Episode 115: Fundamentals - Nutrition in Cancer with Chloe Nottingham, Dietitian Part 1

We are what we eat.

Join us as we discuss with the excellent Chloe Nottingham, a specialist cancer dietitian with years of experience.

Malnutrition can lead to worse outcomes in cancer care.

Depending on the cancer type between 40-80% of patients suffer from malnutrition.

Why is that so important;

- Lower treatment tolerance 

- Lower treatment completion and doses

- More delays getting onto treatment

- Lower survival rates

- Reduced wellbeing and energy

- Longer hospital stays

Getting good nutrition support and eating well can massively impact your cancer journey.
If food was a drug we would pay a fortune for it !!!!

Chloe helps us plan a route to healthy and sensible ways of keeping our body weight and muscles working.

Enjoy!!!

Transcript

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Simply Oncology Podcast Recording Diet in Cancer-20260723_153440-Meeting Recording

July 23, 2026, 2:34PM

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 And welcome back to this episode of the Simply Oncology Podcast. Mike, we are going to talk about food. We are what we eat and I think probably one of the most common questions I get from patients is what can I eat to try and help take control
 over my cancer situation, to help my cancer treatment, to help my recovery. So this is a huge topic, Mike. Absolutely, John. And I'm thinking, you know, we talk about, you know, these complex drugs and therapies that we're giving to patients, but actually we haven't even talked about the basics. Food, that's one of our...
 basic needs. And to do that, we have invited the lovely Chloe Nottingham, who is one of a specialist cancer dietitian here at our very own Royal CORNWALL HOSPITALS. Chloe, welcome. Hello, thank you for having me.
 Now, Chloe, we're going to talk about a lot of things today. We're going to be talking about what dietitians do. We're going to be talking about what advice you give patients. We're probably going to tackle a few food myths, sugar, fasting, all of those things.
 We've got the seagulls listening outside. We're going to talk to them as well. So Chloe, tell us a little bit about the dietitian role in oncology. Yeah, so the dietitian's role is really varied, but we're a really essential part of the team.
 So our main role is to sort of translate that evidence based nutrition information to our patients to help support them through their cancer journey. So we should be screening patients with regards to their risk of malnutrition and their nutritional status.
 at point of suspicion and certainly at point of diagnosis to give dietary advice dependent on symptoms, how patients present and to support them through their treatment. So that can be sort of food first, actually what patients are eating and drinking if they're able to.
 Those that are struggling a little bit more to sort of maintain weight and muscle mass through their treatment, it can be the use of prescribable products such as supplement drinks. And then again, a little bit more input can be for those.
 complicated, sort of more complicated patients requiring what we call enteral feeding. So that might be feeding tubes to support patients. So a huge variety there. I'm going to jump in on the screening part of it because we're rubbish at that, I think.
 Well, when I say we are rubbish, I think I'm rubbish at that. Well, I'm going to hit you with a couple of questions, right? So I've heard of the must score. Yeah. Often lambasted, but very simple. Yeah. When we screen, how many patients are malnourished and what is malnourished?
 And why can't we apply a simple screening tool so that we at least know the scope of the problem? So unfortunately, I agree, we are not great at screening our patients and that means we're often picking them up later down the line when nutritional complications are arising and getting worse. There are
 a lot of different screening tools out there, like you say, MUST is one of them, but there are potentially more robust cancer specific screening tools such as GLIM.
 Pros and cons of screening tools. So the pros are they obviously pick up patients at a higher risk of malnutrition, enables us to sort of get in there quicker. But like anything, it does take time, it does take training, you know, and there are so many pressures that nurses, healthcare assistants, doctors, dietitians,
 have and sometimes these things, you know, take a step back. And so in cancer, in patients who are suffering from cancer in whatever stage it may be, why is nutrition such an issue? What are the main issues that are there experiencing that mean that we actually need the specialist dietetic input? Yeah, so
 It's again, cancer itself has huge implications on the way we use nutrition, absorb nutrition, digest metabolic needs for nutrition changes, our requirements increase. And then we throw cancer treatment at patients, which also has a huge impact on ability to eat and drink.
 how we utilise that nutrition. And there are a huge range of side effects that patients can get and most patients will get at least one of them throughout their treatment that all again impact appetite and ability to eat. So nausea, constipation, pain, swallowing issues,
 And so that diet specific dietetic input to help, you know, identify and tackle those is really important. And how big is the issue? Do you get a feel for, I mean, again, we're talking really general, I suppose, certain type of cancers might be more or less affected by this, but generally, in your experience,
 If you look to the whole population of patients with cancer, all stages, how many would value a dietetic input? I would say 100% of patients would value dietetic input, but we know that malnutrition rates vary from about 40 to 80%. So our sort of highest risk malnutrition cancers would be upper GI,
