The Truth about Cancer Patients and Nutrition: I Can Cope Program

1. The Truth about Cancer Patientsand Nutrition:I Can Cope Program

2. PREVENTION: • 30% to 40% of all cancers may be prevented by changes in diet and physical activity

3. Role of Weight: • Yo-yo dieting has been shown to decrease immunity and may increase susceptibility to cancer • Being overweight increases the chance of getting several types of cancers, including breast and prostate

4. Maintain a Healthy Weight and be Physically Active • A body mass index (BMI) of 18.5 – 25 is recommended • Healthy weight results from a balance of calories (energy) in and energy expended.

5. ACS Guidelines: Choose a diet rich in plant-based foods. • Using the “plate method” think of ¾ of your dinner plate contents as being of plant origin and ¼ animal or other protein source, especially limiting red meats.

6. Eat Plenty of Vegetables, Fruits, Grains and Legumes • Eat 5 - 9 servings daily • Eat a variety of fruits and veggies; choose 100% juices. • Include dark green and orange vegetables, as well as dry beans and peas each week. • Enjoy whole grains, beans and peas with each meal

7. Limit High Fat Foods from Animal Sources • Choose fish, poultry, or beans as an alternative to beef, pork, and lamb • When you eat meat, select lean cuts and smaller portions

8. Prepare and Store Foods Safely • Use safe storage methods and promptly chill or freeze leftovers. • Avoid burning of meat juices. • Consume only occasionally meat and fish grilled in direct flame, and cured or smoked meats.

9. Alcohol and Cancer Risk • Increases risk of: • Mouth and esophageal cancers • Pharynx and larynx cancers • Liver cancer • Breast cancer in women • Combined use of alcohol and tobacco greatly increases risk compared to drinking or smoking alone **Drink alcohol in moderation, if at all.**

10. What about Sugar? • You CAN eat sugar: sugar does not “feed” cancer cells BUT • Stick with mostly naturally occurring sugars such as in fruit and dairy foods • Avoid foods and beverages high in processed sugars but low in other nutrients e.g.: soda and sweets • Choose whole grains over refined versions

11. Cancer Treatment Side-effects: • Appetite changes • Weight loss→ muscle loss, weakness, decreased immune strength • Nausea and vomiting • Diarrhea or constipation • Dry mouth and mouth sores • Difficulty swallowing

12. Nutrition Education: • Studies show cancer patients who receive nutrition counseling lose less weight, experience fewer side-effects and have overall better Quality-of-Life during treatment than those who do not.

13. What about supplements? • High-calorie drinks and bars • Canned or powdered types • Homemade creations • Specialized formulas • Vitamins and Minerals • Herbs and other dietary supplements

14. Nutrition and HIV

16. Lancet 2003; 362: 1234-37

17. ‘A new variant famine’? • Secondary effects of the AIDS epidemic on food security, famine and nutrition could be as great as the primary effects • Present southern Africa drought and food crisis compounds AIDS epidemic • Historical coping strategies are in danger of collapsing. • Present food crisis more intractable • High degree of vulnerability in areas not affected by drought • Household impoverishment has occurred more rapidly • Despite early rains in early 2003, high levels of vulnerability persist

18. Nutrition and HIVSub-Saharan Africa vs. Europe / N. America • At risk populations for HIV/AIDS also at high risk of food insufficiency • Poor quality of food as well as limited quantity – limited choices • Higher burden of infectious diseases and therefore need for effective antioxidant systems • Chronic malnutrition in the general population introduces complex issues of equity and distribution

19. Adults and children with HIV infection have increased energy needs from the time they first become infected – these need to be met in ways that are appropriate and adequate • Monitoring weight is a very useful way of following disease progression in an individual • HIV infected adults and children are susceptible to misinformation and commercial exploitation – know your facts

20. Total energy expenditure TEE Activity-related Energy Expenditure – (AEE) AEE Appetite and Food intake ILLNESS … Resting Energy Expenditure (αBMR) REE HIV-associated wasting

