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4/3/2013 Nutrition Considerations of Oncology Patients Tinrin Chew, RD, CSO Certified Oncology Dietitian May 2, 2013 Objectives • Understand nutritional problems associated with cancer therapies and nutrition considerations • Identify patients at high nutritional risk • Describe 2 nutrition considerations in supporting immune function Tinrin Chew, RD, CSO 2 1 4/3/2013 Nutrition not only plays a role in cancer treatment, it plays a vital role in cancer process: From Initiation to Promotion to Progression Therefore, nutrition is crucial in long term survival Tinrin Chew, RD, CSO 4 Nutrition Problems Associated with Cancer Treatment • • • • • • • Nausea/vomiting Soreness of mouth and/or throat Constipation, diarrhea, gas, bloating Loss of appetite and/or Taste alteration Anemia Fatigue Mal‐absorption and micronutrient deficiencies Tinrin Chew, RD, CSO 5 Other Factors Impact Nutrition • • • • • • • • Treatment related side‐effects Fatigue Depression Fear Anxiety Lack of Social Interaction Financial Pain Tinrin Chew, RD, CSO 6 2 4/3/2013 Nutrition Goals • • • • • • Improve Nutritional status, and thus immune competence Increase potential for a favorable response to therapy Decrease potential side effects of the therapy Maintain body weight and lean boy mass Improve/enhance recovery from treatment Improve quality of life and Survival Tinrin Chew, RD, CSO 7 Nutrition Approach to Ca Treatment Paradigm Shift Traditional Approach • Eat regardless the source • Nourishment/Functional • High Calorie • High Protein • High Fat • Weight Gain (SAD) No supplements ‐‐ fear of • interference with treatment • • Rest • • • • • • Foods/phytonutrients Balanced Diet Lean Protein/AA Good Fats/Omega 3’s Maintain Body Weight Vitamins, mineral and dietary supplementation Exercise 8 Tinrin Chew, RD, CSO Tips in Managing Treatment Related Side‐effects Lack of Taste— • Nausea— Ginger High Protein Zinc Iron J Altern Complement Med. 2008 Jun;14(5):545‐51 • Diarrhea— Electrolyte repletion Rice congee Probiotics Soluble fiber Glutamine (?) Room Temp. food various spices/herbs Wound Healing— Protein, A, C, E, Zn Tinrin Chew, RD, CSO 9 3 4/3/2013 Tips in Managing Treatment Related Side‐effects • Involuntary Weight • Neuropathy— Loss— Glutamine Alpha lipoic acid Acetyl-L-Carnitine (CNS Drugs. 2007;21 Suppl 1:39-43) Omega 3 fish oil HMB, Arginine, and Glutamine (Juven®) Acupuncture Exercice Tinrin Chew, RD, CSO • • • • • • • 10 Specific Nutrition/Lifestyle Considerations: Maintain Hydration Status Maintain Body Weight (< +/‐5%) Adequate Protein Intake Healthy GI Tract Functional Foods Phytonutrients Essential Fatty Acids Amino Acids Probiotics Vitamin and mineral supplement Exercise Tinrin Chew, RD, CSO 11 Maintain Hydration: Fluids 2% weight loss dysfunction/dehydration Headache, anorexia, nausea, dark/low urine Dehydration: Cells can’t work well as wilted plants Exacerbates fatigue, pain, nausea, constipation Fluids clear toxins Daily Needs: Body Weight (lb) 2 = oz/day Post chemo for 3‐5 days Mix it up! Soups, fruit juices, protein shakes, smoothies, watermelon, tea, water,etc. (electrolyte repletion) Non‐caffeinated is better; limit caffeine to 2 cups/day Tinrin Chew, RD, CSO 4 4/3/2013 Fluids ─ Post Chemo Body Weight (lb) 2 = oz/day Example: (160 lb 2 = 80 oz/day) 25% 25% Broth Water Miso Soup Or Chicken Rice Soup Weak Tea Chicken Noodle Soup 25% 