- Email: [email protected]
Nutrition in Cancer Care
Accepted Manuscript Nutrition in Cancer Care Katayoun Moini, MHS, PA-C, RD, CNSC
PII:
S2405-7991(16)30013-5
DOI:
10.1016/j.cpha.2016.03.001
Reference:
CPHA 28
To appear in:
Physician Assistant Clinics
Please cite this article as: K. Moini, Nutrition in Cancer Care, Physician Assistant Clinics (2016), doi: 10.1016/j.cpha.2016.03.001. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Nutrition in Cancer Care Katayoun Moini, MHS, PA-C, RD, CNSC PA Program Director & Assistant Professor
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Charles R. Drew University of Medicine & Science [email protected]
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Disclosures: None
~ Hippocrates
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Let food be thy medicine and medicine be thy food
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Synopsis/Abstract
Cancer and the treatment of cancer can impact the nutritional status of our patients.
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Medical providers can significantly improve the quality of life for cancer patients by intervening early and often, building rapport and implementing a daily process for
individualizing nutrition support. This article will focus on unpleasant nutrition-related
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effects of cancer and cancer treatments, and provide strategies to improve the nutrition status of patients. It is up to medical providers to emphasize the importance of nutrition in
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our patients and demand these issues be addressed early through patient education and
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expert consultation.
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Article Content
Introduction
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Food. We all need it, crave it and rarely go a day without it. So why do we allow patients with life altering disease processes undergoing invasive therapies go days, weeks, even months without adequate nourishment? Would a coach allow an elite athlete to
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perform even one day without proper nourishment? Would a parent allow a child to simply not eat for days? Would you be okay with a job that did not allow you to eat during work
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hours? Instead of using common sense we turn to studies to validate that it is acceptable for our patient to not be receiving nourishment.
The importance of individualized nutrition support for cancer patients cannot be over emphasized. Good nutrition is necessary for our patients to achieve positive outcomes
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and improved quality of life.
Burning more & eating less
Both cancer and cancer treatment negatively influence patient nutrition status.
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Malnutrition caused by weight loss, anorexia and gastrointestinal abnormalities results in
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inadequate nutrient intake and impaired nutrient absorption. The phenomenon known as cancer cachexia (CC) is characterized by anorexia, involuntary weight loss, progressive wasting of lean body mass & adipose tissue and hypermetabolism. 1-4 Tumor factors proposed to be mechanisms contributing to CC include: •
Pro-Inflammatory Cytokines
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Proteolysis inducing factors
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Lipid mobilizing factors
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Treatment of cancer involves multiple modalities and further contributes to malnutrition.
Dysgeusia
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Xerostomia
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Odynophagia & dysphagia
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Diarrhea
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Malabsorption
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Radiation involving the gastrointestinal tract may cause:
Surgical treatment involving the gastrointestinal tract may cause: Delayed gastric emptying
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Malabsorption
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Nutrient deficiencies
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Dumping syndrome
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Glycemic abnormalities
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Cytotoxic chemotherapy, immunotherapy and treatment with corticosteroids and sex hormone analogs add to the list of undesirable side effects: Fluid and electrolyte imbalance
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Glycemic abnormalities
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Nausea & vomiting
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Diarrhea
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Nitrogen loss
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Oral and intestinal mucosal inflammation and degradation
Intervene early, intervene often, and in other words don’t get behind the 8-ball
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Communicating and building rapport with your patients is key to this process. Educate your patients about the potential implications of malnutrition before treatment is even initiated. Provide your patients with options to start improving their nutrition status
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prior to onset of negative symptoms and provide education about enteral and parenteral nutrition early in the process. Advocate for your patients and empower your patients to advocate for themselves by educating them about the positive impact of nutrition
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intervention early treatment. A negative perception of nutrition intervention (for example use of tube feeding) can significantly delay and negatively impact the initiation of much
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needed nutrition support. Nutrition pays a price
There are multiple cancer therapy modalities, all of which have a negative affect on normal cells, tissues and organs. Disruption of gastrointestinal function is a common
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adverse effect of therapy. Additional symptoms of fatigue, dysgeusia and anorexia further diminish any pleasure associated with food or nutrition. In fact, nutrition often becomes a subject of contention and stress for patients. 5
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Assess and reassess on a continuum
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Determining and providing adequate and appropriate nutrition support is an ongoing process. The involvement of a qualified nutrition support team is essential for successful outcomes. The nutrition support plan must be treated the same as the clinical therapeutic plan, constantly adjusted to meet daily nutritional changes. The nutrition support team should consist of an experienced certified nutrition support dietitian, pharmacist, case manager, social worker and the medical provider overseeing the patient. Ideally, nutrition goals for calorie, protein, micronutrients and fluids should be determined
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prior to initiation of cancer therapy and will be dependent on diagnosis, specific therapies, nutrition status, prognosis, co-morbidities, organ function, performance status and individual patient beliefs and preferences. Intervention strategies will depend on
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measured outcomes such as fluctuations in weight; changes in negative and positive acute phase proteins and gastrointestinal symptoms. 6
Nutrient requirements for calories may vary from 25 to 35 kcal/kg/day and for
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protein from 1.0 to 2.5 g/kg/day. Inadequate or excessive provision of either calories or protein may have detrimental physiologic consequences; however, adequate provision can
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improve nutrition status, response to therapy and reduction in symptoms. Calculation of energy expenditure can be particularly challenging, as predictive equations may under or overestimate requirements. Utilization of advanced assessment tools, such as indirect calorimetry and measurement of negative and positive acute phase proteins help improve
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accuracy of the nutrition support prescription. 7-9 Fluid, electrolyte and micronutrient calculations will be influenced by gastrointestinal symptoms, medication effects, co-morbidities and intake. Daily fine-tuning
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may often be required.
