An Overview of How to Nourish the Cancer Patient by Mouth

KATHLEEN KELLY, RD

Nutrition education should start at diagnosis to prevent complications caused by malnutrition and weight loss. The cancer patient experiencing difficulty with eating requires extensive counseling. The causes of anorexia may be mechanical, psychological, or physiologic. Treatment of cancer also interferes with adequate intake. The diet needs to be tailored to the patient. Counseling on diet modification and supple- mentation or relaxation techniques may improve the patients intake. Ongoing diet instruction, encour- agement, and reinforcement will allow the patient to achieve their goals.

Cuncer 589897-1901,1986.

HE PERSON WITH CANCER may experience nutritional T deficits even before diagnosis. These people as well as other people with cancer often struggle to maintain good nutrition throughout treatment periods. Attempting to replete nutritional deficits orally can seem impossible, and for some people it is. The ideal method of treating the nutritional consequences of cancer is to prevent them from occumng.

Preventing Nutritional Deficits in the Cancer Patient

It has been well documented that certain types of cancer will cause eating disorders. These disordefi include an- orexia, maldigestion, malabsorption, and anatomical changes preventing adequate ingestion. The. treatments used in the attempt to cure cancer also art! not without their own specific effects on the nutritional status of the patient.

The goal in preventing malnutrition in the cancer pa- tient is mainly in an effort to preserve the highest quality of life for these people. Currently there is no evidence that nutrition will improve the patient's outcome. Studies are needed to determine if providing patients who have certain types of cancer with high amounts of one nutrient and/ or less of another would affect tumor growth. Also im- portant to note is the success of preventing weight loss, or reversal of nutrition deficits in the cancer patient often relies on responsiveness of the tumor to antineoplastic therapy.

All patients diagnosed with cancer, especially with can- cers and treatments that are known to have profound ef-

Presented at the American Cancer Society Second National Conference on Diet, Nutrition, and Cancer, Houston, Texas, September 5-7, 1985.

From MLG Labs, Inc., Hingham, Massachusetts. Address for reprints: Kathleen Kelly, RD, MLG Labs, Inc., 400

Accepted for publication February 20, 1986. Washington Street, Braintree, MA 02 184.

fects on the nutritional status of the patient, should be evaluated by a health professional with expertise in nu- trition, the registered dietitian. A nutritional assessment which includes a diet history, history of other diseases which rely on diet therapy, anthropometrics, evaluation of laboratory values which indicate nutrition deficits, es- timation of caloric needs, and a comparison to present intake should be completed.

Prevention of weight loss and other nutrition deficits begin with patient education. The patient should be made aware of the potential side effects that treatment may have on the nutritional status by interfering with ingestion of adequate amounts of nutrients. The patient will then be prepared to make adjustments in his diet on the onset of any problems. Each person's diet varies, therefore each patient's nutritional needs and therapy should be ad- dressed on an individual basis. Tables 1 through 3 explain some dietary dilemmas the cancer patient may encounter and provide basic suggestions for continued nourishment during these times.

Nutrition Assessment and Support of the Cancer Patient

After the initial assessment and education have been accomplished the patient should be monitored. Continued surveillance of the diet provides the opportunity to make changes in the diet quickly before weight loss.

The patient with anorexia may need nutritional sup- plements if attempts to take in high-calorie and high-pro- tein liquids and foods are not successful. There are many cookbooks and guides available to cancer patients.'-" These guides will provide variety. Commercially available supplements can add calories and protein conveniently. This is important in the tired and weak patient without support systems.

1897

TABLE 1. Eating Disorders Caused by Cancer or Cancer Treatment

Dietary dilemma/Suggestions to prevent nutrition deficits

Decreased appetite Instruct patient to eat, even if he is not hungry Apply behavior modification techniques Encourage small frequent meals and snacks (large amounts of food may be overwhelming) Patient should eat solid foods first, avoid filling up on liquid drinks, consume nutritious drinks after meals Avoid noncaloric liquids, water, coffee, tea Encourage light to moderate exercise, as tolerated, to stimulate appetite Concentrate on foods that are high in calories and protein

sunflower seeds, cheese, milk, yogurt, and cereals

granola bars, breakfast bars, ice cream

High protein food suggestions: eggs, fish, shellfish, beans and peas, i.e , soybean products (tofu), poultry, peanut butter, sesame seeds,

