The Washington Manual of Oncology, 3 Ed.

Nutritional Support

Re-I Chin • Amy Glueck • Carolina C. Javier

 I. IDENTIFICATION AND ASSESSMENT OF PATIENTS AT NUTRITIONAL RISK. Nutrition plays a supportive role in the care of the patient with cancer, whether the goal of therapy is curative or palliative. Nutritional interventions will maintain and preserve body composition and lean body mass, support functional status, and enhance the quality of life. Proactive assessments of nutritional status are essential to assure success in intervention and to improve patient outcome. Treatment modalities may have an impact on the nutritional status of the patient and increase the risk for weight loss and malnutrition. Oncology dietitians play a key role in optimizing nutrition for the cancer patient through counseling and education of patients and their families, and other members of the health-care team. The assessment and nutritional surveillance of the patient with cancer can help meet therapeutic goals.

1. NUTRITIONAL ASSESSMENT. Nutritional assessment is an essential component in the nutritional care of the patient with cancer, because it will provide an estimate of body composition, such as fat, skeletal muscle protein, and visceral protein. It will likewise identify patients who are at risk of cancer-induced malnutrition and determine the magnitude of nutritional depletion in patients who are already malnourished.
2. Patient history and examination. Information that pertains to the patient’s medical history and physical examination will reveal usual body weight, any recent weight change, or inclusion of new or special diets. Unintentional weight loss of 10% or more of body weight within the previous 6 months could mean a significant nutritional deficit and is a good indicator of clinical outcome. Signs of malnutrition such as muscle wasting, loss of muscle strength, and depletion of fat stores may be revealed by a physical examination. However, body weight alone is insufficient as a nutritional assessment tool and will fail to show important changes in disease or therapy-related caloric intake or metabolic rate.

 In addition, detailed information should be obtained regarding change in appetite, food intake, gastrointestinal problems, and concomitant disease.

1. Anthropometric assessment. Anthropometric measurements are often used in the assessment of nutritional status, particularly when a chronic imbalance occurs between protein and energy intake. Such disturbances change the patterns of physical growth and the relative proportions of body tissues such as fat, muscle, and total body water. The measurement of the triceps skinfold (TSF) is used to calculate an estimation of fat stores, whereas the midarm muscle circumference (MMC) (includes the basic anthropometrics of weight and height) assesses lean body mass MMC (cm) = Arm circumference (cm) − 0.314 × TSF (mm).

 Standards for age and gender have been established; however, there are wide variations among individuals, and interobserver measurement variability is considerable.

 Anthropometric measurements may be markedly affected by nonnutritional factors and are rarely performed in the routine clinical setting.

1. Assessment of protein status. Serum protein concentrations such as retinol-binding protein, transferrin, prealbumin, and albumin can be used to assess the degree of visceral protein depletion.

 The relationship between malnutrition and serum protein levels is related to the patient’s hydration status and the half-life of the individual protein. Visceral protein status is frequently assessed by the measurement of one or more of the serum proteins. One of the first organs to be affected by protein malnutrition is the liver, which is the main site of synthesis for most of these serum proteins.

 The synthesis of serum proteins is impaired by the limited supply of protein substrates, resulting in a decline in serum protein concentrations. Many nonnutritional factors influence the concentration of serum proteins and reduce their specificity and sensitivity. Total serum protein is easily measured and has been used as an index of visceral protein status in several national nutrition surveys; however, it is a rather insensitive index of protein status. Serum albumin reflects changes within the intravascular space and not the total visceral protein pool. Serum albumin is not very sensitive to short-term changes in protein status; it has a long half-life of 14 to 20 days (Table 42-1). Reduced catabolism largely compensates for reductions in hepatic synthesis of serum albumin.

 Each transferrin molecule binds with two molecules of iron, and thereby serves as an iron-transport protein. Transferrin responds more rapidly to changes in protein status because of its shorter half-life and smaller body pool than albumin. Like serum albumin concentrations, serum transferrin concentrations are affected by a variety of factors, including gastrointestinal, renal, and liver disease.

 The nutritional status of the patient also can be defined by using objective data. The Prognostic Nutritional Index (PNI) has been shown to predict clinical outcome in cancer patients. The PNI is based on serum albumin level, serum transferrin level, delayed cutaneous hypersensitivity, and TSF thickness.

