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Clinical Nutrition and Dietetics Flashcards

1
Q

Cancer cachexia syndrome is characterized by …

A

decreased appetite and food intake with loss of body weight and lean body mass

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2
Q

Weight loss in cancer patients is associated with… (4)

A
  1. Poor performance status
  2. Increased metastatic sites and tumour burden
  3. Shorter survial
  4. Possible worse anemia and oral mucositis during chemo
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3
Q

EPCRC cachexia definition

A

A multifactoral syndrome defined by ongoing loss of skeletal muscle that cannot be fully reversed by conventional nutritional support and leads to progressive functional impairment

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4
Q

Main effects of cachexia (5)

A
  1. Physical deterioration
  2. Weakness
  3. Mental fatigue
  4. Decreased QOL
  5. Pronounced weight loss
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5
Q

Cachexia stats (3)

A

50% of patients have progressive weight loss
Cachexia is observed in 80% of advanced cancer
Cachexia is responsible for 20-40% of cancer deaths

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6
Q

In cachexia, death usually occurs when a patient has lost __% of their pre-diagnosis weight

A

30%

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7
Q

Primary causes of cachexia

A

Pro-inflammatory, pro-cachetic, and endocrine factors –> inflammatory/ metabolic changes –> increased systemic inflammation and acute phase response, protein breakdown, lipolysis, decreases in protein synthesis, lipogenesis, and appetite

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8
Q

Secondary causes of cachexia

A

Reduced appetite d/t tumor, cancer treatment, and psychological factors – pain, GI obstruction, NV, taste alteration, inactivity, pre-operative fasting, depression

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9
Q

Pathophysiology of cachexia is characterized by ___, driven by __

A

a negaive protein and energy balance; inflammation

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10
Q

Tumour cells initiate production of pro-inflammatory factors (3)

A
  1. Interleukins (IL1, IL6, IL11)
  2. Interferon-gamma
  3. TNF-alpha
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11
Q

Patient at most risk of malnourishment are… (4)

A

Lung, head and neck, GI, pancreatic cancers

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12
Q

Methods of nutritional assessment (6)

A

Diet hx, anthropometric measurements, lab tests, bioimpedance analysis, presence of nutrition impact symptoms

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13
Q

Why is weight loss an inadequate indicator of cachexia? (3)

A
  1. Cachexia is under-recognized in obese pts with sarcopenic obesity
  2. Sarcopenia can be present but obscured by accumulation of fluids
  3. Third-spacing of fluid in low oncotic pressure is an indicator of nutritional deficiency and inflammation even w/out weight loss
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14
Q

Generally albumin <2.2 g/dL reflects ___ and prealbumin <18 mg/dL reflects ____

A

severe malnutrition; decreased caloric intake

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15
Q

Nutritional focused PE findings include…

A

pallor, stomatitis, cheilosis, glossitis, thrush, quality of hair/ nails, loss of muscle mass, sunken eyes, skin turgor, bowel sounds, bloating, ascites, peripheral edema

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16
Q

Diagnosis of cachexia - primary indicators (3)

A

Weight loss >10%
Low caloric intake = 1500 kcal/ day
Systemic inflammation: serum CRP >/= 10 mg/ L

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17
Q

EPCRC cachexia diagnosis (3)

A
  1. Total body weight loss >5% in 6 mo w/out starvation
  2. Total body weight loss >2% in pt w/ BMI <20
  3. Appendcular skeletal muscle index consistent with sarcopenia (<7.26 m, <5.45 F) and >2% weight loss
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18
Q

Stages of cachexia

A
  1. Precachexia
  2. Cachexia
  3. Refractory cachexia
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19
Q

Precachexia

A

Weight loss = 5%, anorexia and metabolic change

May have poor appetite and impaired glucose tolerance

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20
Q

Refractory cachexia

A

Cancer not responsive to tx
Low performance score
<3 month’s expected survival

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21
Q

Cachexia validated questionnaires (2)

A
  1. Anorexia/ Cachexia subscale of FAACT questionnaire

2. The Scored Patient-Generated Subjective Global Assessment (PG-SGA)

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22
Q

Cachexia related progostic score

A

Glasgow Prognostic Score (mGPS)

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23
Q

Weight loss in pts is associated with … (5)

A

Chemo related side effects, fewer completed chemo cycles, reduced chemo response, increased surgical risk, decreased survival rates