21. Growth in HIV-infected children: sub-Saharan Africa experience • Growth is severely affected in HIV-infected children • Growth faltering is common and occurs early in life. • Indus. countries >50% by 5yr vs. SSA 50% by 1 yr • Decreases in length- and wt- for-age observed by 3 mos of age (Bobat 1998, Bobat 2001) • While both wt and length are severely affected, a disproportionate effect on wt (wasting) is reported in some cohorts by age 1 year

22. Growth faltering has marked effect on survival • Poor growth strongly andindependently associated with poor survival in US, European, African, and HIV+ haemophilia populations. • In US children on antiretrovirals, poor growth is an independent risk factor for death (McKinney1994, Benjamin 2003, Carey 1998). • Ugandan infants with low wt. had a 5-fold increase in risk of death by age 25 mos. (Berhane 1997).

23. BMI <16 ≥ 22 Median Survival time 0.8 yrs 8.9 yrs Body Mass Index at time of HIV Diagnosis BMI <18 is a significant independent predictor of mortality and is comparable to CD4count. J Acquir Immune Defic Syndr, 37(2) 2004

24. Body compositionabnormalitiesHIV-infected children • HIV-infected children have disproportionate decreases of lean body mass with preservation of body fat (Miller 1993, Arpadi 1998). • Reduced lean body mass is detectable prior to decelerations in linear growth.

25. Diarrhoea has marked impact on growth • Diarrhoea reported 90% of HIV-infected children • Chronic diarrhoea 6 times more likely to develop in HIV-infected vs. uninfected children (Keusch 1992). • Persistent diarrhoea associated with 11-fold increased risk of death (Thea 1990). • The mean growth for HIV-infected infants with >1 episodes of diarrhoea / yr was 1.4 cm/yr less than infants with <1 episode (Villamor 2004).

26. Growth velocity is inversely related to viral load 12-month growth velocity(cm/yr) vs HIV viral load (HIV RNA copies/ml) performed in HIV-infected children (n=42) • Growth velocity and FFM are inversely related to level of viral replication • Viral replication remains a negative determinant of growth rate even after adjusting for food intake. Arpadi 2000

27. Potentially modifiable factors involved in HIV-associated growth abnormalities • Dietary deficiencies • prevention and treatment • Diarrhoeal illnesses • prevention, detection, and nutritional management • HIV replication and immune suppression • use of anti-retroviral medications

28. Growth, body composition and dietary intake? • In contrast to simple malnutrition, pre-HAART studies found enteral supplements improved wt and fat stores but not ht or lean body mass(Miller 1995, Henderson 1994).

29. Viral suppression improves growth and body composition abnormalities • Large studies detect improvements in growth (wt>ht) attributable to protease inhibitor use(Buchacz 2001, European Collaborative 2003) • Improvements in gut absorption reported(Canani 1999) • Dietary intake is stable with ART(Miller 2001).

30. WHO Technical Review Growth abnormalities in HIV-infected children • HIV impairs the growth of children early in life, especially height growth. Often occurs before the onset of OIs /other symptoms. Growth failure associated with increased risk of death. • The exact mechanisms of wasting are complex but insufficient food intake and diarrhoea are major causes of poor growth, especially in resource-poor countries • Cotrimoxazole improves growth and survival • ART, when clinically indicated, improves weight, growth and development of infected children

31. WHO Technical Review Energy and protein needs • Energy needs increase by about 10% in adults and children from the time of infection • During and after severe illnesses, these needs might increase by a further 20-30%. In children this may be up to 150%. • No evidence for increased protein requirements other than in a balanced diet i.e. 12-15% of the total energy intake • Anorexia and poor dietary intake are important causes of weight loss • Improving the diet alone, though, may not result in weight recovery and improvement in clinical status

32.  viral load Oxidative stress Micronutrient deficiencies HIV+++ HIV+ Infections NAIDS  CD4 Micronutrients and HIV infection Henrik Friis

33. Does micronutrient status / intake affect HIV infection? • Increased micronutrient status / intake mayaffect • Transmission of HIV infection • mother-to-child transmissions • sexual transmission • Infectiousness and susceptibility • Progression of HIV infection • HIV load, CD4 counts, AIDS, death • Morbidity from other infections • Drug acceptability, efficiency, safety

