Cancer Nutrition Therapy PDF

Neoplastic Disease: Cancer Chapter 23 Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. ...

Neoplastic Disease: Cancer Chapter 23 Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Cancer Cancer not a single disorder Many types over 100 different disease types Different characteristics Occur in different body locations Take different courses Require different treatments Definition Disorder of cell growth and regulation Abnormal cells divide without control and are able to invade other tissues Epidemiology Second leading cause of mortality in the United States (first CVD) Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Cancer In Jordan-2018 Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May 3 not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Phases of Carcinogenesis A carcinogen is a physical, chemical, or viral agent that induces cancer. ▪ Carcinogenesis is a biologic, multistage process that proceeds on a continuum in three distinct phases: ▪ Initiation ▪ Promotion ▪ Tumor progression, including metastasis Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May 4 not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May 5 not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Phases of Carcinogenesis: Initiation Transformation of cells produced by the interaction of chemicals, radiation, or viruses with cellular deoxyribonucleic acid (DNA). Occurs rapidly, but cells can remain dormant for a variable period until they are activated by a promoting agent. Transformation from normal cells to a detectable cancer can take many years or even decades. Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May 6 not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Phases of Carcinogenesis: Promotion Initiated cells multiply and escape the mechanisms set in place to protect the body from the growth and spread of such cells. A neoplasm, new and abnormal tissue with no useful function, is established. Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May 7 not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Phases of Carcinogenesis: Progression Tumor cells aggregate and grow into a fully malignant neoplasm or a tumor. In the process known as metastasis, the neoplasm has the capacity for invasion that can spread to distant tissues and organs. For a cancer to metastasize, it must develop its own blood supply to sustain its growth of rapidly dividing abnormal cells. In normal cells, angiogenesis promotes the formation of new blood vessels, which are essential to supply the body’s tissues with oxygen and nutrients. In cancer cells, tumor angiogenesis occurs when tumors release substances that aid in the development of new blood vessels needed for their growth and metastasis. Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May 8 not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Signs and Symptoms of Cancer Unexplained weight loss An unexplained weight loss of 10 pounds or more may be the first sign of cancer Fever Fever is very common with cancer, but it more often happens after cancer has spread from where it started Fatigue May happen early in some cancers, like leukemia Some colon or stomach cancers can cause blood loss that’s not obvious Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Signs and Symptoms of Cancer Continued Pain Most often, pain due to cancer means it has already spread (metastasized) from where it started Skin changes Darker-looking skin (hyperpigmentation) Yellowish skin and eyes (Jaundice) Reddened skin (erythema) Itching (pruritis) Excessive hair growth Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Etiology of Cancer Multifactorial Genetic, environmental, and/or lifestyle factors result in genetic and epigenetic changes and unrestrained proliferation of cells. Risk factors include growing older; tobacco use; exposure to sunlight, ionizing radiation, certain chemicals and other substances (carcinogens), some viruses and bacteria, and certain hormones; family history of cancer; alcohol consumption; poor diet; lack of physical activity; and being overweight. Carcinogens Chemicals, physical agents (UV radiation), viral agents (human- papilloma virus) and bacterial agents (Helicobacter pylori). Major categories of genes that influence cancer Oncogenes Altered genes that promote tumor growth and change programmed cell death (apoptosis) Tumor-suppressor genes Cause apoptosis (cell death), but may lose function if mutated. Deactivated in cancer cells Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Etiology of Cancer: Carcinogenesis Epigenetics Study of changes in gene activity that are not caused by changes in DNA sequence Chromatin The complex of DNA and proteins—primarily histones—in the nucleus of a cell (see Figure 23.3). One function of chromatin is to control gene expression and DNA replication. Changes in gene expression can result from alterations in chromatin structure by methylation of cytosine residues in dinucleotides and modification of histones by acetylation or methylation. Hypermethylation of promoter regions is a common mechanism by which tumor-suppressor loci are epigenetically silenced in cancer cells. When tumor-suppressor genes are not properly expressed, control of the cell cycle is lost. Because nutrients involved in methylation such as folic acid can alter gene expression at the transcriptional level, epigenetics has great importance within the field of nutrition. Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Figure 23.3: D N A and Chromatin Structure Source: Modification of: Figure 10.15 from p. 217 of ISBN 9781133587552, Russell/Hertz, Biology: The Dynamic Science 3e (Cengage book). Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Etiology of Cancer: Cancer and Nutrition Nutritional genomics (nutrigenomics) Study of genetic variations that cause different phenotypic responses to diet Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Etiology of Cancer: Nutritional Risk Factors Heavy consumption of red meat (including meat that has been processed, increases cancer risk, especially for colorectal, bladder, prostate, breast, gastric, oral, and pancreatic cancers) In general, tumor development is suppressed by diets that contain levels of protein below that required for optimal growth and development; whereas it is enhanced by protein levels two to three times the amount that is required. (Krauses) Food preparation methods such as smoking, salting, and pickling foods and preservative (Nitrates are added as preservatives to processed meats. Nitrates can be readily reduced to form nitrites, which in turn can interact with dietary substrates such as amines and amides to produce N-nitroso compounds (NOCs): nitrosamines and nitrosamides, which are known mutagens and carcinogens). High-temperature cooking of meats:Charring or cooking meat at high temperatures over an open flame (400° F or more) can cause the formation of polycyclic aromatic hydrocarbons (PAHs) and heterocyclic amines (HCAs). Intakes of total fat/certain types of fat Consumption of alcohol Obesity Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Etiology of Cancer: Nutritional Protective Factors Fruits and vegetables (may reduce risk of cancers of the mouth, pharynx, esophagus, stomach, colon, rectum, larynx, lung, ovary (vegetables only), bladder (fruits only), and kidney) antioxidants (e.g., vitamin C, vitamin A and the carotenoids, vitamin E, selenium, zinc) Whole grains Fiber Vitamin D Coffee and Tea: contain various antioxidant and phenolic compounds Folate and Folic Acid: affects DNA methylation, synthesis, and repair. Soy and Phytoestrogens: Diets containing modest amounts of soyprotect against breast cancer, especially before reaching adulthood apparently because of exposure to the weak estrogenic effects of isoflavones early in life. However, the use of soy remains controversial for women already diagnosed with hormone-sensitive cancers (e.g., breast, endometrium) and for postmenopausal women. Men with hormone-sensitive cancer such as prostate cancer may benefit from regular consumption of soy foods. Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Cancer and Nutrition: Nutritional Preventive Factors Numerous dietary components being studied as potential chemopreventive agents include: Carotenoids Resveratrol Quercetin (a flavonoid) Silymarin (a flavonoid) Catechins (found in green and black tea) Curcurmin Diallyldisulfide (garlic) Thymoquinone (black cumin). Several substances derived from various spices (capsaicin, gingerol, anethole, diogenin, eugenol). Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Pathophysiology Cancers are characterized by: Unregulated cell growth Tissue invasion Metastasis (spread of cancer from the primary site to nearby or distant areas through the blood or lymph) A neoplasm is benign when it grows without tissue invasion; in contrast, a malignant neoplasm will spread from the primary tissue to other body tissues. (neoplasm: literally means “new growth“; an abnormal mass of tissue, the growth of which exceeds and is uncoordinated with that of normal tissue) Specific cancer types have typical routes for metastasis that include the lymphatic system, circulatory system, or nearby body cavities. For example, breast cancer typically metastasizes to brain and lung tissue through both the circulatory and lymphatic systems. Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Other Abnormal Phenotypes Include: Failure to differentiate Loss of apoptosis Genetic instability leading to mutations Increased angiogenesis: (angiogenesis: development of new blood vessels) Evasion of the immune system Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Medical Diagnosis Diagnostic procedures Blood and physical tests Cytologic tests Imaging Biochemical analysis of blood, serum, urine, and other body fluids that can detect tumor biomarkers (see Table 23.3) Provide information about: Tissue type of the tumor, primary site, extent of disease, and tumor’s potential to recur Tumors are classified and assigned a stage using the Tumor Node Metastases (T N M) Staging System Tumor Node Metastases (TNM) Staging System- a systematic way of describing the size, location, and spread of a tumor; T describes the primary tumor according to its size, N applies to the lymph nodes and whether cancer cells have spread to them, and M refers to metastases and whether the cancer has spread to distant sites. Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Names of Selected Cancers Lung Nonsmall cell lung cancer—subtypes include squamous cell carcinoma, adenocarcinoma, and large cell carcinoma Small cell lung cancer (also called oat cell cancer) Lung carcinoid tumor Breast Ductal carcinoma in situ (D C I S) Invasive (or infiltrating) ductal carcinoma Invasive (or infiltrating) lobular carcinoma (I L C) Prostate: Prostate adenocarcinoma Rectum/colon: Adenocarcinomas Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Treatment A patient may undergo one or more of the following treatments depending on the cancer diagnosis: Chemotherapy (including hormonal therapy and molecularly targeted therapy) Radiation Surgery Biologic therapy (including immunotherapy and gene therapy) Dependent on the location of the tumor, size of the tumor, and health of the individual Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Treatment: Focus on Nutritional Concerns Surgery Surgery is used in cancer prevention, diagnosis, staging, treatment (for both localized and metastatic disease), palliation, and rehabilitation. Considered the most effective mode of treatment Removing a metastasized tumor (debulking) may improve quality of life and permit adjuvant therapy to be more effective. ( For example, removing a tumor blocking the esophagus would allow the patient to eat normally.) Palliative (non-curative) surgery is used to ameliorate disease and/or treatment-related symptoms without attempting to cure the cancer. (Surgical removal of a tumor that is causing a spinal cord compression is an example of palliative therapy) Advances in surgery have allowed certain procedures to be performed laparoscopically Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Cancer Diagnoses Requiring Surgery Cancers of the head and neck Esophageal cancer Gastric cancer Intestinal cancers Pancreatic cancers Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Chemotherapy Differs from surgery or radiation in that it affects the whole body Used to eradicate cancer, control size and spread, and/or alleviate symptoms Adjuvant Administered after surgery to remove any cancer cells that were missed Neoadjuvant Administered to shrink the tumor so it can be more easily treated by radiation or surgery Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Chemotherapy Side Effects Chemotherapy affects rapidly dividing cells; hence, the rapidly dividing gastrointestinal cells will be significantly affected by most chemotherapeutic agents. (nausea and other gastrointestinal (GI) problems) Common side effects due to toxicity of rapidly dividing cells Neutropenia (low white blood cell count) Thrombocytopenia (low platelets count) Anemia Diarrhea Mucositis (inflammation of a mucous membrane (e.g., mouth sores)) Alopecia (hair loss). Cardiotoxicity Neurotoxicity Nephrotoxicity Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Radiation As for thyroid carcinomas, localized cancers of the head and neck Alteration in cellular and nuclear material (DNA) from electromagnetic rays (gamma rays and X-rays) and charged particles (electrons) Continuously proliferating cells are most susceptible Toxicity of radiation therapy (RT) is localized to the region that is being irradiated Administered internally or externally, either alone or in combination Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Radiation Side Effects Delayed wound healing Fatigue, mucositis, dysgeusia (is a taste disorder that causes foul, rancid, metallic, or salty taste perception), xerostomia secondary to salivary gland destruction, dysphagia (swell difficulties), odynophagia (painful swallowing), severe esophagitis, and dehydration (head and neck) Radiation enteritis (small intestine inflammation), fistulas, strictures, chronic malabsorption, and severe diarrhea (abdominal and pelvic) Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Biological and Targeted Therapy Biological therapies may be used to treat the cancer itself or the side effects of other cancer treatments. Immunotherapy Focuses on enhancing the immune system to attack cancer cells or by providing specific substances in order to enhance the immune response Cytokines Signaling proteins produced by white blood cells Help to mediate and regulate immune responses, inflammation, and hematopoiesis Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Hematopoietic Stem Cell Transplantation (HSCT) Option for patients with hematalogic and some nonhematologic malignancies Previously referred to as a “bone marrow transplant,” HSCT is a potentially curative treatment for hematologic malignancies, and is used primarily in the treatment of hematologic and lymphoid cancers (chronic and acute leukemia, lymphoma) Three sources of stem cells Donor (allogenic) Genetically identical twin (syngeneic) Self (autologous) Conditioning regimen serves two purposes To provide sufficient immunosuppression to prevent rejection and allow