Laura A. Stokowski, RN, MS
November 20, 2013
Full Story: http://www.medscape.com/viewarticle/814581
Editor’s Note:
In this 2-part series, Medscape looks at diet as an essential therapeutic strategy for cancer patients. Part 1 focuses on the nutritional assessment of cancer patients, foods that help patients cope with side effects, and ways to make fortifying foods more appealing to the cancer-dulled appetite. Part 2 looks at extreme nutrition and the growing interest in fighting cancer with food.
Speaking to Medscape on these topics are 2 high-profile cancer nutrition and food experts. Suzanne Dixon, MPH, MS, RD, is a dietician, author, speaker, and internationally recognized expert in chronic disease prevention health, and cancer nutrition. Rebecca Katz, MS, is a chef; nutritionist; national speaker; and award-winning author whose books include One Bite at a Time, The Cancer-Fighting Kitchen, and The Longevity Kitchen.
Nutrition Affects Cancer Outcomes
After receiving a diagnosis of cancer, a patient’s thoughts often turn to treatment options and prognosis. Many patients face surgery, radiation therapy, chemotherapy, or a combination of those strategies. Most of their questions and concerns are about how they will get through it all.
Nutrition is not likely to be on their list of immediate concerns, but it should be. Not only will patients reap the benefits of being healthier and better able to withstand treatments and side effects, but mental outlook and quality of life can be improved by taking control of one’s nutritional health. Patients might have little control over their disease, but what they eat remains under their own purview, and deciding to eat well and taking the steps to do so is empowering.
“The days when healthcare professionals could just tell cancer patients to eat whatever they want, and not to worry about what they eat, are over,” says Rebecca Katz, author of The Cancer-Fighting Kitchen. [1] “Patients are starting to rebel against that. They are realizing that what you eat can make a difference in how you feel, your outcomes, the side effects you experience, and how well you will get through treatment. We need to acknowledge that food is important.”
No “One Size Fits All” Strategy
Good nutrition is important. But what exactly is good nutrition for the patient with cancer? Does it differ from general recommendations for good nutrition in anyone?
Little consensus exists on dietary recommendations for patients with cancer.[2] Because so many patients turn to online sources for health-related information, a recent study reviewed the online recommendations published by 21 cancer centers. Only 4 centers provided nutritional guidelines, one half of which recommended a low-fat diet and one half a high-calorie diet. The same study reviewed nutrition guidelines on other cancer-related Websites and found no consistency in dietary recommendations. Such words as “healthy” and “balanced” are often used, but seem to be defined differently.
Suzanne Dixon believes that basic good nutrition guidelines are appropriate for some cancer patients, but when looking at the entire spectrum of cancers, huge differences become apparent in the ability of patients to take in and absorb enough of the right kinds of nutrients. On one end of the spectrum are patients with head and neck cancers, pancreatic, and often lung cancer; metastatic disease; and those undergoing treatments for advanced cancers, who have enormous difficulty maintaining adequate nutrition. Addressing these issues is vital, because poor nutritional status goes hand-in-hand with suboptimal outcomes. On the other end of the spectrum, patients with some cancers (particularly breast and prostate) can have “poor nutrition” of an entirely different nature and actually experience excessive weight gain, which also is associated with poorer prognosis.
The bottom line, explains Dixon, is that “you can’t lump all cancer patients together. Nutritionally speaking, the breadth of needs and issues in cancer is huge.”
Periodic Nutrition Screening
The fact that patients with different types of cancer will have different nutritional concerns supports the critical need for nutrition screening and assessment — not just at the outset of cancer treatment, but periodically as the patient progresses through treatment, when new problems can crop up.[3] Unfortunately, says Dixon, although it might be available in some cancer centers, nutrition screening is not a universal component of cancer care, especially in outpatient settings.
