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CBT to Maintain Long Term Positive Diet Modification in Colorectal Cancer Survivors

Introduction

As a colorectal cancer survivor, the author became interested in the studies outlined in the literature review showing a correlation between diet and cancer. After the diagnosis, research was carried out to find ways to build and strengthen the immune system for the impending operation to remove tumours and subsequent treatment of chemotherapy.

This unearthed various diets for optimum health during cancer treatments and different theories as to why they have a positive effect on the body and long term health. This resonated with the author and so an interest in the link between food and cancer was ignited.

A positive prognosis after treatment was partly explained as a result of adopting healthier lifestyle choices i.e. healthy diet and a positive mental attitude. The author continues to adhere to this change in lifestyle. It was observed by the author, through a volunteering role with Macmillan Cancer Support, that for some cancer patients, the end of cancer treatments means the end of their adopted healthy eating strategies. As research suggests a possible link between food and cancer, it is therefore assumed that healthy eating is more a way of life than an adjunctive treatment to assist with cancer treatments and disease side effects.

For this purpose, the author is interested in the possibility of Cognitive Behavioural Therapy (CBT) used to assist cancer survivors in the maintenance of positive diet modification to reduce the possibility of disease recurrence.

Prior to refining this proposal, a review of background literature was carried out. It was important to establish if prior studies had made any relevant links between diet and the incidence of cancer. It was then important to investigate whether, if links had been made, could positive diet modification significantly impact treatment outcomes and/or disease prognosis. From this information, gaps have been identified in the current knowledge base which has led to the design of this research proposal.

It must be stated that the author acknowledges potential bias due to the fact of being a colorectal cancer survivor maintaining adherence to a positive diet modification.

Details are included of the literature review, an introduction to the study which includes the hypothesis, aims and objectives and a description of the proposed design and methodology.

Abstract

The following literature review presents evidence of a positive correlation between a healthy diet and the prevention of cancer, also that adopting a healthy diet can have a positive impact on treatment outcomes and ultimately prognosis and the benefits of behavioural counselling in order to maintain adherence to a positive, healthy diet.

The purpose of this proposal is to outline quantitative research by means of a Randomised Controlled Trial (RCT) longitudinal study, over a period of 6 months, as this time scale has not been previously evidenced. It will surround the efficacy of CBT to help maintain long term positive diet modification in colorectal cancer survivors who have completed treatment.

The study will comprise of 20 CBT Diploma student therapists with 5 participants each. Therapy for participants will consist of one session per week over a period of 6 weeks with follow up at 3 months and 6 months. Assessment tools used will be Food Frequency Questionnaire and Core 34 Outcome Measure.

Hypothesis

It is hypothesised that colorectal cancer survivors participating in a 6 week structured CBT programme will report higher levels of adherence to positive, healthy diet modification in comparison to those who have not received CBT.

In comparison to those in the control group, it is predicted that at 6 month follow up, the intervention group will report an increase in consumption of fruit and vegetables and a decrease in the consumption of unhealthy foods.

Independent Variable – CBT and the Eatwell Guide

Dependant Variable – FFQ

Literature Search

The literature search comprised of accessing research papers online at National Institute of Clinical Excellence (NICE) and Scottish Intercollegiate Guidelines Network (SIGN) websites as well as information from Cancer Research UK and Macmillan Cancer Support. The Scottish Government and Department of Health websites were also accessed to ascertain figures relating to the incidence and prevalence of cancer occurrence in this country.

Background to the Study

The author visited both NICE and SIGN websites and the general population advice on both of these sites are similar and are as follows; eat at least five portions of vegetables and fruit per day; eat unprocessed foods with minimal red meat consumption; limit alcohol; avoid smoking; be physically active (at least thirty minutes brief walking per day, five days per week).

NICE guidelines also state that there are reasons to believe that many deaths from colorectal cancer could be prevented. Trials show about three quarters of deaths may be associated with lifestyle and therefore theoretically avoidable.

The Scottish Government (2017) website states that Scotland’s unhealthy diet is widely cited as a factor in its poor health record.