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24
Q

Nutritional therapy is particularly valuable in …

A

the precachexia stage

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25
Cachexia treatment multitarget support includes (4)
Nutrient, physical, psychosocial, pharmaceutical
26
Off-label pharmaceutical agents used
Progestational agents Glucocorticoids Cannabinoids Anabolic agents
27
Specific nutritional recommendations for cachexia
Protein 1-1.5 g/kg/day Calories min 1700 M and 1300 F --> in metastatic dz aim for 30-35 kcal/kg.d Fluids 1 mL per 1 kcal consumed or 20 mL/kg day Micronutrients: Vit A, B, C, D, Zn, Fe, Se deficiencies are common
28
Fish oil may affect cachexia by...
inhibiting pro-inflammatory cytokines that contribute to acute phase protein reponse
29
Fish oil may benefit weight maintanence in patients with...
Non-small cell lung cancer, head and neck cancer, pancreatic cancer, colorectal and gastric cancer undergoing chemo, pediatric cancer
30
Carnitine deficiency has been identified in ___% of patients with advanced cancer
78%; supplementation normalizes levels
31
How is glutamine related to cachexia?
Cachexia depletes skeletal glutamine; glutamine modulates protein turnover and enhances synthesis
32
Glutamine supplementation may improve...
Nitrogen balance, protein synthesis; revent deterioration of gut permeablity
33
Have force-feeding, appetite stimulating medications, or IV nutrition been shown to improve quality of quantitity of life?
No
34
Lab tests for nutritional assessment
CBC, electrolytes, FBG, albumin, transthyretin (prealbumin), iron panel, serum B12
35
Which cells preferentially use glutamine for energy?
Enterocytes, lymphocytes, macrophages
36
Common uses of glutamine (4)
1. Chemo-induced mucositis (flueorouracil, anthracycline) 2. GI toxicity of chemo and radiation 3. Chemo-induced peripheral neuropathy (oxiliplatin, paclitaxel) 4. Cachexia (w/ HMB and arginine)
37
Glutamine dosage
10-15 g TID
38
Glutamine a/e and interactions
None common | Caution in pts w/ severe hepatic and renal impairment
39
Glutamine controversy
Some suggest that tumors are dependent on glutamine for growth and maintanence; this is mostly refuted
40
Fish oil may benefit cachexia in ....
muscle and weight maintanence in non-small cell lung cancer, head and neck cancer, colorectal and gastric cancer, and pediatric cancer
41
Fish oil may benefit patients in chemotherapy by...
- reducing peripheral neuropathy (paclitaxel) - improving neutrophils number and function - improving QOL and functional status (stage III lung) - may increase efficacy of chemo (metastatic breast, NSCLC)
42
Fish oil may reduce the efficacy of which chemotherapy?
Cisplatin
43
Fish oil dosing
2-3 g EPA and DHA
44
Fish oil adverse effects
Nausea, loose stools | Possible anticoagulant effect (not show post surgery)
45
Which fatty acid in fish oil may create chemo-negating effects?
16:4(n-3)
46
Flaxseed has chemoprotective effects in post-menopausal women by ...
altering estrogen metabolism, increasing the ratio of 2-hydroxyestrogen to 16 alpha hydroxyestrone
47
Flaxseed is commonly used in ...(4)
1. Breast cancer 2. Prostate cancer 3. Hot flashes 4. Constipation and diarrhea
48
Flaxseed's effects on breast cancer include... (3)
1. Prevetion 2. Decrease in proliferation and growth 3. Increase in apoptosis via upregulating p53
49
Flaxseed's effects on prostate cancer include... (2)
1. inhibit proliferation of | 2. Lower total and free T, PSA
50
Flaxseed dosage
25 g (2-3 tablespoons) freshly ground, with water
51
Flaxseed adverse effects
Initial gas and bloating, constipation | Inhibit absoprtion of other medication
52
Fermented Wheat Germ Extract uses (4)
1. Melanoma 2. Colorectal cancer 3. Head and Neck 4. Febrile neutropenia
53
Fermented wheat germ extract and melanoma
Improved survival and progression-free survival in stage III when combined with decarbazine
54
Fermented wheat germ extract and colorectal cancer
Reduced metastases, higher overall survival, longer progression-free survival combined with radiation or chemo
55
Fermented wheat germ extract and head and neck cancer
Fewer local relapses and progressions in stage II and III | Better quality of life in stage III and IV
56
Fermented wheat germ extract and febrile neutropenia
Reduced incidence in pediatric cancer
57
Fermented wheat germ extract dosage
one sachet in water once a day; possbily increased in people >90 kg
58
Fermented wheat germ extract adverse reactions and interactions
Mild and infrequent diarrhea, nausea, flatulence, soft stool, constipation, dizziness Take 2 hours away from foods/ supplements with vitamin C
59
Fermented wheat germ extract contraindications (5)
