Nutrition for an ImmuneCompromised Patient Jyothi Prasad Manipal Hospital
1. Evidence based nutrition guidelinesfor oncology2. The benefit of Neutropenic diet - fact or fiction?
Why shouldn’t nutrition be a forgotten ingredient inoncology care?• 20-40% cancer patient deaths are related to cancer induced or treatment related malnutrition• Malnutrition causes: Diminished tolerance to therapy Lower survival rates Diminished quality of life Longer hospitalization• Effects of symptoms on dietary intake is profound – 60% of head and neck and GI patients lose weight upon beginning treatment
Impact of malnutrition• Head and neck ca treated – the strongest predictor of survival was pre treatment weight loss• Postoperative morbidity and quality of life significantly influenced by preoperative nutrition• Immuno competence goes down• Inability to tolerate anti neoplastic treatments• Postoperative complications• Surgical insult on post operative patients is well tolerated by nourished individuals
Nutritional issues in Oncology• Systemic effects of cancer on nutrition• Localized tumor effects• Nutritional problems of therapy• Nutrition intervention and tumor growth• Efficacy of nutrition support• Guidelines for nutrition support• Unproven diet and nutrition claims
Cancer Cachexia Starvation amidst plenty• The failure of nutritional repletion despite adequate caloric intake in patients with malignancy. This is mediated by pro inflammatory cytokines• The prominent feature of clinical feature of cachexia is weight loss in adults and growth failure in children. There is competition between the tumour and the host for nutrients resulting in an accelerated starvation state• Anorexia, inflammation, insulin resistance, and increased muscle protein breakdown are frequently associated with cachexia• Cachexia is different from Anorexia. Anorexia is EFFECT rather than CAUSE OF cachexia.• Cachexia is distinct from starvation, age related loss of muscle mass, primary malabsorption and hyperthyroidism and is associated with increased morbidity and mortality
Pathogenesis of Cancer induced Cachexia Cancer induced cachexia is invariably associated with the presence and growth of tumor CANCERNausea/Vomitting Anorexia Metabolic changes: Energy, protein, lipid and cho WEIGHT LOSS NEOPLASTIC CACHEXIA SYNDROME
The Cachexia JourneyPre Cachexia Cachexia Severe syndrome Cachexia Death Weight loss Weight loss Severe muscle wasting Reduced food intake Fat loss Systemic inflammation Immuno compromised >6-9 months 3-9 months <3 months Survival
Changes that occur in metabolismCarbohydrate Protein • Insulin resistance • Increased protein • Increased glucose synthesis catabolism • Decreased protein • Gluconeogenesis synthesis • Increased Cori cycle activity • Decreased glucose tolerance Fat • Increased lipid metabolism • Decreased lipogenesis • Decreased activity of lipoprotein lipase (LPL
Therapy related issuesRadiation related problems Surgery related problemsOropharyngeal Area Radical Resection of Oropharyngeal Area Loss of taste Xerostomia & odynophagia Chewing & swallowing difficulties Teeth loss EsophagectomyLower Neck & Mediastinum Gastric stasis & hypochorhydria Esophagitis with dysphagia secondary to vagotomy Fibrosis with esophageal stricture Steatorrhea secondary to vagotomy Diarrhea secondary to vagotomy Premature satietyAbdomen & Pelvis Regurgitation Bowel-damage syndromes (acute or chronic) with Gastrectomy (high subtotal or total) diarrhea, malabsorption, stenosis Dumping syndrome & obstruction, fistulization Malabsorption Achlorhydria & lack of intrinsic factor and R protein Hypoglycemia Premature satiety
Nutritional support – how to go about? Assess: Patient history, look for signs, weigh regularly and know the lab values Plan: Nutritional requirements - set short term and long term goals and individualize needs Intervene: Symptom management - strategies for patients, enteral and parenteral nutrition Evaluate: Effectiveness of intervention, achievement of long and short term goals
Evaluation : Before beginning intervention• Cardinal principle: Individualize to needs of patient• Short-term goal: Improve nutritional status• Long-term goal: Normalize Nutrient Intake Alleviate disease symptoms• Outcomes??? Better Quality of life / Vigor Fewer Crisis / Improved Treatment Response
Screening Vs Assessment Screening Assessment• Done to detect the possibility of • More intensive and thorough nutrition risk • Needs intervention, follow up• All patients in all settings require it regularly• Required to be stored in the medical • Assessment must have weight file history, appearance, functional• Patient generated SGA is often used status, diet history, biochemical and is useful and easy to score parameters, medication and planned• Score generated guides nutrition treatment intervention • Assessment can include financial and• If screen indicates risk, full psychosocial aspects is possible assessment must be done • Has to be done by a dietician or doctor only
Nutritional assessment criteria1. Anthropometry: Weigh regularly BMI Severe weight loss Mid – arm circumference2. Laboratory data: Not always the most accurate when viewed alone Serum albumin : Level falls only after significant depletion has occurred Serum pre albumin: Can be used for assessment Serum transferrin: More sensitive marker for marginal protein depletion Total iron binding capacity Delayed hypersensitivity skin testing to a recall antigen Total lymphocyte count3. Diet history 24 hour recall, Food frequency etc
Who is severely malnourished?• Weight loss more than 10%• Poor intake for 2 weeks or more• BMI less than 18.5• Mid arm circumference: Male <17.6cms Female <17.1 cms• Subjective global assessment score – “C”• Mini nutritional assessment score - <25• Albumin on entry <3gm %• Total lymphocyte count <1500