Calorie additions: butter or margarine, gravy, sauces, cream, milk shakes, stuffing, sour cream, salad dressing, vegetable dips, whipped cream,

Add commercially available nutrition supplements as needed

Use herbs and spices to make food more tasty, i.e , lemon juice, mint, extra salt or sugar, oregano; see cookbooks for suggestions of which herb

Serve food at cold or room temperature Tart foods or drinks may be refreshing: lemonade, fresh fruit, cranberry juice Vary color and texture Avoid extremely sweet foods If meat has an unpleasant taste use other source of protein, soy products (tofu), poultry, eggs, milk, cheese, fish, beans, peanut butter Avoid smells from cooking food if possible

Changes in taste

or spice is best to flavor specific foods

Decreased intake secondary to depression

Pain

Emotional support, psychosocial intervention and possibly mood elevating drugs may be necessary; this should be evaluated by a specialist

Often indirectly affects intake; methods of pain reduction include medicine, distraction, relaxation techniques and skin stimulation; this should be under the direction of a physician

TABLE 2. Mouth and Throat Problems Caused by Cancer or Cancer Treatment

Dietary dilemma/Suggestions to prevent nutrition deficits

Mouth or throat imtation Avoid smoking and alcoholic beverages

Specific types of irritation follow

Mouth sores Avoid extreme temperatures, spicy and hot foods, tart or acid foods and juices, raw fruits and vegetables, dry course food, highly salty food Mouth care as directed by physician Rinse mouth with viscous xylocaine before meals Drink supplements without flavor Avoid foods with an acidic pH Foods usually tolerated are liquids at room temperature, applesauce, cooked cereal, strained cream soup, custard, soft cooked eggs, plain ice

Using a straw to drink liquids may help

Avoid alcohol and tobacco Avoid commercial mouth washes Rinse before and after meals with half hydrogen peroxide and half water Citrus may stimulate saliva, suck on lemon wedges Artificial saliva will provide temporary relief Sugar-free candies, gum or popsicles may stimulate saliva (avoid foods that may increase bacteria) Moisten food by adding gravy, sauce, melted butter, broths, yogurt, mayonnaise Sip liquids throughout the day, select nutritious liquids as much as possible Bioteine toothpaste may help

Rinse with soda water Rinse with hot tea and lemon

Inability to swallow solids Puree foods: use cookbooks to add variety and well balanced foods to diet Liquid supplements homemade and commercially available Add a liquid vitamin and mineral supplement if necessary Consult speech therapist and occupational therapist to determine if patient can be taught to swallow or if tools are available to assist patient

cream, jello, milk shakes, mashed potato, popsicle, pudding, sherbet, bland foods, puree, or baby foods

Dry mouth

Thick sticky saliva

swallowina

No. 8 HOW TO NOURISH THE CANCER PATIENT BY MOUTH * Kelly 1899

TABLE 3. Gastrointestinal Disturbances Caused by Cancer or Cancer Treatment

Dietary dilemma/Suggestions to prevent nutrition deficits

Nausea and vomiting Attempts to reduce nausea before vomiting begins may be achieved with dietary changes as follows or with the use of antiemetics Eat dry foods such as dry toast, crackers, etc. when you first get up Avoid greasy, high fat foods such as fried foods, cold cuts, cream soups, gravies and whole milk (these foods may be reintroduced into the diet

Avoid foods with strong odors Avoid very sweet foods Do not lie down immediately after eating Eat and drink slowly several small meals per day

Determine if any antidiarrheal agents are necessary; bulking agents or other medicine may be necessary if patient has mal digestive problems;

Enzymes may be added to the treatment Eat smaller foods more frequently Drink plenty of liquids (mild): nectars or weak tea Liquids should be at room temperature or warm Avoid carbonated beverages Use only cooked vegetables Boiled rice, cream of rice cereal, bananas, dry toast and potato may help to control diarrhea Avoid caffeine (in coffee, strong tea, cocoa) Avoid gas producing foods, i.e., beans, cabbage, broccoli, brussel sprouts, cauliflower Avoid highly spiced foods If milk and milk products Seem to cause diarrhea, use low-lactose prdducts New supplement with water soluble fiber in it has been proven beneficial in the control of certain types of diarrhea (Enrich Ross Laboratories,

when nausea is not a problem)

