The document provides an overview of nutrition considerations for cancer and HIV/AIDS. It discusses how cancer and HIV develop and their impacts on nutrition status. Key points include that both can lead to wasting and nutritional deficiencies. Cancer treatments like chemotherapy and radiation can damage tissues and impair appetite. HIV damages immune cells and increases risk of infections. Nutrition therapy aims to maintain weight and muscle mass for both conditions. The document also covers ethical issues around withholding or withdrawing nutrition support for terminally ill patients.

1. Chapter 23 – Nutrition, Cancer, and HIV Infection
Chapter Outline Instructor Resources
I. Cancer
A. Introduction to cancer & HIV
1. Are distinct disorders
2. Are similar from a nutrition standpoint
3. Have debilitatingeffects with regard to nutrition
4. Can lead to severe wasting
B. Cancer overview
1. Growth of malignant tissue
2. 2nd leading cause of death in U.S.
3. Many different kinds
4. Different courses
5. Different locations
6. Different treatments
C. How Cancer Develops - Carcinogenesis
1. Mutations in the genes that control cell division
2. Promote cellular growth
3. Interfere with growth restraint
4. Prevent cellular death
5. Tumor grows
6. Blood vessels form to provide nutrients
7. Tumor cells can spread (metastasize)
8. Reasons why cancers develop are numerous and varied
9. Carcinogens - cancer-causingsubstances
D. Nutrition and Cancer Risk - Diet & lifestyle strongly influence risk(see Table23-2)
1. Nutrition and Increased Cancer Risk
a. Obesity
b. Alcohol
c. Food preparation methods
2. Nutrition and Decreased Cancer Risk
a. Fruits & vegetables
b. Antioxidant phytochemicals &nutrients;fiber
E. Consequences of Cancer
1. Depends on location, severity,treatment
2. WastingAssociated with Cancer: “Cancer cachexia”
a. Characterized by:
1. Anorexia
2. Muscle wasting
3. Weight loss
4. Fatigue
b. Involuntary weight loss of >10% is cause for concern
c. Many factors play a role in wastingassociated with cancers (e.g., cytokines)
3. Metabolic Changes
a. Increased rateof protein turnover

2. b. Reduced muscle protein synthesis
c. Elevated serum lipids
d. Insulin resistance
4. Anorexia and Reduced Food Intake - Causes:
a. Chronic nausea & early satiety
b. Fatigue
c. Pain
d. Mental stress
e. Gastrointestinal obstructions
f. Effects of cancer therapies
F. Treatments for Cancer
1. Surgery
a. Purposes: Remove tumors,determineextent of cancer, & protect nearby tissues
b. Raises energy & protein needs
c. Contributes topain, fatigue, & anorexia
2. Chemotherapy
a. Inhibits tumor growth
b. Shrinks tumors before surgery
c. Prevents or eradicates metastasis
d. Has toxic effects
e. Anemia & neutropenia
3. Radiation Therapy
a. Damages cancer cells’ DNA and leads to cell death
b. Shrinks tumors
c. Can damage healthy tissues
d. Radiation enteritis
4. Hematopoietic Stem Cell Transplantation
a. Replaces blood-forming stem cells that havebeen destroyed by high-dose chemotherapy
or radiation therapy
b. Ideally uses patient’s own cells
c. If donor cells are used, need immunosuppressant drugs
d. Chemo/radiation/drugs impair immune function & increase foodborne infection risk
e. Patients usually requirenutrition support post-transplantation
5. Biological Therapies - stimulateimmuneresponse against cancer cells
a. Antibodies
b. Cytokines
c. Other proteins
6. Medications to Combat Anorexia and Wasting
a. Megestrol acetate - Appetite stimulant
b. Dronabinol - Appetite stimulant &antiemetic
c. Anabolic steroids, growth hormone, & insulin-likegrowth factor
1. Under investigation
2. Help restorelean body mass
7. AlternativeTherapies
a. Up to 80% of cancer patients combine1 or more CAM therapies with standard treatment
b. Patients often don’t discuss with physicians
G. Nutrition Therapy for Cancer
1. Objectives:

3. a. Maintain healthy weight
b. Preservemuscle mass
c. Correct nutrient deficiencies
d. Provide a diet that is tolerable& enjoyed
2. Protein and Energy
a. Protein needs may increase(1.0-1.6 g/kg body weight)
b. Energy needs may increase(25-35 kcalories/kg body weight)
c. How to Increase kCalories and Protein in Meals
3. Managing Symptoms and Complications
4. Low-Microbial Diet = “neutropenic diet” - includes foods that areunlikely to be
contaminated with microbes
5. Enteral and Parenteral Nutrition Support - Enteral &/or parenteral nutrition if malnourished
II. HIV Infection
A. Overview
1. Can lead to AIDS
2. Attacks the immune system and disables defenses against other diseases
3. Global incidence is declining
4. Prevalence continues to be high in Sub-Saharan Africa
B. Prevention of HIV Infection
1. Those at risk areencouraged to undergo testing
2. Spread by direct contact with contaminated body fluids
C. Consequences of HIV Infection
1. Helper T-cells are most affected
2. Early symptoms arenonspecific:
a. Fever
b. Sore throat
c. Malaise
d. Swollen lymph nodes
e. Skin rash
f. Muscle & joint pain
g. Diarrhea
3. Opportunistic infections
4. AIDS-defining illnesses
a. Severe infections
b. Certain cancers
c. Wasting
5. Lipodystrophy = Abnormalities in body fat & fat metabolism
a. Fat accumulates at the baseof the neck
b. Lipomas
c. Lipid abnormalities &insulin resistance
6. Weight Loss and Wasting - linked to:
a. Accelerated disease progression
b. Reduced strength
c. Fatigue
d. Increased risk of death
7. Anorexia and Reduced Food Intake
a. Emotional distress,pain, & fatigue

4. b. Oral infections
1. Candidiasis
2. Herpes simplex virus
c. Respiratory disorders
d. Cancer
e. Medications
8. GI Tract Complications
a. Nausea, vomiting& diarrhea
b. AIDS enteropathy
9. Neurological complications
a. Mild to severe dementia
b. Muscle weakness & gait disturbances
c. Pain, numbness,& tingling in legs and feet
10. Other Complications
a. Anemia
b. Skin disorders
c. Eye disorders
d. Kidney diseases
e. CHD
D. Treatments for HIV Infection
a. Standard drug treatment is at least 3 antiretroviral drugs
b. Has multipleadverse effects
c. Difficult toadhere to
2. Control of Anorexia and Wasting
a. Anabolic hormones
b. Appetite stimulants
c. Regular physical activity
3. Control of Lipodystrophy - treatments are under investigation
4. AlternativeTherapies - should avoid herbals with St.John’s wort, Echinacea, garlic, zinc
E. Nutrition Therapy for HIV Infection
1. Weight & muscle mass maintenance
2. Prevention of malnutrition
3. Cope with nutrition-related sideeffects
4. Nutrition assessment should start soon after patient is diagnosed
5. Weight Management
a. If excessive body weight,moderate wt loss recommended because of increased riskfor
CVD and diabetes
b. If weight loss or wastingoccurs:
1. 35-40 kcalories per kilogram
2. 1.2-2.0 grams protein per kilogram
3. Small, frequent feedings
4. Nutrient-densesnacks
5. Liquid formulas
6. Metabolic Complications
a. Insulin resistance
b. Elevated TG & LDL
7. Vitamins and Minerals
a. Needs are highly variable

5. b. Avoid excessive amounts
8. Symptom Management - discomfort, N&V can cause nutrition problems
9. Food Safety - water & cryptosporidiosis
10. Enteral and Parenteral Nutrition Support - later stages of illness
III. Nutrition in Practice - Ethical Issues in Nutrition Care
A. If providing nutrition carecan do littleto promote recovery,is it appropriatetowithhold or
withdraw nutrition support?
1. Patient autonomy - The right to make own health care decisions
2. Disclosure - Informed consent
3. Decision-making capacity - Mental capacity tomake appropriatehealth caredecisions or
designated surrogate
4. Treatment benefits (beneficence) should outweigh harm (maleficence)
5. Distributivejustice - Would caregiven to one patient unfairly limit the careof other patients?
B. What kind of treatments can help to sustain a patient’s life?
1. Nutrition support & hydration
2. Cardiopulmonary resuscitation (CPR)
3. Defibrillation
4. Mechanical ventilation
5. Dialysis
C. Do patients havea right to life-sustaining treatments?- Yes, but it may be futile & a difficult
decision for themedical personnel.
D. How have thecourts resolved conflicts involvingnutrition support?
1. Landmarkcase - Patient in persistent vegetativestate
2. Advanced directives prevent matters from going to court
3. 2nd case involvingfeeding tuberemoval
E. How can people ensure that their wishes will beconsidered in the event that they become
incapacitated?
1. Living will,advance health care directive - Instructions specifyingwhat life-sustaining
medical procedures aredesired or not desired
2. Durable power of attorney = health careproxy; another person is appointed to make health
care decisions in the event of incapacitation
F. How does a “do-not-resuscitate”order differ from other advanced directives?
1. Order to withhold CPR in the event of a cardiac arrest
2. DNR does not exclude use of other life-prolonging measures
G. Have advancedirectives changed theway that medical careis provided?
1. Not really
2. Only ~47% in the U.S. haveone
H. What resources areavailableto individuals whohave difficulty making decisions about life-
sustainingmedical treatments?
1. Ethics committees
2. Referral to hospice carefor dying patients