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1 Welcome to Seminar on Optimal Nutrition Support to Cancer Patients Meera Kaur, PhD, RD. [email protected] KILDONAN MEDICAL CENTRE 2 Outline of the Session • • • • • • • • • 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 3 4 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 5 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 6 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. 7 8 Clinical Outcome in Cancer Patients Meera Kaur, PhD, RD KILDONAN MEDICAL CENTRE 9 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 10 Patients’ characteristics • Type of Cancer: • Treatment Received: • Exclusion Criteria: Meera Kaur, PhD, RD KILDONAN MEDICAL CENTRE 11 Inoperable Carcinoma Esophagus (Stage III or IV with no prior treatment) Radiation and/or Chemotherapy Pediatric patients, pregnant and nursing mothers 12 Nutritional Support • • • • • • 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 , 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 13 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 14 Results Meera Kaur, PhD, RD KILDONAN MEDICAL CENTRE 15 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 4 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) 62 Cont Anthropometrical indices of patients Parameters TSF (mm) Control I T 8.311.4 Experimental I T 7.861.0 10.51.1 10.32.01 MAC( cm) 20.01.2 19.81.3 20.31.9 19.91.3 MAMC (cm) 19.761.9 19.362.0 21.11.21 21.11.09 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 17 Biochemical Indices of Patients Parameters I Control T T. Protein (g%) 6.91.3 Albumin (g%) 6.40.7 Experimental I T C Vs E P< 7.11.1 7.50.6 0.05 4.1±0.3 3.1±0.6 3.80.4 4.70.5 0.05 Globulin (g%) 3.40.8 3.70.9 3.81.4 2.80.4 0.05 A/G 1.30.5 1.00.3 1.60.2 0.05 0.870.13 Alkaline 11.57.7 11.03.2 Phosphatase (Unit %) 12.813.5 5.83.6 0.05 SGPT (unit/ml) 208129.9 100.313.2 198.3135.7 44.711.1 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 18 19 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 20 21 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 22 Discussion… 23 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… 24 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 25 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 26 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 27 Summary 28 • 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 29 • 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 30 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 31 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 32 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 33 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 34 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