ศลัยา คงสมบรูณเ์วช MA., RDN., CDT.สมาคมนกัก าหนดอาหารแหง่ประเทศไทย

ศนูยส์ง่เสรมิสขุภาพไวทลัไลฟ์ โรงพยาบาลบ ารงุราษฎร์โรงพยาบาลเทพธารนิทร์

MNT discussion from A Case of Acinar Cell Carcinoma

การประชุมวชิาการสมาคมนกัก าหนดอาหารแหง่ประเทศไทย24-26 เมษายน พ.ศ. 2560

นกัก าหนดอาหารยคุ Thailand 4.0

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Recommendation•All adult patients should be screened for malnutrition risk on entry into oncology services. Rescreening should be repeated routinely throughout treatment to facilitate referral as needed.Rating: Consensus: Imperative

Patient should be referred to an RDN for evaluation to conducts a nutrition assessment and provides MNT, including the Nutrition Care Process.

Rating: Consensus; Conditional

at risk

http://dx.doi.org/10.1016/j.jand.2016.05.010 2

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https://www.slideshare.net/lionelchewvunliung/ms-tah-pei-chien-mnt-cancer-guidelines-changes-in-guidelines-update/15

Screening Tool FundamentalsSCREENING 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 exam7

https://www.slideshare.net/lionelchewvunliung/ms-tah-pei-chien-mnt-cancer-guidelines-changes-in-guidelines-update/15

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ABCD

Anthropometric Assessment

Anthropometric measurements in adult oncology patients:

• height and weight• weight change• body mass index• Lean body mass

Rating: Consensus; Imperative

ในผูป่้วยสงูอายุ การศกึษาได ้แสดงใหเ้ห็นความสมัพันธอ์ตัราการเสยีชวีติเพิม่ขึน้ในคนที ่under weight ทีน่ ้าหนักลดลงโดยไมไ่ดต้ัง้ใจ 5% ใน 30 วนัหรอืดชันมีวลกาย <20 (ปกติ<18.5)

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Height:184 cm; BW: 78 kgBMI =23.04 kg/m2

RDNs should consider the six identifiers of malnutrition,

Criteria for nutrition diagnosis of malnutrition in adult oncology patients.The presence of two or more of the following criteria or characteristics supports a nutrition diagnosis of malnutrition in adult oncology patients:

•Insufficient energy intake•Unintended weight loss•Loss of subcutaneous fat•Loss of muscle mass•Localized or generalized fluid accumulation (that may mask

weight loss)•Reduced grip strength

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Biochemical assessment

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RDNs should evaluate available data regarding

○Biochemical data, medical tests, and procedures of adult oncology patients. Examples include glucose; white blood cell count;

○ nutritional anemia profile (i.e., hemoglobin, hematocrit, folate, vitamin B-12, and iron values);

○ electrolyte and renal profile ○ liver function○ inflammatory profile, including C-reactive protein value○ GI function tests (i.e., swallowing study, abdominal films, gastric

emptying, and transit time). ○ In cases where biochemical data are not available, RDNs should

recommend, as indicated.

Rating: Consensus; Imperative

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Nutrition-focused physical findings and history of adult oncology patients, including but not limited to age older than 65 years

• loss of muscle mass,

• loss of subcutaneous fat,

• presence of pressure ulcers or wounds,

• nutrition impact symptoms,

• changes in appetite or vital signs,

• change in functional indicators (ie, Karnofsky performance scale and grip strength),

• localized or generalized fluid accumulation.

• Client history–patient/family/client medical/health history, including but not limited to dysphagia, depression, and pain fatigue;

• medical treatment or therapy;

• other diseases, conditions, and illnesses, including cancer cachexia.

• Social history should include psychological/socioeconomic factors (eg, social support).

Rating: Consensus; Imperative 16

Rationale

Assessment is needed to effectively determine nutrition diagnoses and plan nutrition interventions.

An adult oncology nutrition assessment should characterize and document the presence of, or expected potential for altered nutritional status and nutrition impact symptoms. These symptoms that impede intake, digestion, or absorption can be caused by the cancer itself or the oncology treatment.