The tendency has been to wait until nutrition becomes a problem before intervening, but a push is now on to integrate nutrition screening and referral to a qualified cancer dietitian — if possible, a Certified Specialist in Oncology Nutrition (CSO) — earlier in the course of care. Patients with certain types of cancer are likely to experience specific nutritional problems that are more effectively prevented than treated after the fact. Symptoms and adverse effects of treatment might respond to dietary interventions alone, but often require pharmacologic management as well.
However, most centers don’t have enough dietitians to see every patient, so screening is inconsistently conducted. “We would like it to be a standard of care that nutrition screening is part of the initial assessment of all patients with cancer,” says Dixon.
Nutritional Solutions to Side Effects
“The huge revolution in management and amelioration of cancer treatment side effects and new treatment protocols has changed how we manage patients nutritionally,” says Suzanne Dixon. “We have better medications to treat nausea, for example, than we ever had before, but remember that with the organ-sparing protocols often used today in head and neck cancers, we are seeing more side effects, such as mucositis and dysphagia, that can impair the ability to eat.”
Still, some treatment-related effects continue to plague patients with cancer. Diarrhea and constipation are common problems. Some of the antiemetic agents used to treat nausea and vomiting, as well as many pain medications, are constipating. “We are getting better at putting patients on some type of laxative or agent to prevent constipation at the time patients start taking these drugs. It’s tough, because some patients will resist taking more pills. They think they will just wait and take the laxative if they have a problem, and then they end up with fecal impaction. Patient and family education is very important — they need to know that this is not your garden-variety constipation. It must be prevented, and there are many options. Some patients are simply too embarrassed to mention this to their doctor.”
It’s important to assess the patient with constipation, however, and not just assume that constipation is a side effect of their medications. For instance, adhesions or small-bowel obstructions could be anatomical causes of constipation, and the nutritional management of these will be quite different.
Food can help ameliorate some of these side effects. In The Cancer-Fighting Kitchen, Rebecca Katz lists specific foods that can be recommended to patients experiencing many of the common side effects of cancer treatment. For constipation, Katz recommends consuming warm fluids, such as herbal teas and broths, and foods rich in fruits and vegetables. Diarrhea can be reduced with such foods as oatmeal, polenta, and rice.
Dysgeusia, or altered sensation of taste, is a common oral side effect of cancer therapy.[4] Few effective treatments have been found for this side effect, which can significantly affect a patient’s quality of life. Katz believes that if you know the right techniques, you can restore good taste to food for these patients. She developed an acronym — FASS — which stands for fat, acid, salt, and sweet. These 4 flavors (what Katz calls “fast fixes for taste-bud troubles”) can make food taste better when a patient is experiencing dysgeusia. Food tastes best when these 4 flavors are in balance.
Here’s how it works. For patients who have a persistent metallic taste in their mouths, or who find that foods taste bitter, a little sweetener (Katz recommends grade B organic maple syrup) can counteract the bad taste. If food tastes too sweet, patients should add a few drops of acid (lemon or lime juice). Lemon juice also balances the taste of overly salty foods. If the patient complains that all food is tasteless, or “tastes like cardboard,” the best fix is adding a little sea salt, and possibly a spritz of lemon juice. Patients with mucositis, however, might find the addition of salt or citrus painful. For those with mouth sores or difficulty swallowing, Katz suggests soothing, nonspicy foods, such as broths, soups, and smoothies.
Avoiding Weight Loss or Gain
Cancer can be associated with involuntary weight loss, which according to Dixon, as a sign of malnutrition, is a “huge red flag.” Moreover, in some cancers (eg, upper gastrointestinal tract cancers and lung cancer), unintentional weight loss may have begun before the diagnosis, so the patient is starting treatment in a state of nutritional deficiency.
Dixon spends a lot of time explaining to patients (even those who would like to lose a few pounds) the importance of avoiding unintentional weight loss during treatment. “Normally,” she explains to patients, “if you go on a diet, first your body burns equal parts lean and fat tissue. Eventually, the enzymes needed for fatty acid oxidation are released, and you shift to burning fat. But if you superimpose any type of inflammatory process, such as chemotherapy, surgery, or the presence of a tumor, those enzymes are suppressed. The shift to burning fat doesn’t happen, and you will continue to burn lean muscle mass, leading to weakness and fatigue.” Depletion of muscle mass is a poor prognostic indicator in cancer, regardless of body mass index.[5] Even overweight or obese patients with some types of cancer are at risk for the negative effects of malnutrition and unintentional weight loss.
