neoplastic disease knh 411. cancer carcinogenesis – etiology fat! pufa’s and mufa’s replace...
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Cancer
Carcinogenesis – Etiology
Fat!PUFA’s and MUFA’s replace saturated fat
Calories: want to watch weight
Alcohol: avoiding excessive amounts; flavinoidsGenes may be affected by antioxidants, soy, protein,
fat, kcal, alcoholNutritional genomics – study of genetic variations
that cause different phenotypic responses to diet
ChemotherapyCommon side effects due to toxicity to rapidly
dividing cells:Neutropenia: ow WBC count; be careful with food
safety; medications may cause; feeling of tirednessThrombocytopenia: low platelet countAnemia: relates to feelings of sluggishness/tired,
diarrhea, difficulty eatingDiarrheaMucositis: inflammation of mucous membrane;
mouth source; want food at room temperature—eliminates high calorie high protein diet
Alopecia: hair loss; creates psychological profileCardiotoxicity, neurotoxicity, nephrotoxicity: because
of chemo treatment, will have cardiac, nerve, and kidney damage
RadiationSide effects:
Delivering electromagnetic rays and particles to destroy the cancerDelayed wound healingFatigue, mucositis, dysguesia, xerostomia
(may need artificial saliva), dysphagia, odynophagia, severe esophagitis, dehydration
Radiation enteritis, fistulas, strictures, chronic malabsorption, severe diarrhea
TPN (IV nutrition therapy) may be warranted to prevent weight loss
Nutrition Therapy
Prevent *malnutritionReversing this is extremely difficult
Treatment (chemo/radiation) or surgery may cause malnutrition
As a dietician: want to control symptomatic treatment Prokinetics: can help prevent gastric emptying Pharmacological agents may help with malnutrition
Screening and assessment importantBe aware of cancer dg and treatments most likely to
cause malnutrition
Nutrition Implications
Cachexia –
One of last stages of cancer (Greek for “bad”)Metabolic alterations Tumor induces hypermetabolic catabolic state
through chemical mediatorsTumor specific “cachectic factors”Weight loss, anorexia, muscle wasting, fatigue, early
satietyStandard therapy – nutrition support
Nutrition Implications
Abnormalities in CHO, lipid, protein metabolism (in the presence of a malignant tumor)Normal physiologic conservation seen in starvation
does not occurCHO – insulin resistance, increased glucose
synthesis, gluconeogenesis, increased Cori cycle activity, decreased glucose tolerance and turnover
Anorexic stageCachexia stage
Nutrition Implications
Abnormalities in CHO, lipid, protein metabolismProtein - amino acids not spared, depletion of lean
body mass, increased protein catabolism, or decreased protein synthesis
Lipid – increased lipid metabolism, decreased lipogenesis, decreased LPL, presence of lipid-mobilizing factor (LMF)
Nutrition Implications
Cancer treatmentNausea, vomitingEarly satietyDysgeusiaDiarrheaMucositisXerostomiaConstipationWeight lossAnemia
Nutrition Interventions
Nutrition AssessmentSGA (subjective global assessment)
Triage tool to assess who you would need to see first: Rate them from 1-9, 1=no intervention, 9+ symptoms
to manage want to triage them as the first patient to be seen
A-well nourished cancer client B-moderately nourished cancer client C-severe malnutrition
Anthropometrics including height, weight, detailed weight hx, fluid retention, body composition
Biochemical including serum hepatic proteins Clinical signs and symptoms
Nutrition Interventions
Nutrition AssessmentDetailed diet hx and current intake
Foods tolerated, special diets, use of CAM, supplements, liquid nutritional supplement preferences
Nutrition Interventions
Determining Nutrient RequirementsIndividualizedKcal to maintain weight and prevent loss Protein to prevent negative nitrogen balance
and meet synthesis needsFluid needs - 30-35 mL/kg or cc’s/kcalMultivitamin mineral supplement < 150%
DRINeed to look at dietary recall to address who to
get to 150% of DRI (supplemental and food stuffs)
Nutrition InterventionsNausea & Vomiting
Avoid noxious odorsReview medication list for potential causesSmall, frequent mealsPro-kineticsCAM – acupressure, acupuncture, hypnosis, guided
imagery
Nutrition InterventionsNausea & Vomiting - Chemotherapy
Small, low-fat meals morning of, avoid fried, greasy and favorite foods for several days, fluid in between meals
Clear liquid dietElectrolyte-fortified beveragesNon-acid fruit drinksAvoid favorite foods Avoid “creamy” liquid nutritional drinks Anti-emetics 30-45 min. before meal
Nutrition InterventionsEarly Satiety (big problem)
Small, frequent nutrient-dense meals (want to avoid gastric dumping)
Beverages between meals and should contain nutrients
Avoid high-fiber and raw vegetablesPro-kinetics
Nutrition InterventionsMucositis (inflamed GI tract from mouth to
anus)Thorough and systematic assessment of mouthGood oral hygiene importantOral glutamineNarcotic analgesicsEat soft, non-fibrous, non-acidic foodsAvoid hot foodsEncourage liquids; non-acidic juicesHigh-kcal, high-protein shakes & supplements
Nutrition InterventionsDiarrhea
Drink small amounts of fluid frequently throughout day
Avoid large amounts of fruit juiceOral rehydration fluids and nutritional beveragesAntidiarrheal medicationsFoods high in soluble fiber
Nutrition InterventionsDysgeusia
Assess taste changes – metallic taste, aguesia, heightening of certain tastes (sweets), aversions
Avoid metal utensils, drink from glass Incorporate other high-protein foods if aversion to
meats exists Increase spices, flavors Non-sweet supplements, or juice- or yogurt-based
alternatives
Nutrition InterventionsXerostomia
Artificial saliva/ mouth moisturizersGels, lozenges, mouthwashesSugar-free gum, sour-flavored hard candy
Nutrition InterventionsAnorexia
Pharmacologic agents to increase appetitePharmacologic agents to treat weight lossPhysical activityOral supplements
Nutrition InterventionsNutrition Support (if the gut works, use it)
Enteral vs. parenteral Nutrition support inappropriate for those with terminal
cancer or for pts. with poor prognosis for whom other therapies have been exhausted
ASPEN practice guidelines for nutrition support