Assessment of nutritional requirements and nutrition status The involvement of a registered dietitian with experience in specialized nutrition
support is critical for the appropriate and adequate provisions of nutrients to patients undergoing cancer therapies. Specialized education and training allow for evidence based, aggressive approach early in the course of treatment. As mentioned previously, multiple factors occurring during cancer therapy predispose patients to malnutrition or nutritional
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risk including but not limited to reduced nutrient intake, absorption and utilization occurring simultaneously with increased nutrient losses and requirements. The process of performing a nutrition assessment is similar to performing a comprehensive history and
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physical examination, however the focus is all nutrition. The process includes obtaining a nutrition focused: •
Diet history18
o Food aversions and preferences
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o Dietary restrictions
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o Current nutrient deficiencies or nutritional issues
o Meal and snack consumption patterns and intake o Intentional and unintentional weight changes o Bowel routine and habits
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o Level of activity Medical history
o Identify acute and chronic illnesses which may influence nutrition
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status
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o Surgeries or procedures involving the gastrointestinal system or alimentary tract
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Social history o Tobacco, alcohol and illicit drug use
o Financial resources influencing access to nutrition and food purchasing o Living conditions
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o Meal planning and preparation capabilities o Religious & spiritual beliefs
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Medication history and active medications
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o Support system
o Review for potential drug-nutrient interactions
o Review for medication induced nutrient deficiencies or toxicities
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o Radiation therapy involving the head, neck or gastrointestinal tract o Chemotherapy induced nutrient deficiencies or toxicities
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Allergies to foods
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o Use of vitamin, herbal or alternative supplements
The process continues by obtaining and evaluating anthropometric and laboratory
requirements.
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data and finally is completed through clinical evaluation and estimation of nutritional
Anthropometric data includes body frame, height and weight. This data is utilized to calculate nutritional needs based on one of the following as a point of reference: Ideal body weight
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Adjusted body weight
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o Adjusted for obesity, paralysis and amputations
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Actual body weight
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Usual body weight
Utilizing the correct weight when calculating nutritional, fluid and electrolyte requirements is vital to prevent complications of underfeeding or overfeeding patients. This calculation will also assist with determining the degree and severity of malnutrition. 19
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Performing a nutrition focused physical examination may reveal additional elements that effect overall nutritional status. A systematic approach to the physical examination should be utilized with particular attention to nutrition-related pathologies.
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Assessment of energy expenditure is the next step in determining nutritional
requirements. Energy expenditure calculation is challenging in the setting of acute illness with formulas often under or over estimating energy needs. Calculation involves
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estimation of resting energy expenditure. The most accurate measure is through indirect calorimetry by measurement of oxygen consumption, carbon dioxide production and
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minute ventilation. Limitations of this method include: Oxygen setting > 50% on ventilator
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Acceptance and utilization by hospital staff
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More time intensive that calculation methods
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Excludes insensible losses of the bowel and skin
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Measure resting energy requirements and may still require provision of a
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stress or activity factor if patient is ambulatory
Predictive equations
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Other methods for calculating energy expenditure include:
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Requirements based on kilocalories per kilogram of body weight (utilizing the appropriately calculated body weight)
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Body surface area
These methods are quick and do not require specialized equipment, however clinical judgment is required for selection of the correct weight and stress factor calculation.20
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Assessment of protein requirements includes first determining rates of protein turnover, synthesis, breakdown and oxidation during times of stress. Several tools can be used to help determine the appropriate provision of protein in the nutrition prescription,
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including anthropometric data, gastrointestinal absorption and digestion capability,
nitrogen balance studies, hepatic and renal function and laboratory assays such as serum transport proteins. All of these tools however have drawbacks and should not be solely
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relied on to determine nutrition status, particularly in times of stress and inflammatory metabolic processes.21
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Assessment of lipid requirements varies depending on type of disease manifestations and degree of stress. Adequate essential fatty acid intake is necessary to prevent deficiency and related complications. Assessment of lipid metabolism, degree of stress and appropriate type of lipid provision is another essential component of nutrition
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The correct selection of appropriate macronutrients to fulfill calculated energy, protein and lipid requirements can be determined once specific macronutrient
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requirements are established.
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Specialized Nutrition Support (SNS) Oral intake is the first step to specialized nutrition support. Increase oral intake by
implementing calorie and protein dense foods in small portions eaten frequently throughout the day. Incorporate liquid and solid calorie and protein dense supplements within this plan. Enteral nutrition (EN) therapy and parenteral nutrition (PN) therapy are both options for cancer patients. Both may be utilized alone, in conjunction, or as a supplement
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to oral intake. Both EN and PN have indications and contraindications, which must be investigated by the nutrition support team. Both modalities are options for aggressive nutrition support when oral intake becomes inadequate to meet nutritional goals.
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Discussing EN and PN early in the treatment process with patients is essential, as both modalities may be viewed as negative interventions by patients, resulting in a delay in
nutritional needs and deficiencies. 10
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Help is on the way – Pharmacologic options
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initiation of necessary treatment. Both forms of SNS can be tailored to address specific
Multiple pharmacologic agents are available to assist with symptom management and can be implemented early in the treatment plan. As with any intervention, adverse effects must first be considered prior to implementation. A thorough review by the nutrition support team of the patient’s current condition and treatment plan will help
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determine the most appropriate pharmacologic intervention. Options include: Progestational Agents: Stimulate appetite and weight gain
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Glucocorticoids: Reduce anorexia, nausea and vomiting
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Cannabinoids: Stimulate appetite and reduce nausea and vomiting
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Often the side effect of a medication may alleviate or exacerbate additional symptoms. Diligent review of medications, side effects and current symptoms will assist with proper pharmacologic intervention selection. 11-13 The anti-emetics listed below have noted side effects that may be advantageous in certain circumstances: •
Scopolamine patch: anticholinergic activity may help reduce diarrhea.
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Metoclopramide: prokinetic activity may assist with delayed gastric emptying in patients experiencing fullness and early satiety.