Nutrition requirement guidelines Calories (Harris-Benedict formula) • Obese patients: 21-25 kcal/kg • Non-ambulatory/sedentary adults: 25-30 kcal/kg • Sepsis: 25-35 kcal/kg • Slightly hypermetabolic or those in need of weight gain or those with stem cell transplant: 30-35 kcal/kg • Hypermetabolic or severely stressed: ≥35 kcal/kg Protein needs • Normal or Maintenance: 0.8-1.0 g/kg • Non-stressed cancer patient: 1.0-1.5 g/kg • Bone marrow transplant or HSCT patients: 1.5 g/kg • Increased protein needs: 1.5-2.5 g/kg • Hepatic or renal compromised or elevated ammonia: 0.5-0.8 g/kg• Vitamins Minerals Folate Magnesium Vit C Zinc Retinol Copper Iron
Fluid requirements• 16-30 years, active: 40 mL/kg• 31-55 years: 35 mL/kg• 56-75 years: 30 mL/kg• 76 years or older: 25 mL/kg1 mL/kcal of estimated energy needs
Managing symptoms• Nutrition can help manage symptoms. The key is to start early• Specific diet modifications will help minimize nutrition related side effects• Each side effect has numerous approaches for management• Strategies for patients include teaching and trial and error pragmatism• Screening and assessment will identify those who require aggressive intervention• For others enteral and sometimes parenteral support is a must
When Is Initiation of Enteral Nutrition Indicated?• Actual or anticipated inability to meet 50% of needs for 7 or more days Advantages• Contributes to Quality/Length of life in meaningful way Food in liquid form Keeps the stomach and• Can improve tolerance to treatment intestines working normally and/or ultimate outcome Fewer complications than• A functioning gut (to some degree) parenteral nutrition is present Nutrients used more easily by• Is not contraindicated the body • Obstruction? • Gastroparesis? Can be administered at home• NG tube or PEG depends on the length of stay
Parenteral Nutrition• Appropriate for patients who are severely malnourished or have contraindications to enteral feeding – severe nausea or vommitting, fistulas in intestines, loss of body weight with enteral nutrition, stomach and intestines removed etc• Requires central venous line and daily laboratory evaluation and composition adjustments• Complication include Hypoglycemia, Hyperglycemia Hypokalemia,Blood clots,Infection at site of insertion, Elevated liver enzymes• In transplant patients TPN is not used as the patients are nourished prior to transplant to withstand the procedure as the mortality & morbidity is high• TPN is reserved for patients with unintentional weight loss prior to transplant and possess non functioning GI tracts. ORAL NUTRITION ENCOURAGED, ENTERAL NUTRITION ATTEMPTED AND TPN DISCOURAGED!
Complementary Cancer Therapies Glutamine: Neutral, gluconeogenic, non essential aa. May help decrease symptoms, but not consistently documented. Eicosapentanoic acid (Omega 3 fatty acid): Potential role in inflammation, may help cachexia Probiotics: Healthy bacteria, may decrease opportunistic infections, improve nutrient absorption etc Zinc, Co-enzyme 10 etc . . . . . . . . .
Neutropenia and neutropenic diet?• Neutropenia is defined as the neutrophil count below 1.5 x 10 9/1• Neutrophils are needed against defense and when the neutrophil count falls below the risk of developing an infection greatly increases• In bone marrow transplant patients it falls below 0.5 and is called profound neutropenia• Many food contain food borne pathogen which may be harmful for a person with very low immunity• A diet that limits certain types of foods to limit the exposure of certain types of bacteria and limit food borne infection in an already immune compromised patient
Neutropenic diets - demystified• Neutropenic diets restrict many foods especially fresh fruits, veg, juices, curd etc.• Patients, especially paed find it difficult as it excludes many foods, importantly fresh fruits and veg• Though foods contain harmful bacteria and bacterial translocation is possible, recent studies have been unable to obtain significant differences between placebo and intervention groups• Unanswered questions in regard to the neutropenic diet include the following: (a) which food should be included; (b) which food preparation techniques improve patient compliance; (c) which patient populations benefit most; and (d) when should such a diet be initiated• Without scientific evidence, the best advice for neutropenic patients is to follow food safety guidelines as indicated by government entities.
Food safety guidelines – A common sense approach All patients need to follow 4 basic steps to food safety Clean: Wash hands, surfaces, produce and clean lids for canned produce Separate: Don’t cross contaminate. Separate foods and cutting boards. Especially true for flesh foods Cook: Cook to proper temperatures. Use a food thermometer to check internal temperature Chill: Refrigerate promptly. Cold temp slows the growth of harmful bacteria• While shopping be careful and read all the labels for expiry date• Be smart while eating out and transport food carefully and go by rules• Be aware of food borne illnesses and know the symptoms!!
Future directions in oncology nutrition• We have a knowledge base with cancer survivors• We know about potential carcinogens thru food and water – prevention is the keyPractice issues:• Development of cancer rehab programmes. Evaluation of intervention is needed• Benefit of nutrition intervention to be documented – outcome research• Oncology nutrition to be a special field and a oncology nutritionist to be a part of the multi disciplinary team
To conclude . . . . . . All patients undergoing HSCT with myeloablative conditioning regimens are at nutritionrisk and should undergo nutrition screening, assessment if required and a proper nutrition plan Nutrition support therapy is appropriate in patients undergoing HSCT who aremalnourished . When PN is used, it should be discontinued as soon as toxicities have resolved Enteral nutrition should be used in patients with a functioning GI tract in whom oral intakeis inadequate to meet nutrition requirements Pharmocological doses of Glutamine may benefit patients Patients should receive couselling regarding food safety guidelines as they may pose ainfectious risk Nutrition support therapy is appropriate for patients who develop moderate to severe GVHDaccompanied by poor oral intake