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KILDONAN MEDICAL CENTRE

1. Welcome to Seminar on Optimal Nutrition Support to Cancer Patients Meera Kaur, PhD, RD. kaur@cc.umanitoba.ca. KILDONAN MEDICAL CENTRE. 2. Outline of the Session. Motivation for this Study Objectives The concept The food development Clinical outcome Materials and methods

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KILDONAN MEDICAL CENTRE

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  1. 1 Welcome to Seminar onOptimal Nutrition Support to Cancer PatientsMeera Kaur, PhD, RD.kaur@cc.umanitoba.ca KILDONAN MEDICAL CENTRE

  2. 2 Outline of the Session • Motivation for this Study • Objectives • The concept • The food development • Clinical outcome • Materials and methods • Results and discussion • Implications for the healthcare professionals • Summary and conclusion • References • Acknowledgement Meera Kaur, PhD, RD KILDONAN MEDICAL CENTRE

  3. 3 Motivation for this research • Approximately 50 % of hospitalized cancer patients are malnourished. • Effective nutritional support to cancer patients is particularly challenging in developing countries due to the high cost of proprietary enteral formulae. • Hence, the objectives of this study were …. Meera Kaur, PhD, RD KILDONAN MEDICAL CENTRE

  4. 4 Objectives of the study To: • develop natural ingredient-based, low- cost enteral food (LCEF) for cancer patients • determine physicochemical and nutritional properties • evaluate clinical outcome in cancer patients Meera Kaur, PhD, RD KILDONAN MEDICAL CENTRE

  5. 5 The concept • Improving the bioavailability of nutrients in natural ingredients by suitable processing • Modifying the texture of natural ingredients to suit enteral tube or oral feeding • Enhancing with synbiotics and conditionally essential nutrients Meera Kaur, PhD, RD KILDONAN MEDICAL CENTRE

  6. 6 The process for LCEF (patented) Malted Cereals Vegetable/fish oil Malted Mung Bean Mixing Cooking Homogenizing LCEF Spray drying Fortification Toasted Soy Milk + LAB Popped Amaranth Meera Kaur, PhD, RD KILDONAN MEDICAL CENTRE

  7. 7 Nutritional information Form Powder % of cal. Moisture (g%) 2.1 Protein (g%) 22 19-20 Fat (g%)-4 g fish oil 16 30-31 Available Carbohydrate (g%) 56 49-50 Energy (Kcal/100g) 456 Vitamins+minerals (g%) 2.5 Total dietary fiber (g%) 5.0 Soluble dietary fiber (g%) 2.3 Insoluble dietary fiber 2.7 Calcium (mg%) 300 Phosphorous (mg%) 314 LAB (cfu/g) 5.4×106 BCAA (g/100g of protein) 13.31(2.9g/100g food) L-Glutamine (g%) 4.0 Meera Kaur, PhD, RD KILDONAN MEDICAL CENTRE

  8. 8 Clinical Outcome inCancer Patients Meera Kaur, PhD, RD KILDONAN MEDICAL CENTRE

  9. 9 Materials and Methods Meera Kaur, PhD, RD KILDONAN MEDICAL CENTRE

  10. 10 Patients’ characteristics... Characteristics Experimental Control (n=32) (n=31) Gender ratio (M/F) 19/13 17/14 Age (years)* 51.8±7.4 53.7±7.7 BMI (kg/m2)* 17.6±3.4 17.4±4.6 Usual wt (kg)* 66.1±2.4 65.8±3.7 Wt. loss at admission(%)* 7.1±3.6 7.3±1.8 Performance Status (Zubrod) 2.1±0.62.1±0.7 *Values are mean±SD Meera Kaur, PhD, RD KILDONAN MEDICAL CENTRE

  11. 11 Type of Cancer: Treatment Received: Exclusion Criteria: Inoperable Carcinoma Esophagus (Stage III or IV with no prior treatment) Radiation and/or Chemotherapy Pediatric patients, pregnant and nursing mothers Patients’ characteristics Meera Kaur, PhD, RD KILDONAN MEDICAL CENTRE