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Serotonin Antagonists: may help reduce diarrhea.14
Combating symptoms with nutrition Many nutritional strategies can be implemented to assist with symptoms resulting
can have positive effects on nutrition status. Anorexia (poor appetite)
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from cancer treatment therapies. Even small improvements in the symptoms listed below
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Loss of appetite is a common symptom negatively affecting nutrition status. Factors contributing to loss of appetite include stress, anxiety, medication and therapy side effects
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and reduced physical activity. This continued loss of appetite and interest in food often escalates to tension during mealtimes and even toward well-meaning friends and family members trying to encourage oral intake. A few strategies listed below may help improve nutrition status when appetite is poor: 15, 16
Encourage patients to take advantage of times or days appetite improves.
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Encourage small portions of calorie and protein dense foods throughout the
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day.
Encourage consistent grazing on dense but small snacks every 1-3 hours.
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Boost fluids. Although staying hydrated is important, avoid filling up on
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calorie-less fluids. Encourage sports drinks, fruit nectars, smoothies and liquid supplements in small amounts throughout the day. Give soups a boost with non-fat milk powder and a small amount of grated cheese or olive and canola oil.
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Boost foods. Add non-fat milk powder to foods. Add to milk, soup, mashed sweet or regular potatoes, muffins, puddings, eggs, pancakes, oatmeal, waffles and pancakes. Snack smart: Strawberry Newtons, pretzels, baked tortilla or potato chips,
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cinnamon graham crackers, wheat thins, animal crackers, ginger snaps,
peanut butter to crackers and fruit.
Boost Fruit: Fruit canned in light syrup, applesauce, dried fruit, banana chips and fruit leathers.
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gummy candies, granola, vanilla wafers and marshmallows. Add jelly, jam or
Boost Dairy: String or mozzarella cheese, flavored yogurt, sorbet, flavored milk, low fat cottage cheese. Add Parmesan cheese to soups and scrambled eggs.
Boost protein: Thin sliced cooked chicken, turkey or ham. Tuna canned in
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water. Scrambled eggs, egg beaters or salted boiled eggs. Beef or turkey jerky. Protein bars or liquid supplements containing over 10 grams of
Encourage patients to eat what they like. Patients may not desire the
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protein and less than 10 grams of fat per bar.
healthiest options. Remember adequate consumption of calories and protein is most crucial.
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Encourage patients to eat when hungry rather than sticking to a meal schedule.
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Incorporate an appetite stimulant
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Encourage increasing activity 1 hour before meals if possible
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Early satiety Patients undergoing cancer therapy will often complain of feeling full after having consumed only a small amount of food. The strategies for managing early satiety are
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similar to those utilized to manage a poor appetite. However, a few additional approaches should be employed: 17
Limit dietary fiber to less than 3 grams per serving
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Increase protein intake to at least 15 grams per meal
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Avoid carbonated beverages and excessive beverages prior to meals
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Nausea & Vomiting
Nausea can dramatically decrease the amount of nutrients consumed. The following strategies may help decrease triggers of nausea while increasing the amount of nutrients consumed.
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Addressing nausea early in the course of treatment, experimenting with multiple strategies and empowering your patients to be proactive when symptoms arise are essential for successful management. Multiple pharmacologic therapies exist that
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successfully alleviate nausea. Incorporating medications prior to the onset of nausea and
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then treating breakthrough nausea will improve symptom relief. Adequate intravenous or oral hydration is imperative during times of nausea.
Recognizing triggers of nausea is also an important aspect of patient education. Triggers may include certain odors, brushing teeth, and movement such as riding in a vehicle. A bland diet with incorporation of isotonic liquids may help reduce or alleviate nausea: 17 •
Provide small, frequent meals
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Encourage consumption of liquids between instead of with meals
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Avoidance of high fat, fried and spicy foods
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Encourage sipping liquids through a straw
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Avoidance of foods with strong odors
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Avoidance of lying down for at least 2 hours after eating
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Prescribe antiemetic 15 to 30 minutes prior to eating
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Encourage the consumption of the following foods:
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Toast and crackers
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Pretzels
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Vanilla Wafers
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Ginger Snaps
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Angel Food Cake
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Oatmeal or Cream of Rice
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Baked or broiled chicken or turkey breast without skin
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Yogurt
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Sherbet
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Canned Fruits
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Broth
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Popsicles
Discourage the consumption of the following foods: •
Fatty, greasy and fried foods
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Very spicy foods
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Foods with strong odors
Diarrhea Diarrhea is a frequently encountered symptom of cancer therapy. Resulting from
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multiple etiologies including treatment side effects, medications, diet, and infectious
microorganisms. In addition to contributing to malnutrition, dehydration and electrolyte imbalance, diarrhea is uncomfortable, inconvenient and discouraging.
