Nutrition Care process for Oncology Patients
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Nutrition Care Process for Oncology Patients
Comunicación y Gerencia
Presented by:Salmeh Bahmanpour
Nutritionist(PhD)
Praise be to ALLAH the Merciful
PhD’s Seminar
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Agenda
Section I: IntroductionSection II: Cancer-related MalnutritionSection III: Nutrition Care process Section IV: Practice Recommendation Questions & Answers
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Agenda
Section I: IntroductionSection II: Cancer-related MalnutritionSection III: Nutrition Care process Section IV: Practice RecommendationQuestions & Answers
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OncologyThe term “Oncology “ is
derived from the Ancient Greek onkos (bulk, mass, or tumor), and the suffix -logy (study ).
Oncology is a branch of medicine that deals with cancer.
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What is Cancer ? Cancer is actually a cluster of more than 100 disease that arise due to an uncontrolled 1
•cellular growth•cell signalling•cell physiological function•cell gene expression • cell death
The development of tumour from cancer cells is a multistep process occurs in three stages1:
1)Initiation(Precancerious Cell)2)Promotion(Precancerious Lesions)3)Progression(a Cluster of Abnormal
Cell)
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An estimated 12. 6 million people were diagnosed with cancer across the world in 2008.
The burden of cancer will increase to 22 million new cases each year by 2030.
Cancer Mondial 3website provides access to various databases source containing information on the occurrence of cancer worldwide
•World Health organization(WHO)•GLOBOCAN•UICC(Union International Cancer
Control)•IARC( International Agency for
Research on Cancer), •CI5 (Cancer Incidence in Five
Continents)
Cancer Statistics2
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Cancer Mondial report:
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Agenda
Section I: IntroductionSection II: Cancer-related MalnutritionSection III: Nutrition Care process Section IV: Practice RecommendationQuestions & Answers
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Cancer –related Malnutrition Malnutrition, refers to the nutritional
depletion associated with uncomplicated starvation4.
Starvation:• Reduce Energy Expenditure• Preserve muscle Mass• At the Expense of Fat Mass. • Promptly responds to nutritional supplementation
Cancer-related Malnutrition:• Increase Energy Expenditure• Accelerate in Muscle & Fat Mass Depletion. • Minimally response to Standard Nutrition
Supplement.
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Cancer –related Malnutrition Cancer-associated nutritional
depletion is usually defined as Cancer Anorexia-Cachexia Syndrome(CACS)1.
The term "Cachexia' is derived from Greek words “kakos,” (bad) and “Hexis “, (condition).
CACS is characterized by different symptoms5:
• Anorexia& Reduced Food intake• Wasting• Fatigue & Astenia (a reduced daily
Activity)• Impaired immune Function.
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CANCER
The prominent clinical feature of cachexia is weight loss in adults7.
The degree of cachexia (observed weight loss within the previous 12 months (or less)is classifyed:–Mild: <5 % –Moderate: 5-10%–Severe: >10%
Diagnostic Criteria for Cachexia6
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Stages of cancer cachexia7
There are two main factor in cancer-cachexia’s staging7:
1.The rate of ongoing loss of weight in combination
2.Depletion of body protein mass
– Weight loss ≤5%
– Anorexia– metabolic
change
– Weight loss >5% or– BMI <20 and weight
loss >2%– Sarcopenia and weight
loss >2%– Often reduced food
intake– Systemic inflammation
–procatabolic–not responsive to
anticancer treatment
–Low performance score
–<3 months expected survival
Spectrum of Cachexia
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CachexiaTwo most Prominent Symptoms
of CACHEXIA are Anorexia And Wasting6.
A.Pathogenesis of Anorexia :A-1-Peripheral factorsA-2-Brain NeurochemistryA-3-Pro-inflammatory cytokinesA-4-Hypothalamic energy
metabolismB.Pathogenesis of wasting:
B-1-Abnormalities in Carbohydrate Metabolism
B-2-Abnormalities in Protein Metabolism
B-3-Abnormalities in Fat Metabolism
B-4-Abnormalities in ENERGY Metabolism
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Pathogenesis of Anorexia:A-1-Peripheral factors4
Cancer Anorexia result from the resistance of hypothalamic neurons to peripheral signals.