  12. 12 Nutritional Support • Feeding mode: BolusTube feeding • Energy requirement: Herris-Benedict Equation • Protein requirement: 1.5-2.0g /Kg/day • Initiation of feeding: Within 24 of admission • Feeding duration: Till Discharge (45-60 days) • Additional nutrients L-glutamine, Fish oil, in experimental diet: Lactic acid bacteria (LAB) • Control diet: Isocaloric, Isonitrogenous proprietary enteral formula , Meera Kaur, PhD, RD KILDONAN MEDICAL CENTRE

  13. Tolerance Calorie intake Anthropometric indices Biochemical indices Liver function tests Infectious episodes Test for lactose intolerance Length of hospital stay 13 Outcome measures Meera Kaur, PhD, RD KILDONAN MEDICAL CENTRE

  14. 14 Results Meera Kaur, PhD, RD KILDONAN MEDICAL CENTRE

  15. 15 Energy Estimated and Intake Meera Kaur, PhD, RD KILDONAN MEDICAL CENTRE

  16. 16 Changes in body weight Meera Kaur, PhD, RD KILDONAN MEDICAL CENTRE

  17. Parameters Control Experimental C Vs E I T I T p < TSF (mm) 8.311.4 7.861.0 10.51.1 10.32.01 0.05 MAC( cm) 20.01.2 19.81.3 20.31.9 19.91.3NS MAMC (cm) 19.761.9 19.362.0 21.11.21 21.11.090.05 I=At the initiation of study; T=At the termination of study; NS=not significant Values are mean ±SD 17 Anthropometrical indices of patients Meera Kaur, PhD, RD KILDONAN MEDICAL CENTRE

  18. Parameters Control Experimental C Vs E I T I T P < T. Protein (g%) 6.91.3 6.40.7 7.11.1 7.50.6 0.05 Albumin (g%) 4.1±0.3 3.1±0.6 3.80.4 4.70.5 0.05 Globulin (g%) 3.40.8 3.70.93.81.4 2.80.4 0.05 A/G 1.30.5 0.870.13 1.00.3 1.60.2 0.05 Alkaline 11.57.7 11.03.2 12.813.5 5.83.6 0.05 Phosphatase (Unit %) SGPT (unit/ml) 208129.9 100.313.2 198.3135.7 44.711.10.05 I=At the initiation of study; T=At the termination of study; Values are mean ±SD 18 Biochemical Indices of Patients Meera Kaur, PhD, RD KILDONAN MEDICAL CENTRE

  19. Commonly isolated organisms Staphylococcus Coagulase negative Staphylococcus aureas Streptococcus pneumoniae Stenotrophomonas maltophilia Number of infectious episodes Control: 5.3±2.3 Experimental: 3.2±0.8 C Vs E: p<0.05 19 Infectious episodes Meera Kaur, PhD, RD KILDONAN MEDICAL CENTRE

  20. 20 Other parameters • Tolerance of the feed: Well tolerated • Presence of lactose in stool: Nil • Length of hospital stay (days): Experimental (E): 52.4±1.4 Control(C): 63.3±0.78 C Vs E: p<0.05 • Cost of nutrition support/day: Experimental (E): $3-5 Control(C): $10-15 C Vs E: p<0.05 Meera Kaur, PhD, RD KILDONAN MEDICAL CENTRE

  21. 21 Discussion Meera Kaur, PhD, RD KILDONAN MEDICAL CENTRE

  22. 22 Discussion… Use of Glutamine in cancer patients: Evidence of positive outcome Oguz et al. (2007): colorectal cancer postoperative complication&hospital stay Ziegler (2001): cancer, BMT  N2,infection, mucositis , hospital stay Shewchuk et al. (1997): Morris Hepatoma 7777 tumor-directed natural killercytotoxic activity or faster response to an immune challenge. Meera Kaur, PhD, RD KILDONAN MEDICAL CENTRE