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Determining the cause of diarrhea will guide the treatment. Some simple medication adjustments can lessen osmotic load in the gut and improve diarrhea. When utilizing
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medications containing sugar alcohols such as mannitol, sorbitol and xylitol, dilute the medication with 20-30 ccs of water. Many elixir form medications contain these ingredients. Additionally, be vigilant about evaluating medications taken either orally or given enterally to treat electrolyte imbalances. Magnesium and potassium containing
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medications given orally are frequently associated with gastrointestinal upset and diarrhea, further contributing to the electrolyte imbalance. Strategies to lessen these side effects include: 17
Diluting elixir medications with water
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Reducing dosage of oral electrolyte replacement medications when possible
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Adjusting frequency or timing of oral electrolyte replacement
Switching to intravenous delivery of oral electrolyte replacement during times of diarrhea exacerbation
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Substituting less irritating forms of the medication, such as enteric coated medications when possible
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Utilizing nutrition to deliver necessary electrolytes
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Monitoring laboratory values closely and being diligent about adjusting oral or intravenous electrolyte replacement based on serum electrolyte trends to avoid need for bolus dosing
encourages foods that are easier to digest and tolerate:
Increase fluid intake with: sports beverages, cranberry juice, diluted grape juice, rice
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The following list of low residue foods eliminates foods that provoke diarrhea and
milk, warm decaffeinated tea, broth, popsicles, flat ginger-ale, coconut water Reduce lactose intake: Avoid milk, encourage low fat string cheese, low fat yogurt
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without fruit •
Avoid foods high in insoluble fiber (over 2 grams per serving): raw vegetables, raw fruit, bread and cereal with over 2 grams of fiber per serving. Avoid high fat fried or greasy foods
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Increase high potassium containing foods
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(Orange Juice, Bananas-raw or dried, potatoes) Avoid gas producing, cruciferous vegetables: Broccoli, cauliflower, brussels sprouts,
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asparagus, onions, garlic, beans, peas
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Avoid carbonated beverages
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Avoid excess sugar-free chewing gum or products containing sorbitol, mannitol and
xylitol
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Avoid temperature extremes in foods Avoid caffeine and alcohol
Encourage the following foods:
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Pureed cooked fruit (applesauce), bananas, fruit canned in juice
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White rice
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Plain pasta
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Plain white toast
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Mashed or baked potatoes without skin
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Tapioca
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Oatmeal
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Cream of rice
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Saltines
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Baked chips
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Lean meats (beef, turkey, chicken, fish)
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Scrambled egg whites
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Boiled eggs
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Marshmallows
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Gingersnaps
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Pureed fruit pouches
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Dysgeusia
Significant changes in taste can occur from oral mucosal cellular destruction and
desensitization. Fortunately, changes in taste typically diminish over time once therapy has been completed. Olfactory changes may also occur, further exacerbating the displeasure associated with eating. Dysgeusia also contributes to nausea and food 18
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aversions. Helping patients cope with this side effect requires encouraging experimentation with new flavors and avoidance of unpleasant tastes and odors. The basic five tastes of sweetness, sourness, saltiness, bitterness and umami (pleasant savory taste)
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are negatively affected and may become difficult to detect. Strategies to encourage and implement include: 17
Trial of zinc supplementation (chronic losses from diarrhea may alter taste)
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Trial of new flavors and spices such as fresh or dried herbs. Crush mint leaves and add to water or tea.
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Encourage adding salt, soy sauce, balsamic vinegar to foods
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Encourage adding sauces to help moisten foods and add flavor
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Encourage adding tart jams or jellies to fruit
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Dilute juice and add lemon and lime slices to water
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Encourage additional seasoning of meats with fruit or salty marinades; or
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replace meats with eggs, yogurt, cheese sticks, smoothies or flavored milk Encourage eating foods cold or at room temperature
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Encourage hard candy to offset having a ‘bad taste’ the mouth
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Discourage coffee and unflavored tea
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Xerostomia
Chemotherapy, medications and radiation therapy to the head and neck may cause
xerostomia making eating, swallowing and even speaking unpleasant. Strategies to help your patients combat this symptom include: 17 •
Encourage use of sauces and gravies to soften and moisten foods
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Discourage dry foods that may also be difficult to chew such as bread, crackers or unseasoned meats Encourage soups and stews
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Encourage pureed fruits, smoothies and desserts between meals to increase
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calorie intake •
Encourage sour hard candy or foods to help stimulate saliva production
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Mucositis & Pharyngitis
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The oral mucosa is particularly susceptible to destruction during cancer therapy. Oral and throat inflammatory changes, lesions and ulcerations can make eating and swallowing painful and difficult for patients. The following strategies will help reduce oral pain and discomfort: 17
Encourage bland, soft and moist foods
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Encourage fluids, bland smoothies, soups and stews
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Encourage use of straw if lip sores are present
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Discourage dry, difficult to chew foods such as bread, crackers and nuts
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Discourage acidic foods such as citrus fruit, tomatoes and pickled foods
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Discourage spicy and salty foods
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Encourage addition of milk and condensed milk to foods
Encourage mashing or pureeing fruits and vegetable such as potatoes, sweet potatoes and carrots
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Encourage adding canola, coconut or olive oil to foods to help soften texture and increase calories
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Encourage cooked cereal moistened with milk or condensed milk such as oatmeal and cream of rice Encourage protein boosted puddings with added nonfat milk powder
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Discourage alcohol, carbonated beverages or rough textured foods
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Maintenance and prevention
The completion of cancer treatment is a perfect time to continue educating your
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patients about the importance of nutrition. At this point, if oral intake and weight loss
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continue to be a challenge many of the specialized nutrition support techniques described above should still be encouraged and utilized. However, if these issues no longer exist, then this is the perfect opportunity to begin the discussion of maintaining a healthy diet and healthy weight. It is important to remember that cancer patients are particularly vulnerable to misinformation provided by well-intentioned caretakers and the multitude of
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online resources. Fad diets and unnecessary restrictions are not appropriate and can potentially cause harm. The discussions should focus on maintaining a healthy lifestyle. A Registered Dietitian and experienced strength and conditioning coach can assist with
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maintenance of a healthy lifestyle within safe medical parameters and guidelines set by the
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medical team. Some general guidelines include: Eat a variety of healthy foods daily Limit processed, fried and fatty foods Consume 2-3 cups of fruits and vegetables daily
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Encourage whole grains, barley, oats and quinoa
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Increase intake of fish and poultry and reduce red meats
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Cook with olive oil
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Encourage healthy cooking habits such as baking, broiling, poaching and grilling
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Increase intake of foods high in antioxidants and phytochemicals
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Consume foods high in dietary fiber
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Stay active
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Encourage stretching and flexibility
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Stay hydrated with healthy beverages such as water, sports drinks and coconut
Limit alcohol intake
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water
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Summary/Discussion
Cancer treatment results in various medical and social challenges, particularly in the area of nutrition. Individualizing a patient’s nutritional plan requires diligent daily monitoring and evaluation of clinical status, gastrointestinal function, laboratory values,
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intake and output, body weight, history and physical exam, therapies and medications, patient preferences and prognosis. As first line medical providers can significantly improve
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the quality of life for cancer patients by intervening early and often, building rapport and implementing a daily process for individualizing nutrition support. Simply put, we must
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have nutrition to heal. Without adequate and appropriate nutrition a positive outcome is just not possible.
