Nutritional Assessment and Intervention in Cancer

Question 1

What are the consequences of compromised status?

Answer 1

A compromised status usually results in reduced intake due to an altered metabolism leading to malnutrition and weight loss which leads to an overall decrease in quality of life, decreased response to treatment and decreased rates of survival.

Question 2

What are benefits of assessing nutrition in cancer patients?

Answer 2

Early id of patients at risk or experiencing malnutrition allows for early intervention

Helps design appropriate nutritional support

Improves patient wellbeing, survival, immune function and reduce morbidity

improves eligibility and response to treatment

Question 3

Why is it important to improve eligibility and response to treatment?

Answer 3

If a patient is too undernourished/weak they may not be able to take part in certain cancer treatments due to their body not being able to handle the level of toxicity that would be likely to be encountered during these treatments.

Question 4

What is the most powerful independent variable that predicts mortality in cancer patients?

Answer 4

Unintentional weight loss as it is the prime clin manifestation of cachexia.

Question 5

What classifies cachexia based on weight loss in previous 6 mo?

Answer 5

Mod >5%
Severe >10%
V Severe >15%

Question 6

What are the classifications of significant and severe weight loss?

Answer 6

1wk: Sig 1-2; Sev >2
1mo:Sig 5; Sev >5
3mo: Sig 7.5 Sev >7.5
6mo: Sig 10; Sev >10
Unltd: Sig 10-20 Sev>20

Question 7

What is the best anthropometric marker to determine muscle mass? What is the bone corrected and low value?

Answer 7

MAMA; bone correction: men MAMA -10; Women MAMA - 6.5

Low MAMA : <15th percentile for age and sex

Question 8

What is urinary creatinine?

Answer 8

It is a metabolite of creatine phosphate mainly found in skeletal muscle
Proportional to muscle mass, must account for higher/lower muscle mass when determining actual creatinine excretion

Question 9

What is 3 methylhistidine and what is it a marker of?

Answer 9

It is released from actin and myosin degradation → marker of myofibrillar protein degradation ( ~ 90% skeletal muscle protein)
3-MH/creatinine ratio

Question 10

What are the limitations of Urinary creatinine and 3-methyl-Histidine?

Answer 10

• Wide day2day variation

- Both require 24h urine collection and 3 day meat free diet prior

Question 11

What is bioelectrical impedance used for? What are the limitations?

Answer 11

Est of fat-free mass (body fat by diff)

Limits:
- Reliable only if hydration status is normal

• Built-in equations not validated for malnourished or sick persons

Question 12

What measurement tool is the best for lean mass? What does it measure?

Answer 12

DXA → measures bone,soft and fat tissues → total lean body mass and appendicular muscle mass

Anything measured with DXA in the trunk region (full body and segmented measurements) will include all organs, tumours, metastasis therefore when you take total mass it could be misleading.

Question 13

Why is muscle strength a good measurement?

Answer 13

Grip strength is an indicator of nutritional therapy and decreasing grip strength can indicate muscle mass loss even before it is noticeable. This is likely due to both the improvements in muscle mass but also the neuromuscular health of muscles/nerves, etc…It is also highly accurate. Cut-offs for low strength : M <35kg, W > 23kg

Question 14

Describe the functional tests that are used mainly for geriatric patients but can be applied to patients with chronic diseases.

Answer 14

Gait speed :
walking speed < 0.8m/s in 4-m walking test
Best predictive marker of morbidity and mortality

Chair Rise:
Time to rise 5 times from chair without help from arms
Test leg strength and power

6-min walking test:
Distance walked during 6 minutes
Endurance test

Balance test:
Time standing on one foot or one foot in front of the other

Question 15

Why is it important to identify signs of dehydration? What are these indications and their significance?

Answer 15

In order to gain a valid interpretation of lab results

Indications: 
High blood conc of: 
Blood electrolytes 
Blood urea N
Creatinine 
CBC: hematocrit 

Urine specific gravity

Clinical signs:

Low BP especially orthostatic(sleeping/lying down);
rapid heart rate, skin dryness and lack of elasticity,
dry mouth and lips, confusion, thirst

Question 16

What should a nutritional assessment of patients with cancer include at the minimum?

Answer 16

Dietary assessment (usual/24h)

Weight loss history

Body comp

PG-SGA (review of symptoms, level of function)

Biochem data: albumin, CRP, prealb, hemoglobin, others if suspected nutrient deficiencies

Muscle Strength

Physical exam

Question 17

What are some potential nutritional diagnosis and their potential causes?

Answer 17

Involuntary weight loss:
Increased energy and protein demands
Reduced food intake due to dysphagia, taste aversions, inability to prepare foods

Malnutrition:
Altered GI function
Reduced food intake
Unsupported beliefs/attitudes about foods

Dehydration:
Insufficient fluid intakes

Question 18

What are important aspects of nutritional counseling and what should be the goals of the approach?

