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Why is Nutrition Such a Battleground?. May be the only aspect of care with which family
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1. Therapeutic Nutrition In the Oncology Population Suzanne Dixon, MPH, MS, RD
Oncology Nutrition Specialist & Epidemiologist
Cancer Nutrition Info, LLC
www.cancernutritioninfo.com
5. Cachexia vs. Anorexia Anorexia: ‘Lack of Appetite’ & ‘Involuntary Decline in Food Intake’
Anorexia is EFFECT rather than CAUSE of Cachexia
Cachexia is term to describe the disordered metabolism of diseases including (but not limited to):
Cancer
HIV/AIDS
Sepsis
Other chronic infections
Other Inflammatory Conditions
6. Cytokines Responsible for Metabolic Alterations
7. Disordered Metabolism
9. Treatment Nutrition Goals Phase 1: Getting Through Treatment (Primary Goals)
Prevent or correct nutritional deficiencies
Minimize short-term and long-term treatment side effects
Improve tolerance to treatment
Enhance quality of life during treatment
Help achieve and maintain optimal body weight
Educate family members about special nutrition needs
Evaluate the risks and benefits of nutrition-related CAM (supplements, vitamins, minerals, herbs); consider medication interaction issues!
10. Treatment Nutrition Goals Phase 2: Cancer Fighting Nutrition For Life (Secondary Goals)
Maintain healthy weight
Incorporate healthy nutrition habits for long-term health
Maximize cancer preventive potential of the diet (minimize recurrence risk)
Evaluate the risks and benefits of nutrition-related CAM (supplements, vitamins, minerals, herbs); consider medication interaction issues!
11. Addressing Primary Clinical Nutrition Intervention Goals
12. Screening Vs. Assessment SCREENING
To detect possibility of nutrition risk
Provide information to determine if follow-up is required
All oncology patients in all settings require screening
Screen must be simple & self-administered
Screen determines whether patient is referred to specialist (RD)
If screening detects need for more intensive assessment & intervention, arrange for this immediately
If referral unnecessary, document screen & re-screen at follow-up
ASSESSMENT
More intensive & thorough
Includes intervention, follow-up, intervention, follow-up, etc.
13. The Who & How of Screening Generally, nursing staff performs screen: In-home & Outpatient
May simply provide & collect form to/from patient & return it to the office for screening score & further intervention planning
Different clinics & home care companies use different methods for patient referral
Forms handed to dietitian prior to scoring
Forms scored & referrals made by nursing/medical staff
Referral must be made if patient is classified at risk
Dietitian may keep & store screening forms, but it will need to be in permanent medical record
Best Tool: Patient-Generated Subjective Global Assessment (PG-SGA)
14. Screening Tool Fundamentals SCREENING TOOL
PG-SGA = Patient Generated Subjective Global Assessment
Despite the name, PG-SGA is a good screening tool
PG-SGA is validated for use in oncology populations
Easy to administer & score
ITEMS ON A NUTRITION SCREEN
Weight History & Percent Weight Change
Food Intake: Has It Changed?
Symptoms
Functional Status
Disease & stage
Metabolic demand
Physical exam
15. PG-SGA Scoring & Optimal Intervention PG-SGA Score Guides Nutrition Intervention
Not At Risk: Additive Score = 0 to 1
No intervention required at this time; continue to screen at follow up visits
Stage A/Low Risk: Additive Score = 2 to 3
Well nourished, but may still be at risk; intervention includes education by dietitian or nurse, with pharmacologic nurse or physician triage as indicated by symptom survey
Stage B/Moderately Malnourished: Additive Score = 4 to 8
Moderately malnourished, requires dietitian intervention working in conjunction with nurse, physician, and medical care team as indicated by the symptom check-off for pharmacologic management
Stage C/Severely Malnourished: Additive Score = 9 or greater
Critical need for symptom mgmt and other nutrition intervention. Requires interdisciplinary team discussion to address all aspects affecting nutritional status and discussion of non-oral nutrition options including enteral or parenteral nutrition as dictated by gut function
16. From Screening To Assessment AFTER SCREEN INDICATES RISK, FULL ASSESSMENT:
Weight History & Percent Weight Change; Consider IBW
Appearance, behavior, mental health
Age & Gender
Functional status (Karnofsky Score, ECOG Score, etc.)