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Curriculum: A Case-Based Approach – The Adult Patient. 2nd ed. ASPEN: 2007:56-58
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PII:
S2405-7991(16)30013-5
DOI:
10.1016/j.cpha.2016.03.001
Reference:
CPHA 28
To appear in:
Physician Assistant Clinics
Please cite this article as: K. Moini, Nutrition in Cancer Care, Physician Assistant Clinics (2016), doi: 10.1016/j.cpha.2016.03.001. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Nutrition in Cancer Care Katayoun Moini, MHS, PA-C, RD, CNSC PA Program Director & Assistant Professor
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Charles R. Drew University of Medicine & Science [email protected]
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Disclosures: None
~ Hippocrates
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Let food be thy medicine and medicine be thy food
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Synopsis/Abstract
Cancer and the treatment of cancer can impact the nutritional status of our patients.
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Medical providers can significantly improve the quality of life for cancer patients by intervening early and often, building rapport and implementing a daily process for
individualizing nutrition support. This article will focus on unpleasant nutrition-related
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effects of cancer and cancer treatments, and provide strategies to improve the nutrition status of patients. It is up to medical providers to emphasize the importance of nutrition in
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our patients and demand these issues be addressed early through patient education and
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expert consultation.
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Article Content
Introduction
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Food. We all need it, crave it and rarely go a day without it. So why do we allow patients with life altering disease processes undergoing invasive therapies go days, weeks, even months without adequate nourishment? Would a coach allow an elite athlete to
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perform even one day without proper nourishment? Would a parent allow a child to simply not eat for days? Would you be okay with a job that did not allow you to eat during work
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hours? Instead of using common sense we turn to studies to validate that it is acceptable for our patient to not be receiving nourishment.
The importance of individualized nutrition support for cancer patients cannot be over emphasized. Good nutrition is necessary for our patients to achieve positive outcomes
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and improved quality of life.
Burning more & eating less
Both cancer and cancer treatment negatively influence patient nutrition status.
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Malnutrition caused by weight loss, anorexia and gastrointestinal abnormalities results in
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inadequate nutrient intake and impaired nutrient absorption. The phenomenon known as cancer cachexia (CC) is characterized by anorexia, involuntary weight loss, progressive wasting of lean body mass & adipose tissue and hypermetabolism. 1-4 Tumor factors proposed to be mechanisms contributing to CC include: •
Pro-Inflammatory Cytokines
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Proteolysis inducing factors
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Lipid mobilizing factors
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Treatment of cancer involves multiple modalities and further contributes to malnutrition.
Dysgeusia
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Xerostomia
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Odynophagia & dysphagia
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Diarrhea
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Malabsorption
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Radiation involving the gastrointestinal tract may cause:
Surgical treatment involving the gastrointestinal tract may cause: Delayed gastric emptying
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Malabsorption
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Nutrient deficiencies
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Dumping syndrome
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Glycemic abnormalities
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Cytotoxic chemotherapy, immunotherapy and treatment with corticosteroids and sex hormone analogs add to the list of undesirable side effects: Fluid and electrolyte imbalance
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Glycemic abnormalities
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Nausea & vomiting
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Diarrhea
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Nitrogen loss
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Oral and intestinal mucosal inflammation and degradation
Intervene early, intervene often, and in other words don’t get behind the 8-ball
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Communicating and building rapport with your patients is key to this process. Educate your patients about the potential implications of malnutrition before treatment is even initiated. Provide your patients with options to start improving their nutrition status
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prior to onset of negative symptoms and provide education about enteral and parenteral nutrition early in the process. Advocate for your patients and empower your patients to advocate for themselves by educating them about the positive impact of nutrition
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intervention early treatment. A negative perception of nutrition intervention (for example use of tube feeding) can significantly delay and negatively impact the initiation of much
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needed nutrition support. Nutrition pays a price
There are multiple cancer therapy modalities, all of which have a negative affect on normal cells, tissues and organs. Disruption of gastrointestinal function is a common
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adverse effect of therapy. Additional symptoms of fatigue, dysgeusia and anorexia further diminish any pleasure associated with food or nutrition. In fact, nutrition often becomes a subject of contention and stress for patients. 5
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Assess and reassess on a continuum
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Determining and providing adequate and appropriate nutrition support is an ongoing process. The involvement of a qualified nutrition support team is essential for successful outcomes. The nutrition support plan must be treated the same as the clinical therapeutic plan, constantly adjusted to meet daily nutritional changes. The nutrition support team should consist of an experienced certified nutrition support dietitian, pharmacist, case manager, social worker and the medical provider overseeing the patient. Ideally, nutrition goals for calorie, protein, micronutrients and fluids should be determined
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prior to initiation of cancer therapy and will be dependent on diagnosis, specific therapies, nutrition status, prognosis, co-morbidities, organ function, performance status and individual patient beliefs and preferences. Intervention strategies will depend on
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measured outcomes such as fluctuations in weight; changes in negative and positive acute phase proteins and gastrointestinal symptoms. 6
Nutrient requirements for calories may vary from 25 to 35 kcal/kg/day and for
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protein from 1.0 to 2.5 g/kg/day. Inadequate or excessive provision of either calories or protein may have detrimental physiologic consequences; however, adequate provision can
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improve nutrition status, response to therapy and reduction in symptoms. Calculation of energy expenditure can be particularly challenging, as predictive equations may under or overestimate requirements. Utilization of advanced assessment tools, such as indirect calorimetry and measurement of negative and positive acute phase proteins help improve
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accuracy of the nutrition support prescription. 7-9 Fluid, electrolyte and micronutrient calculations will be influenced by gastrointestinal symptoms, medication effects, co-morbidities and intake. Daily fine-tuning
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may often be required.
