Cancer is a chronic disease characterized by uncontrolled cell growth and the ability to spread to other parts of the body. It is the second leading cause of death worldwide and the fourth in Indonesia, where 30% of cases are related to diet and lifestyle factors. Cancer development is a multistep process involving genetic and environmental risk factors like diet. Nutritional management of cancer patients aims to prevent weight loss and deficiencies through early screening, dietary adjustments tailored to the individual, and addressing symptoms caused by the disease or its treatment.

1. CANCER
Dietetic of Non-Communicable Diseases
Adopted from slides of Muti'ah M. Syahadah
Presented by Mursid Tri Susilo, S.Gz., M.Gizi

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Glossary
CARCINOGEN : Substance that causes cancer.
CARCINOGENESIS : The multistep process (initiation, promotion, and progression) through which
normal cells are transformed into cancer cells.
TUMOR (neoplasm) : Literally means “new growth”; an abnormal mass of tissue, the growth on which
exceeds and is uncoordinated with that of normal tissue.
BENIGN : Describes a cancerous cell or tumor, which does not invade nearby tissue or
spread to other parts of the body.
CANCER : Class of diseases characterized by uncontrolled cell division and the ability of
these cells to invade other tissues, either by direct growth into adjacent tissue
(invasion) or by migration of cells to distant sites (metastasis).
METASTASIS : Spread of cancer from the primary site to nearby or distant areas through the
blood or lymph.
MALIGNANT : Describes a cancerous cell or tumor, which can injure healthy tissue and spread
cancer to other regions of the body.

3. Cancer
• Classified as a chronic disease (diseases characterized by a
slow progression and long duration)
• A major problem in some developed and developing
countries. It is the second leading cause of death
in the world (after cardiovascular diseases)
• In Indonesia, cancer is the 4th leading cause of
death
• As many as 30% of cancer cases are related to diet
and lifestyle, such as overweight/obesity, low intake
of fruits and vegetables, smoking habits, and alcohol
consumption (WHO, 2012)
3

4. • Cancer is the term that encompasses over 100 different disease types
• Each disease type has its unique characteristics, but all types of
cancer share some common characteristics
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CANCER
“Dysregulated cell growth control that caused by an interaction of
dietary, genetic, and environmental risk factors”

5. Cancer Prevalence in Indonesia
5
2013
2018
1,4
0.6
0.74
2.2
2.85
0
0.5
1
1.5
2
2.5
3
2013 2018
Men Women
Based on Indonesia Basic Health Research on 2013 and 2018
Permil (‰)

6. Normal Cell Growth
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• Cells will undergo a proliferation
process according to the body's
needs
• The Stop and Go of the cell
proliferation process is regulated
by :
- Growth Factor
- Density-Dependent Inhibition
- Anchorage-Dependent
Figure 1. Cell Cycle

7. Cancer Cells
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• The cells proliferate continuously
• Classified as anchorage-independent cells (such as blood cells, cancer cells,
and hybridoma)
Figure 2. Carcinogenesis of Breast Cancer

8. • Cancer cells have gene mutations that turn the normal cells
into cancer cells
• Risk Factors that affect the gene mutations of the cells:
8
Source: M. Hurst. Hurst Reviews: Pathophysiology Review 2008. page 90.
Processed foods
Grilled or scorched foods
Diet HIGH in red meat and
animal saturated fat
Diet LOW in fiber and
antioxidants

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Carcinogenesis
Multistep process in which normal cells are transformed into cancer cells

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Cancers Classification:
1. Broadly (by tissue, organ, and system of origin)
▪ Carcinoma → originate from epithelial cells of the skin, GI tract, internal organs, and
other anatomical sites
▪ Sarcoma → derive from muscle, adipose, bone or blood vessels
▪ Lymphoma → originate in the lymphoid tissue
▪ Leukimia → derive from blood-forming tissue such as the bone marrow
2. Specific types (histopathological classifications)
Breast cancer, Prostate cancer, Colorectal cancer, etc.

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Cancers Classification:
3. Grade according WHO classification
4. Tumor Node Metastasis (TNM)

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Nutritional Concerns:
▪ Reduced and Losses in nutritional intake due to anxiety, depression, pain,
taste change, dry mouth, early satiety, nausea, vomiting, diarrhea
▪ Metabolism alterations:
1. Protein
(↑ proteolysis, protein turnover, protein losses; ↓ protein synthesis)
2. Carbohydrate
(↑ glycolysis and gluconeogenesis, insulin resistance, glucose intolerance)
3. Fat
(↑ lipolysis and fatty acids turnover, ↓ total body fat, and hypertriglyceridemia)