GI, oral cavity, head & neck region, cancer type & location
Intake: Diet History & 24-Hour Recall
FFQ generally NOT appropriate in the clinical setting
Diet records are impractical
Biochemical parameters: Albumin, Prealbumin, Transferrin, Hematocrit, Hemoglobin, RBP, glucose, CRP, Serum Creatinine
Medications & Planned Treatment
Psychosocial?? Financial??
17. Symptoms Affecting Nutrition Status Diarrhea
Sore Mouth
Dry Mouth
Altered Taste/Smell
Constipation
Lack of Appetite Fullness/Early Fullness
Fluid status (ascites, edema)
Dumping Syndrome
Nausea/Vomiting
Other Pain
18. Nutrition Can Help Manage Symptoms KEY: START EARLY
Specific Diet Modifications Will Help Minimize Nutrition-Related Side Effects
Each Side Effect Has Numerous Approaches for Mgmt
Nutrients/Food will PROFOUNDLY Affect The Body
Written Materials Alone May Not Be Sufficient
20. When Is Initiation of Enteral Nutrition Indicated? Actual or anticipated inability to meet 50% of needs for 7 or more days
Contributes to Quality/Length of life in meaningful way
Can improve tolerance to treatment and/or ultimate outcome
Patient wants it
A functioning gut (to some degree) is present
Is not contraindicated
Obstruction?
Gastroparesis?
May be able to by-pass with a J-tube
Is there hypomotility of the small intestine as well?
Nausea/Vomiting?
Often can get around this if using a J-tube
21. Beginning Enteral Feeding Use HBE to determine Calorie Needs
Males: BEE = 66.5+(13.7xW{kg})+(5.0xH{cm})-(6.8xA{yrs})
Females: BEE = 655+(9.6xW{kg})+(1.9xH{cm})-(4.7xA{yrs})
(Quick & Easy: 35-50 kcal/kg for hypermetabolic patients)
Protein Needs
1.3 to 1.5 grams/kg body weight (IBW or Adjusted IBW)
Adjusted IBW = (Actual BW - IBW) x (0.25 to 0.4) + IBW
IBW: Males = 106 lbs + 6 lbs/inch + 10%; Females = 100 lbs + 5 lbs/inch + 10%
Fluid Needs
1500 mL for first 20 kg of body weight + 20 mL per kg for
each kg over 20 kg
22. Basic Points For Enteral Feeding SELECT FORMULA CONSIDERING:
Osmolality (280 to 350 mOsm ideal for J-feeds); Albumin??
Calories per cc
Malabsorption (Specialty Formulas, MCT oil)
Account for free water & supplement liberally as needed
ROUTE OF ADMINISTRATION
Will G-Tube Be Tolerated?
Is J-Tube Necessary? (can bypass nausea & high obstructions)
Begin slowly; always, Always, ALWAYS use pump with J-Tubes
Gravity Feed/Bolus
Bolus feeding: 250 - 300 mL over 15 minutes, followed by 25-60 mL water; at least 3 hours b/w each bolus feeding
23. Trouble Shooting for Enteral Feeding Problems
24. Addressing Secondary Clinical Nutrition Intervention Goals
25. Healing 101: No Judging Why judge? It should be clear why a client is doing a specific approach!
Don’t take it personally!
Compliment client on initiative - Do NOT indicate disdain
Don’t forget the power of ‘self-help’
26. Healing 102: Everyone is Unique The story of the medical student and loss of compassion
Use science but be compassionate
Don’t betray your own principles but DO be flexible
Never say never!