Answer 18

Individualized, provide adequate energy and protein
Consider multivitamin/mineral supplements, omega-3 FA
Adapt dietary strategy according to : appetite, rounds of therapy, symptoms, accessible route of feeding
Encourage physical exercise

Goals of approach:
Increase lean body mass/weight stabilization is also a success
Predispose to better response to radio or chemo therapy
Increase immunocompetence
Symptom management
Improve perception of well-being

Question 19

What would be the nutritional approach and interventions for managing Nausea and Vomiting?

Answer 19

CINV - chemo induced nausea and vomiting
Can also be caused by delayed gastric emptying
Usually prescribed anti-emetics (30-45 min before meal even if N&V symptoms not present)
Recommended nutrition therapy is to eat small, low-fat meal the morning of the first treaments and to avoid fried, greasy, and fav foods for severalk days followign the treatment → clear-liquid diet for the first 24hrs after therapy may be indicated
Also avoid ingestion of favorite foods as once a fav food has been vommed the likelihood of its subseq consumption is low

Question 20

What would be the nutritional approach and interventions for managing Early Satiety?

Answer 20

Primary cause is delated gastric emptying
Important for patient with early satiety to eat small, frequent meals that are nutrient dense
Consumption of raw veggies and high fibre foods should be avoided

Question 21

What would be the nutritional approach and interventions for managing Mucositis?

Answer 21

Stomatitis is irritation and inflammation of the epithelial cells of the mucosal membranes lining the GI tract
Mucositis -associated pain is the main source of cancer treatment
Symptoms include:
pain and burning with chewing and swallowing
Narcotic analgesics may be reqd for pain
Nutrition ed to provide guidelines for eating until mucositis resolves.
Should be encouraged to eat only soft, non-fibrous, non-acidic foods; avoid hot foods as it can burn the mucosa; liquids and non-acidic juices should be recommended

Question 22

What would be the nutritional approach and interventions for managing Diarrhea?

Answer 22

Encourage to drink small amounts of fluid frequently throughout the day
Large doses of fruit juice should be avoided as fructose can exacerbate diarrhea
Clear liquid nutritional bevs should be recommended and antidiarrheal meds should be prescribed

Question 23

What would be the nutritional approach and interventions for managing Dysgeusia?

Answer 23

Alterations in taste that can greatly affect a patient’s ability to ingest an adequate amount of nutrition
If metallic taste, avoid metal utensils
If meat not tolerated, adequate protein intake in the form of alts(pb, cheese, etc..)
Ageusia (no taste) encouraged to use more highly spiced and flavorful foods
Sweet foods often taste too sweet therefore alt may be to have patient add non-sweet glucose supplement such as Polycose

Question 24

What would be the nutritional approach and interventions for managing Xerostomia?

Answer 24

Reduced saliva production
May be treated using artificial saliva or mouth moisturizers (gels, lozenges, mouthwashes)
Sugar-free gum found to be most effective at inducing salivation when compared to artificial saliva also cheaper

Question 25

What would be the nutritional approach and interventions for managing anorexia?

Answer 25

Prevalence of anorexia in cancer patients upon diagnosis estimated to be appx 50% and reduced food intake frequently reported in cancer patients
O3FA may stabilize weight in cancer patients on oral diets experiencing progressive, unintentional weight loss
smaller , more frequent meals
Max intake when appetite is most normal
Limit fluid with meals to avoid feeling of fullness
Keep favorite foods readily avaiable at all times
Mild exercisem as tolerated
Eat meals ina pleasant environments
Glass of wine before a meal may help stimulate the appetite
Avoid noxious odors
Try relaxation exercises before mealtimes

Question 26

What is the preferred form of nutrition before and after surgery?

Answer 26

Before: nutrition support before surgery may be beneficial in moderate or severely malnourished patients if administered for 7-14days preoperatively, but the benefits of nutrition support must be weighed against its potential risks

Post op: enteral nutriiton preferred as there are less risks for complication

Question 27

When is prophylactic tube feeding recommended?

Answer 27

5% weight loss over the prior month, 10% weight loss over 6mo
Ongoing dehydration or dysphagia, anorexia, pain that interferes with the ability to eat/drink adequately
Significant comorbidities
Severe aspiration or mild aspirartion in patients >65
High risk of long term swallowing disorders

Question 28

What is the nutritional approach for hematopoietic cell transplantation?

Answer 28

Additional guidelines:
Nutrition support appropriate in patients undergoing hematopoetic cell transplantation who are malnourished and who are anticipated to be unable to ingest and/or absorb adequate nutrients for a prolonged period of time
Enteral nutrition should be used in patients with a functioning GI tract for whom oral intake is inadequate to meet nutrition requirements
Pharma doses of parenteral glutamine may benefit patients undergoing hematopoietic cell transplantation
Patients should receive dietary 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 who develop moderate to severe graft-versus-host disease accompanied by poor oral intake and/or significant malabsorp

Question 29

What are some general guidelines to determine nutrient requirements for cancer patients?

Answer 29

Aim to maintain current weight/prevent treatment or disease-associated loss
Obese: 21-25kcal/kg
Non-ambulatory/sedentary adults: 25-30kcal/kg
Slightly hypermetabolic patients: 30-35kcal/kg
Hypermetabolic or severely stressed patients/ malabsorption: 35kcal/kg or greater