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Nutritional Concerns:
▪ Reduced digestion and/or absorption in certain types of cancer such as GI
tract cancers
▪ Effects of treatment:
1. Drugs
2. Chemotherapy
a common side effect of chemotherapy is nausea and other gastrointestinal (GI) problems, and
also lead to alopecia (hair loss)
3. Surgery
4. Radiotherapy

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Cancer –
Induced
Weight Loss

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Cancer Anorexia - Cachexia Syndrome
Decrease in:
- Quality of life
- Survival rate
Increased cost
Healthy Cancer
Patient

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Nutritional Care for Cancer Patient
✓ Screening for risk of nutritional problems at time of diagnosis
✓ Early nutritional intervention
✓ Prevent or Correct nutritional deficiencies
✓ Minimize weight loss
✓ Nutritional monitoring should continue throughout treatment

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1. Screening of Nutritional Status
▪ Malnutrition Screening Tools (MST)
▪ Malnutrition Universal Screening Tools (MUST)
▪ Subjective Global Assessment (SGA)
▪ Mini Nutritional Assessment (MNA)
▪ Nutritional Risk Index (NRI)
▪ Nutritional Risk Screening (NRS)

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2. Assessment (ABCD) - Anthropometry
▪ Weight
▪ Height
▪ Knee Height
(used to estimated height in bedridden patients)
▪ Body Mass Index
▪ Bodyweight changes in the last 3 months (should
not 10% or above)

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2. Assessment (ABCD) - Biochemistry
▪ Total protein (6 – 8.3 g/dL)
▪ Albumin (4 – 5.2 g/dL)
▪ Prealbumin (21.6 – 32.8 mg/dL)
▪ Creatine (0.5 – 1.2 mg/dL)
▪ Ureum (10 – 50 mg/dL)
▪ Nitrogen balance (0 – 1 g/24 h)
▪ SGPT ( < 42 U/L)
▪ SGOT ( < 37 U/L)
▪ Hemoglobin : (13 – 16 g/dL) men
: (12 – 14 g/dL) women
▪ Ferritin (18 – 270 mcg/L)
▪ Erythrocyte (4.5 – 5.5 millions/ml)
▪ Leukocyte (5000 – 10.000/ml)
▪ Lymphocyte (20 – 40 %)
▪ Hematocrit (40 – 48 %)

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▪ Clinical
- Temperature (36 – 38 °C)
- Blood pressure (Sys:100 – 140 mmHg and Dyas:60 – 90 mmHg)
- Pulse rate (60 – 100 times per minute)
- Respiratory rate (12 – 20 times per minute)
2. Assessment (ABCD) - Clinical and Physical

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▪ Physical
- Edema
- Cachexia
- Stomatitis
- Glossitis
- Cheilosis
- Muscle mass depletion
- Dysphagia
- Dysgeusia
2. Assessment (ABCD) - Clinical and Physical
▪ Physical
- Nausea
- Vomiting
- Diarrhea
- Constipation
- Decreased appetite
- Skin problems
- Hair loss

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2. Assessment (ABCD) - Dietary and Disease History
▪ Dietary History
- Dietary pattern
- Allergy
- Avoided foods
- Diet history before admission and during hospitalization
Dietary intake less than 70% requirement for 5 days or more is
considered “INADEQUATE”

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2. Assessment (ABCD) - Dietary and Disease History
▪ Disease History
- Past and present medical history
- Family medical history
- Surgical and diagnostic procedures
- Drugs and supplements consumption
- Social history (SocHx)

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3. Nutritional Diagnosis – Intake Domain
▪ Problems (P)
- NI.1.1 Increased energy expenditure
- NI.1.2 Inadequate energy intake
- NI.2.1 Inadequate oral intake
- NI.5.2 Malnutrition
- NI.5.3 Inadequate energy and protein intake
▪ Etiology (E)
Hypermetabolism; Prolonged catabolism; Decreased ability to consume food; Limited food
intake
▪ Signs and Symptoms (S)
Unexpected weight loss; Decreased nutritional status; Weakness; Mucositis; Food intake less
than requirement based on records/observations; Decreased appetite; Anorexia; Nausea;
Vomiting; Diarrhea

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3. Nutritional Diagnosis – Clinical Domain
▪ Problems (P)
- NC.1.1 Dysphagia (swallowing problem)
- NC.1.2 Difficulty chewing/biting
- NC.3.1 Underweight
- NC.3.2 Unexpected weight loss
▪ Etiology (E)
Inappropriate diet; Lack of energy intake; Increased energy requirement; Decreased ability
to eat food; Malabsorption; Maldigestion; Negative energy balance
▪ Signs and Symptoms (S)
Decreased muscle mass; Decreased nutritional status; Decreased body weight; Low dietary
intake; Anorexia

