Discussing diet, nutrition, and body weight after treatment for gynecological cancer: a conversation analytic study of outpatient consultations

A diet, nutrition, or weight-related conversation occurred in 18 of the 30 consultations recorded. Across these 18 consultations, there were 21 instances of diet, nutrition, or weight-related talk; these topics were mostly raised once and never more than twice, in a consultation. In all 21 instances, the patient identified a diet, nutrition, or weight-related issue; 9 (43%) of the issues raised were in response to a gyne-oncologist query and 12 (57%) were initiated by the patient as a stand-alone topic (i.e., not in response to a gyne-oncologist query). Analysis of the 21 instances of diet, nutrition, or weight-related talk identified three sequential trajectories and outcomes of this talk (Fig. 1). These three trajectories and outcomes are presented below and appeared to occur irrespective of who initiated the discussion or the patient’s cancer type. Finally, a family member or friend was present in eight of the 18 consultations with diet, nutrition, or weight-related talk but were rarely involved in these conversations.

Fig. 1figure 1

Three sequential trajectories and outcomes of diet, nutrition, or weight-related talk observed during outpatient follow-up after treatment for gynecological cancer

Diet, nutrition, or weight-related talk sustained and care-related outcomes accomplished

Fragments 1 to 3 illustrate instances where diet, nutrition, or weight-related talk continued beyond initiation to accomplish care-related outcomes. The following sequence of actions was observed in these and other instances that followed the same trajectory (beginning at 1.2 if patient initiated):

1.1

Gyne-oncologist inquires about potential treatment late effects, signs of cancer recurrence, or additional concerns.

1.2

Patient reports a diet, nutrition, or weight-related issue post-treatment, that is (a) directly relevant to the clinical activity initiated by the gyne-oncologist’s inquiry, or (b) introduced by the patient as a stand-alone topic. The patient then identifies needing further support in one of three ways:

i.

Asking a question about normality or ongoing management,

ii.

Orientating to the possibility of referral to support, or

iii.

Reporting that current strategies are not working and uncertainty as to why this is the case.

1.3

Gyne-oncologist provides general dietary recommendations if in response to (i), referral to support if in response to (ii), or behavior change counseling if in response to (iii).

The first fragment is an instance where diet-related talk is sustained and leads to general dietary recommendations as a care outcome. It begins with a question from the gyne-oncologist to solicit additional concerns from the patient, a common practice used to transition from the “business” of a medical consultation towards the possibility of closing the consultation [36].

Fragment 1 [G01, P01, 24:21–26:57]

Patient characteristics: ovarian cancer, obese, intending to lose weight

In Fragment 1, the gyne-oncologist asks the patient if they have “any other questions” (line 1). The gyne-oncologist’s use of “any” suggests that the preferred response (i.e., expected answer) to the query is “no” [37]. This is because “any” is a negative polarity item, meaning its use only makes sense in a negative grammatical context (in this case, “No, I don’t have any other questions”) rather than a positive grammatical context (e.g., “Yes, I do have any other questions”) [37]. This preferred response is subsequently delivered by the patient in line 2 (“No, no doctor”) and confirmed again by the gyne-oncologist and patient in lines 3–6. However, as the gyne-oncologist moves to conclude the consultation with “alright,” which closes down this activity [38, 39], the patient identifies that they do in fact have two questions (lines 8–14). This sequence mirrors a phenomenon observed in primary care consultations, known as the “doorknob concern,” where patients defer the initiation of a priority concern until a point where it becomes possible that the consultation will be concluded [40]. After reporting an issue with their bowel function, the patient asks a question about normality that indicates their need for further support (lines 35–36). In this instance, and other similar instances, the gyne-oncologist subsequently provides general dietary recommendations (lines 80–81). Their advice to increase fiber intake is introduced as “other dietary things” the patient could do to manage this late effect of cancer treatment, in addition to laxative use (lines 75–83). This instance is an example of how diet-related issues, identified by a patient in response to a gyne-oncologist asking about additional concerns, can lead to a care-related outcome when the patient indicates needing further support with their diet-related issue.

The next fragment is an instance where weight-related talk is sustained and leads to referral to support. This fragment follows the same trajectory as the previous fragment but in the context of a weight-related issue identified by the patient as a stand-alone topic (i.e., not in response to a question from the gyne-oncologist).