27. Healing 103: Nocebo Effect What about YOUR expectations?
Your power is greater than you believe or know
Don’t betray your own principles but DO be honest & compassionate
Never say never!
28. First Do No Harm Discouragement of a harmless or potentially beneficial intervention may constitute harm (must consider all aspects including psychological, emotional, socioeconomic, etc)
Nutrients & Food Have The Ability To PROFOUNDLY Affect Our Bodies, On Many Levels
For the Client, “Food & Nutrition Are POWER, And YOU Control That Power By Choices!”
29. Think About This If you think you don’t need to think about this, you’re missing the boat
A Few Nutrients of Interest:
Capsaicin
Coenzyme Q-10
Eicosapentaenoic Acid (EPA) (Omega-3s)
Glutamine
Ginger
Milk Thistle
Probiotics
Zinc
35. “Best Bet” Complementary Cancer Therapies Eicosapentaenoic Acid (EPA) (Omega-3s)
Essential fatty acid with potential roles in inflammation, immunity, cachexia
May help decrease cachexia
May improve chemotherapy effectiveness/enhance immune function
Downside:
May have anticoagulant activity so use with caution if platelets low or on coagulation therapy
Generally well tolerated (up to 0.3 g EPA+DHA/kg body weight/day), but diarrhea possible
Dose:
Minimum dose of 2.2 mg EPA per day (best to avoid coagulation complications)
Two new products on the market Prosure & Resource Support
36. What Is Glutamine? Neutral, gluconeogenic nonessential amino acid
Stored primarily in skeletal muscle (75%) and liver (25%)
Nitrogen carrier between tissues
Primary energy source for rapidly proliferating cells (e.g. intestinal epithelium, activated lymphocytes, & fibroblasts)
May be conditionally essential; depleted in stress states (e.g. surgery, sepsis, & cancer)
Appears to be synthesized in muscle tissue in substantial amounts
Plasma concentrations are quite high, second only to alanine
Needed for renal acid-base balance
37. Why Glutamine For Oncology? Neuropathy
Arthralgias
Myalgias
Diarrhea
Enteritis & GI Mucosal Damage
Stomatitis
Muscle Mass Preservation??
38. Glutamine For Neuropathy:Physiology & Possible Mechanisms of Action Role in circulating nerve growth factor levels
increased peripheral neuropathy concurrent with declining serum nerve growth factor concentrations
animal models: glutamine up-regulates nerve growth factor mRNA
ongoing studies are examining nerve growth factor concentrations in banked serum
39. Glutamine For Neuropathy:Physiology & Possible Mechanisms of Action Role in pain perception in the cerebral cortex
glutamine is a precursor amino acid for excitatory neurotransmitters such as glutamate and GABA
glutamine into astrocytes and converted to glutamate (glutamine synthetase), then released into synapse
some glutamate in neurotransmitter capacity, but some used for neuronal energy requirements
hypothesized that high systemic glutamine concentrations may down-regulate conversion of glutamine to glutamate
40. Glutamine For Arthralgias/Myalgias:Physiology & Possible Mechanisms of Action Role in metabolic stress states
Glutamine freely released from skeletal muscles in states of metabolic distress
Advanced malignant disease results in muscle glutamine depletion and weight loss
Stress hormones induce decreased muscle glutamine concentrations, even in healthy adults
Intracellular glutamine concentrations ? more than 50% under metabolic stress
Glutamine is known to preserve glutathione concentrations; glutathione is needed for intracellular redox status
41. Glutamine For Arthralgias/Myalgias:Physiology & Possible Mechanisms of Action Role in metabolic stress states
Previous research suggests that during periods of metabolic stress, approximately 15 to 35 grams of supplemental glutamine may be needed to preserve muscle glutamine concentrations, provide fuel for cells with rapid turnover, and improve overall nitrogen balance.
