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Welcome to Seminar
on
Optimal Nutrition Support to
Cancer Patients
Meera Kaur, PhD, RD.
[email protected]
KILDONAN MEDICAL CENTRE
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Outline of the Session
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Motivation for this Study
Objectives
The concept
The food development
Clinical outcome
– Materials and methods
– Results and discussion
Implications for the healthcare professionals
Summary and conclusion
References
Acknowledgement
Meera Kaur, PhD, RD
KILDONAN MEDICAL CENTRE
Motivation for this research
• Approximately 50 % of hospitalized cancer
patients are malnourished.
• Effective nutritional support to cancer
patients is particularly challenging in
developing countries due to the high cost of
proprietary enteral formulae.
• Hence, the objectives of this study were ….
Meera Kaur, PhD, RD
KILDONAN MEDICAL CENTRE
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Objectives of the study
To:
• develop natural ingredient-based, low- cost
enteral food (LCEF) for cancer patients
• determine physicochemical and nutritional
properties
• evaluate clinical outcome in cancer patients
Meera Kaur, PhD, RD
KILDONAN MEDICAL CENTRE
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The concept
• Improving the bioavailability of nutrients in
natural ingredients by suitable processing
• Modifying the texture of natural ingredients to
suit enteral tube or oral feeding
• Enhancing with synbiotics and conditionally
essential nutrients
Meera Kaur, PhD, RD
KILDONAN MEDICAL CENTRE
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The process for LCEF (patented)
Malted
Cereals
Vegetable/fish oil
Malted
Mung Bean
Mixing
Cooking
Homogenizing
Toasted Soy
Milk + LAB
Popped
Amaranth
Meera Kaur, PhD, RD
KILDONAN MEDICAL CENTRE
Spray drying
Fortification
LC
EF
Nutritional information
Form
Powder
Moisture (g%)
Protein (g%)
Fat (g%)-4 g fish oil
Available Carbohydrate (g%)
Energy (Kcal/100g)
Vitamins+minerals (g%)
Total dietary fiber (g%)
Soluble dietary fiber (g%)
Insoluble dietary fiber
Calcium (mg%)
Phosphorous (mg%)
LAB (cfu/g)
BCAA (g/100g of protein)
L-Glutamine (g%)
2.1
22
19-20
16
30-31
56
49-50
456
2.5
5.0
2.3
2.7
300
314
5.4×106
13.31(2.9g/100g food)
4.0
Meera Kaur, PhD, RD
KILDONAN MEDICAL CENTRE
% of cal.
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Clinical Outcome in
Cancer Patients
Meera Kaur, PhD, RD
KILDONAN MEDICAL CENTRE
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Materials and Methods
Meera Kaur, PhD, RD
KILDONAN MEDICAL CENTRE
Patients’ characteristics...
Characteristics
Experimental
Control
(n=32)
(n=31)
Gender ratio (M/F)
19/13
Age (years)*
51.8±7.4
53.7±7.7
BMI (kg/m2)*
17.6±3.4
17.4±4.6
Usual wt (kg)*
66.1±2.4
65.8±3.7
Wt. loss at admission(%)*
7.1±3.6
Performance Status
(Zubrod)
2.1±0.6
Meera Kaur, PhD, RD
KILDONAN
MEDICAL CENTRE
2.1±0.7
17/14
7.3±1.8
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Patients’ characteristics
• Type of Cancer:
• Treatment Received:
• Exclusion Criteria:
Meera Kaur, PhD, RD
KILDONAN MEDICAL CENTRE
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Inoperable Carcinoma
Esophagus (Stage III or IV
with no prior treatment)
Radiation and/or
Chemotherapy
Pediatric patients,
pregnant and nursing
mothers
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Nutritional Support
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Feeding mode:
Energy requirement:
Protein requirement:
Initiation of feeding:
Feeding duration:
Additional nutrients
in experimental diet:
• Control diet:
Meera Kaur, PhD, RD
KILDONAN MEDICAL CENTRE
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BolusTube feeding
Herris-Benedict Equation
1.5-2.0g /Kg/day
Within 24 of admission
Till Discharge (45-60 days)
L-glutamine, Fish oil,
Lactic acid bacteria (LAB)
Isocaloric, Isonitrogenous
proprietary enteral formula
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Outcome measures
• Tolerance
• Liver function tests
• Calorie intake
• Infectious episodes
• Anthropometric
indices
• Biochemical indices
Meera Kaur, PhD, RD
KILDONAN MEDICAL CENTRE
• Test for lactose
intolerance
• Length of hospital stay
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Results
Meera Kaur, PhD, RD
KILDONAN MEDICAL CENTRE
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Energy Estimated and Intake
Energy Estimated and Intake
3000
2500
Kcal
2000
1500
1000
500
0
1
2
3
E-EST
Meera Kaur, PhD, RD
KILDONAN MEDICAL CENTRE
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5
Week
E-INT
C-EST
6
C-INT
7
8
16
Changes in body weight
Changes in Body Weight
Percent Loss of Body Wt.
