About Julie Julie LG Lanford

MPH, RD, CSO, LDN

• Wellness Director at

Cancer Services, Inc.

• RD since 2005

• 90% of my career working in

oncology.

• Developed website in 2007

My Inspiration

About You!

Poll Question:

How much experience do you have with oncology?

A. I am someone who has personally experienced or cared for someone with cancer.

B. I assist clients who are facing cancer on a regular basis.

C. I assist clients who are facing cancer on an occasional basis.

D. I rarely see clients who are facing cancer.

Resources Significant content for this presentation

comes from:

•Oncology Nutrition for Clinical Practice

•Academy of Nutrition and Dietetics

Evidence Analysis Library

•American Institute for Cancer Research

Objectives

1. Identify 3 common side effects for people facing cancer.

2. Identify nutrition related strategies to assist in managing common cancer related side

effects.

3. Identify 3 common cancer nutrition myths and the corresponding truths.

4. Identify one current recommendation regarding diet for cancer survivors.

Nutrition During Treatment

Clients need to be educated

on the role of nutrition.

• some think it doesn’t matter

• some think it can cure cancer

• most are somewhere in

between

Nutrition During Treatment

RD is uniquely trained to assist

with:

• Screening

• Assessment

• Evaluating nutrient needs

• Symptom management

" Research indicates that poor nutrition status is

associated with higher rates of hospital admissions or

readmissions, increased length of hospital stay, lower

quality of life and mortality in adult oncology patients.

Poor nutrition status is also associated with decreased

tolerance to chemotherapy and radiation treatment.“

- AND Evidence Analysis Library

Nutrition Screening • Identify highest risk

• Prompt RD referral

• Most popular tool for oncology = Patient Generated - Subjective Global Assessment (PG-SGA)

• QUESTIONS TO CONSIDER:

• Who screens?

• How much staff time?

• how to triage?

Nutrition Screening

Screening

should

include:

Height and weight and/or BMI

Weight change

Presence of co-morbidities

Disease severity

Presence of appetite

Assessment

In oncology, malnutrition = under nutrition and/or in body composition

d/t cancer or impact of treatment +/- cancer cachexia.

Cancer Cachexia

% Weight Loss Time Period

>5% 1 month

>7.5% 3 months

>10% 6 months

>20% 1 year

SEVERE MALNUTRITION:

"As part of monitoring and evaluation, 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 unintended weight loss, the RDN should monitor

and evaluate nutrition impact symptoms, markers of

inflammation and other signs of wasting, which may

indicate pre-cachexia or cancer cachexia.“

- AND Evidence Analysis Library

Up to 80% of patients with advanced cancer

may be diagnosed with cancer cachexia

Weight Loss Anorexia and weight loss prior to diagnosis = Up to 40% Already experienced significant weight loss.

up to 80% of upper GI cancer patients 60% of lung cancer patients

Experience malnutrition during treatment = b/t 40% and 80% 6% + wt loss =

response to treatment survival quality of life.

Weight Gain Not all cancer patients lose weight!!! ACS guidelines “… there appears to be no

contraindication to modest weight loss (2 pounds a week or less) during treatment.” Detrimental to long term prognosis of breast cancer.

Energy

Needs:

Estimating Energy Needs Indirect calorimetry:

REALLY???

Healthy individuals:

Mifflin-St Jeor, Harris Bendict

and DRIs.

Acutely Ill:

Mifflin-St. Jeor and Ireton-Jones

Most RD’s estimate energy needs based on body weight…

Macronutrient Needs

CHO

45-65%

Fat

20-35%

Protein

10-25%

ENERGY NEEDS:

• Use actual weight

• Cancer, repletion, weight gain:

30-35 kcal/kg

• Cancer, inactive, non-stressed :

25-30 kcal/kg

• Cancer, hypermetabolic, stressed:

35 kcal/kg

• ? Obese: 15-25 kcal/kg

ALWAYS monitor weight and intake to adjust

recommendations

Macronutrient Needs

PROTEIN NEEDS:

• Using actual weight

• Healthy individuals: 0.8 g/kg/day

• Catabolic individuals: 1.2 - 2.0 g/kg/day

• Metabolically stressed: 1.5 g/kg/day

• Generally for cancer: 1.0 - 1.5 g/kg/day

Monitor labs, weight, intake and adjust recommendations.