Fragment 2 [G03, P26, 03:18–03:51]

Patient characteristics: endometrial cancer, obese, intending to lose weight

In initiating a discussion about weight (line 2), the patient accomplishes two key actions that appear to facilitate care-related outcomes: the patient identifies an issue (weight gain post-treatment) (line 4), and a need for further support (losing weight has been “really hard,” a sentiment repeated twice in lines 2 and 6–7). The gyne-oncologist’s overlap of “really hard” in line 8 is a collaborative completion anticipating the need for further support [41]. The patient then reports their previous experience of seeing a dietitian and indicates a positive outcome of this encounter (lines 9–17). The patient’s stance towards referral to a dietitian as a potential solution to their difficulty losing weight creates an opportunity for the gyne-oncologist to utilize this solution: “Okay do you wanna see a dietitian again?” (line 18), an offer that is accepted by the patient (line 19). When referrals were made in the consultations recorded for this study, these were not always to dietitian services; in another similar instance, a patient with obesity suggested they would benefit from seeing a psychologist to help them with their “triggers” for emotional eating and a referral was subsequently offered by the gyne-oncologist and accepted by the patient. Returning to this instance, although the diet-related issue was raised by the patient as a stand-alone topic and not in response to a query from the gyne-oncologist, it follows the same trajectory as Fragment 1 with the delivery of a care-related outcome when the patient indicates a need for further support.

The next fragment involves a discussion about weight loss that leads to behavior change counseling.

Fragment 3 [G01, P04, 03:48–06:05]

Patient characteristics: endometrial cancer, obese, intending to lose weight

In Fragment 3, the patient brings up difficulty losing weight in response to the gyne-oncologist’s inquiry about additional concerns (line 1). Like Fragment 1, additional concerns were not initially elicited (lines 2–7) but are raised shortly thereafter: “Well I have noticed that I just can’t lose the weight” (lines 8–10). In this instance, the patient continues to explain how their problem persists despite different weight loss attempts, including use of professional support (lines 12–23). These comments diminish the relevance of general dietary recommendations or referral to support. However, the patient’s summary, “So I don’t know what the problem is so” (lines 25–27), finishes with a “trail off” conjunction (“so”), indicating their talk is possibly complete and transition of talk to the gyne-oncologist would be a relevant next turn [42]. The gyne-oncologist responds by acknowledging the patient’s experience (lines 28–31) and later adjusting expectations for weight loss (lines 66–82). Through this talk, the gyne-oncologist provides behavior change counseling that focuses on the difficulty of losing weight and the value of gradual weight loss. The delicacy involved in discussing the patient’s weight is interactionally demonstrated through the gyne-oncologist’s frequent use of qualifiers and hedges (e.g., “you know,” “I think,” “I guess”) [43]. Furthermore, the gyne-oncologist uses indirect language by referring to “people” in general, rather than the patient themselves (lines 67, 75). However, as reported in primary care settings, this non-personal approach, designed to avoid straining the doctor-patient relationship, can produce minimal acknowledgement from patients [44]. This is observed in this fragment with the patient’s minimal responses to the gyne-oncologist’s weight management counseling (e.g., “mm” at lines 29, 32, 74, 77, 79, 81, and 83). When spoken with falling intonation, as in this fragment, “mm” can indicate weak acknowledgement of prior talk and that the speaker of these utterances has nothing further to add [45]. In this case, the gyne-oncologist is affirming what the patient has already made clear, for example, “I just can’t lose the weight” in lines 9–10 is affirmed by the gyne-oncologist in line 28 (“It’s hard to lose weight”). Although this fragment suggests that this approach to behavior change counseling may not be effective in motivating patients towards behavior change, this study was not designed to assess post-consultation outcomes of diet, nutrition, or weight-related talk during outpatient follow-up. Nevertheless, these conversations are recommended as part of optimal survivorship care [5], and this instance demonstrates the delivery of a care-related outcome when the patient raises an issue that is relevant to the current clinical activity followed by a need for further support.

Diet, nutrition, or weight-related talk sustained but no care-related outcomes accomplished

Fragments 4 and 5 illustrate instances where diet, nutrition, or weight-related talk continued beyond initiation but did not culminate in care-related outcomes. The following sequence of actions was observed in these and other instances that followed the same trajectory (beginning at 2.2 if patient initiated):

2.1

Gyne-oncologist inquires about potential treatment late effects, signs of cancer recurrence, or additional concerns.

