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Nutrition Care Process for Oncology. Ingrid Jorud Concordia College Moorhead, MN. Objectives. Identify who is most at risk of developing cancer. Define what cancer is and what nutritional deficiencies may develop. Identify the nutrition maladies associated with cancer.

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nutrition care process for oncology

Nutrition Care Process for Oncology

Ingrid Jorud

Concordia College

Moorhead, MN

objectives
Objectives
  • Identify who is most at risk of developing cancer.
  • Define what cancer is and what nutritional deficiencies may develop.
  • Identify the nutrition maladies associated with cancer.
  • Identify the types of treatment and side effects involved in each.
  • Learn what nutrition care can be given in each case.
  • Discuss the Nutrition Care Process for Cancer.
objectives cont
Objectives (cont.)
  • Identify the ethical issues regarding nutrition with cancer patients
  • Outline some prevention guidelines
what is cancer
What is cancer?
  • Disease of disordered cell growth and replication.
  • Uncontrolled cellular division
  • Ability to invade other tissues, either by direct growth or migration to distant cells.
cancer cell growth
Cancer Cell Growth
  • Normal cellular growth is controlled by genetic factors, hormones, and growth substances secreted by distant cells.
  • Telomeres in cell shorten and stop cell growth after a certain point - cancer cells secrete enzymes to destroy telomere.
  • Cell’s internal clock is destroyed, cell differentiation may change, cell may take on other traits and become misshapen, replicate at a faster rate than normal.
what can put a person at high risk
What can put a person at high risk?
  • Genetics - heredity only plays a small role
  • Diet and physical activity habits
    • Fat content and type (Omega 3 and 6 are better)
    • Low consumption of fruit and vegetables
    • Low intake of whole grains
    • Obesity - BMI > 40 risk of cancer and death more than doubles
  • Environmental/behavioral
    • Smoking
    • Work and chemical exposure
most common cancers
Men

33% Prostate

13% Lung and bronchus

10% Colon and rectum

27% include: Urinary bladder, Melanoma of skin, Non-Hodgkin Lymphoma, Kidney, Leukemia, Oral Cavity, Pancreas

17% Other sites

Women

32% Breast

12% Lung and bronchus

11% Colon and rectum

6% Uterine corpus

18% Non-Hodgkin lymphoma, Melanoma of skin, Ovary, Thyroid, Urinary bladder, Pancreas

21% Other sites

Most Common Cancers
leading mortality
Leading Mortality
  • Lung and bronchus
  • Prostate and Breast
  • Colon and Rectum
  • Pancreas
  • Ovary
  • Leukemia
treatments
Treatments
  • Chemotherapy
    • Antineoplastics - inhibit and combat development of tumors
  • Radiation therapy
    • Use of radiation to control malignant cancer cells
  • Surgery
    • Physical removal of the cancer tumor or organ involved
factors contributing to malnutrition
Factors Contributing to Malnutrition
  • Treatments
    • Chemotherapy
      • Drugs and severity of types that are used
    • Radiation
      • Depending on the location of the cancer and radiation site
    • Surgery
      • Location of tumor to determine surgical location and nutritional status
  • Tumor and abnormal cell growth
affects of disease state on nutrition
Affects of Disease State on Nutrition
  • Tumor
    • Malignant tumors cause changes in energy expenditure and basal metabolic rates.
    • Altered enzyme activity
    • Immune system
changes the occur in metabolism
Carbohydrate

Insulin resistance

Increased glucose synthesis

Gluconeogenesis

Increased Cori cycle activity

Decreased glucose tolerance

Protein

Increased protein catabolism

Decreased protein synthesis

Fat

Increased lipid metabolism

Decreased lipogenesis

Decreased activity of lipoprotein lipase (LPL)

Changes the occur in Metabolism
nutritional assessment of cancer patient
Nutritional Assessment of Cancer Patient
  • Anthropometric Measurements
    • AMC < 60% of standard are consistent with protein depletion
    • BMI < 22, based on UBW and % weight loss is often considered for depletion
    • BIA (Bioelectric Impedance Analysis) - resistance to low intensity electric current by fat and lean tissue
  • Lab values
    • Not always the most accurate for assessment when viewed alone
  • Prognostic Nutritional Index (PNI)
slide14
PNI

Prognostic Nutritional Index measures the risk that a patient has of developing a complication such as sepsis or death related to malnutrition.

