normal eating. For instance, candida, or yeast overgrowth causes sugar cravings. Sugar, in turn, feeds cancer cells increasing their growth. Thus having candida would both exacerbate the illness and make it more difficult for the patient to comply to adhering to a healthy diet. Little wonder that problems related to nutrition have been identified by cancer patients as the most important factor in affecting their sense of well-being (Padilla et al, 1983). All this produces a negative feedback cycle whereby GI problems that result from stress and the sequelae of the cancer treatment feed anxiety and depression, which then interferes with how well the patient can cope with the disease and adhere to a proper nutrition diet. Coping How compliant a cancer patient is to nutritional intervention relates to how well they are coping at any point in time. Coping is not a static concept but varies according to many factors that include: how the illness changes; support systems; attitude (optimist/pessimist); level of depression and anxiety; success and relapses; stress; life events; finances; pain; fatigue; and physical limitations. The poorer the coping skills, the harder it is to adapt to chronic illness. Patients who are problem focused feel demands are in their control and approach a problem looking for solutions. Patients who are emotion focused in contrast have poor coping skills as demands feel out of their control and they tend to avoid a problem and distance themselves. These patients are likely to avoid change and will likely be non-compliant to dietary changes. How can the practitioner enhance coping skills? One way is to work with the patient on cognitive and behavioral approaches to managing stress. Therapies that emphasize cognitive and behavioral changes have been shown to enhance the quality of life for cancer patients undergoing radiotherapy by reducing emotional and physical distress thereby increasing a person’s outlook (Forester et al, 1993). These include adaptive strategies such as include: accepting responsibility, planful problem solving, positive reappraisal of their illness and seeking support. The pitfalls of negative strategies, including confrontive coping, distancing, escape/avoidance, wishful thinking, self-controlling, need to be pointed out to the patient. Though ongoing, the thrust of this work needs to be in the early stages of change. Positive reappraisals might include: Downward comparison: “This is not as bad as the things that happen to other people (having a curable versus a terminal cancer).” This helps to reduce the relative importance of the stressor. Positive reappraisal: “I will come out of this experience better than I went in.” This redefines the stressor as a challenge to improve one’s life and enhance self-growth. In a longitudinal study of women with early-stage breast cancer who completed their primacy medical treatment, positive reappraisal coping at study entry predicted positive mood and perceived health at 3 and 12 months and posttraumatic growth at 12 months (Sears et al, 2003). One woman I know says she feels “grateful” everyday of her life for having gotten breast cancer at the age of 29. She cured herself through diet change, holistic means and spirituality and became a massage therapist and raw food educator to help others improve health and quality of life. She attributes having gotten the cancer as the catalyst for self-growth. Adherence Adherence to any diet is tricky as many factors impact appetite and digestion: stress, coping style, social milieu, sensory preferences, state of being at any point in time – a tired body craves sugar and caffeine to perk up and get going; success of diet; ability to delay satisfaction; desire to live; pain level – too much pain and you may feel that you may as well eat whatever you want as you don’t have long to live so you should enjoy the time you have. What Affects Adherence? Environmental -- Complexity of food choices – cost of healthy food, resource restraints, availability of healthy food. The raw food, organic diet, well documented to enhance the immune system and reduce cancer tumors, especially breast cancer if adhered to, requires significant lifestyle changes. Most food has to be prepared. Restaurants do not serve organic food and the rest of the family is unlikely to be on the diet. Juicing is an important part of the diet and entails a special juicer, quantities of fresh organic produce which may not be easily accessible, and considerable time for preparation. Consequently, though virtually all cancer patients who go on the diet begin to feel better, few will adhere to the diet because of all the psychosocial factors that enter into what, when, how much to eat and what’s involved in food preparation. Social/Cultural Contexts – cultural; religious meaning; social support; meal sizes, gender – females identify with family-food preparing role; taste With an organic, raw food diet as an example, a Jewish person who keeps kosher might find the diet a hard adjustment as would an Italian woman who is used to cooking the Mediterranean diet for her family. Families who do not support the cancer patient’s new diet will also make it harder to adhere to. Behavioral or psychological issues Issues such as self-esteem and self-efficacy will impact adherence. A person with low self-esteem and self-efficacy will experience learned helplessness and feel that what they do has no impact –“Why bother to eat and when I do eat I will eat what I enjoy in the little time I have left.” Individual perceptions/Beliefs Information Processing – conflicting sources of information (contradictory/changing); perceptions of choice Much information on diet is contradictory. As such, at the beginning stages especially, patients might be confused by all the contradictory diets. The practitioner needs to educate and guide the patient in choices to make. Self-efficacy – belief they can carry out prescribed changes to diet. Confidence in ability to change behavior Self-efficacy is a major player in how well a cancer patient will modify their diet. If a cancer patient has had relapses or a poor diagnosis, learned helplessness -- the belief that you can’t change what happens to you so why try -- is of major concern. Attitude varies according to where the patient is in the four periods of the illness trajectory: diagnostic and pretreatment phase; the treatment phase; post-treatment phase; and terminal phase. Patients in the treatment phase, who may be undergoing radiation and