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3. Nutritional Diagnosis – Behavioral Domain
▪ Problems (P)
- NB.1.1 Lack of knowledge related to food and nutrition
- NB.2.1 Physical inactivity
- NB.3.1 Unsafe food intake
▪ Etiology (E)
Lack of exposure to accurate nutritional information; Lack of knowledge regarding safe food
for consumption; Lack of knowledge regarding food preparation, storage and processing
▪ Signs and Symptoms (S)
Low nutrition knowledge score, consumption of unsafe and unhealthy food

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4. Intervention
Provide a balanced diet according to the patient's condition
Prevent and restrain excessive weight loss
Reduces symptoms of nausea, vomiting, and diarrhea
Attempt for healthy attitude and behavior change

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High Energy High Protein Diet
❑ Cancer Diet Terms :
▪ High energy, 36 kcal/kg body weight/day for men and 32 kcal/ kg body weight/day
for women. If underweight or malnourished, 40 kcal/ kg body weight/day for men
and 36 kcal/ kg body weight/day for women
▪ High protein, 1 – 1.5 g/ kg body weight/day
▪ Adequate fats, 15 – 20% of total energy requirement
▪ Adequate carbohydrate, the remains of the total energy requirement
▪ Adequate vitamin and mineral, especially vitamins A, B complex, C, and E

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▪ Low iodine, if undergoing internal radioactive medication
▪ If immunity decreases (low leukocyte status) or will undergo aggressive
chemotherapy, sterile food is given
▪ Small but frequent meal portions
▪ Fiber requirements are 40 g/day or equivalent with 5 servings of vegetables and
fruit
▪ The type of diet is adjusted to the patient's condition :
- Disease progression
- Ability to accept food

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Recommended and Restricted Foods
Food Source Recommended Restricted
Carbohydrate
Rice, porridge, vermicelli, bread, wheat, macaroni,
pasta, corn, potatoes, taro, oatmeal
Avoid those that cause gas, such as sweet potatoes
and cassava
Animal Protein
Eggs, skim milk/low-fat milk, fish, chicken and
poultry
Saturated fatty foods such as innard, full cream milk,
and also especially avoid animal protein sources that
are burned and fried
Vegetable Protein Tempeh, tofu, and lentils -
Vegetable Fresh vegetables
Sayuran yang menimbulkan gas, seperti kol, labu siam,
kembang kol, dan sebagainya
Fruit All kinds of fruit -
Beverage - Strong tea or coffee, soda and alcohol
Others All kinds of spices sufficiently
Fatty foods and the use of thick coconut milk,
preserved food, sharp spices

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Methods of Dietary Intervention
❑ Oral
Most preferred method whenever possible !!
❑ Enteral
Cancer of alimentary canal; Severe complications/side effects of treatment
- Short term (Nasogastric; Nasoduodenal; Nasojejunal)
- Long term (Percutaneous endoscopic - gastrotomy tube or jenunostomy tube)
❑ Parenteral Caution!! “Do not more than 3 months”
GI obstruction; Severe diarrhea or malabsorption; Severe mucositis/oesophagitis;
Intractable nausea or vomiting

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Overcoming Eating Problems
▪ Anorexia
- Recommended to eat the liked or accepted foods even if not hungry
- Avoid drinking before eating
- Emphasize that eating is part of the treatment
▪ Dysgeusia
- The food and beverage are served at room temperature or cold
- Add spices to add flavor
- Beverages are given in the fresh form (e.g. fresh juice)

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Overcoming Eating Problems
▪ Dysphagia
- Drink using a straw
- The food and beverage are served at room temperature or cold
- Food is given in the form of liquid food
- Avoid extremely acidic or salty foods
▪ Xerostomia
- The food and beverage are served at room temperature or cold
- Food is given in the form of liquid food
- Chew candy

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Overcoming Eating Problems
▪ Nausea and Vomiting
- Give dry foods
- Avoid foods with strong odors
- Avoid high fat foods
- Eat and drink slowly
- Avoid extremely sweet foods and drinks
- Limit fluids intake when eating
- In an upright position after eating

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Nutrition Education
Nutrition education is carried out for patients and
their families :
- Nutrition tips to help manage cancer treatment side effects
- Recommended meal plans and recipes
- Information about dietary supplements
- Education about how to promote a healthy lifestyle
- How to manage (loss or gain) body weight

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4. Monitoring and Evaluation
▪ Dietary intake
▪ Drugs and supplements consumption
▪ Nutritional status (e.g. weight, BMI, and weight change)
▪ Biochemistry status
▪ Clinical and physical assessment (e.g. edema, muscle mass, stomatitis,
nausea, vomiting, blood pressure, temperature)
▪ Nutritional knowledge

38. Thank You
"To eat is a necessity, but to eat
intelligently is an art."
– La Rochefoucauld