25% Popsicle, Sherbet , Jell‐O, Soda,Pedialyte, Watermelon Apricot or Peach Nectars Apple Juice, Grape Juice, Milk, lactose free organic preferred 13 Tinrin Chew, RD, CSO Maintain Body Weight • < 5% weight loss or weight gain Tinrin Chew, RD, CSO Cancer Related Malnutrition Increased Infection Rate Increased Hospitalization & Prolonged Stay Poor Treatment Response / Tolerance Decreased Quality of Life Increased Mortality (20‐40% malnutrition) Reduced Performance Status Increased Cost Albrecht, Hem On clin N Am 1996 DeWys, et al, Am J Med 1980 (ECOG) Andreyev,et al, Eur J cancer 1998 Ottery, Seminars in Onc 1995 Clin Nutr. 2007;26:289‐301 5 4/3/2013 High Risk • 5% Body weight loss in one month (or) • 10% Body weight loss in six months • Albumin is less than 3.2 Tinrin Chew, RD, CSO 16 Obesity and insulin resistance may be a high‐risk state for disease progression among cancer survivors The American Cancer Society estimates that one‐ third of the more than 572,000 cancer deaths in the USA each year can be attributed to diet and physical activity habits, including overweight and obesity, while another third are caused by exposure to tobacco products exposure to tobacco products. Mortality from Cancer According to BMI for U.S. Women in the Cancer Prevention Study II Cancer Prevention Study II Calle, E. et al. N Engl J Med 2003;348:1625‐1638 Tinrin Chew, RD, CSO 18 6 4/3/2013 Tinrin Chew, RD, CSO 19 Healthy Gut • Easily compromised by treatment • Contains 70‐80% immunologic secreting cells • Almost 50% of mass of immune system lines the gut • Of healthy people, 40.5% report 1 or more digestive complaint – Sandler, RS, etal, (2000), Abdominal pain, bloating, and diarrhea in the US: Prevalence and Impact. Dig. Dis.Sci, 45, 166‐171 TChew, RD, CSO 20 Healthy Gut—crucial during treatment • • • • Prevent malabsorption Increase nutrient absorption Prevent bacteria overgrowth Support Immune System Support DuringTreatment: • Amino Acids – L‐glutamine • Probiotics • Fiber (prebiotics) • Hydration Tinrin Chew, RD, CSO 21 7 4/3/2013 Maintain a Healthy GI Track • Glutamine – Decrease incidence of severe mucositis – Enteral support to parental nutrition – essential for chemo and xrt related enteritis • Probiotics – Improves host intestinal microbial balance – Stimulate innate immunity of the host – Increase resistance to pathogens, infection, and inflammation – Enhance nutrient synthesis and bioavailability Tinrin Chew, RD, CSO Healthy Intestinal Bacteria affected by: • • • • • • Tumor invasion Chemotherapy Radiation therapy Surgery Prolonged use of antibiotics Aging, refined diet, alcohol intake 23 Tinrin Chew, RD, CSO Nutritional and Therapeutic Effects of Probiotics • Nutrient synthesis and bio‐availability • Reduce recurrence of yeast and bacterial infections, e.g C‐diff. • Maintain gastrointestinal track health, crypt cells and villi height • Reduce chemo and radiation related diarrhea JPEN 2009 Sep‐Oct; 33(5):569‐70 Clin J Onc Nurs.2009 June; 13(3)336‐41 Can Biol Ther. 2007Sep; 6(9): 1449‐54 World J Gastro 2007 Feb 14; 13(6): 912‐5 • Stimulate innate immunity of the host • Possible colon and breast cancer prevention (?) Tinrin Chew, RD, CSO 24 8 4/3/2013 Probiotics: • Examples: acidophilus, lactobacillus, Bifidobacterium, Streptococcus, Saccharomyces • Food Sources: yogurt, butter milk, miso, kefir, sauerkrauts, kimchee, etc. • Supplements—Culturelle®, Align®, VSL‐3®, Florastor®, etc. Tinrin