1. Pregnant and nursing women 2. Pts w/ organ or tissue transplants 3. Pts w/ bleeding gastric or duodenal ulcers, enteritis/ colitis, malabsorption syndrome 4. Pts w/ sensitivity to gluten or fructose 5. W/in 2 days of barium X-ray contrast
60
Probiotics mechanisms (3)
1. antimicrobial against pathogenic bacteria via reducing pH, secreting antimicrobial peptides, inhibition of bacterial invasion and adhesion 2. Enhancing barrier integrity and function via SCFA (ie butyrate) 3. Immunomodulation via action on epithelial cells, dendritic cells, monocytes/ macrophages, lymphocytes
61
Probiotic main use in cancer
Treating intestinal toxicity from chemo and radiation
62
Probiotics and intestinal toxicity
1. Less diarrhea, abdominal discomfort, less hospital care, fewer reductions in chemo dose (fluorouracil) 2. Generally less diarrhea, fewer bowel movements, less severe diarrhea, need for antidiarrheal medication (radiation)
63
Probiotics adverse effects and interactions
Generally none, may temporarily increase gas | Theoretical risk of sepsis in cancer pts with neutropenia
64
Vitamin D anticancer effects are thought to be due to....
induction of cell differentiation, antiproliferation, and angiogenesis, may enhance effects of cytotoxic agents
65
Vitamin D in oncology (2)
1. Improved prognosis | 2. Bone health (w/ bisphosphanates)
66
In which cancers does vitamin D improve prognosis? (4)
Prostate, colorectal*, CLL, large B-cell lymphoma
67
Dose vitamin D w/ caution d/t hypercalcemia in which cancers? (8)
multiple myeloma, breast, parathyroid, lung, kidney, lymphomas, leukemias, any advanced cancer with bone metastases
68
Vitamin D dosing
Base on serum levels - he goe for 100-125 nmol/L
69
Vitamin D adverse effects
GI sxs, renal disease, nephrolithiasis, hypercalcemia, hypercalciuria
70
Monitor vitamin D supplementation in the following conditions (7)
kidney stones, kidney disease, hypercalcemia, GI disease, heart disease, liver disease, other dzs associated with calcium metabolism
71
Nutritional supplements CI in cancer (4)
Iron, copper, folic acid, L-arginine
72
How/ why is iron supplementation CI in cancer?
catalyzes oxidative damage; may be involved in initiation | Should only supplement a deficiency
73
How/ why is copper supplementation CI in cancer?
Important factor in angiogenesis | only supplement w/ known deficiency
74
How/ why is folic acid CI in cancer?
its role in methylation may promote progression | Supplement w/ caution in cancer or pre-cancerous
75
Why is l-arginine CI in cancer?
Stimulates IGF-1, known growth factor of many common cancers
76
Why are antioxidants often discouraged during chemo and radiation?
chemo/ radiation are cytotoxic through oxidative stress
77
What evidence supports antioxidant use during chemo/ radiation? (3)
Cancer cells may not be able to use them Antioxidants may protect healthy cells without protecting cancerous Many antioxidants are pro-oxidant in certain situations; may increase cytotoxicity in cancer cells
78
What is the Breuss cancer cure?
42 day fast with vegetable juices (500 ml) and teas (sage, kidney, cranesbill)
79
What is the main concern with the Breuss cancer cure?
could result in malnutrition, risk discontinuing conventional care
80
What is the Budwig diet?
lacto-vegetarian + mixture of ground flaxseed and cottage cheese/ quark All foods fresh, organic, raw
81
What did Budwig think cancer was caused by?
inadequate cell maturation and incomplete cell growth, impaired cellular maturation
82
What is the Gerson Therapy?
Organic and vegetarian diet + 13 glasses of juices Suplements Coffee enemas up to 5x daily
83
What are harms associated with the Gerson therapy?
Weight loss, electrolyte imbalances | Does not recommend chemotherapy
84
Which type of cancer is particularly vulnerable to ketosis?
Brain tumors
85
Those who stayed on the ketogenic diet reported what findings?
improved emotional functioning, less insomnia
86
What is the Ornish Diet and Lifestyle Modification Program?
Supplemented low-fat vegan diet w/ exercise, stress management, smoking cessation, and group support sessions
87
What were hte effects of the Ornish diet?
In prostate cancer, lowered PSA and fewer pts undergoing conventional tc
88
What supplements are part of the Ornish program?
Soy protein, vitamin E, selenium, vitamin C
89
Generally, what effect does melatonin have when combined with chemotherapy?
Higher tumor regression rate, 5-year survival, better complete and partial response, better tolerance of chemotherapy (all done by same authors)
90
What is the primary use of CoQ10 in chemotherapy?
Prevention of anthracycline-induced cardiotoxicity, poss other chemo toxicity
91
What does fasting do to chemo?
Better effectiveness, possibly less metastases and disease free survival Improved QOL in people

Oncology (7 decks)

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