1. Immune function. Tests of immunocompetence are sometimes used as functional indices of protein status; however, their sensitivity and specificity are low. Nutritional deficiencies can impair nearly all aspects of the immune system, and no single measurement can assess adequacy of the immune response. Examples of immunologic tests include lymphocyte count, measurement of thymus-dependent lymphocytes, and delayed cutaneous hypersensitivity.

TABLE 42-1

Factors that Decrease or Increase Albumin

Albumin	Factors that decrease albumin	Factors that increase albumin
Normal: 3.5–5.0 g/dL	• Acute-phase responsea	• Intravascular volume depletion
Depletion:	• Severe liver failure	• Intravenous albumin or plasminate, blood transfusions (temporary rise)
Mild: 3.0–3.4 g/dL
Moderate: 2.4–2.9 g/dL
Severe: <2.4 g/dL
Half-life approximately 14–20 d	• Redistribution: intravascular volume overload, third spacing, pregnancy, minor decrease with recumbency	• Anabolic steroids, possibly glucocorticoids
	• Increased losses: nephritic syndromes, burns, protein-losing enteropathies, exudates
	• Severe zinc deficiency

^aAcute-phase response occurs with inflammation associated with conditions such as infection, injury, surgery, and cancer.

2. Subjective global assessment (SGA). SGA of nutritional status includes relevant history data (dynamic weight loss, dietary intake, specific symptoms, performance status, primary disease, and metabolic demand) as well as clinical data (subjective estimate of fat and protein stores.) The nutritional assessment tools used for clinical routine are summarized in Table 42-2.

 III. INTERVENTIONS AND NUTRITIONAL THERAPY. An estimate of current energy and protein balance is useful in providing nutritional intervention.

1. Nitrogen metabolism. The measurement of the nitrogen balance can document the effectiveness of nutritional therapy; nitrogen balance is calculated by the following formula:

 The apparent net protein utilization is generated by using the relationship. The obligatory nitrogen loss is roughly equal to 0.1 g/kg of body weight.

 IV. ESTIMATING ENERGY NEEDS IN ADULTS

1. Harris benedict equation (for healthy adults)
2. Men: REE = 66 + 13.7W + 5H − 6.8A
3. Women: REE = 655 + 9.6W + 1.7H − 4.7A
4. Where REE = resting energy expenditure (kcal/d); W = weight (kg); H = height (cm); and A = age (years).
5. Validation studies: Original studies conducted on healthy volunteers. Note that for obese individuals (BMI > 29.9), formula may overestimate REE by 5% to 15% if actual weight is used.

TABLE 42-2

Synopsis of Nutritional Assessment Parameters

Minimal screening assessment

Present weight in relation to ideal weight (weight/height index)

Weight change (percentage weight change/time interval)

Serum albumin

Complete assessment

History

  Dietary data (food records, recall methods)

  Concomitant disease

Physical examination

  Body fat, muscle wasting

  Specific nutritional deficiencies

Anthropometrics

  Triceps skin fold (caliper method)