PNI% = 158 – 16.6A - .78TSF – 0.2TFN – 5.8DH

A indicates albumin (g/dL); TSF –tricep skinfold (mm); TFN – transferrin (mg/dL); DH delayed hypersensitivity skin testing reaction to a recall antigen

<40: low risk;

40-49.99: intermediate risk;

≥ 50: high risk

basic nutrition requirements
Basic Nutrition Requirements
  • Harris-Benedict or Mifflin-St. Jeor
  • Kcalorie
    • Obese patients: 21-25 kcal/kg
    • Non-ambulatory/sedentary adults: 25-30 kcal/kg
    • Sepsis: 25-35 kcal/kg
    • Slightly hypermetabolic or those in need of weight gain or those with stem cell transplant: 30-35 kcal/kg
    • Hypermetabolic or severely stressed: ≥35 kcal/kg
basic nutrition requirements cont
Basic Nutrition Requirements (cont.)
  • Protein
    • Normal or Maintenance: 0.8-1.0 g/kg
    • Non-stressed cancer patient: 1.0-1.5 g/kg
    • Bone marrow transplant or HSCT patients: 1.5 g/kg
    • Increased protein needs: 1.5-2.5 g/kg
    • Hepatic or renal compromised or elevated ammonia: 0.5-0.8 g/kg
basic nutrition requirements cont17
Basic Nutrition Requirements (cont.)
  • Adequate fluid and hydration
  • Vitamins
    • Folate
    • Vitamin C
    • Retinol
  • Minerals
    • Magnesium
    • Zinc
    • Copper
    • Iron
fluid requirements
Fluid Requirements
  • 16-30 years, active: 40 mL/kg
  • 31-55 years: 35 mL/kg
  • 56-75 years: 30 mL/kg
  • 76 years or older: 25 mL/kg
  • 1 mL/kcal of estimated energy needs
nutritional complications and symptoms that cause them diagnosis
Nutritional Complications and Symptoms That Cause Them (Diagnosis)
  • Anorexia
  • Cachexia
  • Dysphasia
  • Nausea and Vomiting
  • Constipation/Diarrhea/Malabsorption
  • Oral Manifestations
    • Xerostomia
anorexia
Anorexia
  • Imbalance between caloric intake and metabolic needs due to a lack or loss of appetite for food, leading to weight loss, cachexia, dehydration, and electrolyte imbalances
  • Causes
    • Alterations in Taste
      • Decreased threshold for bitter taste
      • Decreased like for beef, pork, chocolate, coffee, or tomatoes
      • Metallic or medicinal taste
anorexia causes cont
Anorexia (causes cont.)
  • Taste abnormalities may lead to decrease in digestive enzymes causing delay in digestion
  • Alterations in GI function
    • Ulceration of the mucous membranes may produce mucositis or diarrhea, which interferes with ingestions, digestion, or absorption
  • Metabolic Abnormalities
    • Glucose Metabolism
    • Increased circulation of amino acids or lactic acid
    • Increased free fatty acids
    • All cause early satiety
anorexia causes cont22
Anorexia (causes cont.)
  • Psychological abnormalities
  • Effects of tumor
    • Release of cytokines
      • Cytokines may raise metabolic rate and increase protein catabolism and skeletal muscle protein metabolism
    • Wound healing
      • Decreased ability to heal due to tumor growth and tumor utilization of nutrients
treatment of anorexia in cancer patients
Appetite stimulant

Megestrol acetate

Corticosteroids agents

Exercise may increase appetite

Eat small, frequent high protein high calorie meals.