Information from the Cancer Research UK (2017) website states that the cancer incidence rate in Greater Glasgow and Clyde (701.7 per 1000,000) is higher than the Scottish average (645.6 per 100,000). It informs that four in ten cases of cancer could be prevented by lifestyle changes, such as not smoking, keeping a healthy body weight, cutting back on alcohol, eating a healthy balanced diet, keeping active, staying safe in the sun and others.

It also explains that healthier diets could prevent one in ten cancers and that eating foods high in fibre can reduce the risk of colorectal cancer. Foods high in fibre include wholegrain foods such as brown bread, brown rice, rolled oats, fruit and vegetables and pulses (beans and lentils).Scientists estimate that more than one in ten (12%) of bowel cancers are linked to a low fibre diet

Lifestyle factors have also been linked to the risk of developing many common malignancies and, increasingly, to prognosis. Observational evidence has shown a relationship between so-called energy balance factors (ie, diet, physical activity, and body weight) and risk of cancer recurrence and mortality in cancers of the breast, prostate, colon and, perhaps, other cancers. Interventional work has shown that individuals who make favourable changes in these lifestyle factors after cancer diagnosis feel better, experience less fatigue, and may possibly even decrease risk of cancer recurrence.

Literature Review

Observation of various studies gives probable evidence of a link between dietary factors and cancer and takes into account many different cancers and the incidence comparison between a Western style diet and those of less developed countries (Key, 2003). Among diet related factors, overweight/obesity convincingly increases the risks of several common cancers, thus proving a direct link to diet. After tobacco, overweight/obesity appears to be the most important avoidable cause of cancer in populations with Western patterns of cancer incidence.

Glasgow is one of the most diverse cities in the UK and is counted as home to both an affluent population and also to those considered at the lower end of the socioeconomic scale. A trial I found interesting, linking low income families, counselling and consumption of fruits and vegetables, came from Steptoe (2003). This trial measured the effect of brief behavioural counselling on participants consumption of fruit and vegetables in adults from a low income population. The randomised control trial was carried out in a primary health centre in a deprived, ethnically mixed inner city area using brief behavioural counselling based on the cycle of change model with matched nutrition education counselling. The trial concluded that brief individual behavioural counselling can sustain increases in consumption of fruit and vegetables in low income adults in the general population. After adjustment for covariates, the increase was greater in the behavioural counselling group than the nutritional counselling group.

Vucenik and Stains (2012) research the higher incidence rates of many types of cancers in Western countries and findings suggest this is attributable to factors related to voluntary behaviours such as nutrition and physical activity habits. Grosso et al.,(2013) found fewer incidence of cancers in populations living near the Mediterranean Sea than those in Northern Europe and the USA. Evidence suggests that strict adherence to a Mediterranean style diet could provide protective factors in the incidence of cancers, especially of the digestive tract. The paper concludes from analyses of studies that there is a beneficial decrease in incidence of cancer if the Mediterranean diet is adhered to.

The Mediterranean Diet is typically categorised by a high consumption of fruits, vegetables and olive oil and moderate consumption of sugar and protein.

I then focused on a relevant qualitative study of cancer survivors views regarding the information available to them surrounding diet information and their sources. Beeken et al., (2016) qualitative study of cancer survivors’ views on diet and cancer and their sources of information looks at the abundance of misreporting about diet and cancer in the media and online, and analysis how cancer survivors are at risk of misinformation.

The aim of the study was to explore cancer survivors’ beliefs about diet quality and cancer, the impact on their behaviour and sources of information. Semi‐structured interviews were conducted with adult cancer survivors in the United Kingdom who had been diagnosed with any cancer in adulthood and were not currently receiving treatment. Interviews were analysed using Thematic Analysis and found that emergent themes highlighted that participants were aware of diet affecting risk for the development of cancer, but were less clear about its role in recurrence.

Their cancer diagnosis appeared to be a prompt for dietary change; predominantly to promote general health. Participants reported that they had not generally received professional advice about diet and were keen to know more, but were often unsure about information from other sources.

