Download NUTRITIONAL MANAGEMENT FOR NEOPLASTIC DISEASE

NUTRITIONAL MANAGEMENT FOR NEOPLASTIC DISEASE.
NUTRITIONAL EFFECT OF CANCER:
- Cancer cachexia is a state of progressive weight loss, anorexia, early satiety, asthenia, anemia, and
abnormalities in protein, carbohydrates, and fat metabolism.
- Studies have shown that cancer pt’s have reduced, normal, or increased BEE.
- Tumors exert a constant demand for glucose.
- Proteolysis and lipolysis increases to maintain high rates of glucose synthesis.
- A relative state of insulin resistance may develop.
- Inappropriate mobilization of free fatty acids from adipose tissue and depletion of total body fat.
- Decreased lipid clearance, and elevated free fatty acids in serum.
NUTRITIONAL EFFECT OF CANCER THERAPY:
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NUTRITIONAL MANAGEMENT:
Goal:
- To restore or conserve nutritional status, body composition, and functional status prior to , during,
and after cancer treatment.
- To minimize food-related discomfort associated with cancer or cancer treatment.
- To improve the over all strength, well being, and quality of life.
Description:
- Oral route is the preferred mode of feeding, however, intake may be altered by cancer or anticancer therapy.
- A general diet is recommended with specific modifications based on the pt’ tolerance, tumor site,
treatment and associated side effects, stage of disease, and preexisting disease.
- Diet modification may include:
 High-calorie, high protein diet.
 Texture modification (full- liquid, soft, pureed ..)
 Low-residue diet.
 High-fiber, low-fiber diet.
- When oral intake in inadequate and the risk of malnutrition is high, EN or PN is considered.
- The use of aggressive nutritional support is not recommended for pt’s with terminal cancer, DAT
with emphasis on pleasurable aspects of eating should be emphasized along with providing
emotional support.
Management of common complications:
Anorexia
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Identify factors contributing to loss of appetite.
Suggest small, frequent meals and snacks.
Provide soft, moist solids as these may be well tolerated.
Concentrate dietary energy at the time of day when appetite is best (usually
morning).
Provide favorite foods, as tolerated, in a relaxed, pleasant atmosphere.
Limit low energy foods such as coffee, tea, and clear soups.
Discourage intake of high fiber foods as these can contribute to early satiety and
decrease energy intake.
If poor oral intake is long standing and unlikely to improve with nutrition
intervention, an appetite stimulant (eg, megestrol acetate, corticosteroids
[dexamethasone, prednisone], or cyproheptadine) may be indicated.
Early Satiety
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Recommend small, frequent meals.
Suggest energy-dense liquids between meals to meet fluid needs. Encourage
consumption of fluids 30 minutes before or after meals/snacks.
Limit intake of gas-producing foods.
Avoid high-fiber foods that may contribute to satiety and tend to be low in energy.
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Nausea
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Recommend that foods be chewed well and meals eaten slowly in a relaxed
atmosphere.
Adjust fat intake to a tolerated level.
Use of gastric motility drugs may be discussed with the physician.
Reinforce use of anti-nausea medications as prescribed.
Sip fluids at frequent intervals, separately from solid foods, to help maintain
hydration and settle stomach.
Discourage fasting as it may cause hypoglycemia and worsen nausea.
Provide small, frequent meals or snacks.
Cold or room temperature foods may be better tolerated.
Avoid poorly tolerated foods such as high-fat, high-fiber, spicy, or gasproducing
foods.
Suggest loose clothing at meal times.
Suggest limiting preparation and serving of foods with strong odors.
Advise against lying down immediately after meals unless the head of the bed is
elevated.
Discourage eating favorite foods around treatment times to avoid inducing an
aversion to these foods.
Encourage sleep at times when nausea is anticipated.
Vomiting
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Encourage adequate fluid intake to prevent dehydration.
Recommend starting with small, frequent sips of clear fluids and advancing to full
fluids as tolerated; suggest starting with low-fat fluid choices, such as skim milk and
sherbet.
Suggest small amounts of dry, starchy foods when advancing to solids.
Recommend gradually increasing the portion size and variety of food eaten while
maintaining the frequency.
High-fiber and high-fat foods should be added last as they tend to decrease gastric
emptying.
Avoid eating 1 1/2 to 2 hours pre-treatment and post-treatment.
Mucositis
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Encourage good oral hygiene practices to promote comfort, enhance taste, and
stimulate appetite.
Reinforce the use of analgesics as prescribed (before meals) to reduce the pain
associated with eating.
Encourage the use of an oral baking soda mouth rinse before and after meals (recipe:
1 mL or 1/4 tsp baking soda dissolved in 250 mL or 1 cup water).
Recommend small, frequent, high-energy, high-protein meals and snacks.
Avoid crisp or rough-textured foods; soft, moist, semisolid, or blenderized foods
may be better tolerated.
Discourage intake of known irritants such as:
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tart or acidic foods and fluids
spicy or salty foods and fluids
very hot or very cold foods
tobacco
alcohol-based mouth rinses and alcohol-based liquid vitamin and mineral
supplements .
Recommend dunking or moistening all dry foods in liquid.
Alter consistency and temperature of foods to suit individual tolerances.
Esophagitis
As for mucositis above, plus:
 Suggest the use of a local anesthetic and analgesic before meals.