60
8
58
EXPT
CONT
56
54
52
1
2
3
4 5
Week
6
7
8
6
4
2
0
Expt.
Meera Kaur, PhD, RD
KILDONAN MEDICAL CENTRE
(% )
Weight (kg)
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Cont
Anthropometrical indices of patients
Parameters
TSF (mm)
Control
I
T
8.311.4
Experimental
I
T
7.861.0
10.51.1 10.32.01
MAC( cm)
20.01.2
19.81.3
20.31.9
19.91.3
MAMC (cm)
19.761.9
19.362.0
21.11.21 21.11.09
C Vs E
p<
0.05
NS
0.05
I=At the initiation of study; T=At the termination of study; NS=not significant
Values are mean ±SD
Meera Kaur, PhD, RD
KILDONAN MEDICAL CENTRE
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Biochemical Indices of Patients
Parameters
I
Control
T
T. Protein (g%)
6.91.3
Albumin (g%)
6.40.7
Experimental
I
T
C Vs E
P<
7.11.1
7.50.6
0.05
4.1±0.3 3.1±0.6
3.80.4
4.70.5
0.05
Globulin (g%)
3.40.8 3.70.9
3.81.4
2.80.4
0.05
A/G
1.30.5
1.00.3
1.60.2
0.05
0.870.13
Alkaline
11.57.7 11.03.2
Phosphatase (Unit %)
12.813.5
5.83.6
0.05
SGPT (unit/ml) 208129.9 100.313.2
198.3135.7 44.711.1
0.05
I=At the initiation of study; T=At the termination of study; Values are mean
±SD
Meera Kaur, PhD, RD
KILDONAN MEDICAL CENTRE
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Infectious episodes
Commonly isolated organisms
Staphylococcus Coagulase negative
Staphylococcus aureas
Streptococcus pneumoniae
Stenotrophomonas maltophilia
Number of infectious episodes
Control: 5.3±2.3
Experimental: 3.2±0.8
C Vs E: p<0.05
Meera Kaur, PhD, RD
KILDONAN MEDICAL CENTRE
Other parameters
• Tolerance of the feed:
• Presence of lactose in stool:
• Length of hospital stay (days):
Experimental (E):
Control(C):
C Vs E:
• Cost of nutrition support/day:
Experimental (E):
Control(C):
C Vs E:
Meera Kaur, PhD, RD
KILDONAN MEDICAL CENTRE
Well tolerated
Nil
52.4±1.4
63.3±0.78
p<0.05
$3-5
$10-15
p<0.05
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Discussion
Meera Kaur, PhD, RD
KILDONAN MEDICAL CENTRE
Discussion…
Use of Glutamine in cancer patients:
Evidence of positive outcome
Oguz et al. (2007): colorectal cancer  post operative
complication & hospital stay
Ziegler (2001): cancer, BMT  N2, infection, mucositis ,
hospital stay
Shewchuk et al. (1997): Morris Hepatoma 7777  tumordirected natural killer cytotoxic activity or faster response to
an immune challenge.