 head and neck, hepatobiliary. But yeah, the majority of patients unfortunately diagnosed with cancer and certainly those going through treatment will have a larger increased risk. And what are we calling malnutrition? What are we calling? Is it 10% drop in?
 ideal body weight? Who's got an ideal body weight? What are we working with, Chloe? Help me out. Yeah, so it can be diagnosed in lots of different ways, but looking at weight is one of them. So we would say a risk of malnutrition would be a body weight drop of 5% or more. So I was way out.
 Okay, fine. And that's where sort of things like MUST alone can be tricky because patients with larger BMIs, it's not so noticeable when that percentage weight loss is occurring. And so, you know, identifying sort of sarcopenia and muscle mass loss is really important, not just, you know, BMI and what the
 patient's weight is now, but it's looking at that history. So what weight were you? How long have you lost that weight? Is it still dropping or have you managed to stabilise it, you know, recently? Have you even started treatment? What's the impact likely going to be? And so what can we achieve? What's the point of addressing
 nutrition? What's the what are we trying to do for these for these patients? So what's the outcome? What we're trying to do and what we know that dietetics can do. So it works two sides. We know that those at a greater risk of malnutrition have higher mortality, are more likely to suffer with treatment side effects.
 may need reduced doses in their chemotherapy, may not finish treatment if they are not fit enough. So the flip side of that is the fitter we get our patients, the stronger we get them, the more muscle mass we can maintain through treatment, the better outcomes they have. So we have recently done an audit
 into specifically into upper GI patients here at RCHT over a three-year period. And the outcomes that we were able to show is that patients that saw the dietitian had reduced complications post-op. And what complications are they? They can they can range from sort of chest infections after oesophagectomy.
 through to, you know, those that ended up on ITU with sepsis, anastomotic leaks. So these are significant. And if we think about it, never mind the physiological cost to the patient, the actual financial cost to a health system of a solitary ITU stay or a stay with pneumonia, it can be quite advanced. So that's
 Yeah. So yeah, we were able to reduce length of stay by a day. We almost doubled the number of patients that completed their adjuvant chemotherapy. And like you say, the cost of drugs that we're treating cancer with versus the cost of, you know, diet, food, supplements that are a penny in the hospital.
 And this comes down to the points we've made on this podcast before, which is we need to be looking at doing the basic stuff right first, rather than getting ahead of the horses and looking at all these complicated genomics, etc. That happens in parallel, but let's spend some time, let's spend some money actually getting the basics right.
 to save money and also to help patients. Ultimately, what you're talking about, although there's financial implications, all of that is a better patient journey, a better patient experience through what is really difficult treatment. Yeah. And so we know that, you know, we can improve statistics and cost, but we also know that we're improving quality of life.
 their ability to get, you know, do daily house chores, mobilising around the house easier, their mental health is better when they're better nourished. You know, there's a huge impact. And eating is such a social thing, right? When you're with people, you share a meal, you know, and actually it makes you feel good. People often say,
 what can I eat to help? And imagine like you were telling me as a new like registrar or even just now as an incompetent consultant, what kind of things would you say to that patient as basic first steps?
 I'm going to set a scenario. I'm making it up off the top of my head. I'm 70 years old. I have got bladder cancer and I'm just about to start treatment for that with enfortumab vedotin and pembrolizumab. Right. So. And I've lost. OK, I'm going to keep going. I just, by the way, if you hear flapping at any point on the podcast,
 Mike and I are fanning Chloe, like slaves or something, because we can't have a fan running because it affects the sign. So too many seagulls out there. Yeah, and too many seagulls. So if you hear that, that's what that is. OK, so. I haven't requested that. She's not declined enough, so that's fine. So say I was 14 1/2 stone, and I've dropped to 13 stones, that's about 10%.
 I'm sticking with my own numbers, even if they don't mean anything. What kind of things would you be coming in to say to me and advice would you be giving me? Yeah, so...
 The first thing I think is really important is there is no special diet or special food that we can eat to cure our cancer, to, you know, prevent its spread, to reduce its growth. And the most important thing is that we're not cutting out food groups.
 that you were eating normally. So the main thing is to be eating whatever it takes to maintain your weight and your muscle mass. So again, a varied balanced diet. So I would be looking at, you know, what protein is this patient managing to eat and that
 can be, you know, anything from meat, fish, plant alternatives, dairy, nuts, making sure they're having carbohydrates, so bread, potatoes, pasta, you know, that they've got some sort of fruit and vegetables in their diet. So
 The advice around what they should be eating is, firstly, what do they want to eat? You know, the foods that you fancy are the most important foods to introduce and continue eating. And then it's how can we build upon that? That's a great choice. What do you actually want to eat? You know,
