Download Nutrition for Oncology Patients

Nutritional Aspects
of Cancer Care
Helen Webster
Oncology Dietitian
NHS Tayside
Aims
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Malnutrition
Causes
MUST
Management
Cancer Cachexia
Management
EPA supplements
Alternative diets/supplements
Case studies
Conclusion
Questions
References
What is Malnutrition?
“A state of nutrition in which a
deficiency or excess of energy,
protein and other nutrients causes
measurable adverse affects on
tissue/body form, function and
clinical outcome”
DOH, 2002
• 1 in 4 adults admitted to hospital or
care homes at risk of Malnutrition.
Bapen 2007
• Estimated up to 80% of advanced ca
pts have malnutrition. Poole & Froggatt, 2002
Causes of malnutrition?
Four main causes:
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Decreased dietary intake
Increased requirements
Increased losses of nutrients
Impaired nutrient digestion /
absorption.
Causes of decreased intake
• Reduced appetite due to cachexia /
depression / anxiety
• Symptoms of illness – N&V, sore mouth,
abdo distension, diarrhoea.
• Treatment side effects
• Tumour / ascites pressing on GI Tract
reducing volume available and causing
early satiety
• Taste changes
• Constipation
Causes of decreased intake
• Social isolation, significant life
change, mental illness
• Repeatedly NBM for
investigations / biopsies
• Difficulty with eating / chewing
e.g. ill fitting dentures, poor oral
hygiene / dysphagia
• Difficulty with self feeding
Causes of Increased Requirements
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Cachexia
SOB e.g. lung ca, PE,
Infection
Wound healing
Post op pts
Fractures
Loss of nutrients
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Vomiting
Diarrhoea
Renal losses
Haemorrhage
Wound
Fistula
Impaired digestion / absorption
• Lack of digestive enzymes
e.g. ca pancreas,
pancreatitis, CF
• Loss of surface area for
absorption e.g. pts with
resections, coeliac disease
• Radiation enteritis
Impact:
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Weight loss
Vitamin Deficiency
Impaired immune function
Delayed wound healing
Higher risk of pressure sores
Muscle wasting and weakness –
impairing respiratory function,
cardiac function, mobility
Impact Cont…
• Increased risk of post op
complications.
• Apathy and depression –
vicious circle.
• Lethargy, tiredness, weakness.
• Est. 20% people with cancer
die from effects of malnutrition
rather than cancer itself.
Management of Malnutrition
• Early intervention improves
outcome.
• Ward can screen with MUST, start
fortified diets, food charts, weight
checks, provide assistance.
• Clinics – weight, height, BMI, weight
history, recent food intake, consider
planned treatments.
• Refer to dietitian using MUST score
> 2, anything less should be
managed at ward level.
Management of malnutrition
• Treat side effects restricting
intake
• Treat depression if present
• Mouth care – be proactive!
• Modify diet
• Consider supplements
• Consider artificial nutrition if
appropriate
Nutritional Supplements
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Ensure plus – 330 kcal, 13 g protein.
Ensure plus juce – 330 kcal, 10 g protein.
Enshake – 600 kcal, 15 g protein.
Calogen - 405 kcal in 3 x 30 ml doses.
Procal liquid – 300 kcal, 6 g protein in 3 x 30 ml
doses.
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Procal powder – 100 kcal, 2 g protein.
Want to try some?
Which do you prefer?
Others available.
Enteral Feeding
• Various routes: NG, NJ,
PEG, RIG, PEJ, Surg Jej.
• Used to meet full / part
nutritional requirements.
• Various feeds.
• Emergency feeding
regimen for out of hours.
Refeeding Syndrome
• Refeeding syndrome –
“severe fluid and electrolyte
shifts and related metabolic
complications in
malnourished pts undergoing
refeeding.”
• During starvation the body
adapts to save energy.
• On refeeding: increased
insulin release leads to
uptake of glucose, Phos and
K+ into cells.
Refeeding Continued…
• Magnesium is used as a co-factor for
cellular pump activity
• Reactivation of the Na/K+membrane
pump leads to more K+ moving into
cells
• Reduced phosphate causes
increased magnesium excretion
(urine)
• Stimulation of protein synthesis leads
to increased demand for phos, K+
and glucose by the cells
• Increased thiamine use – cofactor in
CHO metabolism
Parenteral Nutrition
• Intravenous nutrition
• If the gut works – USE IT!