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Dietary assessment

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Past Family Medical History

Medical History• Celiac disease• Hypothyroidism

Family History• Father passed away due to lung cancer

Diet• Patient had IgG food intolerance test: patient eliminates leek, garlic, milk, gluten, wheat,

spelt, barley, and oats• Non-processed organic whole foods including all types of meat (beef, chicken, fish and

lamb)• 24-hour diet recall

– Breakfast: Whole grains,, mixed berries, bananas, and almond milk– Lunch: Steak with asparagus, onions, carrots, zucchini, and beetroot– Dinner: Riceberry with chicken, potatoes, onions, Chinese kale, broccoli, and eggplant– Snacks: apple, nuts and seeds

• Past diets– Budwig Diet: quark (cottage cheese), flaxseed oil, vegetables, fruits, and juices– Gallbladder/liver cleanse: 4 tbsp Epsom salt, ½ cup olive oil. 1 large apple or grapefruit

24-hour diet recallNeed portion size of each menu for each meal to assess adequacy of caloric and nutrients intake

Nutrition Assessment CriteriaRDNs should assess the following:

○Food, beverage, and nutrient intake and related history, including

but not limited to energy and protein intake;

○ changes in food and fluid/beverage intake;

○ adequacy and appropriateness of nutrient intake or nutrient

administration;

○ actual daily intake from enteral nutrition and parenteral nutrition

and other nutrient sources;

○ changes in type, texture, or temperature of food and liquids;

○ use of supplements

○ food avoidance and intolerances; meal or snack pattern changes;

○ prescription medications, over-the-counter medications,

herbal preparations, and complementary or alternative medicine products;

○ factors affecting access to food.

21Academy of Nutrition and Dietetics.http://dx.doi.org/10.1016/j.jand.2016.05.010

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Estimated Daily Protein Needs in CA Pt

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Estimated Fluid Needs in Cancer

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ADA 2000

Estimated Pt’s Nutrition Requirement

• Energy ７８Kg ｘ 30 = 2340 kcal/day

• Protein 78 kg x 1-1.2g = 78-93.6g/d

• Fluid 78 kg x 35 ml= 2730 ml

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Nutrition Assessment for the Stages of Cancer Cachexia

Recommendation

• In patients with lung, pancreatic, or head and neck and GI cancers or those who are at high risk for weight loss or have experienced UWL, RDNs should assess for nutrition impact symptoms, markers of inflammation (eg, elevated C-reactive protein value), and other signs of wasting that may indicate precachexia or cancer cachexia.

Rating: Consensus; Conditional

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Common nutrition impact symptoms in adult oncology patients.

•Adverse effects on weight or body composition•Impaired immune response•Decreased muscle strength•Increased fatigue•Impaired wound healing•Impaired glucose function•Impaired psychosocial function, including depression•Reduced quality of life•Reduced response to treatment•Increased treatment toxicities•Treatment delays•Increased hospitalizations or length of stay

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Nutrition Screening and NCP Flowchart

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Estimated Daily Protein Needs in CA Pt

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Estimated Fluid Needs in Cancer

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ADA 2000

Micronutrient Requirement

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สารอาหารทางการแพทยท์ี่ส าคญัตอ่การเพิม่ภมูคิุม้กนั

• น า้มนัปลา (omega-3) : 2.2 mg EPA per day

– ตา้นการอกัเสบโดยเกีย่วขอ้งกบัการสรา้ง eicosanoids(prostaglandins, leucotrienes, และ thromboxanes)

• กลตูามนี (Glutamine)

– ชว่ยป้องกนัความผดิปกตขิองล าไส ้(enteropathy)

– เพิม่การท าลายเซลมะเร็งเละเพิม่การท างานของ natural killer cells (NK)

• แอล-อารจ์นินี (L- Arginine) : EAA กระตุน้ระบบภมูคิุม้กนั

ในรา่งกาย เสรมิสรา้งการสงัเคราะหโ์ปรตนี ใชส้รา้งไนตรคิออกไซด ์(Nitric Oxide)

• วติามนิดี

• สารตา้นอนมุลูอสิระ เชน่

vitamin C, Selenium45

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Nutrition411.com

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Early nutrition counseling is important

It appears advisable to use a hypercaloric(30-35kcal/kg body wt), high-protein diet rich in BCAAs (50% leucine), and EPA for patients with cachexia who can tolerate oral feeding.

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Diet and Counseling

Recommendation Grade

References

• At moderate nutritional risk patients (MST = 2)

- Recommend high protein-energy diet - High protein and high energy diet - Try 6 smaller meals/snacks per day - Include 3-4 servings of energy and protein rich foods or drinks daily - Oral nutritional supplements 2-3 servings per day

C Bauer, 2007

• At high nutritional risk patients (MST = 3-5)

- Recommend high protein high energy diet - Recommend high protein high energy supplements 2-3 times per day - Consider intensive nutrition support

C Bauer, 2007

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Algorithm of Nutrition Support for CA Patients

References

• Academy of Nutrition and Dietetics. Oncology Evidence-Based Nutrition Practice Guideline for Adults. http://dx.doi.org/10.1016/j.jand.2016.05.010

• Interdisciplinary Nutrition Care Plan for Cancer. www.nutrition411.com

• Medical Nutrition Therapy Cancer Guidelines Update https://www.slideshare.net/lionelchewvunliung/ms-tah-pei-chien-mnt-cancer-guidelines-changes-in-guidelines-update

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