The flip side, says Dixon, is the phenomenon of weight gain in some cancers, particularly breast and prostate cancer, and in some patients with colon cancer. The reasons are multifactorial and include the effects of hormone-based treatments, fatigue, altered sleep patterns, a tendency to be more sedentary, and not exercising as much during cancer treatment as they normally would.
Some patients might pay less attention to a healthy diet after a cancer diagnosis, and body weight begins to creep up. Postdiagnosis weight gain of this type should be avoided, cautions Dixon, because it is associated with increased risk for cancer recurrence and mortality. For patients prone to gaining weight after a cancer diagnosis, Dixon advocates a healthy diet of vegetables, fruits, whole grains, and low-calorie foods; aerobic activity, such as walking; and other exercise, such as training with elastic resistance bands.
Is it ever OK to lose weight during or after cancer treatment? Yes, says Dixon. “The key is whether the weight loss is voluntary or involuntary. This point is often misunderstood. The new cancer survivorship guidelines from the American Cancer Society even say that if obese or overweight cancer patients are on a healthy diet and exercising, losing a little weight intentionally is fine, even during treatment.”[6]
Combating Anorexia
One of the most well-described nutritional problems in patients with cancer is anorexia, which is the loss of the desire to eat. Underlying causes of this common symptom include psychological factors (stress, anxiety, depression), tumor factors (altered metabolism, pain, early satiety, dysmotility, swallowing difficulty) and treatment factors (fatigue, nausea, chemosensory alterations, mucositis).
Loss of appetite can contribute to cachexia — a profound metabolic derangement with a heterogeneous clinical presentation that results in loss of lean body mass. A recent international consensus defined cachexia as a “multifactorial syndrome defined by an ongoing loss of skeletal muscle mass (with or without loss of fat mass) that cannot be fully reversed by conventional nutritional support and leads to progressive functional impairment. Its pathophysiology is characterized by a negative protein and energy balance, driven by a variable combination of reduced food intake and abnormal metabolism.”[7] Cachexia often progresses through stages from precachexia to refractory cachexia.[7]
The diagnostic criterion for cachexia, established by international consensus, is weight loss > 5% (or > 2% in individuals already showing depletion of body weight or skeletal muscle mass).[7]Moreover, the wasting of skeletal muscle can occur even before overall weight loss becomes apparent, and despite the ingestion of adequate calories, tumor-related factors can interfere with maintenance of fat and muscle.[8] Although a secondary disorder, cachexia is often the proximal cause of death in patients with cancer.
“Weight loss shortens survival,” says Dixon, who emphasizes very early intervention for patients experiencing anorexia who are unable to ingest enough food. “These patients never feel hungry, so they need to eat by the clock or even ‘graze,’ eating small amounts of food all day,” explains Dixon.
But cachexia, she warns, can’t be reversed with calories alone. “Patients with more advanced cancers have deranged metabolisms. Their tumors can be a source of cytokines and signals that raise metabolism and suppress appetite. These patients often use fuel inappropriately. Instead of using fat for energy, tumors can create a situation in which the body uses lean tissue. You might be able to slow the process, but you can’t undo it, even with total parenteral nutrition. Medical therapies have been abysmal failures in these patients.”
This is why Dixon is a big advocate of screening, planning, and prevention. In some patients, this means a long-term feeding tube, usually a percutaneous endoscopic gastrostomy (PEG), for the administration of enteral feedings, should that become necessary. “Many patients are afraid of getting a PEG before they start treatment. Some will decide against the PEG, not realizing that the effects of radiation are cumulative. They make it through treatment, and they think they will start to feel better. However, many will hit their lowest point and become unable to eat weeks or even months after their treatment ends. If they have a PEG, they can start to use it at that point and continue for up to 6 months after treatment. For head and neck cancer patients with feeding tubes, consultation with a speech and language specialist is vital to develop a plan to preserve swallowing function.”