Meera Kaur, PhD, RD
KILDONAN MEDICAL CENTRE
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Discussion…
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Use of fish oil in cancer patients:
Evidence of significant positive outcome
Christopher & Wigmore (2005): cancer  wt. Gain,
prevent cachexia
Barber (2001): pancreatic cancer  lean tissue, reverse
cachexia
Barber et al. (1999): pancreatic cancer  acute-phase protein
response (APPR) and
wasting
Meera Kaur, PhD, RD
KILDONAN MEDICAL CENTRE
Discussion…
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Use of Branched-Chain Amino Acids (BCAA) in cancer
patients: Evidence of significant positive outcome
Choudry et al. (2006): advanced cancer improves
skeletal
protein &
quality of life
Okada (1988): gastric cancer (173 patients)
improves metabolism and maintain good nitrogen
retention
Meera Kaur, PhD, RD
KILDONAN MEDICAL CENTRE
Discussion…
Use of Lactic Acid Bacteria (LAB) in cancer patients:
Evidence of significant positive outcome
Rafter (2002): cancer enhances the host's immune
response, produces
antimutagenic
compounds
Hirayama & Rafter (2004): cancer improves immune
system
Meera Kaur, PhD, RD
KILDONAN MEDICAL CENTRE
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Discussion
Use of synbiotics (LAB+plant fibre):
Evidence of significant positive outcome
Bengmark (2006): Pancreatitis, trauma  immunoparalysis
Bengmark (2005): Critically ill  pathogens (c. diff)
Bengmark (2005): Clinical Medicine reinforce immune
system
Rayes et al. (2005): Liver transplant  bacterial infection rate
Bengmark (2003) : Critically ill research limited, but great
hope for future; confirmed for LAB
Olah et al. (2002 ): Acute pancreatitis  pancreatic sepsis,
 no.of surgical interventions
Meera Kaur, PhD, RD
KILDONAN MEDICAL CENTRE
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Implications for the Practitioners
• Dietary intervention for the restoration of general
health and nutritional status
• Dietary management of drug-related complications
• Foods rich in natural stimulants and protectants
may be considered for the management of GI
functions and over all health
• Whenever possible and applicable, foods rich in
synbiotics may be included in the diet of patients to
improve liver function and promote gut health
• Team approach and adjunctive therapy help
provide optimal nutrition support
Meera Kaur, PhD, RD
KILDONAN MEDICAL CENTRE
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Summary
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• Approximately 50% of hospitalized cancer patients are
malnourished. Nutrition support to cancer patients in developing
countries is particularly challenging because of the high cost of
proprietary formulae.
• Optimal nutritional support to cancer patients is important for
effective medical treatment and overall clinical outcome.
• Research findings indicate that glutamine, fish oil, BCAA and
LAB are anabolic and immunomodulatory nutrients in the
nutritional support for cancer patients.
• In this study, a low-cost natural ingredient-based enteral food
containing glutamine, fish oil, BCAA and LAB shows better
clinical outcome in cancer patients than a proprietary definedingredient-based enteral food. Also, it is cost-effective.
• Further research is necessary to establish the role of specific
nutrients for optimal nutritional support in cancer patients.
Meera Kaur, PhD, RD
KILDONAN MEDICAL CENTRE
Conclusion
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• This study reveals the clinical efficacy of the LCEF
in cancer patients.
• LCEF is cost-effective and provides optimal
nutritional support to the cancer patients.
• Development of the low-cost enteral foods
contributes to patient care, particularly in
developing countries where poverty is prevalent.
Meera Kaur, PhD, RD
KILDONAN MEDICAL CENTRE
References
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Oguz M., Kerem M., Bedirli A., Mentes, B B., Sakrak O., Salman B., H.
Bostanci. (2007),” L-Alanin L-glutamine supplementation improves the
outcome after colorectal surgery for cancer”, Colorectal Disease. 9 (6): 515 520.
Bengmark, S. (2006), “Aggressive management of surgical emergencies,” Ann
Roy Coll Sur of Engl 88(7): 624-629.
Choudry, HA., Pan, M., Karinch, AM., Souba WW. (2006), “Branched-Chain
Amino Acid-enriched nutritional support in surgical and cancer patients”, J
Nutr: 136: 314S-318S.