Micronutrients

Levels may or may not indicate an deficiency.

Micronutrient deficiencies in an already ill person

can cause:

o muscle weakness,

o poor wound healing

o altered immunity

Aim for an intake of 100% of the RDAs

Symptom Management

Symptom Management

Better Nutrition

Improved Outcomes

Happier Patient,

Happy Medical Team!

Poor Appetite/Early Satiety

Poor Appetite/Early Satiety

Key Messages for Clients

• Small, frequent meals

• Caloric density

• Avoid stress at meals

• Eat by the clock

• See eating as part of treatment

• Medical nutrition beverages

• Light physical activity =

appetite

• Easy to prepare foods

Things for RD to monitor

• Evaluate for conditions that may depress

appetite or slow gastric emptying.

• Evaluate use of medications that depress

appetite or slow gastric emptying.

• Work with medical team for meds to

manage appetite, increase gastric emptying

or manage constipation

Fatigue

Fatigue

Key Messages for Clients

• Use easy to prepare meals, snacks,

• Energy dense foods.

• Snacks at bedside.

• Easy to chew foods.

• Small, frequent meals.

• Eat well when appetite is best

• Limit "duties or chores”

• Encourage light activity

Things for RD to monitor

• Monitor weight and modify intake plan as

needed to stabilize weight.

• Consider physical therapy consult for

strengthening

• Evaluate for anemia

• Consider use of mvi and mineral

supplement

Constipation

Constipation

Key Messages for Clients

• 8 cups of fluids/day

• 25-35g fiber

• Hot beverage, hot cereal or high fiber food

• Probiotics and/or other supplements

• Physical activity and/or stretching

• Allow enough bathroom time

Things for RD to monitor

• Educate patient on importance of adequate

hydration, fiber intake and total food intake.

• Discuss medications

• Encourage appropriate use of stool softeners as

needed.

• Contact medical team if no bowel movement for 3

days.

• Work with medical team for meds to manage

constipation

Diarrhea

Diarrhea

Key Messages for Clients

• Small frequent meals

• Low-fat, low fiber diet

• Diet and symptom history

• Avoiding gas producing foods, caffeine and

alcohol.

• Consider bulking agents, pectin or soluble fiber

foods

• Avoid sorbitol or other sugar-alcohols

Things for RD to monitor

• Consider use of mvi and mineral

supplement to make up for losses and

malabsorption

• Work with medical team for meds to

manage diarrhea

Nausea/Vomiting

Nausea/Vomiting Key Messages for Clients

• 5-6 small meals/day

• Limit exposure to food smells

• Eat cool foods

• Avoid greasy, high fat foods

• Consume fluids between meals

• Avoid strong smells

• Rest with head elevated after eating.

• Take nausea medicine as prescribed

• Take pain meds with crackers or light food.

Things for RD to monitor

• Work with medical team to adjust meds for nausea

symptoms around meals and to minimize sleepiness.

Taste/Smell Changes

Taste/Smell Changes

Key Messages for Clients

• Rinse mouth or brush teeth before eating.

• Little or no taste = seasonings

• "off" taste = Fruity and salty flavors; sugar

free lemon drops, gum or mints

• Bitter or metallic tastes = no metal

silverware; flavor water with lemon

• Salty, bitter, or acid taste = naturally sweet

foods

• Meats tastes bitter or strange = Add marinade

or sweet and sour sauce; choose alternative

protein sources

• Smells bother = cool foods; use cup with lid

and straw to mask odors.

Taste/Smell Changes

Things for RD to monitor

• Check mouth for thrush

• Consider zinc in form to provide 50mg elemental zinc.

• Oral hygiene rinse recipe:

• 3/4 tsp salt and

• 1 tsp baking soda in

• 4 cups of water.

• Rinse mouth with 1 cup 3-4x/day or as directed by physician.

