Resources  |  A journey with our patients

‘’As I watch one of our Preabilitation patients finish another gruelling session of high intensity interval training, I notice, his wife excitedly trying to grab my attention. The moment she catches my eye, she reaches in her bag takes out an empty breakfast cereal box. She points to those tiny words under the ingredients label. I can see how proud she is to have found those hidden sugars”

Why does this fill me, an anaesthetist with great joy?

Medway NHS Foundation Trust is a 600 bed District general hospital in Kent. We undertake major colorectal and vascular surgery and are the regional centre for major urology oncological procedures.

Similar to other areas of Britain suffering from socio- economic deprivation, our patient population is inflicted with the dual edged sword of low heath literacy and poor dietary behaviour patterns.

The resultant effect manifests itself through our patients being outliers in population prevalence with regards to obesity, Type II diabetes and life expectancy at birth. Not surprisingly our cancer survival rates are lower than the average for England in both over and under 75 age groups (1).

As a Perioperative clinician, I am used to having difficult conversations around diet and health outcomes in the surgical patient population.

At multiple points in the patient journey from the GP surgery to the morning of the operation, the patients are advised to ‘eat better’ by different professionals, however there was little guidance given on what that constituted in our institution.

A survey of 15 surgeons revealed whilst all of them advised patients to lose weight, only 2 offered direction to the Prehabilitation Programme to gain information about healthy dietary habits pre-operatively (Figure 1)

Patients were turning to internet for information and seemed very confused due to the mixed messages.

At this point I was in the midst of setting up Medway Surgical Patient Education Programme with two equally passionate colleagues.

Together we explored the possibilities of imparting relevant information to patients in a format that would be accessible and encourage adherence.

We reviewed scientific literature regarding perioperative nutrition to find the most recent and robust guidelines around preoperative nutrition. We compiled latest guidelines from the European Society for Clinical Nutrition and Metabolism (2), the joint consensus from the American Society for Enhance Recovery (ASER) and Perioperative Quality Initiative (3).

During our research we had a novel idea – designing the patient information leaflet in association with our patients.

After all, they are the experts in their lifestyles and knowledge of barriers to healthy dietary habits.

The first thing we discovered at a patient survey in our meetings is that patients find it very difficult to decipher if the products they consumed regularly are healthy. This may be due to the confusing nature of the color-coded labels or health claims in front of the package. For instance, a cereal bar with a high sugar content would be marked as healthy, but a handful of walnuts as unhealthy.

We identified this as a clear barrier to achieving healthy dietary habits.

We designed a very simple leaflet pooling information about identification of non and minimally processed food. Consequent to review and input from our patient focus group, we added information about protein intake, the recommended sources, amounts, timing and supplementation.

We trialled the first version of our leaflet to our patients at our Prehabilitation clinics and we asked them for feedback so we could improve the information to make it clear and simple.

This initiative has shown to be effective as patients surveyed using DISCERN criteria (4) for patient information after the education about our nutrition leaflet, found it attained its objectives – clear and precise tool to identify healthy foods in 100% of the patients surveyed (n=20).(Figure 2)

A large number of patients have acknowledged increased ability to detect unhealthy products amongst those they had bought previous to the educational intervention and consequently have looked for healthier alternatives. Encouragingly, so are their family members.

At our clinics patients’ relatives often bring packages from home to point out interesting things they discovered on the package.

Through our journey with the patients we have understood that providing sensible education and resources to patients is an effective strategy to influence their lifestyle. The information tools are more effective and accessible if designed in partnership with our patients.

Figure 1: Survey of senior clinicians in our institution

Do you advise patients to have better nutrition?

What guidance do you offer them regarding healthy dietary habits?

Figure2: Patient review of the information leaflet using DISCERN criteria


  • Kent County Council, Kent County Council, Jan. 2018,
  • Weimann, A., Braga, M., Carli, F., Higashiguchi, T., Hübner, M., Klek, S., … & Waitzberg, D. L. (2017). ESPEN guideline: clinical nutrition in surgery. Clinical nutrition, 36(3), 623- 650.
  • Wischmeyer, P. E., Carli, F., Evans, D. C., Guilbert, S., Kozar, R., Pryor, A., … & Shaw, A. D. (2018). American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on nutrition screening and therapy within a surgical enhanced recovery pathway. Anesthesia & Analgesia, 126(6), 1883-1895.
  • “The DISCERN Instrument.” DISCERN -Welcome to DISCERN,

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