Assessment of nutritional requirements and nutrition status The involvement of a registered dietitian with experience in specialized nutrition
support is critical for the appropriate and adequate provisions of nutrients to patients undergoing cancer therapies. Specialized education and training allow for evidence based, aggressive approach early in the course of treatment. As mentioned previously, multiple factors occurring during cancer therapy predispose patients to malnutrition or nutritional
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risk including but not limited to reduced nutrient intake, absorption and utilization occurring simultaneously with increased nutrient losses and requirements. The process of performing a nutrition assessment is similar to performing a comprehensive history and
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physical examination, however the focus is all nutrition. The process includes obtaining a nutrition focused: •
Diet history18
o Food aversions and preferences
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o Dietary restrictions
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o Current nutrient deficiencies or nutritional issues
o Meal and snack consumption patterns and intake o Intentional and unintentional weight changes o Bowel routine and habits
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o Level of activity Medical history
o Identify acute and chronic illnesses which may influence nutrition
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status
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o Surgeries or procedures involving the gastrointestinal system or alimentary tract
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Social history o Tobacco, alcohol and illicit drug use
o Financial resources influencing access to nutrition and food purchasing o Living conditions
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o Meal planning and preparation capabilities o Religious & spiritual beliefs
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Medication history and active medications
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o Support system
o Review for potential drug-nutrient interactions
o Review for medication induced nutrient deficiencies or toxicities
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o Radiation therapy involving the head, neck or gastrointestinal tract o Chemotherapy induced nutrient deficiencies or toxicities
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Allergies to foods
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o Use of vitamin, herbal or alternative supplements
The process continues by obtaining and evaluating anthropometric and laboratory
requirements.
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data and finally is completed through clinical evaluation and estimation of nutritional
Anthropometric data includes body frame, height and weight. This data is utilized to calculate nutritional needs based on one of the following as a point of reference: Ideal body weight
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Adjusted body weight
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o Adjusted for obesity, paralysis and amputations
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Actual body weight
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Usual body weight
Utilizing the correct weight when calculating nutritional, fluid and electrolyte requirements is vital to prevent complications of underfeeding or overfeeding patients. This calculation will also assist with determining the degree and severity of malnutrition. 19
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Performing a nutrition focused physical examination may reveal additional elements that effect overall nutritional status. A systematic approach to the physical examination should be utilized with particular attention to nutrition-related pathologies.
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Assessment of energy expenditure is the next step in determining nutritional
requirements. Energy expenditure calculation is challenging in the setting of acute illness with formulas often under or over estimating energy needs. Calculation involves
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estimation of resting energy expenditure. The most accurate measure is through indirect calorimetry by measurement of oxygen consumption, carbon dioxide production and
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minute ventilation. Limitations of this method include: Oxygen setting > 50% on ventilator
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Acceptance and utilization by hospital staff
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More time intensive that calculation methods
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Excludes insensible losses of the bowel and skin
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Measure resting energy requirements and may still require provision of a
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stress or activity factor if patient is ambulatory
Predictive equations
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Other methods for calculating energy expenditure include:
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Requirements based on kilocalories per kilogram of body weight (utilizing the appropriately calculated body weight)
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Body surface area
These methods are quick and do not require specialized equipment, however clinical judgment is required for selection of the correct weight and stress factor calculation.20
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Assessment of protein requirements includes first determining rates of protein turnover, synthesis, breakdown and oxidation during times of stress. Several tools can be used to help determine the appropriate provision of protein in the nutrition prescription,
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including anthropometric data, gastrointestinal absorption and digestion capability,
nitrogen balance studies, hepatic and renal function and laboratory assays such as serum transport proteins. All of these tools however have drawbacks and should not be solely
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relied on to determine nutrition status, particularly in times of stress and inflammatory metabolic processes.21
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Assessment of lipid requirements varies depending on type of disease manifestations and degree of stress. Adequate essential fatty acid intake is necessary to prevent deficiency and related complications. Assessment of lipid metabolism, degree of stress and appropriate type of lipid provision is another essential component of nutrition
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evaluation by the nutrition support team. 22
The correct selection of appropriate macronutrients to fulfill calculated energy, protein and lipid requirements can be determined once specific macronutrient
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requirements are established.
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Specialized Nutrition Support (SNS) Oral intake is the first step to specialized nutrition support. Increase oral intake by
implementing calorie and protein dense foods in small portions eaten frequently throughout the day. Incorporate liquid and solid calorie and protein dense supplements within this plan. Enteral nutrition (EN) therapy and parenteral nutrition (PN) therapy are both options for cancer patients. Both may be utilized alone, in conjunction, or as a supplement
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to oral intake. Both EN and PN have indications and contraindications, which must be investigated by the nutrition support team. Both modalities are options for aggressive nutrition support when oral intake becomes inadequate to meet nutritional goals.
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Discussing EN and PN early in the treatment process with patients is essential, as both modalities may be viewed as negative interventions by patients, resulting in a delay in
nutritional needs and deficiencies. 10
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Help is on the way – Pharmacologic options
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initiation of necessary treatment. Both forms of SNS can be tailored to address specific
Multiple pharmacologic agents are available to assist with symptom management and can be implemented early in the treatment plan. As with any intervention, adverse effects must first be considered prior to implementation. A thorough review by the nutrition support team of the patient’s current condition and treatment plan will help
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determine the most appropriate pharmacologic intervention. Options include: Progestational Agents: Stimulate appetite and weight gain
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Glucocorticoids: Reduce anorexia, nausea and vomiting
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Cannabinoids: Stimulate appetite and reduce nausea and vomiting
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Often the side effect of a medication may alleviate or exacerbate additional symptoms. Diligent review of medications, side effects and current symptoms will assist with proper pharmacologic intervention selection. 11-13 The anti-emetics listed below have noted side effects that may be advantageous in certain circumstances: •
Scopolamine patch: anticholinergic activity may help reduce diarrhea.
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Metoclopramide: prokinetic activity may assist with delayed gastric emptying in patients experiencing fullness and early satiety.
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Serotonin Antagonists: may help reduce diarrhea.14
Combating symptoms with nutrition Many nutritional strategies can be implemented to assist with symptoms resulting
can have positive effects on nutrition status. Anorexia (poor appetite)
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from cancer treatment therapies. Even small improvements in the symptoms listed below
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Loss of appetite is a common symptom negatively affecting nutrition status. Factors contributing to loss of appetite include stress, anxiety, medication and therapy side effects
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and reduced physical activity. This continued loss of appetite and interest in food often escalates to tension during mealtimes and even toward well-meaning friends and family members trying to encourage oral intake. A few strategies listed below may help improve nutrition status when appetite is poor: 15, 16
Encourage patients to take advantage of times or days appetite improves.
