Neoplastic Disease

KNH 411

Cancer

Carcinogenesis – Etiology

Fat!PUFA’s and MUFA’s replace saturated fat

Calories: want to watch weight

Alcohol: avoiding excessive amounts; flavinoidsGenes may be affected by antioxidants, soy, protein,

fat, kcal, alcoholNutritional genomics – study of genetic variations

that cause different phenotypic responses to diet

© 2007 Thomson - Wadsworth

ChemotherapyCommon side effects due to toxicity to rapidly

dividing cells:Neutropenia: ow WBC count; be careful with food

safety; medications may cause; feeling of tirednessThrombocytopenia: low platelet countAnemia: relates to feelings of sluggishness/tired,

diarrhea, difficulty eatingDiarrheaMucositis: inflammation of mucous membrane;

mouth source; want food at room temperature—eliminates high calorie high protein diet

Alopecia: hair loss; creates psychological profileCardiotoxicity, neurotoxicity, nephrotoxicity: because

of chemo treatment, will have cardiac, nerve, and kidney damage

RadiationSide effects:

Delivering electromagnetic rays and particles to destroy the cancerDelayed wound healingFatigue, mucositis, dysguesia, xerostomia

(may need artificial saliva), dysphagia, odynophagia, severe esophagitis, dehydration

Radiation enteritis, fistulas, strictures, chronic malabsorption, severe diarrhea

TPN (IV nutrition therapy) may be warranted to prevent weight loss

Nutrition Therapy

Prevent *malnutritionReversing this is extremely difficult

Treatment (chemo/radiation) or surgery may cause malnutrition

As a dietician: want to control symptomatic treatment Prokinetics: can help prevent gastric emptying Pharmacological agents may help with malnutrition

Screening and assessment importantBe aware of cancer dg and treatments most likely to

cause malnutrition

Nutrition Implications

Cachexia –

One of last stages of cancer (Greek for “bad”)Metabolic alterations Tumor induces hypermetabolic catabolic state

through chemical mediatorsTumor specific “cachectic factors”Weight loss, anorexia, muscle wasting, fatigue, early

satietyStandard therapy – nutrition support

© 2007 Thomson - Wadsworth

Nutrition Implications

Abnormalities in CHO, lipid, protein metabolism (in the presence of a malignant tumor)Normal physiologic conservation seen in starvation

does not occurCHO – insulin resistance, increased glucose

synthesis, gluconeogenesis, increased Cori cycle activity, decreased glucose tolerance and turnover

Anorexic stageCachexia stage

Nutrition Implications

Abnormalities in CHO, lipid, protein metabolismProtein - amino acids not spared, depletion of lean

body mass, increased protein catabolism, or decreased protein synthesis

Lipid – increased lipid metabolism, decreased lipogenesis, decreased LPL, presence of lipid-mobilizing factor (LMF)

Nutrition Implications

Cancer treatmentNausea, vomitingEarly satietyDysgeusiaDiarrheaMucositisXerostomiaConstipationWeight lossAnemia

Nutrition Interventions

Nutrition AssessmentSGA (subjective global assessment)

Triage tool to assess who you would need to see first: Rate them from 1-9, 1=no intervention, 9+ symptoms

to manage want to triage them as the first patient to be seen

A-well nourished cancer client B-moderately nourished cancer client C-severe malnutrition

Anthropometrics including height, weight, detailed weight hx, fluid retention, body composition

Biochemical including serum hepatic proteins Clinical signs and symptoms

Nutrition Interventions

Nutrition AssessmentDetailed diet hx and current intake

Foods tolerated, special diets, use of CAM, supplements, liquid nutritional supplement preferences

Nutrition Interventions

Determining Nutrient RequirementsIndividualizedKcal to maintain weight and prevent loss Protein to prevent negative nitrogen balance

and meet synthesis needsFluid needs - 30-35 mL/kg or cc’s/kcalMultivitamin mineral supplement < 150%

DRINeed to look at dietary recall to address who to

get to 150% of DRI (supplemental and food stuffs)

Nutrition InterventionsNausea & Vomiting

Avoid noxious odorsReview medication list for potential causesSmall, frequent mealsPro-kineticsCAM – acupressure, acupuncture, hypnosis, guided

imagery

Nutrition InterventionsNausea & Vomiting - Chemotherapy

Small, low-fat meals morning of, avoid fried, greasy and favorite foods for several days, fluid in between meals

Clear liquid dietElectrolyte-fortified beveragesNon-acid fruit drinksAvoid favorite foods Avoid “creamy” liquid nutritional drinks Anti-emetics 30-45 min. before meal

Nutrition InterventionsEarly Satiety (big problem)

Small, frequent nutrient-dense meals (want to avoid gastric dumping)

Beverages between meals and should contain nutrients

Avoid high-fiber and raw vegetablesPro-kinetics

Nutrition InterventionsMucositis (inflamed GI tract from mouth to

anus)Thorough and systematic assessment of mouthGood oral hygiene importantOral glutamineNarcotic analgesicsEat soft, non-fibrous, non-acidic foodsAvoid hot foodsEncourage liquids; non-acidic juicesHigh-kcal, high-protein shakes & supplements

Nutrition InterventionsDiarrhea

Drink small amounts of fluid frequently throughout day

Avoid large amounts of fruit juiceOral rehydration fluids and nutritional beveragesAntidiarrheal medicationsFoods high in soluble fiber

Nutrition InterventionsDysgeusia

Assess taste changes – metallic taste, aguesia, heightening of certain tastes (sweets), aversions

Avoid metal utensils, drink from glass Incorporate other high-protein foods if aversion to

meats exists Increase spices, flavors Non-sweet supplements, or juice- or yogurt-based

alternatives

Nutrition InterventionsXerostomia

Artificial saliva/ mouth moisturizersGels, lozenges, mouthwashesSugar-free gum, sour-flavored hard candy

Nutrition InterventionsAnorexia

Pharmacologic agents to increase appetitePharmacologic agents to treat weight lossPhysical activityOral supplements

Nutrition InterventionsNutrition Support (if the gut works, use it)

Enteral vs. parenteral Nutrition support inappropriate for those with terminal

cancer or for pts. with poor prognosis for whom other therapies have been exhausted

ASPEN practice guidelines for nutrition support

Nutrition InterventionsNutrition Support

Home nutrition support May maintain quality of life Lack of appetite and food intake may be greater concern

to family members, caregivers than to pt.