Eat when appetite is normal

Limit fluid with meals to avoid early satiety

Keep favorite foods handy

Glass of wine before a meal may help to stimulate appetite

Avoid strong food odors

Find a liquid nutritional supplement that is appealing

Treatment of Anorexia in Cancer Patients
cachexia
Cachexia
  • Wasting syndrome that causes: weakness and loss of weight, fat, and muscle, electrolyte imbalances, impaired organ function, and immunosuppression
    • Common with lung, pancreas, upper GI tract cancers
    • Less common in breast and lower GI cancer
  • Caused by malabsorption, anorexia, and other factors contributing to nutrient deficiencies
    • Not related to tumor size or type.
    • Increased nutrient needs
    • Due to metabolic rate changes or demands
    • Alterations in GI function
types of cachexia
Types of Cachexia
  • Primary
    • Anorexia
    • Decrease in Nutrients
    • Changes in Metabolic Pathways
  • Secondary
    • Weight loss due to mechanical factors limiting intake
nutritional deficiencies due to cachexia
Nutritional Deficiencies due to Cachexia
  • Carbohydrate Metabolism
    • Cori cycle increases so that glucose usage is greater than conversion and to keep up with demand, amino acid is used
    • Impairment of insulin sensitivity or glucose tolerance
      • Lead to hyperglycemia
  • Protein Metabolism
    • Used when energy stores of glycogen are decreased
    • Decrease in protein synthesis that may be due to decreased intake or decreased albumin production by liver
nutritional deficiencies due to cachexia cont
Nutritional Deficiencies due to Cachexia (cont.)
  • Fat Metabolism
    • Normal and Abnormal Metabolism
      • Stimulated by insulin

resistance leading to

hyperlipidemia and

decreased fat stores.