Bengmark, S.(2005), “Synbiotics and the mucosal barrier in critically ill
patients”, Curr opi gastro 21(6): 712-716.
Bengmark, S. and Martindale R. (2005), “Prebiotics and synbiotics in clinical
medicine”, Nutr Cli Prac 20(2): 244-261.
Christopher, D., Stephen, WJ. (2005), “Systemic inflammation, cachexia and
prognosis in patients with cancer. Anabolic and catabolic signals”, Cur Opi
Clin Nutr & Met Care. 8(3): 265-269.
Meera Kaur, PhD, RD
KILDONAN MEDICAL CENTRE
References
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Rayes N., Seehofer D. and Theruvath T. (2005), “Supply of pre- and probiotics
reduces bacterial infection rates after liver transplantation - A randomized,
double-blind trial”, Am J Trans 5(1): 125-130.
Hirayama, K., Rafter, J. (2004), “The role of lactic acid bacteria in colon cancer
prevention: mechanistic considerations”, Antonie van Leeuwenhoek
(November): 391-394.
Olah A., Belagyi T., Issekutz A., Gamal M E. and Bengmark S. (2002),
“Randomized clinical trial of specific lactobacillus and fibre supplement to
early enteral nutrition in patients with acute pancreatitis”,The Brit J Sur
89(9): 1103-1107
Rafter, J. (2002), “Lactic acid bacteria and cancer: mechanistic perspective”,
Brit J Nutr: 88 (Supplement, September): 89-94
Barber, MD. (2001), “Cancer cachexia and its treatment with fish-oil-enriched
nutritional supplementation”, Nutr: (September): 751-755
Meera Kaur, PhD, RD
KILDONAN MEDICAL CENTRE
References
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Ziegler, T R. (2001), “Glutamine supplementation in cancer patients
receiving bone marrow transplantation and high dose chemotherapy”, J
Nutr: 131: 2578S-2584S.
Barber, MD., Ross, JA., Preston T., Shenkin A., Fearon KCH. (1999), “Fish
oil–enriched nutritional supplement attenuates progression of the acutephase response in weight-losing patients with advanced pancreatic cancer”
J Nutr: 12(4): 1120-1125.
Shewchuk, LD ., Baracos, VE., Field, CJ. (1997), “Dietary l-glutamine
supplementation reduces the growth of the morris hepatoma 7777 in
exercise-trained and sedentary rats”, J Nutr: 127(1): 158-166.
Okada, A., Mori, S., Totsuka, M., Okamoto, K., Usui, S., Fujita, H., Itakura, T.
and Mizote. H. (1988), “Branched-chain amino acids metabolic support in
surgical patients: a randomized, controlled trial in patients with
subtotal or total gastrectomy in 16 Japanese institutions” JPEN 12(4):
332-337.
Meera Kaur, PhD, RD
KILDONAN MEDICAL CENTRE
Acknowledgement
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I gratefully acknowledge:
• The financial support provided by the Council of
Scientific and Industrial Research (CSIR),
Government of India, New Delhi, India.
• Dr. A. Anantha , MD, DMRE and S. Taramani,
RD, Kidwai Memorial Institute of Oncology,
Bangalore, India, for their support while
conducting the clinical trial.
Meera Kaur, PhD, RD
KILDONAN MEDICAL CENTRE
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Thank you
for gracing the session!
Any question?
Meera Kaur, PhD, RD
KILDONAN MEDICAL CENTRE
Natural Vs Defined ingredient-based formula
Natural ingredient-based
Carb:
cereals and millets
Protein:
Fat:
milk, legumes, etc.
edible oils
Fibre:
Flavor:
naturally present
need not to add
Color:
need not to add
Osmolality: desirable range
Efficacy:
more physiological
Cost:
less expensive
Meera Kaur, PhD, RD
KILDONAN MEDICAL CENTRE
Defined- ingredient-based
glucose,fructose,
maltodextrin,etc.
peptides, amino acids, etc.
fatty acids, MCT,
triglycerides, etc.
externally added
must be added to mask
off flavor of defined sources
added to enhance
acceptability
usually high
less physiological
more expensive