14SCIENCE REPORTER, AUGUST 2015

A special type of diet designed to meet the requirements of people with low immunity is known as Neutropenic diet.

cancer are closely interlinked. Many patients who are diagnosed with cancer are mostly malnourished at the time of diagnosis. Malnourished patients have a hard time dealing with cancer and its treatment.

Sometimes with the progression of the disease or with the onset of cancer treatment, a patient may become malnourished, if good nutrition support is not provided. Malnutrition in cancer is a cause of concern as it adversely affects the quality of life and survival of a patient. Dealing with nutritional problems in cancer facilitates faster recovery. Well-nourished patients are more capable of withstanding the harsh cancer treatments such as chemotherapy or radiation therapy.

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SCIENCE RREPOPORTER AUGUST 2015

CANCER affects people irrespective of their age, gender or social status.

Nearly 35% of all cancers are related to diet. Other factors such as genetic mutations, environmental pollutants, UV rays and emotional stress are also responsible for causing cancer.

It is important to take steps to prevent cancer but once cancer strikes, it is a tough road ahead. Once cancer is diagnosed, coping with the disease and the harsh cancer treatments becomes a diffi cult task. Cancer and its treatment leave a patient drained both emotionally as well as physically. Along with medical intervention, emotional support, good nutrition and relaxation techniques like meditation and listening to good music also play a big role in the healing process.

Nutrition plays a vital role in fi ghting the deadly disease. Good nutrition is like an army that helps the body fi ght the battle against cancer. Nutrition and

Cancer and the BodyWhen cancer strikes, it disturbs the normal physiological and metabolic processes of the body. The complex interaction between the host tissue and tumour result in metabolic aberrations which increase basal energy expenditure as well as reduce utilization of nutrients by the host. Cancer cells develop at the expense of the host tissue, adversely affecting the normal metabolism of the body and resulting in

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There are many survivors who have successfully won the battle against cancer. “Cancer is curable” when detected on time and treated along with good nutritional support.

Build up your defenses against cancer

15 SCIENCE REPORTER, AUGUST 2015

loss of lean body mass due to increased tissue protein breakdown.

The fast-growing cancer cells increase the body’s energy needs so drastically that proteins are broken down to meet the energy requirements leading to negative nitrogen balance in the body. This results in muscle wasting, loss of body weight and muscular weakness in cancer patients.

Fats are also broken down to meet the energy needs of the body but glucose utilization by the cells is reduced due to metabolic disturbances such as reduced insulin release and increased insulin resistance which impairs glucose tolerance. The body is unable to convert carbohydrates into glucose and use it as a source of energy which propels other nutrients like proteins and fats to break down to meet the high energy demands imposed by the developing cancer cells.

If the tumor develops anywhere in the gastrointestinal tract, the normal digestion, absorption and utilization of nutrients is also seriously affected. Anorexia or loss of appetite is a common

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problem seen in cancer patients which usually results from several physical as well as psychological factors such as pain and discomfort due to the disease, depression, anxiety and fear for the outcome of this potentially fatal disease or treatment.

Anorexia is chiefl y responsible for weight loss and weakness leading to protein energy malnutrition. Anorexia causes reduced food intake. This increased demand for energy and reduced intake causes depletion of the body’s stores of energy and other nutrients posing signifi cant challenges in maintaining the patient’s nutritional status.

Malnutrition and Cancer TherapyCancer patients are usually malnourished at the time of detection which is quite evident from certain characteristic features like weight loss, loss of appetite, muscular weakness and lethargy. It has been reported that nearly 80% of the patients with upper gastrointestinal tract cancer and 60% patients with lung cancer have already experienced signifi cant

weight loss at the time of diagnosis. Signifi cant weight loss is defi ned as at least a 10% loss of body weight in six months’ time.

Protein energy malnutrition is a frequent secondary diagnosis in cancer. The tumour and its effect on the body along with altered physiological and metabolic changes cause signifi cant reduction in the intake of food. Since cancer cells multiply at an abnormally rapid rate as compared to normal cell division, the metabolism of the body increases signifi cantly thereby increasing the demand for energy and protein.

This is why feeding a cancer patient poses major challenges for the medical team as well as for the care giver of the patient. It is important to provide good nutritional support to the patient as early as possible as it is easier to prevent than treat malnutrition. Nutrition support must be provided before the decline in the nutritional status begins.

Medical Nutrition Therapy (MNT) Dietary counseling and nutrition support early in the treatment of cancer can prevent the much dreaded complication of cancer “cachexia”. Cancer cachexia is characterized by anorexia (loss of appetite), early satiety, poor absorption of nutrients, muscle weakness, low immune states, and increased risk of infections which ultimately leads to death. Cachexia is estimated to cause 20-40% of cancer deaths.