Chew, RD, CSO 25 Prebiotics‐‐Just having probiotics is not enough • Not all probiotics will survive • Non‐digestable substances (FOS, inulin, lactulose) that feed probiotics • Releases SCFA decrease colon PH enhance mineral absorption (Ca, iron, Mg) • Decreases some pathogenic bacteria Supplements: Fiber Choice® Fibersure® Metamucil Clear and Natural® Dietary Sources: Asparagus, Banana Onion, Garlic, Flax Legumes, Barley…. Tinrin Chew, RD, CSO 26 Specific Nutrition Considerations: Functional Foods • • • • Amino Acids – L‐Glutamine Probiotics Essential Fatty Acids Phytonutrients/Phytochemicals Tinrin Chew, RD, CSO 27 9 4/3/2013 Key Points About Fat In The Diet Dietary Fats EAT THESE FATS LIMIT THESE FATS Tinrin Chew, RD, CSO 28 Omega 6 vs. Omega 3 Vegetable oils,hydrogenated fats • Pro‐inflammatory • Alter estrogen metabolism • Suppress immune function • Promote cancer cell proliferation • Stimulate tumor vascularization and metastasis • Omega 6 rich diets were associated with a relatively poor prognosis in breast cancer patients fish/fish oil, flax oil, and wild game • Anti‐inflammatory • Increase tumor suppressive gene‐‐ P53 • Influence insulin • • • • • sensitivity and membrane fluidity Slow cell division; thus tumor growth rate Less aggressive tumor Improves cachexia Decrease blood clot Lubricate the skin Am J of Clin Nut 2004 June; 79(6) 935‐45 Tinrin Chew, RD, CSO 29 Functional Foods: Phytonutrients / Phytochemicals Naturally occurring plant compounds (fruits, vegetables, and whole grains) • Antioxidants– scavenge “free radicals” • Detoxifiers / Neutralizers– destroy and eliminate toxic components • Hormone Modulators– alter hormone production favorably • Cell Regulators—control rampant cell growth Tinrin Chew, RD, CSO 30 10 4/3/2013 Plant‐based Diet • Antioxidants: Carotenes, polynenols, tocopherols, vitamin C, etc. (yellow, orange, dark leafy greens, cocoa, tea, citrus..) • Anti‐inflammation: Omega 3 fats (EPA,DHA), flaxseeds, turmeric, rosemary, oregano, green tea, red wine, berries • Anti‐carcinogens: Cruciferous (increases detox phase II enzyme), curry, green tea, pomegranate, citrus, brazil nuts, Tinrin Chew, RD, CSO Be Colorful • Include varieties of fruits, vegetables, whole grain and legume • Incorporating spices and herbs in cooking • Eat > 2 types of vegetables at a meal Goal: • 8‐10 servings vegetables & fruits/day • > 3 servings whole grain and legumes Tinrin Chew, RD, CSO 32 Specific Nutrition Considerations: vitamins and mineral supplement • Pre‐existing nutritional deficiencies prior to diagnosis • Adverse side effects of treatments on GI track • Treatment or disease state induced deficiencies • • • • (zinc, selenium, vitamin C, E, A, etc.) Type of Chemotherapy or treatment Other medications depleting micronutrients Supporting Liver detox pathway New research on needs TChew, R.D. 33 11 4/3/2013 • • • • • • • Specific Nutrition/Lifestyle Considerations: Maintain Hydration Status Maintain Body Weight (< +/‐5%) Adequate Protein Intake Healthy GI Tract Functional Foods Phytonutrients Essential Fatty Acids Amino Acids Probiotics Vitamin and mineral supplement Exercise Tinrin Chew, RD, CSO 34 Resources www.eatright.org www.oncologynutrition.org (finding an Onc RD) www.aicr.og http://cancerdietitian.com/ www.mskcc.org/aboutherb www.mayoclinic.com http://nccam.nih.gov/health www.cancer.gov/cam http://dietary‐supplements.info.nih.gov Tinrin Chew, RD, CSO 12