  23. 23 Discussion… Use of fish oil in cancer patients: Evidence of significant positive outcome Christopher & Wigmore (2005): cancer wt. Gain, prevent cachexia Barber (2001): pancreatic cancer  lean tissue,reverse cachexia Barber et al. (1999): pancreatic cancer acute-phase protein response (APPR) and wasting Meera Kaur, PhD, RD KILDONAN MEDICAL CENTRE

  24. 24 Discussion… Use of Branched-Chain Amino Acids (BCAA) in cancer patients: Evidence of significant positive outcome Choudry et al. (2006): advanced cancer improves skeletal protein & quality of life Okada (1988): gastric cancer (173 patients) improves metabolism and maintain good nitrogen retention Meera Kaur, PhD, RD KILDONAN MEDICAL CENTRE

  25. 25 Discussion… Use of Lactic Acid Bacteria (LAB) in cancerpatients: Evidence of significant positive outcome Rafter (2002): cancer enhances the host's immune response, produces antimutagenic compounds Hirayama & Rafter (2004): cancer improves immune system Meera Kaur, PhD, RD KILDONAN MEDICAL CENTRE

  26. 26 Discussion Use of synbiotics (LAB+plant fibre): Evidence of significant positive outcome Bengmark (2006): Pancreatitis, trauma immunoparalysis Bengmark (2005): Critically ill  pathogens (c. diff) Bengmark (2005): Clinical Medicine reinforce immune system Rayes et al. (2005): Liver transplant bacterial infection rate Bengmark (2003) : Critically ill research limited, but great hope for future; confirmed for LAB Olah et al. (2002 ): Acute pancreatitis pancreatic sepsis,  no.of surgical interventions Meera Kaur, PhD, RD KILDONAN MEDICAL CENTRE

  27. 27 Implications for the Practitioners • Dietary intervention for the restoration of general health and nutritional status • Dietary management of drug-related complications • Foods rich in natural stimulants and protectants may be considered for the management of GI functions and over all health • Whenever possible and applicable, foods rich in synbiotics may be included in the diet of patients to improve liver function and promote gut health • Team approach and adjunctive therapy help provide optimal nutrition support Meera Kaur, PhD, RD KILDONAN MEDICAL CENTRE

  28. 28 Summary • Approximately 50% of hospitalized cancer patients are malnourished. Nutrition support to cancer patients in developing countries is particularly challenging because of the high cost of proprietary formulae. • Optimal nutritional support to cancer patients is important for effective medical treatment and overall clinical outcome. • Research findings indicate that glutamine, fish oil, BCAA and LAB are anabolic and immunomodulatory nutrients in the nutritional support for cancer patients. • In this study, a low-cost natural ingredient-based enteral food containing glutamine, fish oil, BCAA and LAB shows better clinical outcome in cancer patients than a proprietary defined-ingredient-based enteral food. Also, it is cost-effective. • Further research is necessary to establish the role of specific nutrients for optimal nutritional support in cancer patients. Meera Kaur, PhD, RD KILDONAN MEDICAL CENTRE

  29. 29 Conclusion • This study reveals the clinical efficacy of the LCEF in cancer patients. • LCEF is cost-effective and provides optimal nutritional support to the cancer patients. • Development of the low-cost enteral foods contributes to patient care, particularly in developing countries where poverty is prevalent. Meera Kaur, PhD, RD KILDONAN MEDICAL CENTRE

  30. 30 References Oguz M., Kerem M., Bedirli A., Mentes, B B., Sakrak O., Salman B., H. Bostanci. (2007),” L-Alanin L-glutamine supplementation improves the outcome after colorectal surgery for cancer”, Colorectal Disease. 9 (6): 515 - 520. Bengmark, S. (2006), “Aggressive management of surgical emergencies,”Ann Roy Coll Sur of Engl 88(7): 624-629. Choudry, HA., Pan, M., Karinch, AM., Souba WW. (2006), “Branched-Chain Amino Acid-enriched nutritional support in surgical and cancer patients”, J Nutr: 136: 314S-318S. Bengmark, S.(2005), “Synbiotics and the mucosal barrier in critically ill patients”, Curr opi gastro 21(6): 712-716. Bengmark, S. and Martindale R. (2005), “Prebiotics and synbiotics in clinical medicine”, Nutr Cli Prac 20(2): 244-261. Christopher, D., Stephen, WJ. (2005), “Systemic inflammation, cachexia and prognosis in patients with cancer. Anabolic and catabolic signals”, Cur Opi Clin Nutr & Met Care.8(3): 265-269. Meera Kaur, PhD, RD KILDONAN MEDICAL CENTRE