The findings suggest that cancer survivors are aware of some dietary messages, such as to eat a balanced diet, and report making dietary changes. Although often prompted by a cancer diagnosis, these changes are made primarily because of a desire to feel well and be healthy generally, rather than specifically for disease prevention. The majority of patients’ information about diet had been obtained from informal sources (e.g. online, media, others) and there was some confusion over what constitutes a balanced diet.

However, it seems little is known about whether cancer survivors believe diet to be important for their long‐term health, post‐diagnosis. A recent survey of 3,300 colorectal cancer survivors found that over 20% would like more advice on diet and lifestyle, suggesting that many do not feel sufficiently informed in this area (Department of Health‐Quality Health., 2012). Some survivors may want information about diet because of specific nutritional needs or side effects post‐treatment, whereas others may want more information for their general health or to prevent recurrence.

The paper concludes that patients would welcome guidance from health professionals on diet. Interventions that provide clear dietary recommendations for those diagnosed with cancer and those in recovery, and which emphasise the benefits of healthy eating for overall well‐being to reduce incidence of future recurrence.

In literature on cancer, the relative importance of diet has been subject to considerable discussion.  However, there appears to be little quantitative analysis surrounding how diet can impact outcomes after diagnosis, during treatment and ultimately prognosis. A very informative study by Ravasco et al (2005) evidences the impact of dietary counselling or nutritional supplements on the outcome of colorectal cancer patients, nutritional, morbidity and quality of life, undergoing radiotherapy and at three months after treatment.

The results show that during radiotherapy, both interventions had positive outcomes. Dietary counselling was of similar or higher benefit but three months after radiotherapy, it was the only method to sustain a significant impact on outcomes.

This literature review outlines:

  1. A probable link between diet and cancer.
  2. Eating a ‘Mediterranean’ style diet, i.e. high in fibre, low in saturated fats, can help lower the incidence of cancer.
  3. The effect of behavioural counselling on participants consumption of fruit and vegetables in adults proved successful 3 months after study completion.
  4. Emergent themes from studies of cancer survivors suggest that they are aware of the role of diet in a cancer diagnosis.

Aims and Objectives

  • To identify the efficacy of CBT in long term maintenance of positive diet modification in colorectal cancer survivors
  • To state the authors hypothesis of findings
  • To set realistic measurement that can lead to further research in this area

As this research has not been carried out, the findings proposed are based on previous research conducted in the field of diet and its relationship to cancer in terms of prevention and the impact of positive diet modification with cancer survivors.

Risk Assessment

Risk will be carried out by use of the Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE 34) (Appendix   ) at the initial assessment session. This will highlight four domains; functioning, wellbeing, problems and risk over the last seven days, including risk to self and others. The mean of all 34 items can be used as a global index of distress. The use of the Core 34 is primarily for the purpose of study inclusion/exclusion criteria. However, as this is a particularly vulnerable client group, who have recently completed cancer treatments, the Core 34 will be used to further assess risk at study follow ups and measured by the relevant therapist for each participant.

Supervision will be utilised on a regular basis as an integral part of the process of ensuring professional standards of competence and practice. Diploma students will access supervision as part of their Diploma course.

Sample

The study proposes an outline of 100 participants. Participants will be invited to take part in the proposed research through their engagement with ‘Transforming Care after Treatment’ (TCAT). This is a national Macmillan service which employs professionals to support patients on completion of their treatment offering practical help and financial advice. The TCAT programme is a partnership between the Scottish Government, Macmillan Cancer Support, NHS Scotland and local authorities to support a redesign of care following active treatment of cancer. The programme was officially launched by the Cabinet Secretary for Health and Wellbeing in June 2013.

As a result of earlier detection and better treatments, the world of cancer has changed and many more people are surviving. TCAT give people affected by cancer more support in dealing with the physical, emotional and financial consequences of cancer treatment and enable them to play a more active role in their own care. The aim of the programme is to support and enable cancer survivors to live as healthy a life as possible for as long as possible.

