DIET CONSIDERATIONS FOR PATIENTS UNDERGOING CHEMOTHERAPY … · 2015-02-18 · PATIENTS UNDERGOING...
Transcript of DIET CONSIDERATIONS FOR PATIENTS UNDERGOING CHEMOTHERAPY … · 2015-02-18 · PATIENTS UNDERGOING...
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DIET CONSIDERATIONS FOR PATIENTS UNDERGOING
CHEMOTHERAPY AND BMTDr.Vinitha KrishnanHOD -Apollo Speciality Hospital -Chennai
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INTRODUCTION
• Concerns in nutrition planning• Nutritional assessment• Strategies for nutritional support • Food safety guidelines• BMT diet plan• Diet considerations for patients on chemo
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RISK FACTORS
•MALNOURISHED PATIENTS•Relapsed ALL•Long-term steroid therapy•History of multiple infections•Metabolic disorders (neurological impairment)•Solid tumors
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TRASPLANTATION -PHASES
• CYTOREDUCTION• CYTOPENIA• ENGRAFTMENT• ORGAN FAILURE(any time) .
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TRASPLANTATION-METABOLIC CHANGES
• Negative nitrogen balance• Glucose intolerance• Increase in the need for antioxidant
vitamins• Mineral deficiency (Zinc)
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NUTRITIONAL PROBLEMS IN HSCT PATIENTS
• Sore throat and mouth• Decreased salivation and dry mouth• Lack of appetite (anorexia)• Nausea, vomiting and food aversion• Early satiety
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NUTRITIONAL PROBLEMS IN HSCT PATIENTS
• Alteration in smell and taste• Loss of taste• Mucositis / oesophagitis• Diarrhea• Malabsorption
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NUTRITIONAL RISK ASSESSMENT: WHY & HOW?
WHY?o Conditioning therapy has deleterious
consequences on the integrity of the gastrointestinal tract
Increased risk of malnutrition
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NUTRITIONAL RISK ASSESSMENT: HOW?
NutritionalScreening
Nutrition Support Team
Nutritional Assessment
Nutritional Intervention
Malnutrition UniversalScreening Tool-MUST•Unintentional weight loss?•Body Mass Index?•Dietary intake?
Malnutrition UniversalScreening Tool-MUST•Unintentional weight loss?•Body Mass Index?•Dietary intake?
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AIMS OF NUTRITIONAL SUPPORT
• Maintenance of nutritional status• Adequate and specialized nutrition may also:
– Improve tolerance to chemotherapy– Prevent and reduce mucositis– Reduce septic complications– Modulate the biological response
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NUTRITIONAL SUPPORT RECOMMENDATIONS
• Low microbial Diet• 130-150% of the estimated BEE
(30-50kcal/kg/day)• Protein:1.5-2g/kg/day• Lipids-30-40%of non-protein energy• A Balanced calorie intake with both fat and
carbohydrate is recommended.
