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6-Clinical Nutrition 1 > Nutritional assessment and intervention in cancer > Flashcards

Nutritional assessment and intervention in cancer Flashcards

1
Q

What are the factors that affect nutritional status of a person with cancer?

A
  • presence of tumor
  • host response
  • anti-cancer treatment
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2
Q

What are the consequences of compromised status?

A

reduced intake + altered metabolism –>

malnutrition + weigh loss –>

decreased quality of life
decreased response to treatment
decreased survival

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3
Q

What are the benefits of assessing nutrition in cancer patients?

A
  • Early identification of patients at risk, or experiencing malnutrition allows for early intervention
  • Helps design appropriate nutritional support
  • Improves patient wellbeing, survival, immune function and reduced morbidity
  • Improves eligibility and response to treatment
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4
Q

Nutritional screening vs assessment

A

Screening: process of identifying characteristics known to be associated with nutritional problems

  • Purpose is to quickly identify individuals with nutritional risks
  • Should be easy to use, cost effective, valid, reliable, sensitive

Assessment: process of assessment of body compartments and analysis of structure and function of organ systems and their effects on metabolism

  • Most often performed by dietician
  • Includes medical and dietary history, physical examination, anthropometric measurements and analysis of biochemical and functional status. Specific to cancer: review of symptoms.
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5
Q

What are some nutritional screening tools for cancer?

A
  • NRI: Nutritional Risk Index (Busby)
    Albumin x % ideal weight
  • MUST: Malnutrition Universal Screening Tool
  • SNAQ: Short Nutritional Assessment Questionnaire
  • NRS: Nutritional Risk Screening-2002
  • MNA: Mini-Nutritional Assessment (short and long)
    Both screening and assessment for the elderly
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6
Q

How is percent weight loss calculated?

A

initial weight-current weight/initial weight x100

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7
Q

How is unintentional weight loss classified?

A
  • Most powerful independent variable that predicts mortality in CA
  • Prime clinical manifestation of cachexia
  • Classification of cachexia, based on weight loss in previous 6 mo: }
    Moderate > 5%
    Severe > 10%
    Very severe > 15%
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8
Q

What is the severity of weight loss if I lost >2% in 1 week?

A

severe

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9
Q

What is the severity of weight loss if I lost 1-2% in 1 week?

A

significant loss

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10
Q

What is the severity of weight loss if I lost 5% in 1 month?

A

significant loss

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11
Q

What is the severity of weight loss if I lost >5% in 1 month?

A

severe

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12
Q

What is the severity of weight loss if I lost 7.5 % in 3 months?

A

significant loss

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13
Q

What is the severity of weight loss if I lost >7.5 % in 3 months?

A

severe

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14
Q

What is the severity of weight loss if I lost 10% in 6 months?

A

significant loss

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15
Q

What is the severity of weight loss if I lost >10% in 6 months?

A

severe

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16
Q

What is the severity of weight loss if I lost 10-20% in unlimited time?

A

significant loss

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17
Q

What is the severity of weight loss if I lost >20% in unlimited time?

A

severe

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18
Q

What are the assessment tools for muscle mass loss?

A
  • Anthropometry: mid-upper arm muscle area
  • Creatinine/height index
  • 3-methylhistidine excretion
  • Bioelectrical impedence (BIA)
  • DXA: appendicular muscle mass index
  • Imaging techniques: CT scan, MRI
  • Densitometry: hydro- or air displacement
  • Stable isotope dilution
  • Total body potassium counting
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19
Q

What is Mid-upper arm muscle area (MAMA) and how is it interpreted?

A
  • Calculated from mid-arm circumference and triceps skinfold
  • Low MAMA : < 15th percentile for age and sex
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20
Q

What is Urinary creatinine excretion?

A

Urinary creatinine is a metabolite of creatine phosphate, mainly found in skeletal muscle: index of muscle mass
- Creatinine / height ratio

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21
Q

What is 3-methyl- histidine excretion?