Each TCAT team focuses on a specific cancer. The proposed research would be Glasgow based with participants who are survivors of colorectal cancer and have had active treatment for the disease. Treatment would include Chemotherapy/Radiotherapy and/or an operation to remove tumours.

Through engaging with this service, participants will be given an information sheet (Appendix  ) informing them about the proposed research and a contact number and e-mail address will be provided if they hold an interest in positive, healthy diet modification and long term adherence and decide to take part.

An initial assessment session will include participants completing the assessment form (Appendix  ) and the Core 34 Outcome Measure (Appendix   )

The chosen population will sign an informed consent form (Appendix   ) and the option to withdraw will be made clear at this point. Withdrawing will be a simple process of contacting the author in writing and this will be immediately actioned.

It should be noted that organisational ethical approval is required before commencement of this study.

Inclusion criteria

The study will include both male and female colorectal cancer survivors of all ethnicities, without presence of metastasis, and include cancer staging 1-3. These stages are representative of localised cancers without metastasis.

Participants will be aged between 45-60 years at completion of cancer treatment, which includes either chemotherapy/radiotherapy or both. This age group has been chosen to represent an average coverage of CC as diagnosis below this age (45) is uncommonCancer Research UK (2018) found that age specific incidence rates of CC significantly increase around the ages of 45-54, with male incidence rates higher than females around the age of 45-49.

Treatment will have been recently completed within an 8 week timescale. This is representative of when patients first access the TCAT team.

Participants who have undergone surgery prior to chemotherapy/radiotherapy, in order to remove tumours and who are presently disease free and do not have a restricted diet, will also be included in the research.

Potential participants should express a genuine interest to engage in therapy which involves discussion of thoughts and feelings.

Exclusion criteria

Exclusion will include issues detrimental to the gastro intestinal tract, for example, the presence of a gastric band which could inhibit adherence to this particular type of diet.

CC survivors who have had surgery to remove parts of the bowel will also be excluded as adherence to a specific clinical diet is necessary.

Other exclusions would include scoring above the clinical cut off range in the Core 34 assessment measure as this could impact the motivation of individuals to adhere to the diet modification.

Study Method

The Scottish Collaborative Group (SCG) Food Frequency Questionnaire (FFQ) will be used to assess nutrient intake at baseline, 3 months and 6 months. FFQ’s are a traditional dietary assessment method alongside Food Diaries and 24 hour recall methods. All methods stated are currently used by the NHS in diet related procedures and measures.

Hollis et al, 2017, reports in a recent validation study of FFQ’s that in contrast to 24 hour recalls and Food Diaries, the FFQ has the advantages of being less burdensome to participants and being able to assess long term, usual diet.

FFQ’s are typically composed of a structured food list and a frequency response section for participants to report how often each food was eaten over a specified period of time.

Because of the unique challenges related to assessing the complex human diet, diet assessments in nutritional epidemiology have been a constant research topic for decades. Many nutritional scientists have dedicated their research to develop new dietary assessment tools and improve traditional methods. FFQ’s are considered as the best approach to measuring habitual diet in a large population, in terms of cost, representativeness, and intensity of participant involvement compared to other methods (BMJ, 2016).

Information and guidance from the National Health Service (NHS) ‘Eatwell Guide’ will be made available to participants at the start of the research proposal by each therapist. The Eatwell Guide (Appendix    ) is a policy tool used to define government recommendations on eating healthily and achieving a balanced diet (www.gov.uk, 2016).

Study Design

Practitioner based research uses a wide range of both qualitative, quantitative and mixed methods of research. Quantitative methods include experiments, questionnaires, coding schemes and includes the measurement of variables and the application of statistical techniques. A qualitative approach includes methods based on interviews or open ended questionnaires and may seek to elucidate meanings; it mainly uses the researcher as the tool. A mixed approach incorporates both these styles of research which results in diversity ie large scale surveys alongside single case studies or small scale interviews.

Merits for a quantitative approach include being able to measure the effectiveness of therapy by measuring change in set variables, it is useful for studying large numbers of clients, the data collection can be relatively quick and in turn the analysis of this data can be less time consuming.