Yuvraj Singh made a successful comeback after fi ghting cancer

Coping with cancer and its treatment can be highly stressful and enervating but with good nutritional support right from the beginning one can overcome the challenges

16SCIENCE REPORTER, AUGUST 2015

There is no standard diet for all cancer patients, the nutritional goals are highly individualized and variable. For the same patient, the nutritional goals maybe different at different points of time during the course of the disease.

Nutrients are delivered to the patient by oral, enteral or parenteral route. As long as the patient can eat orally, the other methods are best avoided. Enteral feeding is also known as tube feeding in which food is given in liquid form through a catheter or a tube. This method is used

when the patient cannot eat orally due to surgery of upper gastrointestinal tract or diffi culty in chewing or swallowing as in the case of cancer of the oral cavity or oesophagus. Sometimes the tube feeding may be initiated along with oral feeding to prevent malnutrition.

Parenteral nutrition or administra-tion of nutrients directly into the vein (peripheral vein or central vein) is the last resort as it is expensive and increases the risk of complications. Intravenous administration of nutrients is an important option for those who cannot tolerate oral or tube feedings. In this, nutrients in their pre-digested form are directly injected into the circulation.

The majority of cancer patients can meet their nutritional requirements through small changes in their diet along with partial oral supplements. Commercially available nutritional supplements are a good option for meeting the increased demands of energy and proteins. Since diet alone may not be suffi cient in meeting these needs, supplements can be taken at regular intervals to make up for any energy defi cit.

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There are several supplements available in the market but the choice of supplements depends on the patient’s requirement, clinical condition and taste preferences. Supplements should be given after consultation as some supplements are specially designed for meeting the increased energy and protein needs of the cancer patients. Intensive nutritional support is necessary only in severely malnourished patients or patients undergoing major cancer treatments.

Dietary Management in CancerA well-nourished patient is better able to cope with the side effects of cancer therapy and may even tolerate higher doses of certain treatments. Getting enough calories and proteins in the diet helps one to be better equipped to withstand the side effects of cancer treatments as the patient has the nutrient reserves which will help in keeping up the strength, prevent body tissue from breaking down, rebuild tissues and maintain defenses against infections.

Since the eating habits and eating pattern change during the course of the

Patient’s diffi culties pose a challenge for the caregiver

If the tumor develops anywhere in the gastrointestinal tract, the normal digestion, absorption and utilization of nutrients is also seriously affected.

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disease and its treatment, adjustments need to be made to provide food to the patient at odd times of the day. During cancer therapy, the patient may develop a dislike for most of his/her favourite foods which makes it challenging to feed the patient.

The kind of diet recommended for a cancer patient is different from a normal healthy diet which is why patients may get confused with the new suggestions which focus on increasing calories from fat and providing protein more than the usual requirement. A high calorie, high protein and high fat diet is given to cancer patients to prevent malnutrition and weight loss which is vital for survival. Less emphasis is given to high fi bre foods

such as fruits and vegetables especially when a patient’s food intake is already reduced. Also sometimes high fi bre foods are omitted from the diet as in the case of diarrhea or mouth sores.

Here are some of the major nutritional requirements in cancer:1. Energy: Suffi cient energy in the form of carbohydrates and fats needs to be given to prevent weight loss and to spare proteins for tissue synthesis. The energy requirement is high due to increased metabolic demands as a result of fast growing cancer cells. A well-nourished patient may require around 2000 kcal/day. A malnourished patient may need 3000-4000 kcal/day depending on the degree of malnutrition.

2. Protein: Protein requirement is increased due to breakdown of tissues and for wound healing especially when healthy tissues are damaged due to cancer treatment. A high protein diet supplying 1.5-2.0 gm/kg bodyweight is prescribed for cancer patients. Proteins must be of good quality to support tissue repair and regeneration. An adequate calorie and protein ratio must be maintained to ensure protein is utilized for tissue formation and not wasted in meeting energy needs. This means that along with high protein in the diet, the patient must receive suffi cient calories from fats and carbohydrates to prevent any tissue breakdown.3. Vitamins and Minerals: B complex

DEALING WITH NUTRITIONAL PROBLEMS IN CANCERNutritional Problem Dietary AdviceAnorexia or loss of appetite Small frequent meals with reduced fl uid and fi bre intake.

Food should be served in an attractive manner to stimulate appetite.

Calorie and protein dense snacks can be given along with nutritional drinks as meal replacers.

Changes in taste Adding fl avourful seasonings to food such as lemon, spices and condiments to stimulate appetite. Different(taste fatigue) and smell fl avoured (chocolate, vanilla, strawberry) supplements (nutritional drinks) can be given to prevent taste fatigue.

Mouth ulcers or sores Soft foods without harsh fi bre like semolina (suji) upma, boiled and mashed potatoes, soft-cooked rice, pasta, noodles and boiled eggs must be given. Spicy and hard foods like dry toast/rusk must be avoided to prevent any irritation.

