Nutrition & GIST The Life Raft Group

1. Nutrition & GISTThe Life Raft Group Christy Tangney, PhD, FACN, CNS Cheryl Sullivan, MS,RD,CSND,LDN February 27th, 2008 ©2003 RUSH University Medical Center

2. Benefits of Adequate Nutrition • Feel better • Decrease your risk for infection • Improve wound healing • Improve strength and energy • Tolerate side effects of treatment better ©2003 RUSH University Medical Center

3. Nutrition Related Side Effects During Treatment Such as… Poor Appetite Nausea and/or Vomiting Diarrhea Constipation Ingestion & Heart Burn Bloating ©2003 RUSH University Medical Center Eldrige B, Hamilton K, 2004

4. Anorexia Cancer Cachexia- more complicated metabolic scenario which contributes to changes in muscle function, fluids and energy metabolism as well as immunosuppression.. WHAT can I DO? Smaller, frequent meals Nutrient dense foods Pleasant dining atmosphere Assistance with meal preparation Nutrition is part of treatment Liquid nutrition supplements Possible use of appetite stimulants: Marinol, Megace Poor Appetite ©2003 RUSH University Medical Center Eldrige B, Hamilton K, 2004

5. Why? Chemotherapy, radiation, immunotherapy, pain, fatigue, mucous drainage, constipation, certain medications Acute, Delayed or Anticipatory WHAT can I DO? Eat small, frequent meals to prevent empty stomach Eat foods at cool or room temperature Avoid strong aromas Use peppermints, lemon drops, root beer barrels Take medications as prescribed Nausea and Vomiting ©2003 RUSH University Medical Center Eldrige B, Hamilton K, 2004

6. Why? Diet, stress, inflammation of intestinal mucosa, medications, lactose intolerance Uncontrolled diarrhea can lead to dehydration and malnutrition WHAT can I DO? Limit insoluble fiber, increase soluble fiber Possible lactose restriction Restrict high-fat foods, caffeine, very sweet foods, gas-forming vegetables Encourage multivitamin use Diarrhea ©2003 RUSH University Medical Center Eldrige B, Hamilton K, 2004

7. Increase soluble fiber Legumes (1/2 cup cooked) – Black Beans, Kidney Beans – Lima Beans, Navy Beans – Northern & Pinto Beans Citrus fruit (grapefruit, orange) Prunes (1/4 c) Pears Brussel Sprouts Restrict gas-forming vegetables Cabbage; radishes; onions; broccoli; Brussels sprouts; cauliflower; How to treat diarrhea ©2003 RUSH University Medical Center Eldrige B, Hamilton K, 2004

8. Why? Dehydration, medications, lack of physical activity Why Important? poor appetite Bowel protocol to prevent constipation Medications to promote bowel movements High fiber diet, with gradual increase 25-35g fiber/day 64fl-oz daily Constipation ©2003 RUSH University Medical Center Eldrige B, Hamilton K, 2004

9. Ingestion & Heart Burn WHAT can I DO? • Avoid overeating • Remain sitting up for 30 mins – 60mins after consuming meals • Limit caffeine • Limit high fat foods • Avoid tight fitting clothes • Limit food that incorporates air (little carbonated products) • Elevate the head of your bed ©2003 RUSH University Medical Center

10. Bloating • Limit carbonation • Choose less high fat foods (fried, greasy foods) • Simethicone, Bean-o, Gas-ex • Limit dairy or milk products if you have a lactose intolerance ©2003 RUSH University Medical Center

11. Why? Certain chemotherapies and/or radiation therapy Why Important? Speed of recovery depends on nutritional status WHAT can I DO? Avoid tart, acidic, salty or spicy foods Soft foods to liquid diets Chilled foods and beverages Use straw or head tilt Baking soda, water, saline rinse Medications Sore Mouth or Throat ©2003 RUSH University Medical Center Eldrige B, Hamilton K, 2004

12. Why? Radiation to Head & Neck, some chemotherapy agents, medications, dehydration, oral infections, surgery Dental and gum disease, difficulty eating, talking, taste alterations WHAT can I DO? Add broth, soup, sauces, gravy Drink plenty of fluids Soft/bland foods, cold or at room temperature Chew sugarless gum/candy Limit caffeine Artificial saliva Avoid very sweet or sticky foods Dry Mouth (Xerostomia) ©2003 RUSH University Medical Center Eldrige B, Hamilton K, 2004

13. Etiology not well understood Ageusia- very little or no sense of taste Dysgeusia- metallic, bitter, salty or sweet taste May return either partially or completely; May take up to a year after therapy ends WHAT can I DO? Plastic or glass eating utensils if c/o metallic taste Sugar-free gums or candies (or sweeteners) can eliminate bitter taste Choose foods that don’t require cooking Experiment with new foods, marinades, spices Red meat not usually well tolerated Taste and Smell Alterations ©2003 RUSH University Medical Center Eldrige B, Hamilton K, 2004

