Clinical Nutrition and Dietetics Flashcards
Cancer cachexia syndrome is characterized by …
decreased appetite and food intake with loss of body weight and lean body mass
Weight loss in cancer patients is associated with… (4)
- Poor performance status
- Increased metastatic sites and tumour burden
- Shorter survial
- Possible worse anemia and oral mucositis during chemo
EPCRC cachexia definition
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
Main effects of cachexia (5)
- Physical deterioration
- Weakness
- Mental fatigue
- Decreased QOL
- Pronounced weight loss
Cachexia stats (3)
50% of patients have progressive weight loss
Cachexia is observed in 80% of advanced cancer
Cachexia is responsible for 20-40% of cancer deaths
In cachexia, death usually occurs when a patient has lost __% of their pre-diagnosis weight
30%
Primary causes of cachexia
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
Secondary causes of cachexia
Reduced appetite d/t tumor, cancer treatment, and psychological factors – pain, GI obstruction, NV, taste alteration, inactivity, pre-operative fasting, depression
Pathophysiology of cachexia is characterized by ___, driven by __
a negaive protein and energy balance; inflammation
Tumour cells initiate production of pro-inflammatory factors (3)
- Interleukins (IL1, IL6, IL11)
- Interferon-gamma
- TNF-alpha
Patient at most risk of malnourishment are… (4)
Lung, head and neck, GI, pancreatic cancers
Methods of nutritional assessment (6)
Diet hx, anthropometric measurements, lab tests, bioimpedance analysis, presence of nutrition impact symptoms
Why is weight loss an inadequate indicator of cachexia? (3)
- Cachexia is under-recognized in obese pts with sarcopenic obesity
- Sarcopenia can be present but obscured by accumulation of fluids
- Third-spacing of fluid in low oncotic pressure is an indicator of nutritional deficiency and inflammation even w/out weight loss
Generally albumin <2.2 g/dL reflects ___ and prealbumin <18 mg/dL reflects ____
severe malnutrition; decreased caloric intake
Nutritional focused PE findings include…
pallor, stomatitis, cheilosis, glossitis, thrush, quality of hair/ nails, loss of muscle mass, sunken eyes, skin turgor, bowel sounds, bloating, ascites, peripheral edema
Diagnosis of cachexia - primary indicators (3)
Weight loss >10%
Low caloric intake = 1500 kcal/ day
Systemic inflammation: serum CRP >/= 10 mg/ L
EPCRC cachexia diagnosis (3)
- Total body weight loss >5% in 6 mo w/out starvation
- Total body weight loss >2% in pt w/ BMI <20
- Appendcular skeletal muscle index consistent with sarcopenia (<7.26 m, <5.45 F) and >2% weight loss
Stages of cachexia
- Precachexia
- Cachexia
- Refractory cachexia
Precachexia
Weight loss = 5%, anorexia and metabolic change
May have poor appetite and impaired glucose tolerance
Refractory cachexia
Cancer not responsive to tx
Low performance score
<3 month’s expected survival
Cachexia validated questionnaires (2)
- Anorexia/ Cachexia subscale of FAACT questionnaire
2. The Scored Patient-Generated Subjective Global Assessment (PG-SGA)
Cachexia related progostic score
Glasgow Prognostic Score (mGPS)
Weight loss in pts is associated with … (5)
Chemo related side effects, fewer completed chemo cycles, reduced chemo response, increased surgical risk, decreased survival rates
Nutritional therapy is particularly valuable in …
the precachexia stage
Cachexia treatment multitarget support includes (4)
Nutrient, physical, psychosocial, pharmaceutical
Off-label pharmaceutical agents used
Progestational agents
Glucocorticoids
Cannabinoids
Anabolic agents
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
Fish oil may affect cachexia by…
inhibiting pro-inflammatory cytokines that contribute to acute phase protein reponse
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
Carnitine deficiency has been identified in ___% of patients with advanced cancer
78%; supplementation normalizes levels
How is glutamine related to cachexia?
Cachexia depletes skeletal glutamine; glutamine modulates protein turnover and enhances synthesis
Glutamine supplementation may improve…
Nitrogen balance, protein synthesis; revent deterioration of gut permeablity
Have force-feeding, appetite stimulating medications, or IV nutrition been shown to improve quality of quantitity of life?
No
Lab tests for nutritional assessment
CBC, electrolytes, FBG, albumin, transthyretin (prealbumin), iron panel, serum B12
Which cells preferentially use glutamine for energy?
Enterocytes, lymphocytes, macrophages
Common uses of glutamine (4)
- Chemo-induced mucositis (flueorouracil, anthracycline)
- GI toxicity of chemo and radiation
- Chemo-induced peripheral neuropathy (oxiliplatin, paclitaxel)
- Cachexia (w/ HMB and arginine)
Glutamine dosage
10-15 g TID
Glutamine a/e and interactions
None common
Caution in pts w/ severe hepatic and renal impairment
Glutamine controversy
Some suggest that tumors are dependent on glutamine for growth and maintanence; this is mostly refuted
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
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)
Fish oil may reduce the efficacy of which chemotherapy?
Cisplatin
Fish oil dosing
2-3 g EPA and DHA
Fish oil adverse effects
Nausea, loose stools
Possible anticoagulant effect (not show post surgery)
Which fatty acid in fish oil may create chemo-negating effects?