For the purpose of the proposed research, a quantitative approach will be used based on the statistical gathering of empirical evidence and analysing this data.

Randomised Controlled Trials (RCT) are credited with the ability to identify the potency of an intervention under highly controlled conditions. Vossler et al, 2015, states the research design prioritised by the evidence based practice movement is the RCT and why NICE and SIGN tend to base their clinical recommendations on RCT evidence.

A Randomised Controlled Trial is therefore proposed, comprising of a parallel study of two groups;

G1 comprising of CBT and Eatwell guide.

G2 comprising of Eatwell Guide only.

Participants will be randomly allocated into each group. Assigning the participants by chance rather than choice will reduce any potential bias that may occur.

Group 1- Intervention Group

Participants will be provided with the Eatwell Guide. The Eatwell Guide is a policy tool used by the National Health Service (NHS) to define government recommendations on eating healthily and achieving a balanced diet. (www.gov.uk, 2016).

Group 1will also participate in 6 sessions of CBT. The therapy will be conducted on TCAT premises in Glasgow. To keep costs of the proposed research to a minimum, 10 CBT final year Diploma students will be recruited to facilitate the therapy. They will be randomly allocated 5 participants each and therapy will be conducted on a weekly basis. This will continue over a period of 6 weeks. At 3 and 6 month follow up, the Core 34 and FFQ will be completed.

Group 2 – Control Group

Participants will be provided with the Eatwell Guide and given an outline and explanation surrounding the contents by a further 10 final year Diploma students. At 3 and 6 month follow up, Core 34 and FFQ will be completed.

Treatment Protocol

CBT sessions will cover the following strategies;

Cognitive strategies to help changethe mind-set

Motivational strategies to remind participants why sticking to a plan is worthwhile

Psychological strategies to help manage issues such as feeling discouraged, deprived or unmotivated

Behavioural strategies to help establish new habits

Problem solving strategies to help overcome everyday challenges

Session 1

Think Differently

This session will include the confidentiality contract, the structure of sessions, socialisation to the cognitive model, the aims of the therapy, participant goal setting (in terms of sustaining diet modification) and developing the appropriate mindset. Psycho-education will be used to explain the cognitive model and the links explained between trigger situations, thoughts, feelings, physical and behavioural responses

Thoughts surrounding personal sustainability of long term diet modification will be discussed and sabotaging thoughts leading to behaviours of unhealthy eating will be explored using the Five Factor Model with subsequent modification. Participants will be asked to continually monitor any negative, self-sabotaging automatic thoughts surrounding the positive diet modification, and the subsequent impact on the other areas, through the use of this tool.

The Eatwell Guide will be given out with further homework surrounding the commencement of following the guidance of the proportions in which different types of food are needed to maintain a healthy balanced diet.

Session 2

Schedule Eating   

Activity Schedules will be introduced during this session for the therapist and participant to aid in identifying levels and times of meal occurrence. From this, the participant will further identify times of the day when they usually feel hunger or craving for foods/snacks deemed ‘unhealthy’. Subjective Units of Distress (SUDS) will be used to rate emotions attached to this. An eating schedule will be produced in accordance to the needs of each participant. An eating schedule eliminates spontaneous eating reducing the probability of impulsive eating decisions.

Danger times will be highlighted and value lists of activities for distraction will be used until the craving has passed. Diaphragmatic Breathing will be taught to reduce the incidence of anxiety experienced through cravings for unhealthy foods. Also, to explore the emotions and thoughts as they come and go and by sitting with them enough, their power lessens and become easier to cope with.

Further development of the appropriate mindset, i.e. instilling hope, increasing self- acceptance and developing realistic expectations will be covered.

Session 3

Stay in Control

The exploration of advantages and disadvantages of returning to unhealthy eating patterns will be covered and an ‘advantages’ list made to help keep focus on the goal. This list also helps cement the positive reasons of eating healthily. Every time the ‘advantage’ list is read, the neural pathways of the brain are being strengthened and helping rewire the brain’s automatic thinking.