Dysphagia or diffi culty Thick drinks can be given when solid food is diffi cult to swallow.swallowing

Nausea Strongly fl avoured or fried food must be avoided. Onions, cabbage or strong smelling vegetables must not be given. Very sweet foods like cakes, pastries, sweetened beverages must be avoided.

Vomiting Do not give any food till vomiting stops. Use of anti-emetics can help relieve vomiting. Once vomiting stops start with clear liquids like clear soups, coconut water, lemon water and slowly progress to full liquid (milk/buttermilk) and soft diet such as khichri or upma which is easily digestible. Avoid giving fat-rich foods or fried foods which stay in the stomach for long.

Diarrhoea Do not give fi bre-rich foods like fruits and vegetables except bananas and potatoes which can be given in diarrhea. Give soft bland diet without much spices, like bread, rice, noodles, etc. Do not give milk as it worsens diarrhea, instead give buttermilk/lassi.

Constipation Increase fi bre and fl uids in the diet. Add some bran to dishes, sprouts to salads and fruits like guava and apple to relieve constipation.

Dryness of mouth Sip small quantities of fl uid like water, milk or juice to relieve dryness along with meals/snacks. If fl uid is restricted, give ice chips or lemon wedges to suck which stimulate saliva secretion. Sugar-free chewing gum can also be given.

Food aversions Avoid favourite foods within 24 hours of chemotherapy. Due to chemotherapy, patients usually develop an aversion for protein-rich foods like meat, milk, eggs, etc. as they leave a metallic taste in the mouth. Use substitutes such as protein supplements when milk is not acceptable.

Weight loss Increase calorie and protein dense foods in the diet and reduce intake of low calorie foods like salads, whole fruits, whole grains like broken wheat dalia or brown rice. Limit fl uid intake to increase food intake.

Weight gain This usually happens not because of fat deposition but due to water retention in the body. When sudden weight gain occurs, it happens due to fl uid retention. In such a case, reduce sodium/salt intake in the diet to get rid of extra fl uids from the body. Consult a doctor if weight gain occurs for more specifi c medical advice.

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nuts and almonds, granola bars, cakes, pastries, bread rolls, French fries, corn, banana and potato chips, etc. in between meals or whenever the patient feels hungry.4. Thick soups with added corn starch can be given to the patient. One can increase calories further by adding some butter and milk cream, grated cheese, macaroni or noodles to the soup.5. Applying butter or ghee to chapattis, substituting whole milk for water for preparing dishes, adding scrambled eggs/cottage cheese (paneer) to rice preparations like pulao or biryani helps to increase calories as well as proteins in dishes.6. Instead of whole fruits, fruit juices are a better option for patients with poor appetite and increased energy needs. Glucose or sugar can be added for extra

vitamins are needed for energy and protein metabolism, as they help in releasing energy from carbohydrates. Vitamins A and C are required as structuring materials and vitamin C aids in wound healing also. Minerals such as calcium, phosphorus, and Vitamin D are needed for bone formation especially in bone disease. Vitamin B 12, folic acid, iron, Vitamin C and proteins are needed to prevent iron defi ciency anaemia from any blood loss that may occur as in the case of intestinal bleeding in colon cancer.4. Fluid Intake: Unless contraindicated, fl uid intake must be increased to compensate for any losses through diarrhea, vomiting, infection and fever. Fluids also aid in fl ushing out toxic chemicals from chemotherapeutic drugs as well as byproducts of breakdown of destroyed cancer cells. Adequate

fl uid intake helps to lessen the load on kidneys and prevents dehydration due to GI losses. It also helps prevent UTI or urinary tract infection and infl ammation.

Practical suggestions for increasing calories and proteins are given below:

1. Consuming high protein and high calorie nutritional supplements in between meals or as meal replacements when the patient does not feel like eating a full meal due to fatigue, anorexia and pain.

2. Increasing protein in the diet by adding whole or skimmed milk powder to milk not only makes it a concentrated source of protein but calories too.

3. Consuming high calorie snacks like jaggery and peanut chikki, potato and cheese sandwiches, deep fried pakoras, paneer rolls, dried fruits like cashew

FOOD SAFETY: DO’S AND DON’TS1. Avoid all raw fruits and vegetables like salads, cut fruits le in the open.

2. Consume only cooked vegetables prepared in a hygienic environment.

3. Fruits with skin must be avoided. Instead canned or tetra-packed juices or fruits with thick peels like oranges and bananas can be consumed a er thorough washing. Canned/packaged foods must be checked for expiry before consump on. Bloated/leaky cans or packs must be discarded as it indicates food spoilage.