Peripheral Signals are:1.Short-term
•Decreased Ghrelin(orexigenic)•Increased
Cholecystokinin(anorexigenic)2.Medium-term
•Increased Polypeptide YY (anorexigenic )
3.Long-tem•Increased Leptin(anorexigenic) •Insuline, which cooperates with leptin
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Pathogenesis of Anorexia:A-2-Brain NeurochemistryThere are two distinct subsets of neurons within hypothalamus , involved in regulation of food intake .
1- Anorexigenic Neurons• pro-opiomelanocortin (POMC)• Melatonin
2- Orexigenic Neurons • Neuropeptide Y(NPY) • Agouti-related protein(AgRP)
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Persistent activation of POMC, which Suppress the activity of NPY/AgRP, were seen in Cancer Cachexia8.
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Pathogenesis of Anorexia:A-3-Pro-inflammatory cytokines4 Tumor Necrosis Factor-a(TNF), interleukins 1, 6(IL-1,IL-6),Interferon Gamma(INF-gamma) and Proteolysis-Inducing Factor(PIF), are responsible for dysfunction of the melanocortin system.
Serotonin , is a suitable potential mediator of cancer anorexia by:
I. hyperpolarized NPY/AgRP neurons
II. suppressing postsynaptic potential in POMC neurons.
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During Cancer, increased hypothalamic IL-1 and TNF-α followed by expression of Serotonin, occure in conjunction, yielding the inhibition of NPY/AgRP neuronal activity8.
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Pathogenesis of Anorexia:A-4-Hypothalamic energy metabolism4Fatty Acid
Metabolism(anabolism/catabolism) within hypothalamic neurons controls food intake and energy metabolism.
The Fatty Acid Synthase(FAS) /Malonyl-CoA pathway could be involved in the pathogenesis of cancer anorexia, because of :
–Up-regulation of anorexigenic Neurons
–Down-regulation of orexigenic Neurons.
Pro-inflammatory cytokines cause an inappropriate switch in hypothalamic neurons from fatty acid oxidation to fatty acid synthesis, increase [malonyl-CoA] and suppress food intake.
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Pathogenesis of Wasting:B-1-Abnormalities in carbohydrate Metabolism4
Upregulation of the GLUT1 and GLUT3 .
Insulin resistance–the release of pro-inflammatory
cytokines.Stimulation of Glycogenolysis &
Gluconeogenesis.Enhance Glycolytic pathway
–Markedly elevated in HEXOKINASE.–Warburg effect: in the presence of
oxygen glucose metabolize to lactic acid
Increased Cori cycle activity
شهر تمام سنگ ”پِترا“/اردن
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Pathogenesis of Wasting:B-2-Abnormalities in Protein MetabolismSkeletal muscle(actomyosin, actin and myosin) wasting is important in the pathophysiology of cachexia and a major cause of fatigue6.
Oxidation of Branched Chain Amino Acids (BCAAs) has been increased9.
There are three main proteolytic pathways that are responsible for protein catabolism in skeletal muscle4.
1) The Lysosomal system.2) The cytosolic Calcium-regulated
Calpain.3) The ATP Ubiquitin-Proteasome
pathway, the most significant proteolytic pathway in cancer.
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Pathogenesis of Wasting:B-3-Abnormalities in Fat Metabolism
Loss of adipose tissue in cancer could be the result of impairment in the formation and development of adipose tissue4.
an extensive depletion of Subcatenious fat loss(lipoatrophy) area(Trunk,Leg, and Arm)6.
Decreased activity of lipoprotein lipase (LPL) (Decreased lipogenesis).
Enhanced expression and activity of Hormone Sensitive Lipase, lead to increased lipolysis .
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Pathogenesis of Wasting:B-3-Abnormalities in Energy Metabolism4There are futile energy expending cycle include:
1.The Na+K+ATP ase transporter leakage.
2.Mitochondrial Membrane protein(UCPs) in Brown Adipose Tissue(BAT) : which released energy as heat instead of ATP.
3.Cori cycle (a 300 Kcal/day energy loss).
4.Pro-inflammatory cytokines (IL-6 and TNF-α ,PIF).
In cancer patients there is an uncoupling of the balance between energy production and energy intake in favour of increased energy production(Heat) 4.
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The majority of cancer patients (40% and 80% ) experience Wasting, Anorexia and weight loss as their disease progresses10.