What about the patient who just doesn’t find any food appetizing? In this situation, Rebecca Katz turns to the oldest medicine known to man: warm, nourishing broth. She spent years developing the perfect recipe for “magic mineral broth,” which she calls the “ultimate culinary alchemy.” Magic mineral broth goes down easy, and patients find it very soothing. “It’s something that friends and families can make for the patient with cancer who is not feeling well; it’s like giving the body an internal spa treatment,” says Katz.
Magic mineral broth is a science-based, nutrient-dense concoction that can relieve many of the side effects of cancer treatment, such as nausea, vomiting, fatigue, and dehydration. It’s easy to swallow for patients with dysphagia. “A bowl of soup is appealing to almost anyone,” says Katz.
Recipe for Magic Mineral Broth
6 unpeeled carrots, cut into thirds
2 unpeeled yellow onions, cut into chunks
1 leek, white and green parts, cut into thirds
1 bunch celery, including the heart, cut into thirds
4 unpeeled red potatoes, quartered
2 unpeeled Japanese or regular sweet potatoes, quartered
1 unpeeled garnet yam, quartered
5 unpeeled cloves of garlic, halved
One-half bunch of fresh flat-leaf parsley
One 8-inch strip of kombu (a type of dried seaweed)
12 black peppercorns
4 whole allspice or juniper berries
2 bay leaves
8 quarts cold filtered water
1 teaspoon sea salt
Rinse the vegetables well, including the kombu. In a 12-quart (or larger) stockpot, combine all ingredients except salt. Fill the pot with water to 2 inches below the rim, cover, and bring to a boil. Remove the lid; reduce heat to low; and simmer, uncovered, for at least 2 hours. Add more water if needed to keep vegetables covered. Simmer until the full richness of the vegetables can be tasted. Strain through a large, coarse mesh sieve. Add salt to taste. Let cool to room temperature before refrigerating or freezing.
References
- Katz R. The Cancer-Fighting Kitchen. Berkeley, Calif: Celestial Arts; 2009.
- Champ CE, Mishra MV, Showalter TN, Ohri N, Dicker AP, Simone NL. Dietary recommendations during and after cancer treatment: consistently inconsistent? Nutr Cancer. 2013;65:430-439.
- National Cancer Institute. Nutrition in Cancer Care (PDQ®).http://www.cancer.gov/cancertopics/pdq/supportivecare/nutrition/HealthProfessional Accessed November 16, 2013.
- Hovan AJ, Williams PM, Stevenson-Moore P, et al; Dysgeusia Section, Oral Care Study Group, Multinational Association of Supportive Care in Cancer (MASCC)/International Society of Oral Oncology (ISOO). A systematic review of dysgeusia induced by cancer therapies. Support Care Cancer. 2010;18:1081-1087. Abstract
- Martin L, Birdsell L, Macdonald N, et al. Cancer cachexia in the age of obesity: skeletal muscle depletion is a powerful prognostic factor, independent of body mass index. J Clin Oncol. 2013;31:1539-1547. Abstract
- Rock CL, Doyle C, Demark-Wahnefried W, et al. Nutrition and physical activity guidelines for cancer survivors. CA Cancer J Clin. 2012;62:243-274. Abstract
- Fearon K, Strasser F, Anker SD, et al. Definition and classification of cancer cachexia: an international consensus. Lancet Oncol. 2011;12:489-495. Abstract
- Suzuki H, Asakawa A, Amitani H, Nakamura N, Inui A. Cancer cachexia — pathophysiology and management. J Gastroenterol. 2013;48:574-594. Abstract
(Adapted from The Cancer-Fighting Kitchen. Courtesy of Rebecca Katz)