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Encourage small portions of calorie and protein dense foods throughout the
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day.
Encourage consistent grazing on dense but small snacks every 1-3 hours.
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Boost fluids. Although staying hydrated is important, avoid filling up on
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calorie-less fluids. Encourage sports drinks, fruit nectars, smoothies and liquid supplements in small amounts throughout the day. Give soups a boost with non-fat milk powder and a small amount of grated cheese or olive and canola oil.
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Boost foods. Add non-fat milk powder to foods. Add to milk, soup, mashed sweet or regular potatoes, muffins, puddings, eggs, pancakes, oatmeal, waffles and pancakes. Snack smart: Strawberry Newtons, pretzels, baked tortilla or potato chips,
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cinnamon graham crackers, wheat thins, animal crackers, ginger snaps,
peanut butter to crackers and fruit.
Boost Fruit: Fruit canned in light syrup, applesauce, dried fruit, banana chips and fruit leathers.
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gummy candies, granola, vanilla wafers and marshmallows. Add jelly, jam or
Boost Dairy: String or mozzarella cheese, flavored yogurt, sorbet, flavored milk, low fat cottage cheese. Add Parmesan cheese to soups and scrambled eggs.
Boost protein: Thin sliced cooked chicken, turkey or ham. Tuna canned in
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water. Scrambled eggs, egg beaters or salted boiled eggs. Beef or turkey jerky. Protein bars or liquid supplements containing over 10 grams of
Encourage patients to eat what they like. Patients may not desire the
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protein and less than 10 grams of fat per bar.
healthiest options. Remember adequate consumption of calories and protein is most crucial.
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Encourage patients to eat when hungry rather than sticking to a meal schedule.
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Incorporate an appetite stimulant
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Encourage increasing activity 1 hour before meals if possible
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Early satiety Patients undergoing cancer therapy will often complain of feeling full after having consumed only a small amount of food. The strategies for managing early satiety are
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similar to those utilized to manage a poor appetite. However, a few additional approaches should be employed: 17
Limit dietary fiber to less than 3 grams per serving
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Increase protein intake to at least 15 grams per meal
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Avoid carbonated beverages and excessive beverages prior to meals
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Nausea & Vomiting
Nausea can dramatically decrease the amount of nutrients consumed. The following strategies may help decrease triggers of nausea while increasing the amount of nutrients consumed.
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Addressing nausea early in the course of treatment, experimenting with multiple strategies and empowering your patients to be proactive when symptoms arise are essential for successful management. Multiple pharmacologic therapies exist that
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successfully alleviate nausea. Incorporating medications prior to the onset of nausea and
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then treating breakthrough nausea will improve symptom relief. Adequate intravenous or oral hydration is imperative during times of nausea.
Recognizing triggers of nausea is also an important aspect of patient education. Triggers may include certain odors, brushing teeth, and movement such as riding in a vehicle. A bland diet with incorporation of isotonic liquids may help reduce or alleviate nausea: 17 •
Provide small, frequent meals
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Encourage consumption of liquids between instead of with meals
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Avoidance of high fat, fried and spicy foods
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Encourage sipping liquids through a straw
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Avoidance of foods with strong odors
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Avoidance of lying down for at least 2 hours after eating
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Prescribe antiemetic 15 to 30 minutes prior to eating
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Encourage the consumption of the following foods:
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Toast and crackers
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Pretzels
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Vanilla Wafers
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Ginger Snaps
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Angel Food Cake
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Oatmeal or Cream of Rice
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Baked or broiled chicken or turkey breast without skin
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Yogurt
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Sherbet
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Canned Fruits
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Broth
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Popsicles
Discourage the consumption of the following foods: •
Fatty, greasy and fried foods
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Very spicy foods
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Foods with strong odors
Diarrhea Diarrhea is a frequently encountered symptom of cancer therapy. Resulting from
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multiple etiologies including treatment side effects, medications, diet, and infectious
microorganisms. In addition to contributing to malnutrition, dehydration and electrolyte imbalance, diarrhea is uncomfortable, inconvenient and discouraging.
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Determining the cause of diarrhea will guide the treatment. Some simple medication adjustments can lessen osmotic load in the gut and improve diarrhea. When utilizing
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medications containing sugar alcohols such as mannitol, sorbitol and xylitol, dilute the medication with 20-30 ccs of water. Many elixir form medications contain these ingredients. Additionally, be vigilant about evaluating medications taken either orally or given enterally to treat electrolyte imbalances. Magnesium and potassium containing
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medications given orally are frequently associated with gastrointestinal upset and diarrhea, further contributing to the electrolyte imbalance. Strategies to lessen these side effects include: 17
Diluting elixir medications with water
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Reducing dosage of oral electrolyte replacement medications when possible
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Adjusting frequency or timing of oral electrolyte replacement
Switching to intravenous delivery of oral electrolyte replacement during times of diarrhea exacerbation
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Substituting less irritating forms of the medication, such as enteric coated medications when possible
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Utilizing nutrition to deliver necessary electrolytes
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Monitoring laboratory values closely and being diligent about adjusting oral or intravenous electrolyte replacement based on serum electrolyte trends to avoid need for bolus dosing
encourages foods that are easier to digest and tolerate:
Increase fluid intake with: sports beverages, cranberry juice, diluted grape juice, rice
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The following list of low residue foods eliminates foods that provoke diarrhea and
milk, warm decaffeinated tea, broth, popsicles, flat ginger-ale, coconut water Reduce lactose intake: Avoid milk, encourage low fat string cheese, low fat yogurt
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without fruit •
Avoid foods high in insoluble fiber (over 2 grams per serving): raw vegetables, raw fruit, bread and cereal with over 2 grams of fiber per serving. Avoid high fat fried or greasy foods
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Increase high potassium containing foods
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(Orange Juice, Bananas-raw or dried, potatoes) Avoid gas producing, cruciferous vegetables: Broccoli, cauliflower, brussels sprouts,
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asparagus, onions, garlic, beans, peas
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Avoid carbonated beverages
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Avoid excess sugar-free chewing gum or products containing sorbitol, mannitol and
xylitol
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Avoid temperature extremes in foods Avoid caffeine and alcohol
Encourage the following foods:
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Pureed cooked fruit (applesauce), bananas, fruit canned in juice
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White rice
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Plain pasta
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Plain white toast
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Mashed or baked potatoes without skin
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Tapioca
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Oatmeal
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Cream of rice
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Saltines
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Baked chips
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Lean meats (beef, turkey, chicken, fish)
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Scrambled egg whites
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Boiled eggs
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Marshmallows
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Gingersnaps
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Pureed fruit pouches
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Dysgeusia
Significant changes in taste can occur from oral mucosal cellular destruction and
desensitization. Fortunately, changes in taste typically diminish over time once therapy has been completed. Olfactory changes may also occur, further exacerbating the displeasure associated with eating. Dysgeusia also contributes to nausea and food 18
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aversions. Helping patients cope with this side effect requires encouraging experimentation with new flavors and avoidance of unpleasant tastes and odors. The basic five tastes of sweetness, sourness, saltiness, bitterness and umami (pleasant savory taste)
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are negatively affected and may become difficult to detect. Strategies to encourage and implement include: 17
Trial of zinc supplementation (chronic losses from diarrhea may alter taste)
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Trial of new flavors and spices such as fresh or dried herbs. Crush mint leaves and add to water or tea.