Malabsorption

Malabsorption

Key Messages for Clients

• Bloating/Gas = avoid cruciferous vegetables and limit swallowed air

• Bloating cramping and gas from milk = eat a low lactose diet

• Gas from beans/legumes = avoid these foods or use beano

• Chronic diarrhea = low insoluble fiber, low fat, low lactose diet

• Bulky, foul smelling stools = low fat diet; use pancreatic enzymes

• Fatty stools = low fat diet; use pancreatic enzymes

Malabsorption

Things for RD to monitor

• Conduct a thorough diet and symptom history to determine cause

• Evaluate for use of medications that may influence GI function

• Ensure proper dosage of pancreatic enzymes:

Should be given with each meal or snack that contains fat.

4,000 units of lipase per 5-7g of fat or 30,000 - 40,000 lipase units per meal

10,000 lipase units per snack, or 500 lipase units/kg with meals increasing as

tolerated.

Do not exceed 2500 lipase units/kg body weight/meal.

Mucositis/Esophagitis

Mucositis/Esophagitis

Key Messages for Clients

• Lower in acid

• Less spicy

• Soft, with added sauce or gravy

• Cool temperature

• Smoothies with low acid fruits

• Avoid alcohol and alcohol containing

mouthwashes and tobacco.

Things for RD to monitor

• Work with medical team for meds to manage pain

(lidocaine gel, spray or rinse)

• Sore throat gargle recipe:

• 3/4tsp salt

• 1tsp baking soda

• 4 cups water

• Gargle with 1 cup, 3-4 times/day

• Glutamine rinses 5g 3x/day

Xerostomia/Thick Saliva

Xerostomia/Thick Saliva

Key Messages for Clients

• Frequent, small meals.

• Add broth, gravies and sauces to meals

• Sip liquids often throughout the day; aim for 8-10 cups

per day.

• Chew on carrots or celery

• Swish and spit with club soda or carbonated water.

• Use a humidifier at home to moisten air

• Practice good oral hygiene.

• Suck on hard candy, frozen grapes or melon balls

• Avoid alcohol and alcohol containing mouthwashes.

Things for RD to monitor

• Monitor for fluid loss (weight loss of >2 pounds

per week)

• Some clients find relief from Biotene gel, liquid

and spray

Moving to Part 2! Questions?

• After treatment is over, survivors should follow the recommendations for cancer risk reduction.

• No problems with nutrition related side effects? = perfect time to focus on creating/maintaining a healthy lifestyle!

Eating Well Beyond Cancer

Nutrition & Survivorship

Nutrition & Survivorship

• Not a guarantee.

• What we eat and how we live can help short-

circuit the cancer process.

• After cancer has developed, several nutrients

also have been shown to delay its progression

BREAK!!!

• MYTH: Sugar Feeds Cancer.

• FACT: All our cells, cancerous or not, use

glucose for energy. Our body doesn’t pick and

choose which cells get what fuel.

MYTH #1

• MYTH: Acidic diets

cause cancer.

• FACT: There’s no good

evidence to prove that

diet can manipulate

whole body pH, or

that it has an impact

on cancer.

MYTH #2

• MYTH: People With Hormone Positive Cancers

Should Avoid Soy and Flax.

• FACT: Major population studies show that

eating soy in moderate amounts - 1 to 2

standard servings a day - does not increase a

woman’s risk for recurrence or death, and does

not show harmful interaction with anti-estrogen

medications.

MYTH #3

• MYTH: Pesticides cause cancer so you should

eat organic.

• FACT: No studies have shown that people who

consume organic foods have better health

outcomes.

MYTH #4

• MYTH: Superfoods prevent

cancer.

• FACT: There’s no such thing as a

‘superfood’. It’s a marketing term

used to sell products and has no

scientific basis. It’s gross

oversimplification to say that any

one food, on its own, could have

a major influence over your

chance of developing cancer.

MYTH #5

• RECOMMENDATION: Eat more

of a variety of vegetables,

fruits, whole grains and

legumes such as beans.

• WHY? Plant foods give

important nutrients called

phytochemicals, which is the

basis for a cancer fighting diet.

They can neutralize damage to

cells (antioxidants) and

support the immune system.

TRUTH #1

• RECOMMENDATION: Avoid sugary drinks. Limit consumption

of energy-dense foods.