  MMC

Laboratory tests

  Creatinine/height index

  Serum transferrin or albumin

Immune function

  Total lymphocyte count

  Delayed hypersensitivity skin tests

Subjective global assessment, clinical experience

Apparative assessment

Bioelectrical impedance analysis

1. Mifflin–St Jeor equation (for healthy adults)
2. Men: REE = 10W + 6.25H − 5A + 5
3. Women: REE = 10W + 6.25H − 5A − 161
4. Where REE = resting energy expenditure (kcal/d); W = weight (kg); H = height (cm); and A = age (years).
5. Validation studies: Equation developed from a sample of obese and nonobese healthy individuals. Some research has indicated that this equation may provide a more accurate estimation of REE than the Harris–Benedict formula in both obese and nonobese individuals, and, therefore, this equation deserves consideration.
6. Ireton–Jones ((for acutely ill adults)
7. Ventilator-dependent patients: EEE = 1784 − 11A + 5W + 244S + 239T + 804B
8. Spontaneously breathing patients: EEE = 629 − 11A + 25W − 609O
9. Where EEE = estimated energy expenditure (kcal/d); A = age (y); W = weight (kg); S = sex (male = 1, female = 2); T = diagnosis of trauma (present = 1, absent = 0); B = diagnosis of burn (present = 1, absent = 0); and O = obesity > 30% above ideal body weight from 1959 Metropolitan Life Insurance Tables (present = 1, absent = 0).
10. Validation studies: Equation developed from a sample of hospitalized patients including critically ill patients and patients with burns. Recent research has reported that this equation underestimates energy requirements.
11. A.S.P.E.N. Energy Expenditure formulas (in calories/kilogram). These formulas have not been validated using evidence-based information. However, they are used as a baseline in clinical practice and adjusted as needed to meet nutrition goals. Using this method, initial calorie goals usually start with 25 kcal/kg and can be adjusted as high as 40 kcal/kg. See table for more specific estimations.
12. Protein Needs. Protein intake is crucial during cancer treatment for the maintenance of lean muscle mass as well as the regeneration and repair of cells. Per the Dietary Reference Intakes, healthy individuals are recommended to consume 0.8g/kg protein. Protein needs can increase for cancer patients, especially those undergoing treatment. A catabolic state can increase protein needs to a range of 1.2g/kg to 2.0g/kg per day.
13. Assessment of nutritional intake. Individuals can meet daily energy needs through a variety of ways.
14. Oral nutrition. The preferred method for providing nutrition for patients who are able to eat is by oral diet, which can be modified according to the physiologic and anatomic constraints of their illness. Nutritional support considerations for individuals with daily energy deficits (e.g., patients with anorexia and resulting weight loss, dysphagia) are listed in Table 42-4.
15. Dietary supplements. Nutrients, vitamins, and minerals that are essential for human health as well as a variety of nonessential nutrients such as phytochemicals, hormones, and herbs are used as dietary supplements; however, these should never replace whole foods. The American Cancer Society (ACS) warns against massive doses of any dietary supplement, and recommends supplements that are close to the daily percentage value for most vitamins and minerals. The United States Department of Agriculture (USDA) states that there is no substitute for a well-balanced diet that follows the dietary guidelines for Americans. The daily percentage value (DV) on food labels, formerly known as the recommended daily allowance, is the average daily dietary intake level that is adequate to meet the nutrient requirements of nearly all (97% to 98%) individuals in a specific life stage and gender group. To account for differences in need and ability for absorption, the DV is set considerably higher than the estimated average requirement. Any recommendations for nutritional supplementation at doses higher than twice the DV should be individualized and are dependent on each individual’s dietary and disease status. The Academy of Nutrition and Dietetics recommends getting all the nutrients needed from the diet first and then considering supplementation only if it is adequately researched.
16. Enteral feeding. Enteral feeding refers to the provision of nutrients, either to supplement oral intake or as the sole source of nutrition, delivered through a catheter or a tube to the gastrointestinal tract for absorption. Enteral feeding is preferred to parenteral feeding because it preserves the gastrointestinal architecture and prevents bacterial translocation from the gut. Enteral feeding has the advantage of delivering nutrients beyond areas of obstruction, at rates that can maximize nutrient absorption. Nutrients should be administered distal to the ligament of Treitz to avoid complications of aspiration pneumonia and gastric ileus. For short-term feeding, a nasogastric or nasoduodenal tube may be used. If there is a need for long-term enteral support, the preferred method is either a gastrostomy or jejunostomy tube, which can be placed either surgically or endoscopically. Nutritionally complete enteral-feeding formulas as well as specialized modular products to meet specific disease-related nutrient requirements are commercially available. Consult with a dietetics professional to determine the most appropriate formula.

TABLE 42-3

A.S.P.E.N. Energy Expenditure Formulas

Medical Condition	Estimated Energy Needs (calories/kg body weight)
Cancer- repletion, weight gain	30–35
Cancer- inactive, non-stressed	25–30
Cancer- hypermetabolic, stressed	35
Sepsis	25–30
Hematopoietic cell transplant	30–35

TABLE 42-4

Nutritional Support Considerations for Individuals with Daily Energy Deficits

Potential problem	Intervention
Anorexia	Small frequent meals seasoned according to individual taste
	Snacks of nutrient-dense liquids such as instant breakfast, milk shakes, or commercial supplements can provide significant protein and calories and are easily consumed
Dry mouth/thick saliva	Encourage good oral hygiene
	Artificial saliva and use of a straw may facilitate swallowing
	Petroleum jelly applied to the lips may help prevent drying
	Avoid coarse foods; some patients may require a liquid diet
Dysphagia	Encourage a soft, more liquid diet and easy-to-swallow foods
	Small frequent meals
	Use liquid nutritional formulas
	Determine the appropriate consistency of food and fluids or any special swallowing techniques given by the speech therapist
Radiation esophagitis	Soft bland diet, using creamy, lukewarm, or cool foods
	Avoid coarse, dry, or scratchy textured foods
	Avoid tart and acidic fruits and juices, alcohol, and irritating spices