14. Gastric Surgery • Smaller, more frequent meals • Avoid foods with a lot of sugar • Avoid added sugars • Drink liquids in between meals • Wait at least 30mins – 60mins after eating • Consume protein containing foods with each meal • High fiber may be difficult to digest following surgery • Avoid milk products if you have a lactose intolerance ©2003 RUSH University Medical Center

15. Nutrient Digestion • Stomach • Intrinsic Factor  needed for Vitamin B-12 absorption • Duodenum • Iron, Calcium, Magnesium, Zinc, Glucose, Vitamin C • Jejunum • Thiamin, Riboflavin, Pyridoxine, Folic Acid, Amino Acids, Vitamins A,D,E,K • Ileum • Fat, Cholesterol, Bile Salt, Vitamin B-12 • Colon • Water, sodium, potassium, Vitamin K ©2003 RUSH University Medical Center

16. Fluid Retention & Edema • Limit Sodium Intake • Less than 2000mg/day • Less than 700mg/meal • Increase physical activity • Fluid restriction if advised by your doctor ©2003 RUSH University Medical Center

17. Nutrition and Recovery • Recover from side effects of treatment • Attain and/or maintain ideal body weight • Choose a Plant-based Diet • Vegetables, fruit, legumes, and whole grains • AICR recommends these foods cover 2/3 of your plate: at least 50%! • Choose 100% whole wheat products (bread, pasta, chips); brown rice, oats, barley, bulgur • Legumes: the beans: black, fava, lima, navy, pinto and kidney; black-eyed pea, chickpeas ©2003 RUSH University Medical Center

18. The “Perfect Plate” Size of your palm Choose fish, poultry, and other lean proteins for ¼ of your plate Size of your fist Eat at least 3 servings of whole grain breads, cereals, pastas, rice, legumes, and sweet potatoes everyday Starch Protein Choose another Eat five or more servings every day of a variety of colorful veggies and fruits & 3 or more servings of low fat dairy per day Vegetable Fruit/Veg/Milk At least size of your fist Plant based foods like veggies & fruits should cover at least half of your plate ©2003 RUSH University Medical Center Created By: Jennifer Ventrelle MS, RD, LDN

19. Nutrition and Recovery • Decrease fat intake • 20-30% of total caloric intake • Choose plant-based fats • Regular physical activity • At least 30 minutes of moderate to vigorous physical activity, above usual activities, on 5 or more days of the week; 45 to 60 minutes of intentional physical activity are preferable • Drink alcohol in moderation • Limit consumption of red meat and processed foods • Limit salt intake ©2003 RUSH University Medical Center

20. Lifestyle Behaviors? Healthy Weight & A Stronger Body ©2003 RUSH University Medical Center

21. 6-9 Fruit/Vegetable Servings/Day • Snack on fresh or dried fruit between meals • Choose 100% fruit juices • Add extra vegetables to soups or pasta sauce • Mix fruit with yogurt • Add vegetables on sandwiches • Salsa • Stirred-fried vegetables • Try a new fruit or vegetable each week Dyer D. A Dietitian’s Cancer Story. Information & Inspiration for Recovery & Healing. Swan Press. 2002 ©2003 RUSH University Medical Center

22. What Counts as a Serving? • Fruits·1 medium apple, banana, orange ·½ cup of chopped, cooked, frozen or canned fruit (in 100% juice)·¾ cup of 100% fruit juice • ¼ cup dried fruit • Vegetables·1 cup of raw, leafy vegetables ·½ cup of other cooked, raw or frozen vegetables ·¾ cup of 100% vegetable juice ©2003 RUSH University Medical Center www.5aday.org

23. What Counts as a Serving? • Beans and nuts·½ cup of cooked for frozen legumes (beans/peas) ·2 tablespoons of peanut butter ·1/3 cup nuts • Dairy foods and eggs·1 cup of milk or yogurt ·1 ½ ounces of natural cheese ·2 ounces of processed cheese ·1 egg • Meats·2-3 ounces of cooked, lean meat, poultry, or fish ©2003 RUSH University Medical Center

24. Whole Grains- What are they? • All 3 parts of the kernel • When refined, removes bran and germ  25% of a grain’s protein is lost, along with at least seventeen key nutrients • Protein, fiber, vitamins and minerals ©2003 RUSH University Medical Center