 It gets to a point, you know, with some patients where appetite is so severely impacted that, you know, fine, if all you can eat at the moment is sweet puddings and, you know, sausage rolls, continue doing that because that is a source of calories and that is a source of protein that we can supplement, you know, with nutritional supplements. We can talk about multivitamins if required.
 but it's what are the building blocks? What are you managing now? And then how can we get to where we need to be? I'm going to give you a flip side question, which is possibly not because we worry a lot in patients with cancer about weight loss. But we also know that sometimes having too much weight on board
 can also be a bit of an issue, particularly if we're thinking maybe less so on the sort of the advanced cancer, but maybe on people who might be then going on to have things like surgery and getting through surgery okay. How do we approach the too much weight in cancer as well? So again, it's going back to what I sort of said earlier that
 Yes, we know that being obese can be certainly.
 it can increase our risk of cancers. But we also know that just being obese doesn't mean that we're not losing muscle mass and having the same impact of nutrition. But for those that are maintaining their weight at a greater weight, then yeah, there definitely are benefits to a safe gradual weight loss before surgery.
 We also know that some surgeons are really keen on a more rapid weight loss to help with that surgery. And so periods of a liver reducing diet, for example, before surgery. Well, a liver reducing diet. We said we were keeping it general. We've gone slightly fat just there with a liver. I'm not letting you pass the gear on that one, Chloe. Why do I want to reduce my liver?
 So this might be sort of raising a few eyebrows. The evidence is... What is it? Is that liver reducing diet is to reduce the liver size. So surgeons find it easier when they're doing actual surgery. To reduce the size of your actual liver? Yes. Okay. And what does that involve? To help mobilise it out the way. So it basically is a really calorie restricted diet.
 diet for about a six-week period before surgery. But it's very important that this is done alongside the dietitian. Don't do it on your own. No, absolutely not. So this is not like going ketotic or fasting, like, you know, following Instagram and following that. No, no. I wasn't going to come back to that. Well, should we come back? Should we talk about it now? No, let's try and keep.
 I know weaving and morphing. Let's just try and stay hot. All right, so liver and what other kind of things would you be saying to people in a weight? Because I think this might be the only time we talk about this, the weight reductive side of things. So it's also really important, you know,
 nutrition preventing
 cancers, nutrition as part of prehab and rehabilitation for cancer, it doesn't come on its own. And physical activity is really important, you know, that we are considering this alongside. So, you know, we don't want to restrict patients' intake too much just so that they start losing weight. And so
 potentially the conversation of, you know, how much physical activity are you doing, what exercises are you able to do? And again, that's something not just for the dietitian, but the MDT as a whole should be approaching with these patients. And of course, with NIGOT, we're in the era of the Manjaro kind of like, why try when you can
 Have an injection.
 What's our position on that? Do we have a position on that? I don't know. I would recommend that, you know, if you are on obesity drugs, that they are done as part of, you know, obesity specialist dietitian. We have had lots of patients on them.
 We get referrals for patients that have lost huge amounts of weight and actually after doing a bit of digging, they're still taking these medications. They were meant to be, but they're still taking them, but actually they're not able to eat and drink. They're suffering with nausea and vomiting there. You know, that's the point where the risk of malnutrition is greater than, you know,
 the risk of that obesity.
 Now, all of this, basically, from what I'm hearing from you, Chloe, is that essentially the earlier you have dietetic input, the better, basically. Ideally, on day one of, oh my gosh, I've got cancer, one of the things should be right, when is when is when is a dietitian getting involved? And we're screening with.
 The must score currently? At the moment we are, but that is something as a department we're looking at. But do you think nationally, on top of just locally, do you think that is happening at the moment? No, no, I don't think it's happening in many centres. So a massive area of need is dietetic input in cancer.
 Yeah, we are under-resourced. You know, even things like prehabilitation have been, you know, been looking at this for years and years with the evidence is out there. We know how much it impacts outcomes, how much that can be a cost saving, more importantly, how much it improves the patient journey and their quality of life. Yeah.
 Still, it's a real struggle to pinpoint resources. And whenever you, we started before Mike very rudely interrupted, I thought. But with a smile. Yeah, a smile. And a fan. Things that we talk about, recommendations for patients, you mentioned protein.
 I'm hearing a recurring theme from you about muscle mass, protein, exercise being part of this dietary equation. So your meats, your nuts, your kind of pulp seeds and things like that. What else are we talking about? Like I often say to people, make sure you've got at least five a day of fruit and veg.
