Psychosocial Support and Nutrition Counselling Among Patients with Cancer Receiving Chemotherapy: A Mixed-Methods Study

Purpose Cancer chemotherapy causes nutrition impact symptoms (NIS) that affect patient diet and nutrition. Such patients, therefore, require nutrition counselling. In this study, we aimed to 1) identify the psychosocial factors of patients who require nutrition counselling and 2) articulate the specic details of the issues for which patients desire advice. Methods We conducted anthropometric measurements, surveys using questionnaires, and interviews with patients receiving outpatient chemotherapy for head and neck, oesophageal, gastric, colorectal, and lung cancers. The questionnaire included items on NIS, patients’ experience of eating-related distress (ERD), and quality of life (QOL). Interviews were conducted with patients who required nutrition counselling regarding specic issues. We provided nutrition counselling in two sessions.


Introduction
Cancer chemotherapy causes nutrition impact symptoms (NIS) such as taste disorder, olfactory disorder, and constipation, and aggravates patients' nutritional issues [1,2]. Studies have shown that 50-80% of patients with advanced cancer experience cachexia, a nutritional metabolic disorder characterised by weight loss, which affects their quality of life (QOL) and for which nutritional support is required [3][4][5].
Approximately 80% of patients with cancer experience anorexia and weight loss [4]. Moreover, numerous patients with advanced cancer, as well as their family members, suffer from eating-related distress (ERD) [6]. In a previous research, it was found that 77.5% of the outpatients receiving chemotherapy needed nutrition counselling, and the need for nutrition counselling was also found to be associated with ERD [7]. Page 3/20 The European Society for Clinical Nutrition and Metabolism practical guideline states: 'We recommend nutritional intervention to increase oral intake in cancer patients who are able to eat but are malnourished or at risk of malnutrition. This includes dietary advice, the treatment of symptoms and derangements impairing food intake (NIS), and offering oral nutritional supplements (ONS)' [8]. However, it does not mention any psychosocial aspects.
Nevertheless, patients may require nutrition counselling, the objective of which is not limited to ensuring adequate caloric and protein intake. Diet is related to various contextual factors that affect patients, such as anxiety regarding weight loss, building physical strength to ght the disease, and the desire to maintain pre-illness lifestyles as much as possible. Therefore, in addition to providing support according to each patient's pathophysiology, nutrition counselling must use a holistic approach. While some studies have explored the views of patients with cancer in relation to nutrition support using mixed-methods study approaches [9,10], no studies have investigated psychosocial factors related to nutrition counselling, and few studies have examined the speci c circumstances in which patients require counselling. Therefore, it is necessary to investigate the psychosocial factors that cause patients to feel anxious and irritable regarding diet and nutrition issues.
Thus, in this secondary analysis, we aimed to identify the psychosocial factors of patients who require nutrition counselling and qualitatively re ne the speci c issues that patients discuss during nutrition counselling. We believe that this study will help provide improved holistic support, tailored to patients' needs.
Objectives 1) To elucidate psychosocial factors of patients who require nutrition counselling.
2) To elucidate speci c issues that patients who require nutrition counselling wish to discuss.

Participants
A survey was conducted between August 2016 and November 2017 in an urban university hospital in Japan. Participants were patients receiving outpatient chemotherapy for head and neck, oesophageal, gastric, colorectal, and lung cancers. The inclusion criteria comprised individuals aged 20-80 years with a cancer diagnosis, who had undergone chemotherapy, had never received nutrition counselling on chemotherapy, were able to understand Japanese, and had provided written informed consent. Patients with severe dementia/mental disorders, those deemed unable to participate by a doctor owing to psychological/physical reasons, and those unavailable on the survey day were excluded.

Study design
This study involved a secondary analysis that combined qualitative assessments of patients' subjective feelings with quantitative analysis [7]. A survey description was provided to patients expressing interest in participating. Those who provided written consent underwent anthropometric measurements and completed the questionnaire. After con rming that they required nutrition counselling, they were asked what speci c issues they desired to discuss. Two individual nutrition counselling sessions were scheduled to be run by registered dieticians specialising in cancer, as twice-monthly nutrition counselling is covered by medical insurance according to a general implementation schedule in Japan. The rst nutrition consultation was conducted for 40 minutes, and the second was performed after a period of approximately 1 month to verify the intervention effects. Before and after the sessions, the patients' body mass index (BMI), C-reactive protein (CRP) and serum albumin (Alb) levels, modi ed Glasgow Prognostic Score (mGPS, a measure used in the assessment of cachexia from the combined Alb and CRP scores), NIS, QOL, and ERD were measured. Anthropometric measurements comprised BMI, muscle mass, body fat percentage, estimated bone mass, and body water content; these were performed using a bioelectrical impedance analysis (TANITA BC308). All surveys, sessions, measurements, and nutritional guidance were scheduled for outpatient chemotherapy practice days.

