Download Nutrition for Patients with GIST

Nutrition for Patients
with GIST
DATE: May 10, 2016 PRESENTED BY: Amanda Bryant RD CSO LD
What we will learn today
• Nutrition considerations for GIST treatment:
– Surgery
– Chemo: TKI
• Nutrition for cancer survivorship
• Other nutrition resources
Most common presentation in
stomach (55-60%) and small
intestines (25-30%)
National Cancer Institute: http://www.cancer.gov/types/soft-tissue-sarcoma/hp/gist-treatment-pdq#section/_1
Nutrition after Surgery
•
Stomach resection
– Depending on resected area: reflux, delayed stomach emptying
and/or dumping syndrome, and early satiety
– Potential for nutrient deficiencies:
• Vitamin B 12
• Folate
• Iron – most common nutrient deficiency
• Calcium
• Vitamin D
– Nutrient maldigestion and other fat soluble vitamin deficiency
• 70% - 100% develop some enzyme deficiency (partial vs
total gastrectomy)
• May or may not be symptomatic
Radigan, A. (2004). Post-Gastrectomy: Managing the Nutrition Fall-Out.
Practical Gastroenterology, series #18
Smith, B. (2008). The use of pancreatic enzyme replacement therapy in cancer. Oncology
Nutrition Connection 16(3).
Nutrition after Surgery
• Small bowel resections
– Duodenum
• Partial vs whipple resection
• Risk of nutrient malabsorption (enzyme deficiency)
– Jejunum or Ileum
• Lactose intolerance (lactase enzyme that breaks down lactose is
synthesized in jejunum and proximal ileum)
• Fat absorption – proximal 100 cm of jejunum
• Vitamin B 12: final absorption in ileum (impaired with >60cm
distal ileum resected)
• Bile acid diarrhea with ~100cm or more distal ileum resected
https://lh5.googleusercontent.com/-AfpIFN0bdo/TXuzjjpXziI/AAAAAAAAB68/nTttDR8iV3Q/s1600/Digestive+Tract+byp
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DiBasie, J, Islam, R. (2012). Bile Acids: An Underrecognized and Underappreciated Cause of
Chronic Diarrhea. Practical Gastroenterology. Series #110
Nutrition after Surgery
•
Anti-dumping diet & early satiety
– Eat small, frequent meals (4-6 times/day)
– Eat slowly and chew thoroughly
– Sit upright and at least 1-2 hrs after eating
– Limit high sugar foods with nausea, vomiting or diarrhea: soda, cakes,
pies, candy, donuts, cookies, certain protein liquid supplements
– Drink fluids between meals
– Consume protein with each meal: eggs, meat (poultry, fish), lunch meats,
nuts, milk, yogurt, cottage cheese, cheese, peanut butter, tofu,
beans/lentils as tolerated
– Include fiber foods as able: whole grain, fruits and vegetables, beans
(black, brown, pinto, kidney, and garbanzo), fiber fortified cereal –
mindful of too much fiber if experiencing early satiety/fullness.
•
Immediate post-operatively: low fiber, avoid high sugar foods, frequent small
meals.
Nutrition after Surgery
• Delayed Stomach Emptying
– Less common
– Seen mostly after truncal vagotomy (reduces acid secretion
and creates gastric stasis) or after whipple procedure
– Small, frequent meals
– Limit/avoid high fiber/high fat/greasy foods that delay
emptying
– Prokinetic agents
Nutrition after Surgery
Prevent nutritional deficiencies:
•
Depending on type of surgery (the greater area of stomach or ileum
resected > risk for supplementation), may need the following
supplementation to reduce/prevent micronutrient deficiencies:
– Vitamin B12: 500 mcg/d
– Folate: 100 mcg/d (500mcg/d if deficient)
– Iron: 18 mg/d (325mg (65 Fe) iron 3x/day if deficient)
– Calcium: 500 mg 3x/d
– Vitamin D: 1000 units/d
– Take iron separate from Calcium/Vitamin D
supplement.
Nutrition after Surgery
•
Impaired Digestion:
– Multifactorial:
• Increased transit time (decreased mixing of food with
digestive enzymes and bile salts)
• Potentially decreased enzyme production
• Larger than normal food particles empty into small
intestine
– Symptoms: steatorrhea, unintentional weight loss, malnutrition,
bloating, gas, pale or clay colored stools, overly foul stool
– Fecal fat test (72 hr study) or Fecal elastase
– Pancreatic exocrine replacement therapy (PERT) and/or Bile
Acid sequestrants
– Pancreas may be functioning properly and still need enzymes
Nutrition after Surgery
•
Other nutrition Complications after small intestine
resections:
– Monitor fat soluble vitamins
– May still require Vitamin B12, iron, magnesium, and/or zinc and
copper supplementation (depending on site of resection &
extent of diarrhea)
– Follow Anti-dumping syndrome diet: separate solids and liquids
at meal time
– May need lactose restriction
– Isotonic beverages with severe diarrhea: dilute juice with water
(1:3 ratio + add ¼ tsp salt for 16 oz. fluid)
– No alcohol/caffeine
OHSU Suggested Guidelines for Nutrition Care: Short Bowel
Syndrome
Nutrition and Chemotherapy
• TKI (Gleevec, Sutent)
– Nausea and/or vomiting
– Diarrhea
– Gas and bloating
– Altered Taste and Mouth Care
– Decreased oral intake may lead to weight loss
– The better you eat, the likely you are to take recommended
dose of TKI
General Nutrition
Recommendations
– Eat small, frequent meals (every few hours) – do
not skip meals!