Session 4

Feel Confident

Reminder cards will be composed to help respond to sabotaging automatic thoughts. Composing these and regularly reading compelling responses, prepares for traps that could potentially be encountered during the course of a day.

The participant will be encouraged to look ahead each morning, to the rest of the day in order to foresee any tempting situations. They will be asked to be aware of any thoughts that could lead them to unhealthy eating and then write responses to these thoughts. They will read their response cards each morning and also at times of temptation to stray from healthy eating. This develops a focus to respond to sabotaging automatic thoughts and gives a replacement habit for vulnerable times.

Session 5

Stay Motivated

Giving credit for each step taken towards a healthy eating plan and acknowledging success will be discussed this session. Accepting discomfort will be revisited and also the ability to strengthen resistance. Adherence to the eating schedule will be discussed with exploration of any setbacks. Changes will be made to the plan, if necessary, to include favourite snacks in order to limit the consumption of certain foods.

Making a healthy eating plan/schedule for life will be covered with discussion surrounding the reasons why eating a balanced diet can reduce further health problems in the future.

Session 6

Strengthen Resistance

Work will surround being able to identify when unhealthy food choices are becoming problematic leading to lapse. Left unaddressed, these initial lapses could have the potential to turn a minor stumble into a prolonged fall. Having the ability to recognise this can minimize the potential to stray from the Eatwell Guide. Acceptance of lapse will be discussed and writing reminder cards to remind participants why sticking to a plan is worthwhile.

Ethics

Ethics in research stemmed from the Nuremberg Code of 1948, the Declaration of Helsinki in 1964 and the Belmont report in 1979. The ethics I have taken into account include: ensuring that the study is outlined well; ensuring that boundaries are provided; making sure it easy to withdraw from the study; maintaining anonymity as the study will be seen by others; ensuring confidentiality; safeguarding participants regarding discussing sensitive topics by ensuring they have a good support network; gaining written consent from participants and using existing tools such as CORE 34 to minimize risk.

Additionally, the six guiding ethical principles of therapeutic work that we are committed to also govern research and include beneficence, non malificence, justice, veracity, confidentiality and autonomy.

Ethical considerations for the proposed research include the vulnerability of participants after a cancer diagnosis and subsequent treatment. Levels of support will be discussed with each potential participant at the assessment stage.

Transparency of the research aim, of CBT being utilised as a measure to help maintain positive diet modification, is essential.

An opt-out clause in the participation contract will be included to be utilised at any stage of the proposed research. All personal information and experiences disclosed as part of the research should be kept confidential and no participant should be identifiable. To ensure this, all participants will be allocated a unique code and all written or recorded data will be kept locked within a secure building.

The level of bias will be reduced by the use of statistics as this will help mitigate any potential bias due to the fact that numbers cannot lie. To ensure the authors expectations do not impact on the interpretation of the actual results, the Macmillan Services Manager overseeing the proposed research, will ultimately define the results.

In respect of good ethical practice, if the hypothesis proves accurate, participants in the control group will be offered a 6 week course of CBT following the completion of the study.

Analysis of Results

The SCG will analyse the FFQ’s at baseline, study half way point and completion of the study.

The FFQ will be split into two separate sections:

First section – Healthy

Second Section – Unhealthy

This will enable a calculation of the average healthy score at each time point for each group.

There will be two separate analysis:

First analysis – to calculate any significant increase in the consumption of healthy foods i.e. fruit and vegetables.

Second analysis – to calculate any significant decrease in the consumption of unhealthy foods i.e. pizza, potato crisps, chocolate.

SCG will use a mixed model of ANOVA (Analysis of Variance) to calculate any significant difference between the intervention group and control group at all three time points. ANOVA looks at the amount of variance in a dependant variable explained by other independent variables.

Results will be reported by way of statistical graphs to assess any enduring effects of the CBT intervention group. SCG will further compare these to highlight effect size. An effect size allows the size of the difference between the intervention and control groups to be quantified in a single value to highlight how significant the difference is. This is carried out by subtracting the mean scores for each group over the added standard deviation of each group. The standard deviation is the average amount of variation in a set of scores.

