Nutrition is an important but often overlooked part of cancer care. Malnutrition can negatively impact treatment tolerance, survival rates, quality of life, and length of hospitalization for cancer patients. A variety of factors like the symptoms of cancer, its treatments, and a condition called cancer cachexia can profoundly diminish a patient's dietary intake and nutritional status. A comprehensive nutritional assessment and individualized nutrition care plan are recommended for cancer patients, with the goals of improving nutritional status in the short term and normalizing nutrient intake in the long term. Enteral nutrition is generally preferred over parenteral nutrition when possible. Food safety guidelines rather than restrictive diets are advised for neutropenic patients. Nutrition support can help manage treatment side effects and

1. Nutrition for an Immune
Compromised Patient
Jyothi Prasad
Manipal Hospital

2. 1. Evidence based nutrition guidelines
for oncology
2. The benefit of Neutropenic diet -
fact or fiction?

3. Why shouldn’t nutrition be a forgotten ingredient in
oncology 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

4. 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

5. 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

6. 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

7. Pathogenesis of Cancer induced Cachexia
Cancer induced cachexia is invariably associated with the presence and growth
of tumor
CANCER
Nausea/Vomitting Anorexia
Metabolic changes: Energy,
protein, lipid and cho
WEIGHT LOSS
NEOPLASTIC CACHEXIA SYNDROME

8. The Cachexia Journey
Pre 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

9. Changes that occur in metabolism
Carbohydrate 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

10. Therapy related issues
Radiation related problems Surgery related problems
Oropharyngeal Area Radical Resection of Oropharyngeal Area
Loss of taste
Xerostomia & odynophagia Chewing & swallowing difficulties
Teeth loss
Esophagectomy
Lower Neck & Mediastinum Gastric stasis & hypochorhydria
Esophagitis with dysphagia secondary to vagotomy
Fibrosis with esophageal stricture Steatorrhea secondary to vagotomy
Diarrhea secondary to vagotomy
Premature satiety
Abdomen & 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

11. ……. Contd
Drug-related Problems
Intestinal Resection - Jejunum & Ileum Noncytotoxic
• Decreased absorption efficiency
including fat Corticosteriods
• Vitamin deficiency with fat-soluble • Fluid & electrolyte problems
vitamin malabsorption
• Bile salt losses with diarrhea or • Nitrogen & calcium losses
steatorrhea • Hyperglycemia
• Hyperoxaluria & renal stones
• Calcium & magnesium depletion Sex hormone analogues
• Fluid retention
Massive Bowel Resection • Nausea
• Life-threatening malabsorption
• Malnutrition • Megesterol acetate - glucocorticoid
• Metabolic acidosis effects
• Dehydration w/wo salt & water balance Chemotherapy
problems
• Nausea
Blind Loop Syndrome • Vomitting
• Vitamin B12 Malabsorption • Loss of appetite
• Diarrhea
Pancreatectomy
• Malabsorption • Anorexia
• Diabetes • Mouth ulcers
• Diarrhea/Constipation

12. Secondary
Intermediary Endocrine infections, malignant
metabolites abnormalities lesions
Nutritional Medications
abnormalities
Neurological Appetite Cytokines
influences
Psychiatric, psyc
hological
influences
Learned aversions Social, cultural &
Food intake
to therapy economic factors
Physical
factors

13. 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

14. 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

15. 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

16. Nutritional assessment criteria
1. Anthropometry: Weigh regularly
BMI
Severe weight loss
Mid – arm circumference
2. 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 count
3. Diet history
24 hour recall, Food frequency etc

17. 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

18. 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

19. 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/kg
1 mL/kcal of estimated energy needs

20. 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

21. 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

22. 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!

23. 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 . . . . . . . . .

24. 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

25. 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.

26. 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!!

27. 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 key
Practice 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

28. To conclude . . . . . .
All patients undergoing HSCT with myeloablative conditioning regimens are at nutrition
risk and should undergo nutrition screening, assessment if required and a proper nutrition plan
Nutrition support therapy is appropriate in patients undergoing HSCT who are
malnourished . 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 intake
is inadequate to meet nutrition requirements
Pharmocological doses of Glutamine may benefit patients
Patients should receive couselling regarding food safety guidelines as they may pose a
infectious risk
Nutrition support therapy is appropriate for patients who develop moderate to severe GVHD
accompanied by poor oral intake

29. Thanks for your
attention!