Questionnaires
The Patient-Generated Subjective Global Assessment-Short Form (PG-SGA-SF) was used to investigate NIS [11]. The items included weight history, anorexia, nausea, constipation, diarrhoea, thirst, dysgeusia, olfactory disorder, vomiting, dysphagia, early satiety, fatigue, and pain. Patients' experience of ERD was assessed using the ERD questionnaire [12], which comprises 19 items in relation to distress concerning ERD treatment, patients' feelings about ERD, and strained relationships with family members because of ERD. Further, QOL assessments were conducted using the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Version 3.0 (EORTC-QLQ-C30) [13]. The questions included those on the global health domain and physical functioning domain; items included role-, emotional-, cognitive-, and social functioning and symptom scales. The social factors survey included questions on the number of people in the household, employment status, monthly food expenses, and who prepares meals.

Interviews
Semi-structured interviews were conducted with patients who required nutrition counselling. Patients were asked: 1) Do you think nutrition counselling is necessary for chemotherapy treatment? 2) Do you require nutrition counselling from a dietician now? 3) What do you desire to discuss in this nutrition counselling?
The interview questions were designed to elicit descriptive responses from the patients. Following the attending physician's instructions, a registered dietician specialising in cancer conducted two individual nutrition counselling sessions in response to the patients' requirements. The interviewer asked 42 patients who required nutrition counselling about the speci c issues they discussed and recorded their responses on a survey form. These were then encoded and categorised using content analysis [14].

Statistical analysis
The factors in uencing nutrition counselling were studied using logistic regression analysis (maximum likelihood estimation). A Wilcoxon signed-rank test was performed to compare changes occurring after nutrition counselling. SPSS version 25 (IBM, Armonk, NY, USA) was used, with statistical signi cance set at 5% (both sides); missing values were excluded from each item.
Content analysis based on Krippendorff's guidelines [14] was performed on the speci c issues the patients discussed during nutrition counselling. The contents of the records were encoded, and those with similar meanings were placed into sub-categories, which were then organised into conceptual categories. The content analysis was performed independently by two researchers, under the supervision of two palliative care specialists who had experience in content research and clinical experience in the eld of palliative care, to ensure its reliability. A common concept emerged from the content analysis and from logistic regression analysis of NIS, QOL, and ERD. Therefore, as part of the mixed-methods approach, the qualitative analysis results were integrated with the quantitative data [9,12].

Patient characteristics
We recruited 174 patients, of whom 23 were excluded. Figure 1 illustrates the research plan, and Table 1 illustrates patients' characteristics. Of the 151 patients, 42 (27.8%) required nutrition counselling, and eight (19.0%) completed individual counselling. Psychosocial factors that in uenced patients' nutrition counselling requirements Table 2 illustrates the psychosocial factors that in uenced nutrition counselling requirements, which comprised the dependent variable. The independent variables were age, QOL, SGA-SF score, employment status (yes vs. no), number of people in the household (two or fewer vs. three or more), meal preparation (self vs. someone else), food expenses (25,000 yen/month or more vs. under 25,000 yen/month; in Japan, the mean cost of food per person is approximately 25,000 yen/month), and ERD (distress from ERD treatment, from patients' feelings about ERD, and from strained relationships with family members because of ERD). The factors that in uenced counselling requirements included the number of people in the household (p=0.014), employment status (p=0.015), QOL (p=0.023), and distress from ERD treatment (p=0.036). Thirty-three (80.5%) patients who required nutrition counselling lived alone or with another person. Patients who were being treated while working and who had low QOL, and those who experienced ERD with treatment, tended to require nutrition counselling.  Table 3 illustrates the results of the content analysis of the speci c issues patients discussed during nutrition counselling.