For example: effect size = intervention group mean – control group mean

standard deviation

Cohen (1992), as cited in Vossler and Moller (2015), suggests that 0.2 is considered small effect size, 0.5 considered medium and 0.8 considered large effect size.

Limitations

Potential limitations of this proposal include the varying ways in which each therapist delivers treatment. As the therapists are final year students, they will not yet be fully trained and competencies will vary considerably.

Some therapists may build a stronger therapeutic alliance resulting in them being more influential than others. This is a common weakness for all psychotherapy studies and which would perhaps benefit from a system of monitoring standards and consistency among therapists which, in turn, would help improve the reliability of the study. This would be an important factor if the study were to be replicated.

As the proposed research is quantitative and suites the purpose of the study,  a potential criticism could be the missed opportunity to obtain qualitative data unique to Glasgow participants.

Some instruments used to measure outcome are based on self-reporting. This aspect could weaken the validity of the study as self-reports can leave the results open to bias, for example, individuals may inaccurately report their intake of specific food group consumption. As with any therapy, a level of trust in the authenticity of participant information is required.

A level of drop out would be expected from both groups from the sample size. This could potentially weaken the outcome in terms of equal outcome measure specific to sample size.

As previously mentioned, it has been acknowledged that there may be the potential for bias as the author is a cancer survivor maintaining adherence to healthy diet modification. However, a possible way to reduce this would be through the use of continual clinical supervision. Also, as previously stated, the findings of the study will ultimately be interpreted by the Macmillan Services Manager.

Dissemination

The author would factor in a period of one month to further disseminate the research findings. The Macmillan services Manager would also be involved at this stage. When statistical findings have been reviewed, the author would endeavour to present these by way of a poster presentation to Macmillan Cancer Support and Cancer Research UK at their annual conferences for the purpose of creating opportunities for different perspectives and ideas to develop future research in this field.

Statistical findings could also be published in the British Association for Counselling and Psychotherapy (BACP) Research Journal to contribute to the growing evidence base for counselling and psychotherapy. Also, to enhance the possibilities for future practice with this specific client group.

The British Association for Behavioural and Cognitive Psychotherapists (BABCP) publishes two high quality journals which members can access online. Research findings could be published here to contribute to the theory, practice and evolution of CBT.

Discussion

Future research could potentially involve different settings and increased sample size to further strengthen generalizability and improve findings.

Exploration on how best to support health professionals to provide advice from the Eatwell Guide to help clients make healthy diet choices would also be beneficial.

Confounding variables include the inclusion of CC survivors who may have undergone different types of disease treatments i.e. chemotherapy/radiotherapy or surgery which could ultimately weaken findings and therefore render the research lacking in reliability.

To conclude, although this is an initial study investigating the impact of CBT to maintain positive diet modification in CC survivors in Glasgow, it is hoped that it could be replicated in future for further research in similar fields including different cancer types and covering a broader area.

Words – 5400

RESEARCH STUDY

C:Program Files (x86)Microsoft OfficeMEDIACAGCAT10j0240719.wmf

I would like to invite you to take part in a research study.

This study is voluntary and participants are free to withdraw at any point without impact on any services offered by TCAT.

The focus of the study is to ascertain if Cognitive Behavioural Therapy (CBT) can help maintain positive, healthy diet modification in colorectal cancer survivors.

Complete anonymity and confidentiality are offered for this study with secure data storage.

The required criteria for participants is as follows:

-You must be a colorectal cancer survivor

-Treatment has been completed in the last 8 weeks (Chemotherapy/Radiotherapy/Surgery)

-Age requirements between 45-60 years of age

-Time commitment 6 months

– A genuine interest to engage in therapy which involves discussion of thoughts and feelings is required.

BENEFITS

The benefits to you include the participation in a study to further research the effects of CBT on colorectal cancer survivors’ ability to maintain a healthy diet.

It is hoped that the study could be replicated in future for further research in similar fields covering a broader area and different cancer types.