Glutamine is vital as energy for rapidly proliferating cells, it may be extracted from muscles and supplied to other cells at the expense of muscle and connective tissue integrity
Altered redox status and resultant oxidative damage may also play a role in pain syndromes
42. Glutamine For Diarrhea/Enteritis:Physiology & Possible Mechanisms of Action Role in provision of energy, nutrients, cellular building blocks to enterocytes
Well-documented that glutamine is preferred fuel for GI tract
Three potential mechanisms through which glutamine appears to exert positive effects on GI tissue:
Primary cellular fuel of enterocytes
Precursor for nucleotides needed for cell regeneration
Source of glutathione, an endogenous anti-oxidant system
43. Glutamine For Diarrhea/Enteritis:Physiology & Possible Mechanisms of Action Cell, Animal, & Human Studies Demonstrate:
Glutamine is documented as preferential fuel for enterocytes, esp. during stress
Controls glycogen synthesis in enterocytes
Decreases protein degradation in enterocytes
Demonstrated to enhance gut cell mass
Demonstrated to increase height of mucosal villi
Demonstrated to increase numbers of mucosal villi
Decreases bacterial translocation under stress
44. Glutamine For Muscle Mass Maintenance:Physiology & Possible Mechanisms of Action Role in weight loss for HIV/AIDS
Loss of body cell mass (BCM) correlates with length of survival in this, and other, populations
Hypothesized that glutamine, which is conditionally essential, may be rate-limiting for repletion of BCM
Muscles synthesize glutamine & release into circulation
45. Glutamine For Muscle Mass Maintenance:Physiology & Possible Mechanisms of Action Role in weight loss for HIV/AIDS
Tissues that consume glutamine extract as needed from circulation
During stress and inflammation, consumption of glutamine exceeds ability of skeletal muscle to supply this amino acid
Blood & muscle glutamine concentrations decrease and muscle breaks down to satisfy needs
46. Glutamine For Muscle Mass Maintenance:Research Evidence Study
Shabert et al. 1999
40 grams glutamine/day in divided doses
26 patients total
Double-blind, placebo controlled (glycine as control)
Over 3 months: glutamine group gained 2.2 kg vs. 0.3 in control (1.8 kg BCM vs. 0.4 kg BCM)
Given common etiology between wasting seen in HIV/AIDS and wasting seen in cancer cachexia, it may be possible to enhance lean body mass retention throughout cancer treatment with glutamine
47. “Best Bet” Complementary Cancer Therapies Glutamine
Amino Acid
May help with diarrhea/GI symptoms & sore mouth/throat
May help decrease mucositis (5-FU)
May help decrease radiation enteritis
May help With Aching Muscles/Nerves (Taxol)
Downside:
No major side effects, some minor side effects
Do not take if you have poor kidney and/or liver function
Dose:
10 grams glutamine powder, three times per day, dissolved in liquid (research has been done with Cambridge Nutraceuticals-Baxter Pharmaceuticals & Glutasolve by Novartis)
48. Think About This Looking at a summary of some other potentially important interventions:
A Few Nutrients of Interest:
Capsaicin
Coenzyme Q-10
Eicosapentaenoic Acid (EPA) (Omega-3s)
Glutamine
Ginger
Milk Thistle
Probiotics
Zinc
50. “Best Bet” Complementary Cancer Therapies Coenzyme Q10
Antioxidant
May protect heart muscle from damage during treatment with certain chemotherapy regimens (adriamycin)
Downside:
Appears to be safe when used in reasonable dose
It acts as an antioxidant and some experts believe antioxidants are counterproductive during radiation therapy; data is mixed concerning antioxidants during radiation therapy, but overall suggests moderate use is ok
Dose:
30 mg two times daily
51. “Best Bet” Complementary Cancer Therapies Ginger
Food spice that also has medicinal properties
Taken as tea or root may help alleviate nausea
Also try 'natural' ginger ales
Downside:
Can act as mild anti-coagulant
Use with caution if low platelets or are on anti-coagulant medications (e.g. coumadin, heparin, etc.)