A
  • 3-methylhistidine is released from actin and myosin degradation → marker of myofibrillar protein degradation (account for ~ 90% skeletal muscle protein)
  • 3-MH/creatinine ratio
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22
Q

What are the limitations of Urinary creatinine and 3-methyl-histidine excretion?

A
  • Wide day-to-day variation

- Both techniques require 24 h-urine collections and 3 day-meat free diet prior

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23
Q

What is Bioelectrical impedance and advantages of it?

A
  • Estimation of fat-free mass (body fat by difference) based on body water, 2-compartment model
  • Foot-to-foot (not recommended) and 4-electrode models: - Instruments accessible, affordable
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24
Q

What are the limitations of bioelectrical impedance?

A
  • Reliable only if hydration status is normal

- Built-in equations are not validated for malnourished or sick persons

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25
Q

What is Dual energy X-ray absorptiometry (DXA) and what are its limitations?

A
  • Imaging technique, based on different tissue density
  • Measures bone, soft and fat tissues → total lean body mass and appendicular muscle mass
  • AMM/height2 identifies sarcopenia:
    <7.25 kg/m2 in men,
    <5.45 kg/m2 in women

Limitations:

  • Expensive but increasingly accessible in research settings
  • Minimal exposure to radiation
  • Assumes normal hydration status
  • Does not account for tumour, metastasis, organ enlargement
26
Q

How is muscle strength measured?

A 
Handgrip strength
- Measured with a dynamometer
- Cut-offs for low strength:
men <35 kg 
women <23 kg
- Correlates with whole-body muscle
strength
27
Q

What are some other functional tests?

A
  • Gait speed
    Walking speed <0.8 m/s in the 4-m walking test
    The best predictive marker of morbidity and mortality (Guralnik, Ferucci et al, 2000)
  • Chair rise
    Time to rise 5 times from a chair without help from the arms }
    Test leg strength and power
  • 6-min walking test
    Distance walked during 6 minutes }
    Endurance test
  • Balance test
    Time standing on one foot, or one foot in front of the other
28
Q

In what situations albumin is high and low in cancer?

A

high –> dehydration

low –> inflammation, protein deficiency, sepsis, hyperhydration

29
Q

In what situations vitamin B12 is high and low in cancer?

A

high –> leukemia, liver mets
low –> gastrectomy

*** If high: do not restrict B12 intake;
if low: IM injections

30
Q

In what situations calcium is high in cancer?

A

high –> some mets, lymphomas, parathyroid tumor

*** do not restrict Ca intake, stop vit. D supplements

31
Q

In what situations folate is low in cancer?

A

low –> some drugs (methotrexate)

32
Q

In what situations glucose is high in cancer?

A

high –> corticosteroids pancreatic CA

** avoid concentrated sugar

33
Q

In what situations hemoglobin is low in cancer?

A

low –> Radio and chemo-Tx, blood losses, leukemia, lymphoma, Hodgkin

*** If hypochromic anemia: may respond to iron supplement
If megaloblastic anemia: folate or B12 supplements
If normochromatic anemia: blood transfusion

34
Q

In what situations potassium is high in cancer?

A

Tx with cisplatine

*** Supplements if dietary intake insufficient

35
Q

In what situations lymphocyte count is low in cancer?

A

Radio and chemo-Tx, leukemia, corticosteroids

*** May respond to increased protein intake

36
Q

What are the indications of dehydration in cancer?

A 
For valid interpretation of lab results 
Indication of dehydration:
High blood concentrations of: 
- Blood electrolytes
- Blood urea nitrogen (BUN)
- Creatinine
- CBC: hematocrit
- Urine specific gravity

Clinical signs:
- Low blood pressure especially orthostatic; rapid heart rate, skin dryness and lack of elasticity, dry mouth and lips, confusion, thirst.

37
Q

How is performance status assessed?