34. Multiple micronutrients and HIV infectionIntervention trial • Randomised trial in Thailand (Jiamton S, 2003) • 481 HIV+ adults • Multimicronutrient or placebo for 48 wks • minerals: zinc 30 mg, iron 10 mg, selenium 0.4 mg, copper 3 mg, iodine 0.3 mg, chromium 0.15 mg, manganese 8 mg, magnesium 80 mg • vitamins A, B-complex, C, D, E, K • Mortality reduced • RR 0.53 (95% CI: 0.22, 1.25) • RR 0.26 (95% CI: 0.07, 0.97) among those with CD4<100 • No effects on HIV load and CD4 counts

35. NEJM 2004;351:23-32

36. x12-15 x20 vs. RNI(daily intake which meets nutrient requirement for 97.5% apparently healthy individuals in an age and sex-specific population)

37. 299 progressed to WHO stage 4 or died of ‘AIDS-related causes’ • 67 of 271 (24.7%) MVS • 70 of 268 (26.1%) MVS + Vit A • 79 of 272 (29.0%) Vit A only • 83 of 267 (31.1%) placebo • MVS vs. placebo • RR 0.71 [95%CI 0.51-0.98; P=0.04] • + reduced progression to stages 3 or 4 • MVS group cf. placebo - higher CD4 and CD8 counts and reduced VL • Adding Vit A reduced the benefit

38. ? Generalisability for policy • Single study, urban • 100 deaths excluded • Possible misclassifications • Why not an intention to treat analysis? • Background maternal mortality 700/100,000! • Mixed staging criteria • Unusual composition based on ‘beneficial effects’ reported in observational studies. ?Nutriceutical effect • No HIV uninfected comparison – mortality and pregnancy outcomes may be true for all women with borderline micronutrient deficiency • Are data true for HIV-infected men as well – do repeat study in men

39. “Neither zinc nor MMN had significant effects on culture conversion, but MMN supplementation increased weight gain in TB patients” (independent from culture conversion rates)

40. WHO Technical Review Micronutrients requirements • HIV-infected adults and children frequently have low levels of micronutrients i.e. low body status • Micronutrient intakes at RDA need to be assured in HIV-infected adults and children through consumption of diversified diets, fortified foods and micronutrient supplements as needed • WHO recommendations on vitamin A, zinc, iron, folate and multiple micronutrients remain the same • Vitamin A supplements reduce diarrhoeal morbidity and mortality especially in young children

41. WHO Technical Review Micronutrients and HIV -ctd • Micronutrients are not an alternative to comprehensive HIV treatment including ARV therapy • Studies have shown that some micronutrient supplements may prevent HIV disease progression and adverse pregnancy outcomes. Additional research is urgently required

42. ‘Either… or…’ • ‘Idealogical’ - optimising nutrition does not eradicate HIV • Financial gain • Fear that ARVs may be displaced as the focus for efforts – 3x5 • Nutrition seen as a soft science and the data is not substantial and therefore not worthy

43. WHO Technical Review Nutrition and Antiretroviral therapy • The benefits of ART are fully recognised but to achieve the full benefits adequake dietary intake is needed • Dietary and nutritional assessment is an essential part of comprehensive HIV care both before and during ART • Long term complications can occur with ART but the benefits outweight the potential harm • CVS, diabetes, bone • Little research has been conducted to fully understand the relationship between nutrition and ART e.g. • Pharmacokinetics in the severely malnourished • Potential benefit regarding adherence • Interactions with herbal treatments and other therapies • Impact of nutritional status on the development of longer term ARV related complications such as lipodystrophy and bone problems

44. Adults and children with HIV infection have increased energy needs from the time they first become infected – these need to be met in ways that are appropriate and adequate • Monitoring weight is a very useful way of following disease progression in an individual • HIV infected adults and children are susceptible to misinformation and commercial exploitation – know your facts

45. Nutritional assessment • Food and Nutrition History • 24h dietary recall inclusive of determination of food access • Anthropometric measurement • Yearly height, weight, BMI, WHR*, consider MUAC and skinfolds • Biochemical Assessment • Yearly fasting lipids, glucose and with change in ARV, yearly hemoglobin; consider OGT in patients with IGT • Nutrition focused medical history and exam • Obtain weight and growth history at each visit