http://www.biologyclass.net/cori.jpg

treatment of cachexia in cancer patients
Treatment of Cachexia in Cancer Patients
  • Treat initial causes
  • Replenish body with protein, carbohydrates, fats, vitamins, and minerals
  • Enteral or parenteral nutrition
dysphasia
Dysphasia
  • Difficult and painful swallowing
  • Resulting from tumor and/or treatment:
    • Chemotherapy, Radiation, or Surgery
treatment of dysphasia in cancer patients
Treatment of Dysphasia in Cancer Patients
  • Therapeutic approaches
    • Swallowing therapy
    • Pain management
    • Oromotor exercises - muscle control for swallowing
    • Altered postural strategies
  • Food Consistencies
    • Semisolid foods, soft foods, medium to thick liquids, dense sticky/bulky foods, and thin and thick liquids.
nausea and vomiting
Nausea and Vomiting
  • Secondary to treatments, progressive disease states, and other therapies.
  • Often involves the cerebral cortex, mediated by the autonomic nervous system.
treatment for nausea and vomiting in cancer patients
Treatment for Nausea and Vomiting in Cancer Patients
  • Parenteral support in cases of greater than 10 episodes in 24 hours.
  • Control of symptom management
    • Pharmacologic Management
      • Serotonin antagonist
      • Dopamine Antagonists
      • Corticosteroids
      • Benzodiazepines
      • Cannabinoid
treatment for nausea and vomiting in cancer patients33
Treatment for Nausea and Vomiting in Cancer Patients
  • Nonpharmacologic Interventions
    • Behavior Interventions
    • Acupressure
  • Dietary interventions
    • Individualized to each patient
    • Eating cold or room temperature foods
    • Avoiding high fat foods which delay gastric emptying
    • Avoid favorite foods on treatment days
    • Ginger
constipation diarrhea malabsorption
Constipation/ Diarrhea/ Malabsorption
  • GI dysfunction caused by drugs, endocrine tumors, malabsorption, chemotherapy, radiation therapy, and other concurrent diseases
  • Diarrhea
    • Carbohydrate malabsorption
    • Inability to properly absorb salt
    • Bacteria infection
constipation diarrhea malabsorption cont
Constipation/ Diarrhea/ Malabsorption (cont.)
  • Malabsorption- ineffective absorption of nutrients
    • Intestinal resection
    • Bile salt deficiency
    • Reduced activity or transport mechanisms
    • Insufficient enzymes
    • Short Bowel Syndrome
    • Antibiotics
    • Signs - Steatorrhea; Caloric Deprivation; Folate, Vitamin B12, Calcium, Magnesium, Vitamin D, and Iron deficiencies
constipation diarrhea malabsorption cont36
Constipation/ Diarrhea/ Malabsorption (cont.)
  • Constipation - extremely common in cancer patients
    • Medication induced
    • Tumor location
    • Hypercalcemia, hypokalemia, and/or uremia
    • Diabetes
    • Inadequate food/fiber intake
    • Poor liquid intake
    • Bowel surgery
treatment of gi dysfunction in cancer patients
Treatment of GI Dysfunction in Cancer Patients
  • Diarrhea
    • Binders of osmotically active substances - pectin
    • Avoid cold meals, milk, fiber rich vegetables, fatty meats and fish, alcohol, and coffee.
    • Rehydration - solutions containing glucose, electrolytes, and water; intravenously
    • Antibiotics
treatment of gi dysfunction in cancer patients38
Treatment of GI Dysfunction in Cancer Patients
  • Malabsorption - Correct deficiencies
    • Enzyme replacement
    • Bicarbonate supplements
    • Vitamins
    • Calcium, Magnesium, and Iron
    • Low fat and high protein diet
    • Parenteral nutrition postoperative
treatment of gi dysfunction in cancer patients39
Treatment of GI Dysfunction in Cancer Patients
  • Constipation
    • Increase fluid intake
    • High fiber foods
    • Laxatives
    • Reversal of hypercalcemia and hypokalemia
oral manifestations
Oral Manifestations
  • Xerostomia - abnormal dryness of mouth
  • Results most commonly from radiation therapy to the head and neck region, surgical excisions, and Sjogren’s syndrome.
  • May be impossible to prevent
treatment of oral manifestations in cancer patients
Treatment of Oral Manifestations in Cancer Patients
  • Frequent oral rinses and sips of water or juice
  • Moist, soft foods; prepare foods with sauces or gravies.
  • Alcoholic and carbonated beverages may inflame mucosa
  • Sucking on hard sugarless candy or gum to stimulate saliva secretion
  • Fine mist of water sprayed into the mouth from a spray bottle
  • Foods and drinks that are very sweet or tart to stimulate saliva production
enteral nutrition
Enteral Nutrition
  • Nasogastric - nose to stomach, short term
  • Gastrostomy & Jejunostomy - stoma placed into stomach or jejunum, long-term use
  • Patients with low body weight
  • Inability to eat or drink by mouth for more than five days
  • Moderate or high nutritional risk
advantages for enteral nutrition
Advantages for Enteral Nutrition
  • Food in liquid form
  • Keeps the stomach and intestines working normally
  • Fewer complications than parenteral
  • Nutrients used more easily by the body
  • Can be administered at home
parenteral nutrition
Parenteral Nutrition
  • Nutrients delivered directly into the blood via catheter inserted into the subclavian (CVC) or other larger peripheral vein.
  • Stomach and intestines not working correctly or have been removed
  • Severe nausea or vomiting
  • Fistulas in stomach or esophagus
  • Loss of body weight and muscle with enteral nutrition.
complications associated with parenteral nutrition
Complications Associated with Parenteral Nutrition
  • Hypoglycemia
  • Hyperglycemia
  • Hypokalemia
  • Blood clots
  • Infection as site of insertion
  • Elevated liver enzymes
diagnostic labels
Inadequate oral food/beverage intake