25. Whole Grains – what are they? • Wheat, corn, rice, oats, barley, quinoa, sorghum, spelt, rye • Whole grains have some valuable antioxidants not found in fruits and vegetables, as well as B vitamins, vitamin E, magnesium, iron and fiber. www.wholegraincouncil.org ©2003 RUSH University Medical Center

26. Whole Grains- What Counts as a Serving? • 1/2 cup cooked brown rice or other cooked grain • 1/2 cup cooked 100% whole-grain pasta • 1/2 cup cooked hot cereal, such as oatmeal • 1 ounce uncooked whole grain pasta, brown rice or other grain • 1 slice 100% whole grain bread • 1 very small (1 oz.) 100% whole grain muffin • 1 cup 100% whole grain ready-to-eat cereal ©2003 RUSH University Medical Center

27. Prebiotics • Non-digestible food ingredient that beneficially affects the host by selectively stimulating the growth and/or activity of one or a limited number of bacterial speices already resident I the colon, and thus attempts to improve host health. • Stimulate colonic motility • Fructans • Chicory root, wheat, artichoke, garlic, tomato, banana, onion • Powder packets, chewables, yogurt… ©2003 RUSH University Medical Center Gibson, GR. J Nutr 1995

28. Probiotics • Live microbial feed supplement which beneficially affects the host animal by improving microbial balance • Bifidobacteria • Lactobacilli • http://nccam.nih.gov/health/probiotics/ ©2003 RUSH University Medical Center

29. Use a gradual plan Start with a high fiber cereal or mix them Add cooked grains to breads muffins, coffee cakes ©2003 RUSH University Medical Center

30. Eat breakfast as a king, lunch as a citizen, and dinner as the beggar on the corner Hungarian proverb ©2003 RUSH University Medical Center

31. Store and Prepare Foods Safely • Wash hands before/after handling raw meat and poultry. • Sanitize cutting boards in a solution of 1 tsp chlorine bleach in 1 qt of water • Wash kitchen towels/cloths often in hot water in washing machine. The sponge • Keep raw meat, poultry, fish, and their juices away from other food. After cutting raw meats, wash hands, cutting board, knife, and counter tops with hot, soapy water. • Marinate meat and poultry in a covered dish in the refrigerator. ©2003 RUSH University Medical Center

32. Serving & Storing Foods Safely • Never leave food out over 2 hours. (1 hour in temperature above 90 °F) • Bacteria that cause food borne illness grow rapidly at room temperature. • Meat and poultry defrosted in the refrigerator may be re-frozen before OR after cooking. If thawed by other methods, cook before re-freezing. ©2003 RUSH University Medical Center

33. Meal Planning • Think of the Perfect Plate • Think of your own health and your family’s: Modelling behaviors • Great resources on the Web • Log in to plan your meals today. Example of the Meal Planner • http://www.mealsmatter.org/MealPlanning/MealPlanner/index.aspx • Cooking Light • Shop smartly: Jewel, Trader Joe’s ©2003 RUSH University Medical Center

34. Oatmeal Cereals Many forms of oatmeal are whole grain…. Old fashioned, quick and Instant Oats from Quaker® all would qualify Steel Cut Irish Oatmeal as shown here is an excellent whole grain source… “Steel cut” means the groats have been steamed and roasted and then cut into thirds, not rolled… they take longer to cook and are chewier Size box: 16 oz Cost: $2.50-4.50 ©2003 RUSH University Medical Center

35. Size box: 28 oz Cost: $5.99 -$7.99 ©2003 RUSH University Medical Center

36. Cereals High in Fiber, low in Sugar and Fat Size box: 10 oz Cost:$1.99 ©2003 RUSH University Medical Center

37. Dietary Supplements • Discuss all dietary supplements (vitamins, herbs, minerals) with your healthcare providers • Dietary supplements are not regulated by the FDA • Should never replace whole foods • Lack of regulatory oversight of dietary supplements has led to misleading health claims ©2003 RUSH University Medical Center

38. Antioxidants • Concern regarding use of antioxidants during treatment due to production of free radicals • If undergoing radiation and chemotherapy not to exceed upper intake limits for the dietary reference intakes for vitamin supplements that contain antioxidants Upper Tolerable Limits • Vitamin C (mg): 2,000 • Vitamin E (IU): 1,000 • Vitamin A (µg): 3,000 • Selenium (µg): 400 • Zinc (mg): 40 ©2003 RUSH University Medical Center fnic.nal.usda.gov

39. Nutrition and Cancer Related Websites • www.cancer.org • www.cancer.gov • www.oncologynutrition.org • www.quackwatch.org • www.cancerRD.com www.cancernutritioninfo.com • http://nccam.nih.gov ©2003 RUSH University Medical Center

40. Thank you!Questions? ©2003 RUSH University Medical Center