16:4(n-3)
Flaxseed has chemoprotective effects in post-menopausal women by …
altering estrogen metabolism, increasing the ratio of 2-hydroxyestrogen to 16 alpha hydroxyestrone
Flaxseed is commonly used in …(4)
- Breast cancer
- Prostate cancer
- Hot flashes
- Constipation and diarrhea
Flaxseed’s effects on breast cancer include… (3)
- Prevetion
- Decrease in proliferation and growth
- Increase in apoptosis via upregulating p53
Flaxseed’s effects on prostate cancer include… (2)
- inhibit proliferation of
2. Lower total and free T, PSA
Flaxseed dosage
25 g (2-3 tablespoons) freshly ground, with water
Flaxseed adverse effects
Initial gas and bloating, constipation
Inhibit absoprtion of other medication
Fermented Wheat Germ Extract uses (4)
- Melanoma
- Colorectal cancer
- Head and Neck
- Febrile neutropenia
Fermented wheat germ extract and melanoma
Improved survival and progression-free survival in stage III when combined with decarbazine
Fermented wheat germ extract and colorectal cancer
Reduced metastases, higher overall survival, longer progression-free survival combined with radiation or chemo
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
Fermented wheat germ extract and febrile neutropenia
Reduced incidence in pediatric cancer
Fermented wheat germ extract dosage
one sachet in water once a day; possbily increased in people >90 kg
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
Fermented wheat germ extract contraindications (5)
- Pregnant and nursing women
- Pts w/ organ or tissue transplants
- Pts w/ bleeding gastric or duodenal ulcers, enteritis/ colitis, malabsorption syndrome
- Pts w/ sensitivity to gluten or fructose
- W/in 2 days of barium X-ray contrast
Probiotics mechanisms (3)
- antimicrobial against pathogenic bacteria via reducing pH, secreting antimicrobial peptides, inhibition of bacterial invasion and adhesion
- Enhancing barrier integrity and function via SCFA (ie butyrate)
- Immunomodulation via action on epithelial cells, dendritic cells, monocytes/ macrophages, lymphocytes
Probiotic main use in cancer
Treating intestinal toxicity from chemo and radiation
Probiotics and intestinal toxicity
- Less diarrhea, abdominal discomfort, less hospital care, fewer reductions in chemo dose (fluorouracil)
- Generally less diarrhea, fewer bowel movements, less severe diarrhea, need for antidiarrheal medication (radiation)
Probiotics adverse effects and interactions
Generally none, may temporarily increase gas
Theoretical risk of sepsis in cancer pts with neutropenia
Vitamin D anticancer effects are thought to be due to….
induction of cell differentiation, antiproliferation, and angiogenesis, may enhance effects of cytotoxic agents
Vitamin D in oncology (2)
- Improved prognosis
2. Bone health (w/ bisphosphanates)
In which cancers does vitamin D improve prognosis? (4)
Prostate, colorectal*, CLL, large B-cell lymphoma
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
Vitamin D dosing
Base on serum levels - he goe for 100-125 nmol/L
Vitamin D adverse effects
GI sxs, renal disease, nephrolithiasis, hypercalcemia, hypercalciuria
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
Nutritional supplements CI in cancer (4)
Iron, copper, folic acid, L-arginine
How/ why is iron supplementation CI in cancer?
catalyzes oxidative damage; may be involved in initiation
Should only supplement a deficiency
How/ why is copper supplementation CI in cancer?
Important factor in angiogenesis
only supplement w/ known deficiency
How/ why is folic acid CI in cancer?
its role in methylation may promote progression
Supplement w/ caution in cancer or pre-cancerous
Why is l-arginine CI in cancer?
Stimulates IGF-1, known growth factor of many common cancers
Why are antioxidants often discouraged during chemo and radiation?
chemo/ radiation are cytotoxic through oxidative stress
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
What is the Breuss cancer cure?
42 day fast with vegetable juices (500 ml) and teas (sage, kidney, cranesbill)
What is the main concern with the Breuss cancer cure?
could result in malnutrition, risk discontinuing conventional care
What is the Budwig diet?
lacto-vegetarian + mixture of ground flaxseed and cottage cheese/ quark
All foods fresh, organic, raw
What did Budwig think cancer was caused by?
inadequate cell maturation and incomplete cell growth, impaired cellular maturation
What is the Gerson Therapy?
Organic and vegetarian diet + 13 glasses of juices
Suplements
Coffee enemas up to 5x daily
What are harms associated with the Gerson therapy?
Weight loss, electrolyte imbalances
Does not recommend chemotherapy
Which type of cancer is particularly vulnerable to ketosis?
Brain tumors
Those who stayed on the ketogenic diet reported what findings?
improved emotional functioning, less insomnia
What is the Ornish Diet and Lifestyle Modification Program?
Supplemented low-fat vegan diet w/ exercise, stress management, smoking cessation, and group support sessions
What were hte effects of the Ornish diet?
In prostate cancer, lowered PSA and fewer pts undergoing conventional tc
What supplements are part of the Ornish program?
Soy protein, vitamin E, selenium, vitamin C
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)
What is the primary use of CoQ10 in chemotherapy?
Prevention of anthracycline-induced cardiotoxicity, poss other chemo toxicity
What does fasting do to chemo?
Better effectiveness, possibly less metastases and disease free survival
Improved QOL in people