Cancer cachexia5 has been implicated in the deaths of 30–50% of all cancer patients.
The consequences of Cancer Cachexia may include– an increased risk of complications, –decreased response and tolerance to treatment,
–a lower quality of life,– reduced survival, – higher health-care costs.
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What is the Oncology science look for? Oncology is concerned with:
•Screening efforts: of populations or the relatives of patients.
•The diagnosis of any cancer in a person
•Therapy•Follow-up of cancer patients
after successful treatment.
Oncology-related nutritional issues are best addresses within the context of Nutrition Care process(NCP).
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Agenda
Section I: IntroductionSection II: Cancer-related MalnutritionSection III: Nutrition Care process Section IV: Practice RecommendationQuestions & Answers
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Nutrition Care Process
The Nutrition Care Process is a systematic approach to providing high quality nutrition care11.
American Dietetic Association(ADA) adopted the NCP in 2003 as a framework for dietetics professionals to use to support decision making in a variety of care settings11.
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Nutrition Care Process The NCP consists of four
distinct, inter-related steps11:
1)Assessment2)Diagnosis3)Intervention4)Monitoring and
Evaluation
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Nutrition Screening How should patients be identified for
referral to the dietitian in order to maximise nutritional intervention opportunities?
Although nutrition screening is not considered part of the Nutrition Care Process but it is a vital support to the NCP10 .
The American Dietetics Association(ADA) and The American Society for Parenteral and Enteral Nutrition(ASPEN) recommend that all Cancer patients undergoes Nutrition Screening as a component of their initial evaluation.
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Nutrition Screening Many nutritional screening tools
generally use a questionnaire format.
Several nutrition screening tools have been used in the cancer population10:
1. Malnutrition Universal Screening Tool(MUST)
2. Mini Nutritional Assessment (MNA)
3. Nutrition Risk Screening(NRS 2002)
4. Malnutrition Screening Tool (MST)
5. Nutrition Risk intake(NRI)
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Nutrition Screening Tools
Nutrition screening tools should be tested for their Sensitivity and Specificity.
Sensitivity: Ability to identify those who are at risk of malnutrition.
Specificity: Ability to detect those who are not at risk of malnutrition.
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Nutrition Screening Tools
Authors Objective ResultRavasco et al (2003)12
Calculating Sensitivity & Specificity
80% Sensitivity89% Specificity
Read et al (2005)13
Compare the MNA against PG-SGA
97% Sensitivity54% Specificity
Slaviero et al(2003)14
Compare the MNA against unintentional weight loss of greater than 10% in 3 month
33% Sensitivity90% Specificity
Several Studies evaluated the use of the scored Mini Nutritional Assessment(MNA) in cancer patients
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Nutrition Screening Tools Several Studies evaluated the use
of the scored Malnutrition Screening Tool(MST) in cancer patients.
Authors Objective ResultFerguson et al (1999)15
Compare the MST against PG-SGA
100% Sensitivity81% Specificity
Isenring et al(2006)
Compare the MST against against PG-SGA in patients undergoing chemotherapy
100% Sensitivity92% Specificity
The Malnutrition Screening Tool (MST) is a quick , simple and reliable and an effective screening tool for identifying patients with cancer in the radiotherapy and chemotherapy setting16.
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Nutrition Screening Tools Malnutrition Screening Tool (MST):
1. Have you Lost weight recently without trying?
2. If above Q is YES, How Much weight(Kilograms) have you lost?
3. Have you been eating poorly because of a decreased Appetite ?
Mini Nutritional Assessment (MNA)
Screening 6 Questions: Food intake Weight history Activity Psychological stress Neuropsychological problems BMIAssessment 12 Questions.
Have you lost weight recently without trying?– If no 0– If unsure 2– If yes, how much weight (kg) have you lost?
0.5–5.0 1>5.0–10.0 2>10.0–15.0 3>15.0 4Unsure 2Have you been eating poorly because of a decreased appetite?
No 0Yes 1
RESULT:If score 0 or 1 not at risk of malnutritionscore ≥2 at risk of malnutrition
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Nutrition Care Process The NCP consists of Four
distinct, inter-related steps:
1)Assessment2)Diagnosis3)Intervention4)Monitoring and
Evaluation
کوه هایp آتشفشانی پِیتون
(ایسلند)
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Nutrition Care Process1)Assessment
Nutrition assessment is the First Step of the NCP and involves the collection and analysis of data that identify the nature and cause of nutrition problems11.