• Used to meet patients
requirements where the gut is
not working
• Short and long term indications
e.g. enterocutaneous fistulae,
post-op ileus, severe malabsorption, short bowel
syndrome, radiation enteritis
etc
• Requested via the nutrition
team
Cancer Induced Weight loss (Cachexia)
• Weight not maintained despite normal
diet
• Complex combination of metabolic
abnormalities.
• Particularly prevalent with solid
tumours.
• Adequate nutrition has little or no effect
• Early visible sign of deterioration
• Associated with Anorexia and Early
satiety
Aetiology of cachexia
 Many different factors
o Cytokine involvement
 Pro-inflammatory cytokines implicated in
metabolic disturbances
 TNF, IL-1, IL-6, IL-8 and LIF
 Mediate acute phase protein response
(APPR)
 Causes increased synthesis of proteins
by the liver e.G. CRP
 Req. Amino acids from lean body tissue
causing weight loss
 CRP elevated in 45 % of ca panc pts at
diagnosis. Falconer et al. 1994
Metabolic changes causing REE
Metabolically
Inefficient
Recycling of
glucose
APPR
Glucose
Production/
turnover
REE
Whole body
Protein
turnover
Protein
catabolism
PIF
Protein
synthesis
Lipogenesis
Lipoprotein
lipase
REE = resting energy expenditure
PIF = proteolysis inducing factor
APPR: Acute phase protein response
Summary of Cachexia
Mechanism of Cancer Cachexia
Effects of tumour on
weight loss
Tumour
Inflammationlike response
Effects of treatment /
anxiety on weight loss
Treatment
Increased
metabolic
rate
Altered use of
protein, fat and
carbohydrate by
the body
Cancer induced early satiety
and anorexia
Side effects
such as:
dry mouth, loss of
appetite, sore
mouth, nausea,
taste changes,
decreased food
intake
Anxiety
Reduced
food
intake
Reversible weight loss can be
stopped / reversed by adequate
nutrient intake
Loss of fat and muscle
tissue
Loss of fat tissue
Combined effects lead to
overall weight loss
Management of Cachexia
• Team approach.
• Cure the cancer – not always possible.
• Increase nutritional intake – diet and
supplements to meet the deficit.
• Reduce effects of factors listed
previously through cancer treatments,
pharmacology, dietary interventions,
involvement of other AHPs etc.
• Improve nutritional status.
• Improve quality of life.
EPA Supplements
• High fish oil content providing patient with mega-dose
of eicosapentaenoic acid (EPA)
• Proven to reduce inflammatory response
• Reduce further weight loss
• Improve quality of life
• Limited evidence, small studies.
• 2 available: Prosure (any cachexic pt) and Forticare
(licensed only for ca pancreas)
• Not widely used as other supplements tend to be more
appropriate/palatable when pts diagnosed.
• Cost implications:
Ensure plus = 3 p on contract (in hospital)
Forticare = £1.80
Prosure = £2.70 Wigmore et al, 1996
Alternative Diets/ Supplements
• Many different types
• Vulnerable/desperate patients
seeking help / advice
• Not evidence based
• Tend to cut out/restrict good
sources of calories and protein
• Tend to encourage lots of f&v >10
portions, bulky, low in kcals and
protein
• Some claim to cure cancers
• Some promote weight loss as part
of the healing process
Bristol Cancer Diet
• Well publicised.
• It recommends:
 High intake of fresh veg & fruit, high in
whole grains beans and pulses on a
regular basis.
• It rules out:
• Sugar and refined carbohydrates, dairy
products, red meat, processed foods,
smoked/cured foods, caffeine, alcohol,
salt .
Problems With The Bristol Cancer Diet
• Cancer patients commonly have poor appetite and
early satiety
• Eating bulky foods such as raw veg, brown rice and
pasta, lentils and pulses – not tolerated.
• People fill up on these quickly.
• Therefore unable to meet calorie and protein
requirements and lose weight.
• Limited evidence.
• Where appropriate Healthy eating advice should be
given by a dietitian and tailored to the individual e.g.
in a weight gaining breast ca pt.