Dose:
Chopped/dried extracts for tea, taken 2-3 times daily
940 mg once daily of powdered ginger root for nausea prevention
250 mg of powder taken 4 times daily for nausea mgmt
52. “Best Bet” Complementary Cancer Therapies Milk Thistle
May help protect the liver from damaging effects of chemotherapy; may protect kidney & other organs
May help the liver regenerate & recover after damage
Downside:
Appears very safe for use in cancer patients; not much data on use in those with liver involvement
Mild nausea is a reported side effect
Mild anti-coagulant; use with caution if platelets are low
May reduce effectiveness of oral contraceptives
Dose:
140 mg standardized to 70-80% silymarin, 3 times daily
Phosphatidylcholine-bound silymarin, 100 mg 3 to 4 times daily
53. “Best Bet” Complementary Cancer Therapies Probiotics
“Healthy Bacteria” in yogurt & other fermented foods
May have selective immune modulating activity
May decrease rates of ‘opportunistic’ infections
May decrease diarrhea, mucositis, improve nutrient absorption
Downside:
Not many downsides however…
Dietary supplement products are poorly regulated and contamination is possible (yogurt & other fermented dairy are good options)
May need to be avoided in severe immune compromise (e.g. BMT populations)
Dose:
Unknown
54. “Best Bet” Complementary Cancer Therapies Zinc
May help restore sense of taste during radiation therapy to head/neck region
May take up to 1 month for noticeable effect
Downside:
Short term use improves immune function, long term use may suppress immune function
DO NOT USE if on cisplatin as zinc may increase toxicity
Dose:
30 - 50 mg daily elemental zinc daily (~135 - 220 mg zinc sulfate, divided into three doses)
55. Use the Resources That Are Available To Evaluate CAM Herbal/Supplement Resources (websites):
http://www.cancernutritioninfo.com
http://www.tnp.com
http://www.mcp.edu/herbal/
http://www.herbmed.org
http://www.naturaldatabase.com/
http://ods.od.nih.gov (http://ods.od.nih.gov/databases/ibids.html)
http://my.webmd.com/medical_information/drug_and_herb/drugs/default.htm
http://www.mskcc.org/aboutherbs
http://www.consumerlabs.com
http://www.quackwatch.org
http://vm.cfsan.fda.gov/~djw & http://www.cfsan.fda.gov/~dms/supplmnt.html
http://www.ncbi.nlm.nih.gov/pubmed
http://www.herbalgram.org
http://www.ars-grin.gov/duke/index.html
http://www.herbs.org
http://dietary-supplements.info.nih.gov
http://nccam.nih.gov
56. Use the Resources That Are Available To Evaluate CAM Look at the Herbal/Supplement Resources (books):
Mosby’s Handbook of Herbs & Natural Supplements
German Commission E Monographs
The Health Professional’s Guide to Popular Dietary Supplements
The Honest Herbal & Herbs of Choice
Herbal Drugs and Phytopharmaceuticals
The Encyclopedia of Medicinal Plants
Integrative Medicine: Your Quick Reference Guide
PDR for Herbal Medicines
Herbal Medicinals: A Clinician’s Guide
H erbal Medicines: A Guide for Healthcare Professionals
The American Pharmaceutical Association Practical Guide to Natural Medicines
Rational Phytotherapy: A Physican’s Guide to Herbal Medicine
Many, many journals also available
57. Does Nutrition Matter for Survival?
58. Findings of Special Interest Body Weight, ER status & Risk of Death After Breast Cancer:
1997 Int J Epidemiol: 1169 early stage breast cancer cases
Lower # estrogen receptors assoc w/ hazard ratio of 1.8
Highest BMI vs. lowest BMI (quartiles) assoc w/ a hazard ratio of 2.5!!