chemotherapy, will be less motivated to eat or have the energy for food preparation and patients in the terminal phase may feel that diet modifications won’t help so why bother. The relation between cancer self-efficacy and patient cancer adjustment, depression, psychological distress, and behavioral dysfunction was studied in 42 cancer patients recruited from a Veterans Administration Medical Center who completed a Cancer Self-Efficacy Scale, the Center for Epidemiological Studies-Depression Scale, the Affect Balance Scale, and the Sickness Impact Profile (Beckman et al, 1997). Correlational analyses indicated that self-efficacy was related to all adjustment measures: cancer adjustment, psychological distress, negative affect, positive affect, and behavioral dysfunction remained statistically significant. As such, increasing self-efficacy, particularly in the early stages of changes, is essential so the cancer patient can feel empowered to successfully adhere to a diet modification program. Some suggested ways to help the patient increase control include: journaling; prayer; spirituality; positive affirmations; detoxifying; exercise; relaxation techniques such as meditation; Chi qong; yoga; Tai chi; progressive relaxation; and reiki; aromatherapy; vibrational medicine; and cognitive-behavioral therapy/support groups. Strategies for enhancing adherence Education Knowledge is power. The more you learn about nutrition’s role in cancer prognosis, the more you will feel empowered to take charge of your life. Motivation – perceived benefits and costs Initially, the practitioner needs to work hard with the patient to educate them on the perceived benefits of dietary change. The more successful the practitioner is in empowering the patient, the more likely to patient will comply with the dietary changes. Behavioral skills – recognition, avoidance, asking for support/help, cognitive reframing of relapse Diet modifications rely heavily on personality characteristics such as feeling comfortable asking for help, support, or advice, and resilience and renewal should the cancer patient relapse in spite of dietary changes. Nutrient –modified foods – specific dietary goals The dietary goals for the cancer patient need to be modified from eating primarily for pleasure to eating for health. Without strict adherence to these goals, it’s easy to slip off the diet or, if feeling unwell, to not eat at all though one needs the necessary nutrition. Interpersonal interactions – support Social support is a key component in empowering a patient to want to eat for health. In a longitudinal study in the Netherlands, self-esteem was measured in 475 recently diagnosed cancer patients and 255 individuals without cancer in relationship to perceived availability of emotional support and problem-focused emotional support (van Halteren, 2004). The results indicated that lower levels of social support and self-esteem were strongly associated with higher levels of depressive symptoms. Depression equals learned helplessness, or lack of self-efficacy. Consequently, social supports are a crucial component in empowering the cancer patient to adhere to diet modifications, and especially in the early stages of TTM . Psychosocial remedies, such as socialization, have been shown to provide a feeling of belonging and are associated with survival (Spiegel, 1993), while participating in support groups help mediate depression in cancer patients (Evans, 1995). In conclusion, dietary changes in cancer patients is a complex issue that needs to be attacked both in terms of health related stages to dietary change and the psychosocial factors, such as self-esteem, self-efficacy and coping style that determine adherence to dietary changes. Works Cited Carlson LE, Angen M, Cullum J, et al, 2004. High level of untreated distress and fatigue in cancer patients. Br J Cancer, 90 (2), 297-304. Evans, Ron L,  Connis, Richard T, 1995. Support groups, social research, mental depression, group therapy. Cancer Public Health Reports, 110 (3), 306. Forester, B., Kornfeld, D. S., Fleiss, J. L., and Thompson, S., 1993. Group psychotherapy during radiotherapy: effects on emotional and physical distress. Am J Psychiatr 11, 1700-1706. Gershon, Michael, 1998. The Second Brain. NY: HarperCollins. National Comprehensive Cancer Network, American Society of Clinical Oncology, July 30, 2004. The NCCN clinical practice guidelines in oncology: www.nccn.org/physician_gls/index.html. Glanz, G., Lewis, FM and Rimmer, B.K., eds., 1997. Health Behavior and Health Education: Theory, Research and Practice. San Francisco: Jossey Bass. Heller, S., 2006. The Anxiety Myth, Why your anxiety may not be all in your but from something phsyical. Delray Beach, FL: Symmetry. Friedman LC, Nelson DV, Baer PE, Lane M, Smith FE, Dworkin RJ., 1992. The relationship of dispositional optimism, daily life stress, and domestic environment to coping methods used by cancer patients. J Behav Medicine, 15:127-141. Kristal, AR, Glanz, K, Kurry, SJ and Patterson, RE, 1999. How can Stages of Change be best used in dietary interventions? Journal of the American Dietetic Association, 99, 679-684. Nelson DV, Friedman LC, Baer PE, Lane M, Smith FE, 1989. Attitudes to cancer: Psychometric properties of fighting spirit and denial. J Behav Med,12, 341-355. (9437), 824-825. Prochaska, JO, Redding, CA and Evers, KE, 1997. The transtheoretical model and stages of change in Glanz, G., Lewis, FM and Rimmer, B.K., eds. 2nd ed. Health Behavior and Health Education: Theory, Research and Practice. San Francisco: Jossey Bass, pp 60-84. Ross L, Boesen EH, Dalton SO, Johansen C., 2002. Mind and cancer: does psychosocial intervention improve survival and psychological well-being? Eur J Cancer, 38, 1447-57. Schroevers, Maya J, Ranchor, Adelita V, Sanderman,  Robert, 2003. Community Support, self-image, mental depression, comparative analysis. Cancer, Social Science & Medicine, 57 (2), 375. Sears, Sharon R., Stanton,  Annette L. and Danoff-Burg, Sharon, 2003. Health Psychology, 22 (5), 487. Spiegel D, Bloom JR, Kraemer HC Gottheil E, 1989. Effect of psychosocial treatment on survival of patients with metastatic breast cancer. Lancet, 2, 888-891. Spiegel D., 1993. Psychosocial intervention in cancer. J Natl Cancer Instit., 85, 1198- 1205. H K van Halteren,  G P A Bongaerts,  D J Th Wagener. Cancer, mental depression,  anxieties,  intervention,  oncology, 2004.  The Lancet, 364 Woolcott, Donna M., Impact of information and psychosocial factors on nutrition behavior change. Read More