Participants will receive a summary of all study findings.

Participants will be reimbursed for reasonable travel expenses up to a maximum of £4.50 per day.

NEXT STEPS

If you meet these requirements and would like more information please contact:

The Author:  Mobile – 7777 777 777

E – Mail- ssssss.sssss@sss.com

ASSESSMENT FORM

CODE:

Name:

Male/Female:

Date of Birth:

Address:

Other members of household/family providing support:

Other agencies providing support:

Telephone:                                         E-mail:

Cancer type:

Stage:

Presence of Metastases: yes/no

Treatment(s):

Treatment Outcome:

Date treatment completed:

Prognosis:

Study Cost

The SCG FFQ’s costs £2 per copy = £200 x 3 batches = £600

Data analysis will be carried out by SCG at a cost of £5.50 per questionnaire per each analysis time point = £1650 per analysis x2 = £3300

CBT therapy will be conducted on the premises of the TCAT programme free gratis.

Trainee therapists will conduct the therapy sessions at no cost but sessions will be calculated to inform their individual one to one therapy hours required as part of the CBT Diploma course. Travel expenses will be reimbursed up to a maximum of £4.50 per day attended = £945

A printed copy of the Eatwell Guide will be reproduced at a cost of 50 pence per copy totalling £50.

The assessment measurement tools, namely Core 34, will be reproduced for each participant x3 at a cost of 20 pence per sheet = £60

Information letters inviting participants to take part will be copied at a cost of 10 pence per copy x 200 = £20

As finance is a major contributor to the impact of a cancer diagnosis on an individual’s lifestyle, re-imbursement of travel expenses will be offered to all participants up to a maximum of £4.50 (the cost of an all-day bus ticket) per day attended = £2475

Personal expenses = £1000

Macmillan Services Manager costs to oversee research and define study results = £2000

Dissemination poster A1 paper and print = £10

Stationary, stamps and printing of summary of study results for each participant = £73

Total cost of research £10533

References

Vossler, A. and Moller, N. (2015). The Counselling and Psychotherapy Research Handbook. 1st ed. London: SAGE Publications.

Scottish Government (2017). Health of Scotland’s Population – Diet. Available at: http://www.gov.scot/Topics/Statistics/Browse/Health/TrendDiet (Last accessed: 2nd June 2018)

Cancer Research UK (2017). Local Cancer Statistics. Available at: http://www.cancerresearchuk.org/cancer-info/cancerstats/local-cancer-statistics/?location-name-1=Greater Glasgow and Clyde (HB)&location-1=SG9 (Last accessed: 1st June 2018)

Vucenik I. and Stains J.P.,(2012). Obesity and cancer risk: evidence, mechanisms, and recommendations. Annals of the New York Academy of Sciences 2012, 1271:37-43.

Timothy J.K., (2003). Diet, Nutrition and the Prevention of Cancer. Public Health Nutrition: 7(1A), 187–200 I: 10.1079/PHN2003588.

Steptoe A., (2003). Behavioural counselling to increase consumption of fruit and vegetables in low income adults:  randomised trial. British Medical Journal 2003; 326:855.

Grosso G., Buscemi S., Galvano F., Mistretta A., Marventano S., La Vela V., Drago F., Gangi S., Basile F., Biondi A., (2013). Mediterranean diet and cancer: epidemiological evidence and mechanism of selected aspects. British Medical Journal.

Beeken R.J, Wardle J, Williams K, Croker H, (2016). European Journal of Cancer care. London: John Wily and Sons Ltd.

Ravasco, P, Monteiro-Grillo I, Vidal P.M, and Camilo M.E, (2005). Dietary Counselling Improves Patient Outcomes, A Prospective RCT in Colorectal Cancer Patients Undergoing Radiotherapy

Department of Health

Hollis JLCraig LCWhybrow SClark HKyle JAMcNeill G. (2017)Public Health Nutrition.. Available at: http://www.gov.scot/Topics/Statistics/Browse/Health/TrendDiet (Last accessed: 2nd June 2018)

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