2.2

Patient reports a diet, nutrition, or weight-related issue post-treatment that is directly relevant to the clinical activity initiated by the gyne-oncologist’s inquiry or introduced as a stand-alone topic. The patient then continues to report:

i.

Being resigned to the status quo, and/or

ii.

Self-managing the issue.

2.3

Patient or gyne-oncologist transition talk to a different subject.

The next fragment is an instance where diet-related talk is sustained, but the patient indicates being resigned to their status quo. Following this, no care-related outcome is accomplished. The fragment begins with the gyne-oncologist inquiring about the patient’s bowel and bladder function as part of the clinical activity of monitoring for late effects of cancer treatment.

Fragment 4 [G03, P19, 00:21–00:46]

Patient characteristics: endometrial cancer, obese, intending to lose weight

In response to the gyne-oncologist’s inquiry about bowel and bladder function, the patient in Fragment 4 identifies that diet is relevant to their bowel issue (lines 1–4). However, unlike Fragments 1 to 3, where patients’ problem identifications are followed by expressing need for further support, in this instance, the patient indicates they are resigned to their current state of function and are self-managing the issue. For example, in line 8, the patient’s resignation is demonstrated through their audible inhalation and exhalation (i.e., a sigh) followed by “it is what it is” [46]. The patient’s claim to be self-managing their bowel and bladder function is accomplished through several practices. First, the patient does not share any specific information about the nature of their problem that has been “a bit touch and go” (line 2). Instead, the patient uses “you know” in lines 6 and 8, proposing shared knowledge of what the issue may be and projecting agreement from the gyne-oncologist [47]. Second, through their statement, “I’m getting there and everything’s working okay” (lines 8–11), the patient accepts the candidate answer produced by the gyne-oncologist in their initial query in line 1, “and bowels and bladder are okay for you?” [48]. This query from the gyne-oncologist demonstrates optimization, a fundamental principle of medical questioning that favors the confirmation of positive health outcomes from patients, allowing the information-gathering part of the consultation to proceed in a timely manner [49]. Thus, although bowel function is reportable as an issue, the patient depicts it as not beyond what is expected and manageable. Third, the patient finishes their turn with a positive assessment of their situation, “and I’m not in pain so that’s good” (lines 11–12). This statement serves as an optimistic projection, a feature used in conversation about problems to move attention away from the issue presently being discussed and onto a new topic [50]. In this instance, the patient’s optimistic projection is accepted by the gyne-oncologist (“Good” in line 13), and the patient transitions talk to their menopausal symptoms indicating the relative priority of this matter over prior talk (lines 14–15). Thus, although the patient identified a diet-related issue that was relevant to the current clinical activity, their indication of being resigned to the status quo and self-managing the issue minimized the relevance of a care-related outcome in this instance.

The next fragment is another instance where diet and weight-related talk is sustained but does not lead to a care-related outcome. In this fragment, a care-related outcome is not made relevant because the patient reports ongoing self-management of their weight.

Fragment 5 [G03, P16, 00:36–02:32]

Patient characteristics: ovarian cancer, overweight, intending to lose weight

In Fragment 5, the patient identifies an issue with weight gain post-treatment as a stand-alone topic (lines 1–10). The patient follows this problem identification by reporting they are self-managing the issue: “yeah so just tryin’ to get a kind of handle on that” (lines 16–17, later repeated in lines 37–38). The patient’s self-management is further supported by their account of the underlying causes of their weight gain post-treatment. For example, they attribute weight gain to “emotional eating” (line 4), and eating more during winter (lines 6–8), while also explaining their capacity to self-manage their weight: “…before I had all my treatment, I had gotten myself into a good kind of routine… doing a lot of walking, hiking, jogging, and I’d lost a bit of weight before then too” (lines 17–21). Similar to the previous fragment, the patient’s use of “you know” (lines 34 and 37) projects an aligning response to their narrative from the gyne-oncologist (see lines 36 and 39) [47]. Additionally, the patient’s optimistic projection in line 34 (“I’m just hoping…”) implicates closing down of this spate of talk about their weight issue [50]. The instance finishes with the patient transitioning talk to their neuropathy symptoms, signaling this distinct change in topic with “actually” (line 65) [51]. Similar to the previous fragment, this fragment demonstrates another instance where the diet, nutrition, or weight-related topic raised by the patient was relevant to the current clinical activity, but the patient indicated they were self-managing the issue so, appropriately in these instances, no care-related outcome was observed.

