Download Nutrition Considerations of Oncology Patients Objectives

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
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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
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Nutrition Problems Associated with Cancer Treatment
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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
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Other Factors Impact Nutrition
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Treatment related side‐effects
Fatigue
Depression
Fear
Anxiety
Lack of Social Interaction
Financial Pain
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Nutrition Goals
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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
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Nutrition Approach to Ca Treatment
Paradigm Shift
Traditional Approach 
• Eat regardless the source
• Nourishment/Functional •
High Calorie
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High Protein
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High Fat
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Weight Gain
(SAD)
No supplements ‐‐ fear of •
interference with treatment
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• Rest
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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
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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
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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
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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
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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
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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
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High Risk
• 5% Body weight loss in one month (or)
• 10% Body weight loss in six months
• Albumin is less than 3.2
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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
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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
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Sandler, RS, etal, (2000), Abdominal pain, bloating, and diarrhea in the US: Prevalence and Impact. Dig. Dis.Sci, 45, 166‐171
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Healthy Gut—crucial during treatment •
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Prevent malabsorption
Increase nutrient absorption Prevent bacteria overgrowth
Support Immune System
Support DuringTreatment:
• Amino Acids – L‐glutamine • Probiotics
• Fiber (prebiotics)
• Hydration
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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:
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Tumor invasion
Chemotherapy
Radiation therapy
Surgery
Prolonged use of antibiotics
Aging, refined diet, alcohol intake
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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 (?)
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Probiotics:
• Examples: acidophilus, lactobacillus, Bifidobacterium, Streptococcus, Saccharomyces
• Food Sources: yogurt, butter milk, miso, kefir, sauerkrauts, kimchee, etc.
• Supplements—Culturelle®, Align®, VSL‐3®, Florastor®, etc.
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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….
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Specific Nutrition Considerations: Functional Foods
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Amino Acids – L‐Glutamine
Probiotics
Essential Fatty Acids
Phytonutrients/Phytochemicals
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Key Points About Fat In The Diet
Dietary Fats
EAT THESE FATS
LIMIT THESE FATS
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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 •
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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
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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
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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
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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 •
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(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.
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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
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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
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