 In cases of peptic esophagitis, antireflux measures and antacid therapy may be
useful.
 Recommend regular antacids before and 1 hour after each meal and before bed.
Swallowing Problems
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Recommend small, frequent, high-energy, high-protein meals of the appropriate
consistency.
Recommend moistening foods with spreads, sauces, salad dressings, or gravies.
If thin liquids are to be avoided, ensure fluid needs are met via other sources as
tolerated (eg, thickened liquids and soups, pureed foods).
If foods "stick," wash them down with high-energy, high-protein liquids.
Thick Saliva or Mucous
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xerostomia
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Encourage consumption of soft, moist foods.
Limit intake of hard or dry foods, such as tough meats, crackers, and vis- cous foods,
such as thick syrups.
Beverages or foods that are slightly tart or carbonated may help thin secretions and
stimulate saliva (eg, lemon-flavored soda pop or soda water, iced tea, papaya,
pineapple, sour lemon drops, sports drinks, Popsicles®).Tolerance to these may be
limited if the individual is also experiencing mucositis.
If milk products are found to affect mucous production, suggest low-fat milk
products or cooked items (eg, custards, puddings) before eliminating dairy products
entirely. Soy-based beverages may be better tolerated than dairy products.
Mucous production may be minimized if clear fluids are consumed after milk or soybased products.
Limit caffeine, alcohol, and spicy foods.
Encourage the patient to rinse mouth with club soda or baking soda rinse.
Assess hydration status. If oral intake is inadequate, encourage consumption of noncaffeinated, cold fluids to help relieve mouth dryness.
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Dysgeusia
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Increased liquid consumption may provide symptomatic relief; however, liquids
have no lubricating properties. Thus, encourage consumption of foods that have
lubricating effects such as sauces, gravies, and salad dressings.
Recommend consumption of soft, moist foods.
Recommend sips of fluid with each mouthful of food to help with chewing and
swallowing.
Suggest methods of moistening mouth throughout the day:
- rinse mouth often with water or baking soda rinse
- suck on ice chips or sugar-free Popsicles –
- use a water spray
- swab the mouth with a tasteless cooking oil
Citric acid-containing beverages (preferably sugar-free) such as lemonade, orangeflavored soft drinks, may help increase secretions.
Discourage the use of commercial mouthwashes and alcohol as they will contribute
to dryness.
Determine specific taste or smell changes.
Encourage consumption of small, frequent, high-energy and protein meals /snacks.
Encourage adequate fluid intake.
Encourage drinking fluids with meals to decrease unpleasant tastes.
Reinforce proper oral care before and between meals to decrease unpleasant taste.
Encourage rinsing with baking soda and water.
Experiment with seasonings and flavorings.
If meat tastes bitter or metallic, suggest:
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Diarrhea
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serving meat cold or at room temperature
including meat in mixed dishes (eg, casseroles, stews)
choosing alternative sources of protein (eg, cottage cheese, milk, milkshakes,
custards, puddings, yogurt, cheese, tofu, eggs)
- Marinating meat in pineapple or lime juice, vinegar, or sweet and sour sauce .
- eating with plastic utensils to help decrease metallic taste
- cinnamon or sugar-free gum or mints, as these may mask metallic taste
Suggest mild-tasting foods (eg, biscuits, milk, puddings, custards) if foods taste
strong or bitter.
Encourage small, frequent meals.
Encourage adequate fluid intake, 1.5 to 2 L daily, depending on output.
Energy-dense fluids should be encouraged if weight loss is an issue.
Try the following modifications one at a time:
- limit bowel stimulants (eg, caffeine, alcohol, prune juice) –
- adjust fat intake as tolerated –
- restrict lactose -restrict fiber -limit gas-producing foods
- limit foods or fluids that exacerbate symptoms (eg, spices)
Encourage potassium-rich foods.
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Constipation
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Encourage regular meals and snacks.
Increase adequate fluid intake (eg, 8 or more cups per day).
If losing weight, encourage fluids with high nutrient density.
Encourage regular intake of natural laxative foods such as prunes or prune juice, and
papaya.
Encourage physical activity as able.
If patient is not taking pain medications, advise a gradual increase in dietary fiber.
The use of stool softeners and laxatives maybe necessary.
Partial Bowel Obstruction
 The level of fiber restriction required will vary depending on the symptoms and
degree of obstruction.
 Low-fiber diet eliminating very high-fiber foods (those containing more than 2 g
dietary fiber per serving). This restriction is used in early clinical signs of bloating,
abdominal cramps, or pending bowel obstruction. In addition, restrict insoluble fiber.
 Minimal-fiber diet avoiding all whole grains, fruits and vegetables, nuts, seeds, and
legumes. Encourage juices (except prune juice).
 Full-fluid to clear-fluid diet. This may be followed for a couple of days until
symptoms resolve, at which time very low-fiber foods can be slowly reintroduced. If
unable to introduce solids, may need to supplement with high-protein nutritional
supplements.
 NPO in case of complete obstruction. Intravenous fluid support/TPN may be
necessary.
 Encourage small, frequent meals and adequate fluids.
 Emphasize high-energy, high-protein fluids if volume tolerated is limited.
 Suggest chewing foods well and eating in a relaxed atmosphere.
 Avoid bowel stimulants such as coffee, alcohol, and prune juice.
 Avoid bulk-forming laxatives.
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