Nutrition in Patients with Cancer and AID

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Cancer

Characteristics of cancer cells

Uncontrolled cellular reproduction

Cells become independent of normal growth signals

Cells contain abnormal nucleus and cytoplasm Mitosis rate generally increases Nucleus of cells may be abnormal shape with clearly abnormal chromosomes
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Cancer, contd

Carcinogenesis

Process resulting in abnormal cell production

Abnormalities in cell replication

Initiation Promotion Progression

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Cancer, contd

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Cancer, contd
Nutrition factors considered important environmental and lifestyle factors in etiology and prevention of cancer

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Nutrition and dietary factors may interact within process of carcinogenesis in all three stages: initiation, promotion, and 5Slide 5 progression

National Cancer Institute guidelines

Do not smoke cigarettes or use other tobacco products Do not drink too much alcohol

Eat five or more daily servings of fruits and vegetables 7/12/12

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Cancer, contd

Nutrition and the diagnosis of cancer

Cancer cachexia

Complex syndrome resulting in severe wasting of lean body mass and weight loss
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Cancer, contd

Benefits of nutritional adequacy

Maintenance of nutritional status

Decreases risk of surgical complications Ensures patients able to meet increased energy and protein requirements Helps to repair and rebuild normal tissues affected by antineoplastic therapy Promotes increased tolerance to therapy Assists in promoting enhanced quality of life
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Cancer, contd

Nutritional effects of cancer treatments

Surgery

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Depends on type and extent of surgical resection Resections of any portion of gastrointestinal (GI) tract Energy and protein requirements may need to be increased
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Cancer, contd
Chemotherapy

Most protocols include combination of chemotherapy agents Act by:

Inhibiting one or more steps of DNA synthesis in rapidly proliferating cells characteristic of malignant cell Or by enhancing hosts immune system to allow for improved response to therapy 10Slide 10

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Cells of bone marrow and

Cancer, contd

Severity and manifestation of side effects determined by:

Chemotherapy agent Dosage Duration of treatment Rates of metabolism Accompanying drugs Individual tolerance

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Cancer, contd
Radiation therapy

Ionizing radiation used to kill cells by altering DNA of malignant cell Interferes with factors controlling replication Used to treat tumors sensitive to radiation exposure or tumors that cannot be surgically resected Some normal cells 12Slide 12

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Cancer, contd

Complications may develop during radiation treatment or become chronic and progress even after treatment completed Primary radiation sites resulting in nutrition problems include:

Head and neck Abdomen and pelvis (GI tract) Central nervous system (CNS)

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Cancer, contd
Bone marrow transplantation

Used to treat certain hematologic malignancies (acute and chronic leukemia and some forms of lymphoma) Used as adjunct therapy for solid tumors such as breast cancer Types of transplant include autologous, allogeneic, and syngeneic Ability to maintain adequate oral intake difficult because of nausea, vomiting, and mucositis
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Cancer, contd

Antineoplastic regimens and BMT result in immunosuppression

Places BMT patient at high risk for infections from bacterial and fungal pathogens Pathogens commonly in environment including fresh fruits and vegetables ordinarily not hazard to healthy people

Low-bacterial diet indicated whenever plasma neutrophil count <1000 mm3

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Food safety guidelines for patients with low immune function or are neutropenic

Avoid undercooked meats and eggs Ensure raw fruits and vegetables washed well and/or peeled (including salads and garnishes) Follow appropriate sanitation guidelines for food preparation and storage 16Slide 16

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Cancer, contd
Graft versus host disease (GVHD)

Major complication with allogeneic BMT Best described as reverse rejection

Grafted tissue or organ recognizes hosts cells as foreign

May result in multiple organ damage, but skin, GI tract, and liver of particular concern Nutritional management complicated

May require intense therapy for as long as 1 to 2 years posttransplant

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Nutrition therapy

Cancer patients at high risk for malnutrition

Recognizing clinical signs and treating symptoms early helps prevent protein-kcal malnutrition

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Nutrition essential 18Slide 18 component of total

Cancer, contd

Anorexia caused by cancer or its treatment

Etiology generally multifactorial

Changes in taste and smell Decreased transit time and subsequent early satiety Opportunistic infections Therapy and other medication side effects Pain Emotional and psychologic effects
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Cancer, contd

Treatment options

Essential to promote adequate nutritional intake Many cancer patients feel loss of control after diagnosis

Managing their nutritional intake assists in regaining control

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Essential nutrient density of food stressed

Small, frequent meals Use of high-kcal supplements Pleasant eating environment

Medications successfully stimulate appetite

Megestrol (Megace) Dronabinol (Marinol)

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Cancer, contd
Nausea and vomiting