Diarrhea

viokase or other enzymes may be added to the treatment

Columbus, OH) Lactose intolerance

Use lactose-free milk substitutes, soy milk, Coffee-Rich (Rich Products, Buffalo, NY), Cool-Whip (General Foods Corp., White Plains, NY),

Use commercially available lactose-free nutrition supplements Treat milk with Lact-Aid (Lactaid Inc., Pleasantville, NJ) (follow directions carefully; Lact-Aid is not useful in some milk products) Avoid untreated foods containing lactose: milk, milk drinks, ice milk, ice cream, and some cheeses If milk is deleted from the diet other sources of calcium should be added to the diet The following cheeses may be tolerated: Swiss, provolone, Edam, blue brick, Muenster, colby, mozzarella, cheddar, pasteurized American

Yogurt usually is tolerated

Avoid gas-producing foods such as bran, broccoli, brussel sprouts, cabbage, corn, green peppers, onions, turnips and carbonated beverages; intolerance should be determined on an individual basis

Avoid air swallowing by avoiding talking while swallowing Eat slowly

Constipation Drink 8-10 glasses of fluid/d Add fiber to your diet, i.e., raw fruits and vegetables, nuts, whole-grain breads, bran or wheat germ which can be added to milk shakes Light exercise Medications to assist normal movements may be necessary

Dumping syndrome Eat small frequent meals Eat slowly and sit up for 0.5 hours after eating Eat solid foods without liquids, take liquids 0.25-0.5 hour after solid food High protein, low carbohydrate diet Avoid concentrated sweets Avoid extreme temperatures when drinking liquids Slowly advance diet as tolerated

kosher products marked Pareve

cheese

Belching and flatus

In the hospital setting the cancer patient needs special attention since he may be hospitalized for long periods of time. Nutrition deficits can actually occur in the hos- pital setting. Therefore, many hospitals have set up de- mand food service for cancer patients. This is often well accepted by the patient who needs to eat immediately upon feeling capable of ingesting food. Variety is also key in providing the hospitalized patient with adequate nu- trition and to alleviate boredom.

The cancer patient’s intake should also be evaluated for adequate vitamin and mineral intake. The person consuming large amounts of one type of food may ex- perience an unbalanced intake. Table 4 reviews deficits that should be prevented. If the diet is inadequate, sup- plementation in a pill form may be necessary.

Those patients who venture into nonconventional forms of cancer therapy may take on a diet that is vege- tarian or another form of diet therapy. The most popular

1900 CANCER October 15 Supplement 1986 Vol. 58

TABLE 4. Micronutrient Deficits That May Occur With Patients should be encouraged to openly discuss their eating habits. All measures to prevent harm from dietary intake or lack of intake should be taken.

Treatment of Certain Cancers

Cause of deficit Micronutrient deficit*

Cancer patients with a history of alcohol abuse (head and neck cancer patients)

Vegetarian diets

Diet consists mainly of milk

Acute and chronic leukemia or

Small bowel resection

lymphoma

Fistulae or small bowel drainage

Chronic antibiotics

Infusion or Dlatinum

Thiamin, riboflavin, niacin, pyridoxin, folk acid, magnesium, potassium, zinc

Calcium, iron, riboflavin, BI2

Iron

Folate, Blz

Fat-soluble vitamins, water- soluble vitamins, minerals

Sodium, potassium, magnesium, zinc

Potassium

Magnesium 1 -

* Other deficiencies can occur with inadequate intake. It may be ad- visable to prevent deficiency by providing vitamin/mineral supplemen- tation when patient’s intake is poor. Symptoms of micronutrient defi- ciency should be monitored.

of these is the macrobiotic diet. The macrobiotic diet is high in fiber and can be low in calories and protein. This can have a devastating effect on the patient with anorexia. Extreme weight loss can occur. Patients who have adopted this philosophy of treatment will forego conventional treatment if they perceive an effort of the health profes- sional to change their habits. Therefore nutritional edu- cation is necessary. The diet can be supplemented with soybean products or other acceptable foods. The macro- biotic diet, as well as other vegetarian diets, also can be low in calcium, riboflavin, vitamin A, vitamin D and B12. People following these diets should be made aware of this and instructed on how to select foods that provide suffi- cient amounts of all nutrients. Moertel et all5 demon- strated that treatment with amydalin (Laetrile) and a diet of enzymes and vitamins was of little benefit to the patient with cancer. In fact, several patients studied showed evi- dence of toxicity.