Diet & Body Weight & Risk of Death After Breast Cancer:
1998 Breast Cancer Res Treat: 472 early stage breast cancer cases, diet data collected & patients followed
Higher consumption of butter, margarine, lard, beer, red meat, liver, bacon increases likelihood of dying AFTER diagnosis of breast cancer
HIGHER body weight (as measured by BMI) assoc w/ higher risk of death AFTER diagnosis of breast cancer
59. Findings of Special Interest Zinc Supplements For Taste Changes:
1998 Cancer: 20 head and neck cancer cases randomized to 45 mg zinc sulfate, 3 times daily or placebo
Those receiving zinc supplement: less worsening sense of taste when compared to placebo
Those receiving zinc recovered their sense of taste faster after treatment
Saturated Fat & Risk of Death After Prostate Cancer:
1999 Eur Urol: 384 confirmed prostate cancer cases
Diet data collected & patients followed
Higher consumption of saturated fat increases likelihood of dying AFTER diagnosis of prostate cancer
60. Findings of Special Interest Diet & Risk of Death After Stomach Cancer Diagnosis:
2000 Nutr Cancer: 877 confirmed stomach cancer cases
Diet data collected & patients followed
Higher consumption of tofu & raw vegetables decreases likelihood of dying AFTER diagnosis of stomach cancer
Processed Tomato Products & Prostate Cancer:
2001 JNCI: 32 men w/ prostate cancer fed 3/4 cup tomato sauce daily for 3 weeks; serum & prostate lycopene concentrations, PSA, oxidative damage assessed pre- and post-intervention
Post-intervention: serum & prostate lycopene significantly increased; oxidative damage & PSA significantly decreased
61. Findings of Special Interest Fasting Insulin & Breast Cancer Recurrence Risk:
2002 Journal of Clin Onc: 512 women with early stage breast cancer (T1-T3, N0-N1, M0) w/o known diabetes followed prospectively
Highest vs. Lowest quartile had twice the risk of distant recurrence & death
Insulin associated w/ BMI and BMI a known risk factor
AHCC® & Hepatocellular Carcinoma (HCC)
2002 J Hepatol: 222 people with confirmed HCC
By self choice: assigned to surgical resection vs. surgical resection plus AHCC® and followed for a time ranging between 2 months to 10 years
Intervention vs. Normal Care:
34% vs. 66% recurrence
80% vs. 53% survival
62. Findings of Special Interest Avemar® & Colorectal Cancer
2003 Br J Cancer: 176 people, Dukes A-D colorectal cancer diagnosis
By self choice: assigned to regular treatment vs. regular treatment plus Avemar® and followed for 30-34 months
Intervention vs. Normal Care:
3% vs. 17% recurrence
7% vs. 23% new metasases
31% vs. 64% progression
75% vs. 54% survival
Lycopene & Advanced Prostate Cancer
2003 BJU Int: 54 men randomized to orchidectomy or orchidectomy + lycopene and followed for 2+ years
PSA of 78% of supplemented group returned to normal vs. only 40% in orchidectomy alone group
Normal bone scans in 25% of supplemented group vs only 15% of orchidectomy alone group having normal scans
2 years after intervention: 87% of supplemented group alive vs. 78% of orchidectomy alone group
63. Findings of Special Interest Diet, Insulin & Risk of Death After Breast Cancer:
2004 Cancer Epidemiol Biomarkers Prev: 603 women with breast cancer asked about diet & had blood samples collected
Higher level of insulin = worse survival
Higher protein & lower fat = better survival
Higher intake of sweets and sugar = worse survival
Breast Cancer & Health Behavior Changes
2004 Eur J Clin Nutr: 354 Finnish & Australian women diagnosed with breast cancer surveyed about experiences & choices
One-third reported changing diet & exercise habits
Both populations reported high need for diet & lifestyle counseling
Both populations reported this need as unrecognized by physicians
64. Nutrition For Prevention of Recurrence:Fantasy or Reality? Consider the research and there is A LOT of it!!
So many things are not in our control, encourage your clients to take advantage of the things that are!
Nutrition & Diet are powerful tools that one can use in the journey to regain and maintain health after a cancer diagnosis.