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STRATEGIES FOR NUTRITIONAL SUPPORT
• Nutrition support– Tailored for each patient
• Strategies:– Dietary counseling– Artificial nutrition– Specialized nutrition
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DIETARY COUNSELING
• Low bacterial diet • Modification of foods:
– Food preferences– Eating ability– Symptoms
• Oral nutrition supplements (hyper caloric,lactose free, hyperproteic, etc)
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BACTERIA FOUND IN FOODS
• More commonly reported bacteria found in foods:
• E. Coli, Pseudomonas Aeruginosa, Klebsiella (fresh fruits and vegetables);
• Other pathogens: Enterobacter agglomeran,Enterobacter colacae, Citrobacter, Salmonella,Shigella, Campylobacter;
• Aspergillus (food, water and ice)
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LOW RISK IMUNOSUPPRESSED DIET
• Sterile diet- foods with no bacteria and fungal growth
• Low- microbial diet- pathogen containing foods are eliminated
Different practice in all HSCT Units
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FOUR BASIC STEPS TO FOOD SAFETY
• CLEAN: Wash hands and surfaces often
• SEPARATE: Do not cross contaminate
• COOK: Cook to proper temperatures
• Poultry, meat, egg, soups & gravies-160 *f
• Sea food-140*f• CHILL: Refrigerate promptly• Refrigerator temp-40*f &
freeze at 0*f
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ARTIFICIAL NUTRITION SUPPORT (ANS)
1. Can the patient eat? Diet ± Supplements2. Evaluate intake3. Insufficient (< 50%) vs sufficient (>50%)
DurationNutritional status MonitorDisease severity Consistenly low
ArtARTIFICIAL NUTRITION
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ARTIFICIAL NUTRITION SUPPORT (ANS)
Timing of ANSand
Enteral/Parenteral nutrition
• Less well defined aspects• Different practices in HSCTunits
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INDICATIONS
ENTERAL NUTRITION• ↓ Oral intake• Nutrient repletion• Support during transition
phase after parenteral nutrition
PARENTERAL NUTRITION• Severe malabsorption• Hyperemesis• Severe mucositis• Malnourished• GvHD gut
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SPECIALIZED NUTRITIONAL SUPPORT
• Glutamine (0.57g/kg/day)• Antioxidants (vitamin E, A and β Carotene)• n-3 Fatty acids (Eicosapenthaenoic acid)
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GASTROINTESTINAL – DIET 1
• Beverages (1 cup)• SupplementsPredigested/ Polymeric formulas-1/2 cup , High protein
drinks-1/2 cup• Cereals (1/2 cup)• Protein Sources
Well cooked chicken (no skin),baked, broiled, or boiled (30g) , well cooked egg only (1no), fish, baked or poached (30g.)
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GASTROINTESTINAL – DIET 1
• FRUITS(½ cup)• Applesauce, Banana, Peaches,Pears, canned in juice or
light syrup• VEGETABLES(1/2 cup)• Carrots, well cooked ,green beans, well cooked sweet
potatoes (no skin), baked or mashed potatoes• MISCELLANEOUS: Sugar 1 packet or teaspoon; salt, as
desired.
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GASTROINTESTINAL – DIET 2
• BREAD AND CEREAL PRODUCTS: 4 or more servings per day
• Cereals with less than 2 gm of fiber per servingBread , rice cakes, noodles , white rice, baked potato chips& pancakes
• DAIRY AND SUPPLEMENTS: 3 or more cups per daySkim milk , Soy milk , Buttermilk, Low fat yogurt (150g)AVOID: Any milk or milk-based product not pre-treated
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GASTROINTESTINAL – DIET 2
• MEAT OR MEAT SUBSTITUTES: 3 or more 30g servings per dayWell-cooked fish, skinless poultry, well cooked eggs , cooked tofu.
• SOUPS: As desiredBroth-based soups made with allowed meats and vegetables
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GASTROINTESTINAL – DIET 2
• FRUITS AND FRUIT JUICES: 2 or more ½ cup servings per day• Juices: cranberry• ½ strength juices: apple, grape, (mix equal parts of
water and juice)• Fresh fruit (peeled): apricots, bananas, melons, pears,
peaches, papaya, mango.• Apples, baked and peeled• Canned fruit: peaches, pears, plums, apricots• Jelly or sauce
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GASTROINTESTINAL – DIET 2
• VEGETABLES: 2 or more ½ cup servings per day• Well cooked, tender vegetables, as tolerated:• Beets, carrots, green beans , lettuce, pumpkin,
sweet potatoes ,potatoes and yams (without skin), winter squash.