Gerson Diet
• Claims a 50% recovery rate if followed
– no evidence to support those claims
• Strictly based on organic fruit and veg
– juiced
• Therefore entirely vegan
• Coffee enemas, thyroid hormones and
liver extract used
• Very expensive, time consuming and
pts lose weight dramatically
Gerson institute, 2006
Metabolic Therapy
• Claims to boost the immune system
• Uses Lætrile (vit B17) a derivative of
bitter almonds/apricot kernels
• Also uses coffee enemas and liver
extract and mega doses of vits and
mins
• Scientific studies showed no effect on
outcome for patients
• Demonstrated higher levels of cyanide
from Lætrile in blood stream of those
taking part
National Cancer Institute, 2006
Immuno-augmentative Therapy
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Iscador – extract of mistletoe
Said to boost immune function
Studies have shown rise in WBC
Seen to affect growth of ca cells
in laboratories
• Limited evidence – mechanism
not fully understood.
Weleda, 2006
Shark Cartilage Extract
• Claim that sharks don’t get cancer.
• Cartilage thought to prevent
angiogenesis.
• One major study showed no effect.
• However phase 3 trial using
Neovastat in USA underway (renal
ca and NSCLCa).
• £20 for 100 capsules online.
• ? Dosage.
Cancerhelp, 2008.
Alternative Diets/supplements
• The weird and the wacky.
• Used by the very vulnerable /
desperate people as well as the
sensible.
• Can be avoided if given
appropriate advice early on.
• Tread carefully.
• Allow the patient to make an
informed choice.
• And allow the dietitian to
support their choice without
detriment to their health.
Case Study 1
• 76 yr old male.
• Admitted with SOB, recurrent
chest infections.
• Recently found to have lung
ca on CT and pleural
effusion.
• C/O poor appetite.
• Mouth “like the Sahara
desert.”
• Gets fatigue from SOB.
• Lost approx 7 kg (1 stone)
over last 4-6 weeks.
Case Study 1
• What steps can be taken to
improve this pt’s nutritional
intake?
• What can be done at ward
level?
• What other proactive measures
would help prevent a worsening
of his nutritional intake?
• What other meds are likely to
be used that will help his
appetite anyway?
Case Study 2
• 72 yr old male pt adm to
oncology unit with
oesophagitis, dry, sore
mouth, dysphagia and pain
on eating and swallowing.
• Has been receiving
radiotherapy for oesophageal
cancer
• Minimal dietary intake
• Unable to wear dentures
• Epigastric pain, particularly
at night.
Case Study 2
• What has caused the
oesophagitis?
• How can we reduce the pain on
eating and at night?
• What sort of mouthcare might
you recommend?
• What dietary steps / advice
may be useful?
• What steps can the ward take?
Conclusion
• No quick fix to nutrition
support for patients.
• Not necessarily about pt
gaining weight.
• Aiming to improve quality of
life for the pt and reassure
anxious relatives.
• Proactive approach is best.
• Early referral and intervention
improves outcome for the
patient.
Conclusion
• Oncology Dietitians available for
patients on ward 32 east, west
and day pt area
• MUST scoring with common
sense and proactive thinking
• Refer other ward’s patients to
local dietitians
• Food first approach
• Not just about supplements –
lots of other issues we can
address as a team to improve a
patient’s oral intake and in turn
their quality of life.
Thanks for listening
• Any questions?
References:
• DOH. Nutrition screening in quality of care 2002.
• McWhirter J.P., Pennington C.R., Incidence & recognition of
malnutrition in hospital. Br MED J 1994:308:945-948.
• Poole K, Frogatt K, weight loss in advanced cancer – a literature
review. Macmillan cancer relief, 2002.
• Tisdale MJ, biology of cachexia, J Natl cancer inst 1997:23:
1763-73.
• Falconer JS, Plester CE, et al. Cytokines, the acute-phase
response, and resting energy expenditure in cachexic patients
with pancreatic cancer. Ann surg 1994;219(4): 325-31.
• Tisdale MJ, metabolic abnormalities in cachexia and anorexia.
Nutrition 2000;6:d164-74.
• Billingsley KG, Alexander HR. The pathophysiology of cachexia
in advanced cancer and AIDS. In: Bruera E and Higginson I,
Cachexia – anorexia in cancer patients: NY: oxford university
press, 1996. P1-22.
References
• Wigmore SJ et al. The effect of polyunsaturated fatty
acids on the progress of cachexia on the progress of
cachexia in patients with pancreatic cancer. Nutrition,
1996;12.
• Bristol cancer help, 2006
www.bristolcancerhelp.org.uk.
• Gerson institute, 2006 www.gerson.org.
• National cancer institute, 2006
http://www.cancer.gov/cancertopics/pdq/cam/laetrile.
• Weleda, 2006 www.iscador.com.
• Cancerhelp, 2008
http://www.cancerhelp.Org.uk/help/default.Asp?Page
=31060.