engraftment of donor cells to grow To eradicate malignant cells Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Nutrition Therapy Malnutrition has been estimated to impact 30–70% of cancer patients and contributes to cancer deaths Nutritional implications Primary goals To prevent malnutrition to optimize nutritional status during treatment To create appropriate individualized nutrition interventions during cancer recovery Malnutrition more prevalent in people who have been sick for longer and who have had multiple treatments People with lung, pancreatic, GI, head and neck, or ovarian cancers at particular risk Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Nutrition Assessment and Diagnosis Nutrition assessment Screening tools The Malnutrition Universal Screening Tool (MUST) The Malnutrition Screening Tool (MST) The Patient-Generated Subjective Global Assessment (PG- SGA) Energy and protein requirements are established individually Fluid needs can be calculated using the same formulas used for most other patients without renal disease Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Energy Determining individualized energy needs is vital to helping people maintain an energy balance and achieve a healthy weight. It is vital to preventing unintentional weight gain or loss associated with cancer and cancer treatment. Methods used to estimate energy requirements for adults include using standardized equations or measuring resting metabolic rate using indirect calorimetry. To ensure that adequate energy is being provided, the individual’s diagnosis, presence of other diseases, intent of treatment (e.g., curative, control, or palliation), anticancer therapies (e.g., surgery, chemotherapy, biotherapy, or radiation therapy), presence of fever or infection, and other metabolic complications such as refeeding syndrome must be considered. Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May 37 not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May 38 not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Protein The degree of malnutrition, extent of disease, degree of stress, and ability to metabolize and use protein are factors in determining protein requirements. Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May 39 not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  RDA for adults: 0.8 g/kg Normal maintenance: 0.8 to 1 g/kg Nonstressed cancer patient: 1 to 1.2 g/kg Hypercatabolic cancer patient: 1.2 to 1.6 g/kg Severely stressed cancer patient: 1.5 to 2.5 g/kg Hematopoietic stem cell transplant patient: 1.5 to 2 g/kg Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May 40 not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Fluid Fluid management in cancer care must ensure adequate hydration and electrolyte balance and prevent dehydration and hypovolemia. Altered fluid balance may occur with fever, ascites, edema, fistulas, profuse vomiting or diarrhea, multiple concurrent intravenous (IV) therapies, impaired renal function, or medications such as diuretics. Individuals need close monitoring for dehydration (e.g., intracellular fluid losses caused by inadequate intake of fluid because of mucositis or anorexia), hypovolemia (e.g., extracellular fluid losses from fever or GI fluids such as vomiting, diarrhea, or malabsorption), and nephrotoxic effects from anti- cancer treatments. Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May 41 not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Signs and symptoms of dehydration include fatigue, acute weight loss, hypernatremia, poor skin turgor, dry oral mucosa, dark or strong smelling urine, and decreased urine output. To carefully assess for hypovolemia, levels of serum electrolytes, blood urea nitrogen, and creatinine also should be evaluated. A general guideline for estimating fluid needs for all adults without renal concerns is 20 to 40 ml/kg. Another method to assess fluid needs recommends 1 ml fluid per 1 kcal of estimated calorie needs. Intravenous hydration (IV) may be recommended for individuals struggling to achieve adequate hydration, but infusion frequency and volume must be determined on an individual basis, considering fluid intake and output. Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May 42 not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Vitamins and Minerals If individuals are experiencing difficulty with eating and treatment-related side effects, a standard multivitamin and mineral supplement that provides no more than 100% of the dietary reference intakes (DRIs) is considered safe. According to the recommendations from leading national scientific groups, whether for primary or secondary prevention, individuals should attempt to meet vitamin and mineral needs though the foods they eat rather than use dietary supplements. Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May 43 not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  In some instances during and after a cancer diagnosis, supplementation or restriction of specific micronutrients may be required above or below DRI levels, depending on the medical diagnosis and laboratory analysis (e.g., iron supplementation for iron-deficiency anemia, B12 injections, and folic acid supplementation during treatment with the chemotherapy) Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May 44 not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Nutritional Diagnosis Varies widely with the type of cancer, tumor burden, and treatment modality Possible diagnoses include involuntary weight loss; increased energy and protein needs; inadequate oral intake; malnutrition; inadequate fluid intake; altered GI function; swallowing and/or biting/chewing difficulty; unintended weight loss; impaired ability to prepare foods/meals; unsupported beliefs/attitudes about food- and nutrition-related topics; and intake of unsafe food (primarily for patients with impaired immunity). Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Nutrition Intervention Intervention goals should be specific, achievable, and individualized to encourage cooperation. Goals must be directed toward an objective measure such as body weight or some other meaningful index. Another goal is to minimize the effects of “nutrition impact symptoms” and to maximize the individual’s nutritional parameters. Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Nutrition impact symptoms can be defined as symptoms and side effects of cancer and cancer treatment that directly affect the nutrition status. Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Interventions for Common Side Effects of Cancer and Treatment Nausea and vomiting Early satiety Mucositis Diarrhea Dysgeusia Xerostomia Anorexia & poor appetite Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Anorexia, poor appetite Encourage small, more frequent nutrient dense meals and snacks. Recommend adding protein and calories to favorite foods. Recommend use of protein and calorie-containing supplements (e.g., whey or soy powder, nutritional supplements). Keep nutrient dense foods close at hand and snack frequently. Advise capitalizing on times when feeling best. Recommend eating meals and snacks in a pleasant atmosphere. Suggest viewing eating as part of treatment. Encourage activities of daily living and physical activity as able. Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Nausea and vomiting antiemetics to control nausea and vomiting (30–45 minutes before a meal is consumed) Recommended nutrition therapy : Small, low-fat meal, avoid fried, greasy foods. A clear liquid diet for the first 24 hours after therapy may be indicated. To provide energy and maintain hydration, consumption of electrolyte-fortified beverages and non-acidic fruit drinks (apple and grape juice, nectars) should be encouraged. It is important for patients to avoid favorite foods at any time the chance for emesis is high, since once a favorite food has been vomited, the likelihood of its subsequent consumption is low. Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  The same principle applies to the use of “creamy” liquid nutritional drinks. A patient who has vomited a nutritional beverage will associate vomiting with that beverage, even if told that their vomiting was probably caused by their treatment. Prokinetics may also be prescribed to minimize vomiting. Non-pharmacologic alternative methods that have been used with varying success to prevent or treat nausea and vomiting include CAM therapies such as acupressure, acupuncture, hypnosis, and guided imagery Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Early Satiety Eat small, frequent meals that are nutrient dense. Beverages should also contain nutrients and should be consumed between meals rather than with meals so as not to add to the feeling of fullness. Consumption of raw vegetables, such as salads, and other high-fiber foods should be avoided. Prokinetics, medications that increase gastric emptying, may be useful. Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Mucositis Mucositis (stomatitis) is irritation and inflammation of the epithelial cells of the mucosal membranes lining the gastrointestinal tract (from the mouth to the anus.) Symptoms will include pain and burning with chewing and swallowing. Narcotic analgesics may be required for pain. Topical therapies. Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  The patient should be encouraged to eat only soft, non-fibrous, non-acidic foods. Hot foods should be avoided as they can burn the mucosa. Liquids should be encouraged to prevent dehydration; non-acidic juices such as nectars may be helpful. High-kcalorie, high-protein milkshakes or nutritional supplements may be beneficial at this time. Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Diarrhea Drink small amounts of fluid frequently throughout the day. Large amounts of fruit juices should be avoided as excessive fructose. Clear liquid nutritional beverages and other oral rehydration fluids are recommended. Intake of foods high in soluble fiber may help Antidiarrheal medications Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Dysgeusia alterations in taste Metallic taste : avoid metal utensils and instead use plastic utensils. If nutritional supplements are consumed, they should be poured into a glass first, as often the metal container is also offensive. Meats are often not tolerated, incorporate other high-protein foods including peanut butter, cottage cheese, cheese, poultry, and soy meat substitutes into the diet. Patients should be encouraged to use more highly spiced and flavorful foods, such as marinated foods. Sweet foods often taste too sweet to individuals undergoing cancer therapy. Many homemade drinks and nutritional beverages may be too sweet for these patients. An alternative may be to have the patient add a non-sweet glucose supplement Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Xerostomia reduced saliva production Treatment : use of artificial saliva (saliva substitutes) and/or mouth moisturizers. Mouth-moisturizing lubricants come in the form of gels, lozenges, and mouthwashes. Sugar-free gum and sour-flavored sugar-free hard candies may help increase the flow of saliva in the mouth Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Anorexia Nutrition Therapy for the Treatment of Anorexia Eat smaller, more frequent meals Maximize your intake when appetite is most normal Limit fluid with meals to avoid feeling of fullness Keep favorite foods readily available at all times Mild exercise, as tolerated (check with physician) Eat meals in a pleasant environment Avoid noxious odors; ventilate eating area Find a liquid nutritional supplement that is appealing and drink only 2–4 o z at a time (to avoid a feeling of fullness); keep unopened beverage in the refrigerator Try relaxation exercises before mealtimes Consider pharmacologic agents/appetite stimulants Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Cancer Cachexia Cancer cachexia : progressive weight loss, anorexia, generalized wasting and weakness, immunosuppression, altered basal metabolic rate, and abnormalities in fluid and energy metabolism. There is also increased loss of adipose tissue, which is related to an increased rate of lipolysis, rather than a decrease in lipogenesis. Increased levels of lipid-mobilizing factor and proteolysis- inducing factor secreted by tumor cells will lead to increased loss of fat and muscle mass. Cancer cachexia is caused in part by cytokines (immune-modulating agents), produced by the cancer itself or by the immune system in response to the cancer Resting energy expenditure (REE) is elevated, which is in contrast to the REE in chronic starvation, wherein the body adapts to conserve energy and preserve body tissue. Leads to progressive functional impairment and increase closer to the time of death. Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Managing Cancer Cachexia: Pharmacotherapy Cannot be fully reversed by conventional nutrition support Anorexia, a common cancer-related condition, is amenable to treatment with nutrition counseling, diet modification, and pharmacotherapy. A number of pharmacologic agents are currently under investigation for their impact on anorexia, including antihistamines (Periactin), corticosteroids (Decadron, Solu-medrol), progestational agents (Provera, Megace), prokinetic agents (Reglan), and antidepressants (Remeron) Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Interventions during Chemotherapy and Radiation Treatment Medical nutrition therapy (MNT) will be individualized postoperatively to support any changes in ability to consume, digest, or absorb nutrients Specialized nutrition support is recommended for patients actively receiving anticancer treatment who meet the current guidelines for initiation of nutrition Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Interventions Before and After Surgery Parenteral nutrition should be considered for: Individuals undergoing medical treatment for their cancer Individuals at nutritional risk and who do not have a functioning G I tract Individuals who are unable to meet their nutritional need adequately through enteral nutrition Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Interventions for Hematopoietic Cell Transplantation Immunosuppression may prevent the consideration of a central line for parenteral nutrition ASPEN recommendations Appropriate malnourished and anticipated patients(unable to ingest and/or absorb adequate nutrients for prolonged period of time) Enteral nutrition should be used in patients with a functioning G I tract for whom oral intake is inadequate to meet nutrition requirements. Pharmacologic doses of parenteral glutamine may benefit patients. Patients should receive MNT counseling regarding foods that may pose infection risks and safe food handling during the period of neutropenia Nutrition support is appropriate for patients undergoing hematopoietic cell transplantation Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Monitoring and Evaluation Parameters should be based on nutrition diagnoses and interventions implemented Should include: Weight and weight change Caloric and protein intakes Tolerance to diet Changes in symptoms Aspects of Scored (patient generated subjective global assessment (PG-SGA) that suggested problems (0-36 score) Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.