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GASTROINTESTINAL – DIET 2
• DESSERTS:• Cake (plain, without frosting)• Custard made with lactose-free milk• Jelly• Popsicles• Puddings, made with lactose-free milk• Plain cookies• Angel food cake
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GASTROINTESTINAL – DIET 2
Fats with limited portion size:• Butter (1 tsp) ,Cooking oil (1 tsp) , Margarine (1 tbsp)
Mayonnaise (1 tbsp) , Peanut butter (2 tsp)Miscellaneous: • Herbs and spices for seasoning: basil, bay leaf,
rosemary, thyme, cinnamon• Honey,Hard candy,Jelly ,Marshmallows,Fruit roll-ups• Salt, Sugar , Soy sauce , Syrups, Vinegar
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CONCLUSION
• Nutritional screening is important foridentification of patients at nutritional risk
• Artificial Nutrition should be used according to individual needs
• Encourage Enteral Nutrition• Nurition education is A MUST
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Chemotherapy
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• A general name for more than 100 diseases• A disease where abnormal cells grow out of
control and form malignant tumors
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A. Normal cell division
1- damaged cell
2- cell deathB. Cancer cell division
Cancer cells• grow out of control• don’t die normally
Cancer
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Chemotherapy or “chemo”
• What is it?• How does it work?• Nuttritional concerns
Rosy periwinkle –Vinca rosea. Compound from the rosy periwinkle flower, vincristine and vinblastine, are used to treat some cancers.
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‘Chemotherapy involves repeated cycle of cytotoxic drugs at regular intervals’
Eating well during ‘good times’ between doses help maintain nutritional status
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•Interrupts cell division•Prevents DNA production•Interrupts cell metabolism•Chemotherapy will destroy some healthy cells, causing side effects.
How does chemotherapy work?
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Red blood cells
Carry nutrients and oxygen
Neutrophils
A type of white cell that fights infection
Platelets
Helps the blood to clot
Blood cells
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SYMPTOMS EXPERIENCED BY SYMPTOMS EXPERIENCED BY PATIENTS AT ASHPATIENTS AT ASH
17%
83%
0
0.2
0.4
0.6
0.8
1
Present AbsentSYMPTOMS
PERC
ENTA
GE IN
VAL
UE
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• Infection• Fatigue• Fluids• Nutrition• Nausea and vomiting• Oral care
•Skin care•Preventing bleeding•Constipation•Diarrhea•Stress
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INFECTION
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VARIATION OF WBC COUNT
BEFORE, 7416.67BEFORE, 7250
BEFORE, 9716.67
AFTER, 7000AFTER, 5666.67
AFTER, 6883.33
0
2000
4000
6000
8000
10000
12000
I CYCLE II CYCLE III CYCLE
CHEMOTHERAPHY CYCLE
WBC
COUN
T /cm
m
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• Keeping hydrated with fluids is important during chemotherapy treatment.
• Fluids are in water, beverages, and food.• Advice sipping of water or juice.
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• Loss of Appetite (Anorexia)• Loss of Lean Body Mass • Early satiety • Changes in taste and smell• Sore mouth or throat • Disturbance of GI tract
– Nausea and vomiting, Diarrhoea, lactose intolerance, constipation
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• ANOREXIA–High Energy, High Protein foods
• Taste changes–Food chilled –More of food still tastes good –Strong flavour like ginger, lemon or spices –Regular mouth care
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• Nausea and Vomiting– Avoid off – putting smell– Avoid lying down after eating – Plain foods in small quantities – Sip drinks through out day, but wait for 15 minutes
after eating – Suggest ginger flavours, mint and plain biscuits
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• MUCOSITIS– Soft smooth foods with plenty of sauce– Avoid spicy and salty foods, citrus taste– Avoid toast, cracker and pastries – Chilled and warm food better than hot
foods
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• DIARRHOEA– Avoid irritants like pulses, onion, strong spices – Reduce fibre rich foods– Adequate fluid intake – Reduce fat and milk products – BRAT diet
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• CONSTIPATION• Drink plenty of fluids.• Encourage daily walks .• Increase fiber in diet by including well-
washed fruits and vegetables, whole grain breads and cereals.
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• MVI supplements discouraged by NCI• Glutamine• High doses of antioxidants (Vit .A, C, E)
↓ Oxidative stress↑ Responsiveness to chemo↓Toxicity of treatment
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• Enteral nutrition• PEG• PEJ• Parenteral Nutrition• Peripheral• Central
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THANK YOU