– Chew food well
– Include a protein with each meal/snack as able
(boiled eggs, chicken, fish, pork, tofu, etc)
– Adequate fluids – at least 8 cups/day, aim to drink
most between meals (doesn’t have to all be water)
– Eat healthy when feeling well, avoid favorite foods
when not feeling well
Nutrition Impact Symptoms
•
Diarrhea
–
Avoid highly seasoned, fat/greasy foods (>20% fat)
–
Avoid/limit very sweet foods, potentially milk (yogurt and cheese may be ok)
–
Avoid sugar free gums and candies
–
Reduce/avoid alcohol and caffeine
–
Include sources of electrolytes
•
Potassium rich foods (some fruits, vegetables)
•
Magnesium
•
salt
–
Avoid insoluble fibers: skins on fruits/vegetables, whole grains, and beans/lentils,
and nuts
–
Choose soluble fibers: bananas, peeled fruits, well cooked vegetables without tough
skin, oats, white rice and pastas
–
Take anti-diarrhea medication as needed
Nutrition Impact Symptoms
•
Constipation
– Drink something hot in morning (tea or coffee)
– Smooth move tea
– Power pudding! (1 cup each: prune juice, bran cereal,
applesauce; take 2 tbsp. daily with 8 oz. fluid)
– Must drink adequate fluid
– Diluted prune juice
– Whole grains: fruits, vegetables, certain grains (avoid
those that may increase your gas and bloating)
– Physical activity
Nutrition Impact Symptoms
•
Gas and Bloating:
– Avoid carbonation and straws
– Foods to limit: broccoli, cauliflower, onions, brussels
sprouts, cabbage, dried beans
– Dairy can contribute to bloating and discomfort, esp after GI
surgery and aging, try lactose free milks
• FairLife ultra filtered milk, lactose free.
– Simethicone (Gas-X, Maalox) – OTC
– Indigestion/heartburn: avoid overeating, elevate head of
bed, ask about anti-reflux medications if needed.
Nutrition Impact Symptoms
•
Nausea and Vomiting:
–
Room temp or cold foods may be better tolerated
–
Avoid/limit high fiber, high fat/greasy, alcohol, and spicy; choose foods easy to
digest
–
Slightly salty, starchy, bland foods
–
Chew on gum or suck on hard candies (peppermints, root beer barrels, lemon
drops)
–
Avoid laying down after eating or wearing tight clothes
–
Acute nausea onset: sip on clear liquids (diluted juice, jello, broth), dry foods:
saltines, toast, dry cereal.
•
If vomiting: rinse mouth and try not to drink for 30 minutes; then sip on apple
juice, cranberry juice, broth, or frozen flavored ice/popsicles.
–
Acupuncture or relaxation techniques to calm self
–
If persistent nausea: ask provider about anti-nausea medications (there are many
that may be helpful)
Nutrition Impact Symptoms
•
•
Altered Taste
–
Maintain good mouth care
–
Mouth rinse: 1 tsp baking soda, ¾ tsp salt, 1 quart water
–
Tart flavors
–
Ginger, mint
–
Sea salt
Mouth sores (esp. with Sutent)
Ginger-Mint Lemonade:
• ½ lemon (cut into
wedges)
• 1 inch piece fresh
ginger (peeled and
sliced)
• 4 sprigs fresh mint, 1
½ tsp honey
• 1 to 2 oz. water
• Ice
Muddle lemon, ginger,
mint, and honey in glass,
stir in water and top with
ice.
–
eat enough protein and do mouth rinses and oral care
–
Adequate fluid, try straw to bypass irritated mouth
–
Avoid tart, citrus, overly seasoned foods and fluids
–
Avoid commercial mouth rinses
–
Include soft foods: creamed soups, cooked cereal, yogurt, pudding, bananas,
applesauce, mashed potatoes, pasta/rice in sauce, cottage cheese, gelatin,
milkshakes/smoothies
Recipe from: http://www.marthastewart.com/1050429/muddled-ginger-mint-lemonade
Nutrition Impact Symptoms
•
Poor appetite
–
Difficult to stimulate appetite if eating infrequently
–
Choose high calorie foods
–
Every bite counts!
–
Fluids: include source of calories
• Soup made with milk instead of water
• Hard boiled eggs (chill before eating if nauseas)
• Protein bars
• Jello made with 100% fruit juice
• Protein supplements
• Condiments: whipped topping, sour cream, butter, salad dressings,
peanut butter
–
Physical activity
Nutrition through Survivorship
•
Follow plate method - modify as needed
based on your symptoms
•
Avoid a “magic pill” approach
•
Excess weight and poor nutrition not
standalone GIST risk factors
•
BUT, following cancer preventive guidelines
can help through survivorship:
– Reduce risk of other co-morbid conditions
– Reduce risk of second primary cancers
Energy Density
Used with permission from Dr. Barbara Rolls, Volumetrics Eating Plan.
Nutrition Resources
•
American Institute for Cancer Research (www.aicr.org)
– Cancer prevention/survivorship guidelines
– Further suggestions for nutrition impact symptoms
•
National Cancer Institute Eating Hints, Before, During and After
Cancer Treatment booklet
(http://www.cancer.gov/publications/patient-education/eatinghints)
•
USDA guidelines (www.choosemyplate.gov) – myplate method:
learn more about each food group
•
Cancer Fighting Kitchen (http://www.rebeccakatz.com/thecancer-fighting-kitchen)
Other References
•
Academy of Nutrition and Dietetics Oncology Toolkit and
Nutrition Impact Symptoms
•
OHSU Suggested Guidelines for Nutrition
Thank You
Amanda Bryant RD CSO LD
Outpatient Oncology Dietitian
503-418-9731