As was mentioned earlier, the treatment of cancer, che- motherapy, radiation or surgery can have further conse- quences on the nutritional status of the cancer patient. Table 5 provides an overview of the effects treatment has on the body which may interfere with the ability to nourish oneself. It may be necessary for the patient to work extra hard between treatments to increase his weight. This will allow for small amounts of weight loss during treatment. This should be allowed only if the treatment interferes with intake for short periods of time, 1 to 3 days. If intake is poor for longer periods of time other methods of nu- trition support may be necessary.

The patient undergoing a bone marrow transplant or reinfusion protocol will be subjected to a sterile or low- bacteria diet for 4 to 16 weeks. This type of diet as well as the treatment these patients are receiving can have pro- found effects on the nutritional status of the patient. Often the patient’s intake is negligible and weight appears to be stable. This may occur from fluid shifts in the body. It is important to note that weight is not a good indicator of malnutrition in this population; caloric intake should be monitored.

The current diets used with these protocols include a sterile diet, which provides the patient with food that is bacteria-free and has been cooked in an autoclave or foods that have been irradiated. Various degrees of low-bacteria diets are being used. This diet includes well-cooked foods, canned and frozen cooked foods, and no raw fruits and vegetables. The acceptance of these diets vary; therefore means to provide parented nutrition is usually estab- lished before the institution of change.

Patients suffering from graft versus host disease after a bone marrow transplant will continue to have difficulty with adequate food intake. The diet may need to be low in bacteria count for 3 to 6 months after treatment. Lac- tose-free and other diet modifications may need to be un- dertaken secondary to malabsorption or maldigestion. The

TABLE 5 . Damage That Cancer Treatment Causes That May Interfer With Nutrient Intake

Body area surgery Radiation

Oral cavity, esophagus Inability to swallow, difficulty swallowing or chewing Change in taste perception, difficulty chewing, dry mouth, mucositis, painful swallowing, loss of teeth, esophagitis, stenosis, fistulae, frismus

Stomach Dumping syndrom, Bl2 deficiency; fat malabsorption, slowing of gastric emptying, hypochlorhydria due to vagotomy, hypoglycemia

malabsorption, hyperoxaluria, metabolic acidosis, life-threatening malabsorption and fluid losses, gastric hypersecretion

Small bowel Malabsorption of many nutrients, bile salt Anorexia, diarrhea, malabsorption, lactase deficiency, fistulae, obstruction, nausea, vomiting, chronic enteritis or colitis

Colon Water and electrolyte loss Pancreas Malabsorption, diabetes mellitus

No. 8 HOW TO NOURISH THE CANCER PATIENT BY MOUTH - Kelly 1901

patient should be monitored and the diet advanced as tolerated.

Drugs other than chemotherapy can interfere with pa- tient’s intake. Antibiotics may cause anorexia, diarrhea, and low potassium levels. Patients required to take oral potassium supplements often take 24 oz of fluids with no caloric and protein value. In these situations foods high in potassium mixed with high-calorie and high-protein foods could be substituted for medicine.

Malnutrition, chemotherapy and radiation can affect the absorptive capabilities of the small bowel. An ele- mental diet may be necessary on a temporary basis while bowel repairs itself. If surgical removal of the small bowel results in the need for an elemental diet this will be per- manent.

The psychological effect of having a life-threatening disease also must come into consideration. Depression and anxiety may indicate the need for psychosocial in- tervention. Dixon18 reports the possible use of relaxation techniques as intervention for promoting weight gain.

The pediatric patient with cancer requires additional attention since the nutrients vital in growth and mental development should be provided. As survival rates im- prove, so should the nutritional care of these patients.

Patients who are not end-stage and are unable to take adequate nourishment on their own should be assisted with the use of tube feedings. Criteria for patients requiring tube feeding should be set up. An example would be the patient losing 10% of his body weight and is unable to replete himself in 3 weeks will receive a tube feeding.

It appears that many cancer patients responding to an- tineoplastic therapy can stay well nourished. This allows a higher quality of life than if the patient is malnourished. The key to success is early intervention, continued ob- servation and encouragement.

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