Nutrition support affects patients' symptoms
The patients desired another perspective on their diet management. Additionally, diet could possibly motivate patients to seek treatment, especially those with a positive attitude towards diet selfmanagement and those willing to use dietary measures to manage their illness. However, patients appeared to experience distress from eating problems due to NIS, side effects, or multiple complications. Furthermore, they seemed to confuse less relevant information to be less scienti cally rigorous guidelines or dietary rules. Therefore, distress and confusion stemming from NIS need to be managed by providing individual nutrition counselling and information on enriching foods, oral nutritional supplements, enteral and parenteral nutrition, exercise training, and supportive care to enable and improve food intake [15].
There is potential to reduce nutritional risk during cancer treatment and address eating problems, and optimal management could improve treatment tolerance and decrease treatment interruptions [16].

Psychosocial support for patients
Patients who required nutrition counselling either lived alone or with another person, and continued working while undergoing chemotherapy treatment, and had low QOL. Patients wanted their colleagues and nutritionists to understand their symptoms and empathise with their efforts. Healthy eating plays an important role in maintaining a psychological balance that contributes to overall QOL and is closely associated with social contact. Additionally, studies have reported a link between poor appetite following cancer therapy and anxiety, depression, and loneliness [17,18]. Therefore, there is a need to provide nutrition counselling in terms of psychosocial support. For example, if a patient is unable to eat because of anxiety over future events, support should be provided to sustain feelings of hope and well-being [19]. Additionally, patients with cancer undergoing chemotherapy should be encouraged to share valuable moments with friends and family [20] to reduce diet-associated psychosocial distress [21].
Nutritional support from a multidisciplinary team The need for nutrition counselling is related to social factors, such as family structure and employment status, and psychosocial outcomes (anxiety and confusion) can arise from NIS treatment. A multidimensional perspective on food and eating is therefore recommended to support individuals' ways of experiencing and dealing with eating issues [15]. Figure 2 presents

Limitations
This study has several limitations. Many patients dropped out owing to worsening symptoms. Further, 80% of patients who required nutrition counselling did not undergo the counselling because of worsening symptoms, hospital transfer, inability to be contacted, or scheduling problems. The problem of high dropout rates of patients with advanced cancer has been noted in other studies [26,27]. However, this issue underscores the importance of compiling whatever little data can be obtained. For continuous nutrition counselling, a system that allows for exible handling of patients by telephone, e-mail, and webbased contact needs to be created.
It is insu cient to provide nutrition counselling only after nutritional issues worsen or after chemotherapy has begun and symptoms have appeared. Distress, anxiety, and confusion can be reduced if patients and family members know they can consult a dietician when encountering problems. Therefore, dieticians should collaborate with attending physicians and other medical staff members, and intervene early in the treatment of patients.

Conclusions
This study used a mixed-methods design to analyse psychosocial factors affecting patients receiving chemotherapy, speci cally, those issues patients identi ed as wanting to discuss during nutrition counselling, and to better understand the requirements of patients when conducting interventions in relation to nutrition counselling. This study makes an important contribution to the eld because it shows that elucidating patients' speci c nutrition-related issues provides key relevant information, whereas dieticians often conduct patient assessments based only on biochemical data and objective pathology.
However, it is important to determine the concerns of patients more comprehensively to ensure effective help is provided.
Nutrition counselling for patients receiving cancer chemotherapy needs to include methods of handling NIS and provide multidisciplinary support that considers social and psychosocial factors. Although ensuring continuous nutrition counselling for outpatients is challenging, it is important to address patient concerns promptly and create an individually tailored system that facilitates early interactions with patients and maintains nutrition counselling at home or in hospitals.

Con icts of interest
The authors declare no con icts of interest.

Availability of data and material
Data can be made available upon request to the corresponding author.
Code availability Not applicable.

Data transparency
The lead author a rms that this manuscript is an honest, accurate, and transparent account of the study being reported. The reporting of this work is compliant with STROBE guidelines. The lead author a rms that no important aspects of the study have been omitted and that any discrepancies from the study as planned have been explained.
Authors' contributions SK, KA, and EM contributed to the conception and design of the study. SK, MA, KS and AH were responsible for data collection. SK, TY, JK and TT performed the analyses. SK and EM wrote the original draft. All authors critically reviewed the manuscript and approved the nal version submitted for publication.

Ethical approval
The Institutional Review Board of the Medical Research Ethics Committee of Tokyo Medical and Dental University (no. M2015-578) approved this study. The survey began after registering this study as a clinical trial (UMIN registration no.000021540).

Consent to participate
Informed consent was obtained from all individual participants included in the study.

Consent to publish
Consent was obtained from all participants to publish the collected research data in a professional journal, provided that no individual was identi ed.