Diet, nutrition, or weight-related talk not substantially sustained beyond initiation

Fragments 6 and 7 illustrate instances where diet, nutrition, or weight-related talk were not substantially sustained beyond initiation. The following sequence of actions was observed in these and other instances that followed the same trajectory (beginning at 3.2 if patient initiated):

3.1

Gyne-oncologist inquires about changes in weight as part of monitoring treatment late effects or signs of cancer recurrence.

3.2

 Patient reports trying, wanting, or needing to lose weight, or reports a concern about weight gain post-treatment. However, intentional weight loss is not directly relevant to the clinical activity initiated by the gyne-oncologist’s inquiry.

3.3

 Gyne-oncologist does not orient to weight loss as an immediate priority and returns to their broader clinical activity of monitoring for the late effects of treatment or signs of cancer recurrence, or initiates discussion about future clinical surveillance.

The following fragment is an instance where weight-related talk is not substantially sustained following its introduction by the patient. The fragment begins with the gyne-oncologist changing the patient’s hormone replacement therapy, following an assessment of potential risks with the current medication due to the patient’s cancer type and obesity.

Fragment 6 [G01, P08, 31:38–32:06]

Patient characteristics: endometrial cancer, obese, intending to lose weight

After the gyne-oncologist explains the recommended dose for the new hormone replacement medication (lines 1–11), the patient responds, “But really I need to lose weight, really aye” (line 12). In doing so, the patient introduces weight loss as a potentially relevant discussion and seeks agreement from the gyne-oncologist (“really aye”). Although the gyne-oncologist initially provides a weak agreement to the patient’s assessment of their need to lose weight (“I think so”), the gyne-oncologist does not orient to weight loss as being immediately relevant to the current discussion (lines 13–14). The gyne-oncologist accounts for this by identifying that weight loss would help the patient’s “general health” but would not necessarily help their menopause symptoms (lines 16–17), the purpose of the current clinical activity. The gyne-oncologist then supersedes the potential weight discussion with talk about menopause, refocusing the conversation to the primary clinical activity (lines 19–20). Thus, unlike the previous two trajectories where diet, nutrition, or weight-related talk continued beyond initiation, talk in this instance was not pursued further as the topic raised by the patient was not ostensibly relevant to the clinical activity in progress. Nevertheless, this instance demonstrates a potential missed opportunity for weight-related support since the patient displayed readiness for this discussion.

The next fragment begins with the gyne-oncologist directly asking a patient about their weight and exercise (lines 1–3). Thus, unlike Fragment 6, where discussion about intentional weight loss was not considered to be directly relevant to the clinical activity being undertaken at the time, in this instance, discussion about intentional weight loss could be directly relevant in response to the gyne-oncologist’s inquiry. However, the gyne-oncologist then clarifies that their weight question is in relation to concerns about weight loss (lines 8–9).

Fragment 7 [G03, P17, C03, 03:29–04:12]

Patient characteristics: ovarian cancer, overweight, intending to lose weight

The patient initially responds to the gyne-oncologist’s inquiry with a groan (lines 4 and 7), indicating potential difficulty with their weight and exercise. The patient then reports they would like to be losing weight (line 10). However, it becomes apparent in the immediately ensuing talk that the patient is still experiencing significant fatigue post-treatment, and this is further confirmed by their caregiver (lines 14–28). Thus, weight loss attempts now may not be effective. Consequently, despite their original inquiry, the gyne-oncologist does not orient to intentional weight loss as an immediate priority for the patient. The gyne-oncologist accounts for this by indicating that chemotherapy fatigue can continue “for some time” (lines 29–30) and “we’ve got to give your body time to get back as well” (lines 32–33). The patient’s responses in this segment culminate in a display of acceptance of what the gyne-oncologist is saying with “I know” (line 34) [52], and the gyne-oncologist returns to the clinical activity of monitoring for late effects of treatment (line 35), superseding further weight loss talk. Thus, although weight-related talk was initially relevant to the current clinical activity, when it becomes apparent that the patient is not losing weight unintentionally but is still experiencing late effects from the cancer treatment, talk about intentional weight loss is not pursued further by the gyne-oncologist. However, like the previous fragment, this is a potential missed opportunity for weight-related support since the patient had indicated they would like to be losing weight and the talk concluded with the patient accepting, but not necessarily agreeing with, the gyne-oncologist’s stance that weight loss is not an immediate priority.

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