 but at least favouring veg. I don't know where I've picked that up, but it's what I say. Is that, can I expand on that or? Yeah, so if we're going to, you know, into a little bit more detail. So it would be things to avoid would be, because you know, there are always things to cut back on, but it's really important that we're not just telling people don't have this, don't have that, but actually what can they introduce. So
 Both things. So things to avoid would be, you know, reducing alcohol completely if we can, avoiding processed meats and especially ultra processed foods. That's become a real big research target at the moment. And there will be people out there going, I've heard about ultra processed foods, but what are they? And they might be opening a packet of Pringles.
 and eating them going, I wonder what these ultra processed foods are. Yeah, that's sort of it, you know, most things, if it comes in a packet, if it's, you know, contains colours that aren't natural, you know, those are the foods you want to avoid. And so things that we can eat in its most whole, you know,
 most natural form, even coming down to things like fruits. You know, if you're able to eat a piece of fruit, do that rather than having smoothies because of the sugar content is higher, the fibre intake is lower. So yeah, so eating, you know, protein at every mealtime.
 trying to reduce red meat to around 3 portions a week, trying to avoid processed meats like bacon and sausages, choosing leaves. They are delicious. Do we acknowledge that? And again, this is where the dietetic advice comes into the individual patient, because some patients, you know, will be saying,
 Choose those higher calorie foods. And if that's the only ones that you want, then have them. But if we're talking about general guidelines. But I suppose I think again, what you're saying with that is you're not specifically saying you are not having this. It's about moderation, isn't it? Yeah, absolutely. Not exclusion. Yeah, everything in moderation. And so we would be looking at that diet as a whole.
 rather than, you know, specific foods. And again, they may have an unhealthy diet, but that intake in general might be a lot lower than where it needs to be. So we certainly wouldn't come along and tell them to cut out those foods even more. That's the only calories they're getting. Yeah, sure, sure.
 We're on our healthier diet or we're building towards it. We're eating what we fancy. We're introducing our protein and carbohydrates and foods that are as close to their natural source as they can be. So we're making progress. Exercising. And we're exercising. This is the utopia that we live in. Yes.
 But as we get to that, we often start supplements in clinic. Yeah.
 I always use myself as a bad example, but I'm quite happy to put myself out there. I will generally start people on an Ensure type thing. Other products are available. Not that we're not the BBC, so it doesn't really matter. And I'll generally give people two a day and say, take it as well as.
 Keep them in the fridge, keep them cold. You don't have to down them. So back and forth to it as you need. Am I doing more harm than good? Am I doing any good with that? Or like, what is our, what's my opening gambit? If you were on my shoulder, like a little like conscience voice, what would you be saying?
 You know, I think identifying malnutrition for some patients is really obvious. You know, those with really low BMIs, those that are looking frail, those that are struggling to mobilise. And so certainly starting supplements at that point probably isn't a risk at all, because it's likely that they're not managing a well-balanced healthy diet meeting their requirements.
 We have a protocol in place where because of the lack of dietetic resource at the moment and the likelihood that the majority of patients will end up on a supplemented form of nutrition throughout their cancer journey, that yes, start these early before we get to see them. And so when we do get to see our patients,
 they've already had a few weeks of, you know, a boost of nutrition and they can be what we call a sole source of nutrition. So it's protein, carbs, fats, vitamins, minerals, it's everything that the patients need to help get them through that treatment. And then we can come along and decide, you know, there might be a better form or a compact style or a
 that's more suited to them. Because I'm going to put out there that probably about 75% of people who I start on supplements or have been at some point started on supplements, when I ask them, how did you get on? They go, they were awful. I'm never having that again. Or the question you get asked, have you ever had them? You should try a week on them.
 Some are, some are, some are. There are what we call first line products and those would be like the Ensure that you've mentioned, but there is a huge range of different types of supplements, you know, smoothies, milkshakes, savoury options, shot style. And so, you know, we're quite confident that we will find something that the patient is able to take.
 On the flip side of that, it's really important that we help change the mindset of the patient that nutrition is as important as the treatment they are receiving or the antibiotic that they've been prescribed that tastes disgusting, but they still take three or four times a day. And, you know, as part of that, it's explaining
 how the better nourished you are, the less side effects you're going to have, you know, hopefully the easier you're going to find this treatment, the more likely you are to complete it. So by counselling and getting the understanding of why we are using this, how it's going to help you is sometimes enough. But yeah, there are
 A wide range, a wide amount of flavours and types and styles, so...
 just because the ensures aren't the ones that they like, you know, we are likely to find one that they will take.