A

0
Fully active, able to carry on all pre-disease performance without restriction

1
Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work

2
Ambulatory and capable of all selfcare but unable to carry out any work activities. Up and about more than 50% of waking hours

3
Capable of only limited selfcare, confined to bed or chair more than 50% of waking hours

4
Completely disabled. Cannot carry on any selfcare. Totally confined to bed or chair

5
Dead

38
Q

What is subjective assessment?

A

Patient-Generated – Subjective Global Assessment
(PG-SG A)
- Adapted from the SGA (Detsky Index) for oncology patients
- May be used for both screening and assessment
- 2 sections: one filled by patient, one by health-care professional
- Numerical score: useful for triage to initiate intervention
- Has been validated against objectives measures
- May be used to assess improvements/deteriorations of nutritional status

39
Q

Based on available resources, nutritional assessment of patients with cancer should include, at least:

A
  • Dietary assessment (usual and 24 h-food recall)
  • Weight loss history
  • Body composition: anthropometry (MAMA), BIA or DXA
  • PG-SGA (review of symptoms and level of function)
  • Biochemical data: albumin, CRP, prealbumin, hemoglobin, others if suspected nutrient deficiencies (+dehydration/oedema)
  • Muscle strength
  • Physical examination
40
Q

What are Possible Nutrition Diagnosis?

A

Involuntary weight loss

  • Increased energy and protein demands
  • Reduced food intake
  • Difficulty swallowing, chewing
  • Taste aversions
  • Impaired ability to prepare foods

Malnutrition

  • Altered GI function
  • Reduced food intake
  • Unsupported beliefs/attitudes about foods

Dehydration
- Insufficient fluid intake

41
Q

What are the types of nutritional interventions

A

Preventive:
- In prevision of treatment that will affect nutritional status (or pre-cachexia)

Adjuvant:
- To improve nutritional status to initiate and support anti-
cancer treatments (or in cachexia)

Palliative:
- To improve or maintain quality of life when anti-cancer treatments have stopped (refractory cachexia)

42
Q

How should the nutrition counselling done?

A
  • Should be individual
  • Provide adequate energy and protein (next slide)
  • Consider multivitamin/mineral supplements, omega-3 fatty acids?
  • Adapt dietary strategy according to:
    Ø Appetite
    Ø Rounds of therapy
    Ø Symptoms (provide practical tips)
    Ø Accessible route of feeding (oral, enteral, parenteral)
    Ø Encourage physical exercise
43
Q

What are the Goals of the approach?

A

Ø Increase lean body mass (or weight stabilisation ?)
Ø Predispose to a better response to radio- or chemo-
therapy
Ø Increase immunocompetence
Ø Symptom management
Ø Improve perception of well-being

44
Q

What is the AF and protein requirement of Chair/bed-ridden patient in maintenance? (including the stress factor)

A

1.2-1.3 x REE

≥1. 2 (g/kg/d)

45
Q

What is the AF and protein requirement of active patient in maintenance? (including the stress factor)

A

1.3-1.7 X REE

≥ 1.2 (g/kg/d)

46
Q

What is the AF and protein requirement of active patient in anabolism? (including the stress factor)

A

1.7-2.0 X REE

≥ 1.5 (g/kg/d)

47
Q

What is the AF and protein requirement of Chair/bed-ridden patient in anabolism? (including the stress factor)

A

1.5-1.7 X REE

≥ 1.5 (g/kg/d)

48
Q

What are the considerations in nutrition needs of cancer patients?

A
  • Evaluate stress factor
  • Best to determine current intakes and recommend increased intakes when severe weight loss
  • Obese patients may not need more energy but do need more protein
  • Micronutrients: multivitamin/mineral may be recommended
    consider prior and current diet and oral supplement use } avoid mega-doses of single nutrients
49
Q

What are the routes of nutritional administration?