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Encourage adding salt, soy sauce, balsamic vinegar to foods
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Encourage adding sauces to help moisten foods and add flavor
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Encourage adding tart jams or jellies to fruit
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Dilute juice and add lemon and lime slices to water
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Encourage additional seasoning of meats with fruit or salty marinades; or
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replace meats with eggs, yogurt, cheese sticks, smoothies or flavored milk Encourage eating foods cold or at room temperature
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Encourage hard candy to offset having a ‘bad taste’ the mouth
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Discourage coffee and unflavored tea
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Xerostomia
Chemotherapy, medications and radiation therapy to the head and neck may cause
xerostomia making eating, swallowing and even speaking unpleasant. Strategies to help your patients combat this symptom include: 17 •
Encourage use of sauces and gravies to soften and moisten foods
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Discourage dry foods that may also be difficult to chew such as bread, crackers or unseasoned meats Encourage soups and stews
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Encourage pureed fruits, smoothies and desserts between meals to increase
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calorie intake •
Encourage sour hard candy or foods to help stimulate saliva production
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Mucositis & Pharyngitis
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The oral mucosa is particularly susceptible to destruction during cancer therapy. Oral and throat inflammatory changes, lesions and ulcerations can make eating and swallowing painful and difficult for patients. The following strategies will help reduce oral pain and discomfort: 17
Encourage bland, soft and moist foods
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Encourage fluids, bland smoothies, soups and stews
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Encourage use of straw if lip sores are present
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Discourage dry, difficult to chew foods such as bread, crackers and nuts
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Discourage acidic foods such as citrus fruit, tomatoes and pickled foods
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Discourage spicy and salty foods
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Encourage addition of milk and condensed milk to foods
Encourage mashing or pureeing fruits and vegetable such as potatoes, sweet potatoes and carrots
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Encourage adding canola, coconut or olive oil to foods to help soften texture and increase calories
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Encourage cooked cereal moistened with milk or condensed milk such as oatmeal and cream of rice Encourage protein boosted puddings with added nonfat milk powder
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Discourage alcohol, carbonated beverages or rough textured foods
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Maintenance and prevention
The completion of cancer treatment is a perfect time to continue educating your
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patients about the importance of nutrition. At this point, if oral intake and weight loss
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continue to be a challenge many of the specialized nutrition support techniques described above should still be encouraged and utilized. However, if these issues no longer exist, then this is the perfect opportunity to begin the discussion of maintaining a healthy diet and healthy weight. It is important to remember that cancer patients are particularly vulnerable to misinformation provided by well-intentioned caretakers and the multitude of
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online resources. Fad diets and unnecessary restrictions are not appropriate and can potentially cause harm. The discussions should focus on maintaining a healthy lifestyle. A Registered Dietitian and experienced strength and conditioning coach can assist with
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maintenance of a healthy lifestyle within safe medical parameters and guidelines set by the
• • •
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medical team. Some general guidelines include: Eat a variety of healthy foods daily Limit processed, fried and fatty foods Consume 2-3 cups of fruits and vegetables daily
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Encourage whole grains, barley, oats and quinoa
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Increase intake of fish and poultry and reduce red meats
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Cook with olive oil
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Encourage healthy cooking habits such as baking, broiling, poaching and grilling
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Increase intake of foods high in antioxidants and phytochemicals
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Consume foods high in dietary fiber
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Stay active
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Encourage stretching and flexibility
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Stay hydrated with healthy beverages such as water, sports drinks and coconut
Limit alcohol intake
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water
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Summary/Discussion
Cancer treatment results in various medical and social challenges, particularly in the area of nutrition. Individualizing a patient’s nutritional plan requires diligent daily monitoring and evaluation of clinical status, gastrointestinal function, laboratory values,
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intake and output, body weight, history and physical exam, therapies and medications, patient preferences and prognosis. As first line medical providers can significantly improve
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the quality of life for cancer patients by intervening early and often, building rapport and implementing a daily process for individualizing nutrition support. Simply put, we must
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have nutrition to heal. Without adequate and appropriate nutrition a positive outcome is just not possible.
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20. Wooley JA. Energy. In: Gottschlich MM, eds: The A.S.P.E.N. Nutrition Suport Core Curriculum: A Case-Based Approach – The Adult Patient. 2nd ed. ASPEN: 2007:20-27 21. Russell MK. Nutrition Screening and Assessment. In: Gottschlich MM, eds: The
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Curriculum: A Case-Based Approach – The Adult Patient. 2nd ed. ASPEN: 2007:56-58
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