  31. 31 References Rayes N., Seehofer D. and Theruvath T. (2005), “Supply of pre- and probiotics reduces bacterial infection rates after liver transplantation - A randomized, double-blind trial”, Am J Trans 5(1): 125-130. Hirayama, K., Rafter, J.(2004), “The role of lactic acidbacteria in colon cancer prevention: mechanistic considerations”, Antonie van Leeuwenhoek (November): 391-394. Olah A., Belagyi T., Issekutz A., Gamal M E. and Bengmark S. (2002), “Randomized clinical trial of specific lactobacillus and fibre supplement to early enteral nutrition in patients with acute pancreatitis”,The Brit J Sur 89(9): 1103-1107 Rafter, J. (2002), “Lactic acid bacteria and cancer: mechanistic perspective”, Brit J Nutr: 88 (Supplement, September): 89-94 Barber, MD. (2001), “Cancer cachexia and its treatment with fish-oil-enriched nutritional supplementation”, Nutr: (September): 751-755 Meera Kaur, PhD, RD KILDONAN MEDICAL CENTRE

  32. 32 References Ziegler, T R. (2001), “Glutamine supplementation in cancer patients receiving bone marrow transplantation and high dose chemotherapy”, J Nutr: 131: 2578S-2584S. Barber, MD., Ross, JA., PrestonT., Shenkin A., Fearon KCH.(1999), “Fish oil–enriched nutritional supplement attenuates progression of the acute-phase response in weight-losing patients with advanced pancreatic cancer” J Nutr: 12(4): 1120-1125. Shewchuk, LD ., Baracos, VE., Field, CJ. (1997), “Dietary l-glutamine supplementation reduces the growth of the morris hepatoma 7777 in exercise-trained and sedentary rats”, J Nutr: 127(1): 158-166. Okada, A., Mori, S., Totsuka, M., Okamoto, K., Usui, S., Fujita, H., Itakura, T. and Mizote. H. (1988), “Branched-chain amino acids metabolic support in surgical patients: a randomized, controlled trial in patients with subtotal or total gastrectomy in 16 Japanese institutions” JPEN 12(4): 332-337. Meera Kaur, PhD, RD KILDONAN MEDICAL CENTRE

  33. 33 Acknowledgement I gratefully acknowledge: • The financial support provided by the Council of Scientific and Industrial Research (CSIR), Government of India, New Delhi, India. • Dr. A. Anantha , MD, DMRE and S. Taramani, RD, Kidwai Memorial Institute of Oncology, Bangalore, India, for their support while conducting the clinical trial. Meera Kaur, PhD, RD KILDONAN MEDICAL CENTRE

  34. 34 Thank you for gracing the session!Any question? Meera Kaur, PhD, RD KILDONAN MEDICAL CENTRE

  35. Natural Vs Defined ingredient-based formula Natural ingredient-based Defined- ingredient-based Carb: cereals and millets glucose,fructose, maltodextrin,etc. Protein: milk, legumes, etc.peptides, amino acids, etc. Fat: edible oilsfatty acids, MCT, triglycerides, etc. Fibre: naturally present externally added Flavor: need not to add must be added to mask off flavor of defined sources Color: need not to add added to enhance acceptability Osmolality: desirable range usually high Efficacy: more physiological less physiological Cost: less expensive more expensive Meera Kaur, PhD, RD KILDONAN MEDICAL CENTRE

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