**Background:** Patients with upper gastrointestinal (UGI) cancer—including oesophageal, gastric, and pancreatic cancers—have malnutrition rates of 48–90%, driven by symptoms such as nausea, dysphagia, early satiety, and anorexia. Malnutrition worsens outcomes including hospitalization duration, treatment efficacy, complications, and survival. Despite this, many patients do not see a dietitian unless referred. The TEND (Telephone or Electronic Nutrition care Delivery) study tested non-traditional delivery modes (telephone and mobile application) to provide intensive dietetic support close to diagnosis. This qualitative analysis aimed to explore the patient-dietitian experience within that intervention to elucidate the dietitian's roles and identify unmet needs affecting nutritional intake.
**Methods:** This study adopted Yin's qualitative case study approach from a post-positivist standpoint. The 'case' was the 18-week nutrition counselling intervention itself. Six cases were selected using maximum-variation sampling, considering mode of delivery (telephone vs. mobile application), cancer type, and gender. Data sources included 51 telephone conversations (17 hours), 244 written messages, and 4 post-study interviews from the six case participants. Data were inductively coded in NVivo, with a subset double-coded by a second researcher. Yin's analytic techniques—'Relying on theoretical propositions,' 'Explanation building,' and 'Examining rival explanations'—guided the analysis. The resulting coding framework was subsequently applied to all 20 post-study interviews to explore unmet needs more deeply.
**Key Results:** Four themes emerged describing the dietitian's roles and limitations. (1) Regular collaborative problem-solving to encourage empowerment: Patients experienced fluctuating nutrition impact symptoms (nausea, taste changes, obstructions, fatigue, appetite loss) causing anxiety about weight loss. The dietitian provided prompt reassurance, helped patients prioritize conflicting dietary advice, and built self-confidence. One participant stated: 'I've learnt so much from interacting with [the dietitian] … and I think that's the best part of it, that a patient has a chance to interact with a professional like that, and be able to help themselves.' (2) A reassuring care navigator: The dietitian prompted patients to contact medical practitioners for symptom management, supported correct use of medications such as pancreatic enzyme replacement therapy (PERT), and helped patients interpret feedback from other health professionals. (3) Anticipatory guidance: Regular consultations allowed the dietitian to prepare patients for post-operative interventions, enteral feeding, fasting-related weight loss, and expected side effects of chemotherapy/radiotherapy or new medications. (4) Role limitations leading to unmet nutrition needs: Despite intensive counselling, physical symptoms such as anorexia, dry retching, nausea, and diarrhoea could not be managed effectively without multidisciplinary team collaboration for medication review. The dietitian could only recommend patients contact their general practitioner, oncologist, or surgeon, leading to delays caused by appointment wait times, competing chemotherapy schedules, and transport barriers.
**Clinical Implications:** This study demonstrates that rapport and effective nutrition care can be built via telephone and asynchronous mobile application communication without face-to-face contact. The dietitian effectively served as a patient care navigator—a role typically held by nurses or social workers—providing problem-solving, symptom management guidance, and referrals. However, the dietitian's isolation from the multidisciplinary team (by design of the RCT) meant that medication-dependent symptom management remained a critical gap. The findings suggest that dietitians could take on extended or advanced practice roles to address malnutrition and unmet needs in UGI cancer care, but only if integrated into multidisciplinary teams where they can advocate directly for medication adjustments. The use of telehealth and mobile health delivery modes offers a flexible, time-efficient way to deliver this care navigation, but system-level changes are needed to ensure dietitians can collaborate with prescribers to optimize symptom management.