A

Oral: best for patients who are able to eat

Enteral: unable to ingest/digest foods for a prolonged period of time due to obstructions, surgery, radio or chemo Tx

Parenteral: When enteral route not accessible, perioperatively in severe malnourished patients, head and neck CA with multiple treatments

50
Q

Explain oral nutrition

A
  • Normal diets can be enriched and modified in texture
  • Commercial liquid diets may be helpful
  • Food restrictions should be eliminated
  • Take advantage of circadian patterns of appetite
  • Identify sensory changes: food odours, taste aversions
51
Q

Explain enteral nutrition

A
  • Preserves GI architecture, barrier, immune function and gut permeability
52
Q

Explain parenteral nutrition

A
  • Not recommended in advanced cancer patients receiving chemotherapy
  • Should be based on expected survival in the order of months
  • Not when close to death (<3 months)
  • Difficulty of accurately predicting survival is recognized as the main challenge for choosing the right patients for TPN
53
Q

What is Hematopoietic stem cell transplantation? What are its complications

A
  • Hematopoietic stem cell transplantation: treatment for
    hematological cancers
  • Involves total body irradiation as a conditioning regimen: - Eradicate malignant cells
  • Immunosuppression

Complications:

  • infections associated with immunosuppression
  • symptoms of toxicity from TBI graft-versus-host-disease: acute and long-term problems (skin rash, liver dysfunction, GI problems)
54
Q

What is the Nutrition approach for hematopoietic cell transplantation?

A
  • Avoid foods at risk of causing infections and adopt safe food handling during period of neutropenia
  • Provide enteral nutrition when GI tract is intact and oral intake is inadequate
  • Parenteral nutrition for patients unable to ingest or absorb adequate nutrients for a prolonged period and those who develop severe GVHD.
55
Q

What are some Promising nutrition therapies for cachexia?

A
  • omega 3 fa
  • The anabolic response to sufficient protein/amino acids is maintained in CA patients
  • Specific amino acids
56
Q

What are the benefits of omega 3?

A
  • Anti-inflammatory properties,
  • reduce chemotoxicity in animal models
  • weight and LBM gain and improved quality of life
  • maintenance of body weight, maintenance or gain in muscle mass, lesser intramuscular fat and improved chemo treatment efficacy in lung cancer
  • May be recommended in most patients, since not harmful if <3 g/day
  • NOT in patients receiving anti-coagulation therapy
57
Q

What are the benefits of specific amino acids and what are they?

A

Ø Leucine stimulates protein synthesis and insulin secretion → may have anabolic properties
Ø Ingestion of formula enriched with Leu + ω-3 fatty acids in CA patients (+ inflammation) → ↑ muscle protein synthesis, but long term effects?
Ø In CA patients with weight loss: mixture of Gln + Arg + Leu metabolite (HMB) = lean body mass in 4 weeks (vs. loss in control group), no reported side effects

Ø Glutamine & arginine↑immune competence, help wound healing : could be beneficial pre and post-operatively

58
Q

What are the recommendations on exercise and how is it beneficial?

A
  • Inactivity induces muscle loss
  • 1 0 days of bed rest in healthy older subjects –> ≈ one kg of leg muscle loss
  • Resistance exercise + nutritional supplements = lean body mass and strength in elderly and in bed-ridden patients
  • Exercise (resistance) is anabolic and potentiates the anabolic effect of nutrition: should be central to any anabolic therapy
  • May increase appetite and well-being
  • Exercise study in advanced CA patients:
  • Feasible, improved physical performance and strength, no change in fatigue
59
Q

What are the recommendations of exercise during active treatment?

A
  • Safe, feasible, may improve functioning and quality of life
  • No interference with chemoTx
  • Adapt program: lower intensity and duration
  • Avoid during severe Tx side effects
60
Q

What are the recommendations of exercise during recovery?

A
  • Regular adapted program of exercise is essential to aid

recovery

61
Q

What are the recommendations of exercise during long term survivalship?

A

In addition to known benefits of exercise, may reduce recurrence of cancer and increase survival (breast, prostate, colon, ovarian CA)

6-Clinical Nutrition 1 (21 decks)

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