Inadequate fluid intake

Inadequate bioactive substance intake

Hypermetabolism

Increase nutrient needs

Swallowing difficulty

Chewing difficulty

Altered GI function

Altered nutrition-related laboratory values

Food-medication interaction

Involuntary weight loss

Food, nutrition, nutrition-related knowledge deficit

Diagnostic Labels
monitoring of patients
Monitoring of Patients
  • During and after treatment
    • Improvement
    • Maintenance
    • Risk assessments
    • Disease progression
  • Recovery
    • Following health lifestyle
ethical issues
Ethical Issues
  • Care of Dying Patient
    • Autonomy and beneficence
    • Seek decisions of recognized authorities or religious codes, professional guidelines of legal ruling
    • Nutrition and hydration - continuation of nutrition support or voluntary refusal
cancer prevention
Cancer Prevention
  • Healthful Diet
    • Five or more servings of various fruits and vegetables each day
    • Limit high fat and fried products
    • Choose whole grains
    • Limit consumption of red meats, especially high fat and processed
    • Watch your portions
cancer prevention cont
Cancer Prevention (cont.)
  • Physical Activity
    • At least 30 min 5 days a week, 45 min is even better
  • Healthy Weight
    • Balance caloric intake with physical activity
  • Limit Alcohol Consumption
    • Limit to 1 drink/day for women and 2 drinks/day for men.
summary
Summary
  • Definition of cancer
  • Cancer Treatments
  • Basic Nutrient Requirements
  • Contributors to nutritional deficiencies
  • Treatment and disease symptoms
  • Treatment of symptoms
  • Ethical Issues
  • Prevention
references
References

American Cancer Society. (2005). Nutrition for the person with cancer. Retrieved 9/23, 2008, from http://www.cancer.org/docroot/MBC/MBC_6.asp

Berger, A. A., Shuster, John L. Jr, & Von Roenn, Jamie H. (2007). In Berger A. A., Shuster, John L. Jr and Von Roenn, Jamie H. (Eds.), Principles and practice of palliative care and supportive oncology (3rd Edition ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

Berger, M. M., & Shenkin, A. (2006). Vitamins and trace elements: Practical aspects of supplementation. Nutrition Research, 22, 952-955.

Cady, J. (2007). Nutritional support during radiotherapy for head and neck cancer: The role of prophylactic feed tube placement. Clinical Journal of Oncology Nursing, 11(6), 875-880.

Cox, A., & Carson, J. S. (2008). Facing ethical issues in care of the dying patient. Oncology Nutrition Connection, 15(4), 10/1/2008.

Dewell, A., Weidner, G., Sumner, M. D., Chi, C. S., & Ornish, D. (2008). A very-low-fat vegan diet increases intake of protective dietary factors and decreases intake of pathogenic dietary factors. Journal of the American Dietetic Association, 108(2), 347-356.

Elliot, L., Molseed, L. L., McCallum, P. D., & Grant, B. (2006). The Clinical Guide to Oncology Nutrition (2nd ed.) American Dietetic Association.

Gonzalez, L. (2008). Providing a solution for breast cancer survivors: Diet, exercise, and weight management. Oncology Nutrition Connection, 16(3), 10/2/2008.

references53
References

Huhmann, M. B., & Cunningham, R. S. (2005). Importance of nutritional screening in treatment of cancer-related weight loss. Lancet Oncology, (6), 334-343.

Jones, L. W., & Denmark-Whenfried, W. (2006). Diet, exercise, and complementary therapies after primary treatment for cancer. Lancet Oncology, (7), 1017-1026.

Mayo Clinic. (2007). Cancer survivors: Managing late effects of cancer treatment. Retrieved 9/23, 2008, from http://www.mayoclinic.com/health/cancer-survivor/CA00073

Miller, M. F., Bellizzi, K. M., Sufian, M., Ambs, A. H., Goldstein, M. S., & Ballard-Barbash, R. (2008). Dietary supplement use in individuals living with cancer and other chronic conditions: A population-based study. Journal of the American Dietetic Association, 108(3), 483-494.

National Cancer Institute. (2008). Nutrition in cancer care. Retrieved 9/27/2008, 2008, from http://www.cancer.gov/cancertopics/pdq/supportivecare/nutrition

Nelms, M., Sucher, K., & Long, S. (2007). Neoplastic disease. Nutrition therapy and pathophysiology (pp. 751-779). Belmont, CA: Thomson Brooks/Cole.

Yamagishi, A., Morita, T., Miyashita, M., & Kimura, F. (2008). Symptom prevalence and longitudinal follow-up in cancer outpatients receiving chemotherapy. Journal of Pain and Ymptom Management, , 1-8.

Yarbo, C. H., Frogge, M. H., & Goodman, M. (1999). In Yarbo C. H., Frogge M. H. and Goodman M. (Eds.), Cancer symptom management. Sudbur, MA: Jones and Bartlett Publishers, Inc.