4. Total parenteral nutrition (TPN). Providing nutritional support by the parenteral route is an important option for patients for whom oral or enteral nutrition is unsuitable. The hyperosmolar TPN solutions require central venous access to reduce complications of venous thrombosis and phlebitis. Inherent complications such as pneumothorax occur infrequently. Parenteral nutrition is more expensive than enteral or oral nutrition, and adherence to specific guidelines is of utmost importance to minimize complications. Some studies on the use of TPN in cancer patients demonstrated improvement in body weight and total body fat content. Specific minerals, trace elements, and vitamins can be provided with TPN, but TPN does not stop the catabolic process of cancer cachexia, as nitrogen losses continue for patients receiving TPN, or alter the increased protein turnover and the process of lipolysis. When appropriately selected, certain cancer patients receiving TPN have shown significant decreases in morbidity and mortality. This includes patients with severe malnutrition receiving perioperative TPN and bone marrow transplant recipients. The American Society of Parenteral and Enteral Nutrition has recommended TPN supplementation in patients expected to have inadequate oral or enteral nutritional intake for more than 10 to 14 days. TPN can be very beneficial for some patients but the risks must be carefully considered prior to initiation. Complications include but are not limited to: infection at catheter site, sepsis, electrolyte imbalance, hyperlipidemia, hepatic abnormalities and so on. It is important to consult with a dietetics professional to determine the best parenteral nutrition plan prior to feeding.

TABLE 42-5

Common Antioxidants

• Vitamins A, C, and E
• Coenzyme Q10 (ubiquinone)
• Melatonin
• Carotenoids (alpha and beta carotene, astaxanthin, zeaxanthin, lutein, and lycopene)
• Flavonoids
• Isoflavones
• Resveratrol
• Curcumin
• N-acetylcysteine
• Alpha lipoic acid
• Selenium
• Zinc

1. NUTRIENT SUPPLEMENTATION IN ONCOLOGY. Additional nutrients from supplements can help some people meet their nutrient needs as specified by science-based nutrition standards such as the Dietary Reference Intakes. Dietary supplements include things like vitamins, minerals, herbs, or products made from plants. Dietary supplements are also defined to include powdered amino acids, enzymes, energy bars, and liquid food supplements. The use of these dietary supplements is prevalent and growing in the United States. Consumers may not be well informed about the safety and efficacy of supplements and some may have difficulty interpreting product labels. The expertise of dietetics practitioners is needed to help educate consumers on the safe and appropriate selection and use of nutrient supplements to optimize health. Cancer patients commonly use dietary supplements most often without the guidance or expertise of a knowledgeable practitioner, including antioxidants (Table 42-5) and herbs, with the latter associated with potential drug interactions (Table 42-6).

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TABLE 42-6

Common Herb–Drug Interactions and Precautions in Oncology

Botanical product	Common uses	Potential drug interactions and precautions
Ginseng, American or Asian	To improve cognition, immune function, and energy; promotes blood sugar metabolism	None known, but diabetics may need to monitor blood sugars due to a potential hypoglycemic effect
Black Cohosh	Menopausal symptoms	None known
Echinacea	Prevention of colds; used for immune support in cancer patients	None known; no documented interactions with immunosuppressive drugs
Garlic	Hyperlipidemia and atherosclerosis; prevention of colds	May enhance the effect of antiplatelet therapy and warfarin
Ginkgo	To improve cognition; to improve blood flow to the brain and extremities	Contraindicated in bleeding disorders; may enhance the effect of antiplatelet therapy and warfarin
Green tea	Reduce risk of cardiovascular disease and cancer	Can diminish the effect of dipyridamole; possible synergistic effects with sulindac and tamoxifen; large amounts of caffeine may increase the side effects of theophylline; antagonizes the tumoricidal effect of bortezomib
Ginger	Nausea	None known; anecdotal reports of interaction with warfarin but not proven
Kava	Anxiety and sleep	Should not be taken with alcohol, barbiturates, and other drugs with significant CNS effects; large doses may cause scaly ichthyosis
Milk thistle	Liver diseases and “cleansing”	An antioxidant; no known drug interactions
St. John’s Wort	Depression	Should not be taken with prescription antidepressants; may interact with oral contraceptives, warfarin, theophylline, Indinavir, cyclosporine, digoxin; avoid alcohol; induces CYP3A4
Saw Palmetto	Prostate health, urinary outlet obstructive symptoms	None known; may cause mild nausea when taken without food

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