Nausea and vomiting may result from:

Delayed transit time Physiologic symptoms such as hypercalcemia or central nervous system (CNS) involvement Medications Anticipation on part of patient

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Cancer, contd

Treatment options

First line of treatment

Adequate and aggressive antiemetic therapy

Essential to give medication 60 to 90 minutes before meals

If nausea and vomiting prevented, reduced risk of anticipatory nausea and vomiting Cold foods without odor better tolerated Behavioral strategies such as guided imagery and relaxation techniques successful
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Cancer, contd

Taste abnormalities

Taste alteration causes

Changes or destruction of oral mucosa Presence of tumor byproducts systemically Changes in quantity or quality of saliva Inadequate mouth care Drug-related taste changes
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Cancer, contd

Treatment options

Appropriate to avoid foods that taste bad Important to provide alternate food choices to maintain adequate nutrient intake Tart or spicy foods may enhance intake Guidelines for mouth care essential

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Expected outcomes for nutrition therapy
1.

Weight and lean body mass maintained within established goal range Hydration adequate as measured by clinical and physical assessment Adequate energy and protein consumption to perform ADL Comprehension by patient of neutropenic precautions Appropriate and safe use of complementary nutrition therapies by patient
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2.

3.

4.

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AIDS
Acquired immunodeficiency syndrome (AIDS)

Retrovirus human immunodeficiency virus (HIV) causes acquired immunodeficiency syndrome (AIDS)

Retrovirus injects its ribonucleic acid (RNA) into target cell Then transcribes RNA into deoxyribonucleic (DNA) using reverse transcriptase enzyme
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AIDS, contd

Goal of treatment regimens

Maintain viral load of <50 copies/mL Adherence to these regimens often difficult

Number and complexity of medications taken daily

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AIDS, contd

Drug resistance can develop if adherence not maintained

Other side effects

Nausea Vomiting Diarrhea Other metabolic changes

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AIDS, contd

Malnutrition in HIV/AIDS

Documented in all stages of HIV infection Malnutrition in HIV/AIDS multifactorial Most nutritional problems coincide with:

Incidence of high viral loads Opportunistic infections Development of viral resistance

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AIDS, contd
AIDS-related wasting syndrome

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Involuntary weight loss of >10% in 1 month with presence of chronic diarrhea, weakness, or fever for >30 days in absence of concurrent illness or condition

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AIDS, contd
Malnutrition in HIV/AIDS multifactorial

Contributors include:

Altered nutrient intake Weight loss and body composition changes Physical impairment Endocrine disorders Metabolic changes Malabsorption Presence of opportunistic infections Psychosocial issues Economic conditions 32Slide 32

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AIDS, contd

Altered nutrient intake

Anorexia frequent symptom may be caused by:

HIV infection Presence of opportunistic infections Fatigue Fever Medication side effects Physical impairment

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33Slide 33 Mucositis, esophagitis, pain, nausea, and vomiting

AIDS, contd

Chronic weight loss Acute weight loss

Accompanied by increase in metabolic rate decrease in metabolic rate Reliance on glucose as fuel fat stores for energy Depletion of lean body mass

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AIDS, contd

Medications to treat weight loss

Megestrol acetate (Megace) Dronabinol (Marinol)

Antiemetic Appetite stimulant

Side effects include euphoria, dizziness, and impaired thinking

Oxandrolone (Oxandrine) or oxymetholone and testosterone

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Increases lean body mass, mood elevation, and increased libido 35Slide 35

AIDS, contd
Physical impairment

Nausea, vomiting, mouth, and esophageal lesions, and impaired dentition may result from:

Opportunistic infections such as candidiasis and gingivitis Side effects of antiretroviral therapy Prophylactic treatment to prevent opportunistic 36Slide 36 infections

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Endocrine and metabolic disorders

Hypogonadism identified with HIV/AIDS

Condition associated with fatigue, decreased libido, loss of muscle mass, muscle weakness, impotence, and body hair loss Adrenal insufficiency may contribute to changes in appetite, loss of fuel

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AIDS, contd
Fat redistribution syndrome (lipodystrophy)

Syndrome of body composition changes and metabolic disturbances

Shift in adiposity with increase in abdominal obesity Accompanied by increase in serum triglycerides, cholesterol, glucose, and insulin resistance

Etiology of fat redistribution syndrome associated with protease inhibitors as well as nucleoside analog therapy
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AIDS, contd
Malabsorption

Malabsorption result of:

Opportunistic infections that damage GI tract Effects of malnutrition on villus height and enterocyte function Disease itself

Treatment of malabsorption

Treating underlying cause crucial in reversing malnutrition caused by malabsorption

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AIDS, contd

To assist control of malabsorptive symptoms and diarrhea:

Restriction of fat and lactose common Lactose-free supplements and supplements containing medium-chain triglycerides frequently prescribed Probiotics and prebiotics, glutamine and arginine in enteral products or given separately as supplement

Ensure adequate caloric and protein intake as fat and lactose restricted Prevent dehydration

Fluid losses may be high from diarrhea Supplementation with vitamins and minerals priority 40Slide 40

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AIDS, contd

Cycle of malnutrition and wasting

Complex causes

Interventions must be integrated early Conducting nutrition assessment and providing counseling result weight maintenance or gain

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Nutrition assessment in cancer and HIV/AIDS

Initial step evaluate anthropometric data

Body weight compared with the clients usual body weight

Unexplained weight loss concern

Weight loss >10% in 6 months places client at risk BMI <18 associated with malnutrition 42 42Slide

Body mass index (BMI) identifies nutrition risk

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AIDS, contd

Loss of lean body mass characteristic of malnutrition of AIDS

Weight may initially be stable Bioelectrical impedance (BIA) evaluates changes Calculation of upper arm muscle area can provide baseline measurement for monitoring over time

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AIDS, contd

Biochemical indices

Monitoring disease progression (CD4 or viral load) Acute phase proteins measuring inflammatory processes (C-reactive protein) Overall visceral protein stores (serum albumin and prealbumin) Other measures such as transferrin not applicable (possible bone marrow suppression present)
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AIDS, contd

Dietary assessment

Dietary evaluation by:

24-hour recall Food frequency Food diary

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AIDS, contd

Careful attention

Gastrointestinal function Presence of steatorrhea and diarrhea Other physical symptoms that might interfere with adequate oral intake

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AIDS, contd

Nutrition therapy

Overall goals of nutrition management

Preserve lean body mass and gut function Prevent development of malnutrition Minimize symptoms of malabsorption Provide adequate levels of all nutrients to maintain daily physical and mental functioning Prevent nutrition-related immunosuppression Improve quality of life
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AIDS, contd

Objectives of nutrition care

Realistic and individualized objectives Interventions designed based on:

Nutritional assessment Current medical treatment for client

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AIDS, contd

To determine energy and protein requirements

Harris-Benedict equation to determine resting energy expenditure (REE)

1.3 to 1.5 REE should meet most clients energy requirements for maintenance and weight gain MifflinSt. Jeor equation may better predict energy requirements for hospitalized patient

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AIDS, contd
MifflinSt. Jeor Equation
Females: 10 W + 6.25 H 5 A 161 Males: 10 W + 6.25 H 5 A + 5

W = Weight (in kg) H = Height (in cm) A = Age (in years)

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AIDS, contd

Protein requirements

1 to 1.5 g protein/kg of actual body weight based on patients current nutritional status

Vitamin and mineral status needs to be monitored closely because deficiencies may evolve

Suppressed oral intake Increased requirements for certain micronutrients

General multivitamin supplement meeting 100% of the Recommended Dietary Allowance (RDA) for vitamins and minerals routinely recommended In individual situations, other supplements may be warranted 51Slide 51

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Antiretroviral therapy

Antiretroviral therapy requires specific nutrition recommendations

Many antiretroviral medications result in symptoms such as nausea, vomiting, diarrhea, or anorexia that might impair oral intake Number of pills taken can overwhelm patient Ingestion of food along with certain medications may affect absorption of that drug or vice versa

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AIDS, contd

Specific nutrition recommendations include:

Efavirenz (Sustiva)

Avoid taking with high-fat meals Moderate-fat meals increase availability of capsules Take with food

Lopinavir (Kaletra) + ritonavir (Norvir)

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Saquinavir (Invirase)

Take within 2 hours of meal of high-fat foods or large snack containing carbohydrate, protein, or fat Taking with food may decrease abdominal cramping and diarrhea common when this drug initially prescribed Symptoms usually disappear within 8 weeks

Ritonavir (Norvir)

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Indinavir (Crixivan)

Taken on empty stomach Meal can be eaten 1 hour after drug or 2 hours before drug For some, may be necessary to eat small snack with drug, but fat should be avoided

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Prevention of foodborne illness

Crucial component of nutrition therapy and education for HIV/AIDS

As CD4 counts fall, higher risk for infections from foods

Nutrition education focus on safe methods for food purchasing, preparation, and storage

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AIDS, contd

Low microbial diet prescribed with recommendations to avoid:

Undercooked meats and eggs Raw vegetables Fruits

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Physical activity

Regular aerobic exercise and resistance training assist with:

Lipid abnormalities Fat redistribution syndrome Other body composition changes

Recommendations individualized and initiated slowly after physicians approval

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