4. Avoid consuming stale food.

5. Do not consume food le in the open for a long me.

6. Avoid street food or outside food whose quality in terms of food safety and hygiene is doub ul.

7. Wash vegetables thoroughly under running water to remove dirt. Wash hands with soap and water before cu ng vegetables.

8. Keep food prepara on surfaces clean.

9. Use washed knife and utensils for food prepara on and storage.

10. Cook meats, poultry at high temperatures as in pressure cooking for thorough cooking. Do not consume undercooked meat/eggs/poultry etc.

11. Use only pasteurized milk and other dairy products for consump on.

12. Boil milk before consump on; ready-to-use tetra packed milk treated by UHT (ultra high temperatures) process is safe for direct consump on.

13. Avoid yoghurt/curd containing live bacterial cultures as the immune system may not handle even bacteria present in curd which is safe for consump on by healthy individuals.

14. Avoid raw honey as it may contain bacterial spores. Honey consumed as a part of processed foods is safe.

15. Drink only boiled and cooled water. Avoid tap water or water from unknown or unreliable sources.

16. Avoid fruit juices from a street vendor/shopkeeper. Prepare it at home in a hygienic manner or else use tetra packed juices.

Neutropenic diet for a weakened immune systemHigh energy and protein supplements help to meet additional demands of nutrients during cancerCancer and its treatment leave a patient drained both emotionally as well as physically. Along with medical intervention, emotional support, good nutrition and relaxation techniques like meditation and listening to good music also play a big role in the healing process.

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energy to juices. Adding nutritional supplements to milk for extra energy and nutrients and preparing thick milkshakes by adding fruits like banana or chickoo, dried fruits (in powdered form), sugar, whole milk powder, ice cream, etc. helps to boost energy and nutrient value of milk.

7. Milk-based desserts like vermicelli (seviyan) kheer, rice kheer, carrot kheer/halwa, topped with chopped dried fruits are an excellent way to encourage eating in patients with poor appetite.

Nutritional Problems in CancerCancer therapies are known to cause unpleasant side effects in patients. These treatments target the fast-growing cancer cells but also damage healthy cells that normally grow and divide rapidly such as those in the mouth, digestive tract and hair. The damage to healthy cells can produce side effects such as hair loss which is quite common in patients receiving chemotherapy.

Other side effects that cause problems with the food intake such as those in the mouth and GI tract can actually cause nutritional problems affecting the

nutritional status of the patients. Patients who are already malnourished at the time of receiving these cancer treatments run a high risk of becoming severely emaciated with a lower life expectancy and increased chances of getting infections.

Side effects of cancer therapy such as radiations, chemotherapy, surgery, hormone therapy, etc. result in various nutritional problems which need to be corrected in order to prevent the patient from becoming malnourished. Surgery in the gastrointestinal tract (GI) can cause diffi culties in chewing, swallowing, and also lead to malabsorption of nutrients due to impaired digestion and absorption. Radiations in the head and neck region can cause chewing and swallowing diffi culty due to dryness of mouth, mouth sores or pain. Radiations in the lower GI tract as in the case of colon cancer can cause diarrhea or constipation as side effects.

Cancer patients who are especially undergoing chemotherapy run the risk of getting infections. Those who have an Absolute Neutrophil Count (ANC) less than 500 cells/mm3 have a seriously compromised immune system. With such a weak immune system, it becomes

Food served in an attractive manner helps to stimulate appetite

Street food must be avoided by patients with lowered immunity as its safety in terms of food hygiene is doubtful

Thick milkshakes and smoothies help in feeding patients with poor appetite

diffi cult to resist infections as the host body’s defense mechanisms fail to protect it from invading bacteria and other harmful microorganisms.

In such a case, it is important to take precautions to prevent any food-borne illness/food infections. A special type of diet designed to meet the requirements of people with low immunity is known as Neutropenic diet. It focuses on maintaining food safety and hygiene and encourages healthy and safe food handling practices to prevent contamination of food and drinks.

Coping with cancer and its treatment can be highly stressful and enervating but with good nutritional support right from the beginning, one is armed with the necessary strength and stamina required for overcoming the challenges of cancer. There are many survivors who have successfully won the battle against cancer, which shows that “Cancer is curable” when detected on time and treated with a good nutritional support.

Ms Richa Saxena is a Registered Dietitian and Certifi ed Diabetes Educator. She has earlier worked with Wockhardt Hospitals Ltd., Hyderabad and is a Past Visiting faculty for Nutrition at Dr. Reddy’s Foundation for Health Education, a unit of Dr. Reddy’s Lab. Ltd, Hyderabad. Address: M.M.-203, Sector-D, Aliganj, Lucknow-226024, U.P.; Email: 2rd.richa@gmail.com

High calorie and protein

snacks like paneer rolls, cookies and

milkshake, granola bars must be eaten in-

between meals

Malnutrition in cancer is a cause of concern as it adversely affects the quality of life and survival of a patient.