• WHY? The myth that 'sugar feeds cancer' is not completely

true. However, regularly consuming sugary drinks contributes

to weight gain. Water is the best alternative. Unsweetened

tea and coffee are also healthy options.

TRUTH #2

• RECOMMENDATION: Limit consumption of red meats (such as

beef, pork and lamb) and avoid processed meats.

• WHY? The experts found convincing evidence that red meat is

a cause of colorectal cancer and choosing processed meat

increases the chances of colorectal cancer.

TRUTH #3

• RECOMMENDATION: If consumed at all, limit alcoholic

drinks to 2 for men and 1 for women a day.

• WHY? There is convincing evidence that alcohol increases

the risk of cancer of the mouth, pharynx, larynx, esophagus

and breast, as well as colorectal cancer in men. Alcoholic

drinks also probably increase the risk of colorectal cancer in

women as well as liver cancer.

TRUTH #4

• RECOMMENDATION: Limit consumption of salty foods and

foods processed with salt (sodium).

• WHY? The expert panel found that salt and salt-preserved

foods probably increase the chance of developing

stomach cancer. Studies have shown that high salt intake

can damage the lining of the stomach.

TRUTH #5

• RECOMMENDATION: Don't use supplements to protect against

cancer.

• WHY? To reduce your risk of cancer, choose a balanced diet with a variety of foods rather than taking supplements.

OR

TRUTH #6

Food or Pills?

• RECOMMENDATION: Be as lean as possible without

becoming underweight.

• WHY? Maintaining a healthy weight is one of the most

important things you can do to reduce your risk of cancer.

We also know that where we store extra weight affects

cancer risk.

TRUTH #7

• RECOMMENDATION: Be physically active for at least 30

minutes every day. Limit sedentary habits.

• WHY? Our bodies function best when we are using them.

Physical activity has been proven to reduce cancer-related

fatigue, improves our mood and helps keep our

metabolism at a healthy level.

TRUTH #8

Phytochemicals

• Color Matters

• Found in food. NOT pills.

• The more the better

Phytochemicals

• Frosted Flakes

• Coffee

• OJ

• Nabs

• Cheeseburger

• Fries

• Coke

• Candy bar

• Chicken

• Green beans

• Potatoes

• Salad

• Ice cream

• Oatmeal with fruit

& Cinnamon

• Green smoothie

• Green tea

• Yogurt + fruit

• Sandwich with

Hummus & veggies

• Minestrone Soup

• Fruit

• Trail mix

• Veggie pizza with

kale salad

• Chocolate avocado

pudding

Typical American vs Healthy Survivor

MEAT

Refined starch Protein

(animal or plant

based)

Veggies & Fruit

whole

grain

THE PLATE

Typical American vs Healthy Survivor

• Eating enough calories and protein will help keep your muscles and immune system strong.

• Optimize within the challenges you are facing.

• Add calories with healthy fats.

• Focus on ALL areas of wellness.

Challenges of Treatment

• No single food or food substances can cause cancer.

• Is it a habit? • The 80/20 Rule

BALANCE

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Connect Online!

My Favorite Resources •American Institute for Cancer Research: www.aicr.org - The best resource for the latest

evidence based information on nutrition and cancer.

•Center for Science in the Public Interest Nutrition Action Healthletter - www.cspinet.org.

They have an awesome guide to food additives at www.chemicalcuisine.org.

•WebMD – www.webmd.com

•Today’s Dietitian Magazine – www.todaysdietitian.com

•Environmental Nutrition - www.environmentalnutrition.com

•Meals to Heal – www.meals-to-heal.com

References • Maureen Leser, et al. Oncology Nutrition for Clinical Practice. Oncology Nutrition Dietetic

Practice Group, 2013. Print.

•Academy of Nutrition and Dietetics Evidence Analysis Library Oncology Project website.

https://www.andeal.org/topic.cfm?menu=5291. Accessed June 14th, 2015.

• American Institute for Cancer Research website.

http://www.aicr.org/research/research_science_expert_report.html. Accessed June 14, 2015.

• Rock, CL, Doyle, C, et al. Nutrition and Physical Activity Guidelines for Cancer Survivors: CA: A

Cancer Journal for Clinicians. Volume 62, Issue 4, pages 242–274, July/August 2012.

Q&A