How should Nutritional Status be assessed?
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Nutrition Care Process1)Assessment
Comprehensive Assessment are clustered in the following groups10:1. Nutrition Assessment2. Biochemical assessment3. Anthropometric assessment4. Functional assessment5. Client History
• Food consumption• Nutrition and health awareness and
management• Physical activity and exercise• Food availability
Hepatic Transporter Protein– Albumin, prealbumin, transferrin
C-Reactive Protein(CRP) Haemoglobin Blood Glucose
Baselines, during treatment, and following treatment weight
Baselines, during treatment, and following treatment height
Dual Energy X-ray Absortiometry(DEXA), Triceps SkinFold Thickness (TSF); Corrected Arm Muscle Area(CAMA) Bioelectrical Impedance Analysis(BIA) can be
used to assess total body water (TBW).
Karnofsky Performance Status Eastern Cooperative Oncology Group (ECOG) European Organisation for Research and
Treatment of Cancer(EORTC) QLQ-C30, Functional Assessment of Cancer Therapy (FACT) The Short Form Health Survey(SF 36)
5.Client History:I. The individual’s medical and
surgical history II. Current treatments planIII.MedicationsIV. Socioeconomics data
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Nutrition Assessment ToolVery few validated tools have
been developed to assess nutrition status in patients with cancer.
Patient-Generalized Subjective Global Assessment (PG-SGA) is thought of as the gold standard for nutrition assessment in the cancer population due to its high sensitivity and specificity17.
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Several Studies evaluated the use of the scored PG_SGA in cancer patients.
Authors Objective Study Population
Duration of study
Result
Thoresen et al (2002)18
Compare the PG-SGA against Objective Method(anthropometric and assays of serum proteins)
80 patients
3 month
96% Sensitivity83% Specificity
Bauer et al(2002)17
Compare the PG-SGA against SGA
71 patients
11 month
98% Sensitivity82% Specificity
Ravasco et al (2003)12
Calculating Sensitivity & Specificity
200 patient attending radiotherapy
80% Sesnitivity89% Specificity
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Nutrition Assessment ToolThe PG-SGA consists of two section:I. A four-question patient-completed
— Weight History— Presence of nutrition-related Symptoms— Food intake— Activity/functional Level.
II. Healthcare professional— Evaluate metabolic Demand— Disease and its relation to nutrition
requirement— Elements of physical exam.
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Nutrition Care Process The NCP consists of Four
distinct, inter-related steps:
1)Assessment2)Diagnosis3)Intervention4)Monitoring and
Evaluation
چیچن ایتزا(تمدن مایا)/مکزیک
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Nutrition Care Process2- Diagnosis The process of assessment
results in a diagnosis. The Nutrition Diagnosis is
Identification and Labeling that describe11:• the actual occurrence of a
nutrition-related problem• the risk of occurrence of a
nutrition-related problem• the potential for developing a
nutrition-related problem.
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Nutrition Care Process2- Diagnosis The nutrition Diagnosis, labels
Nutrition problem in 3 domains
11 :• Intake Domain• Clinical Domain• Behavioral- Environmental
Domain
A nutrition Diagnostic System is Written in a PES format that states the Problem(P), the Etiology(E), the Sign & Symptoms(S)11.
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Nutrition Care Process2- Diagnosis
Intake Domain11
Problem Etiology Sign/SymptomsInadequate oral intake
Pelvic radiation Therapy
-Diarrhea-Weight loss in a week
Inadequate Enteral Nutrition(EN) infusion
Intolerance of EN -Nausea- Abdominal distention- 7 kg Weight loss in 5 day
Malnutrition Cancer cachexia -Wasting of the muscle- weight loss of more than 7.5% in 3 month
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Nutrition Care Process2- Diagnosis
Clinical Domain11
Problem Etiology Sign/SymptomsAltered GI Function
Recent ileostomy surgery
- 2 L/day ostomy diarhhea output
Altered GI Function
Biweekly chemotherapy
-Nausea-Vomiting-Anorexia
Swallowing Difficulty
Obstruction esophageal tumor
- Dysphasia-Odynophagia-5 kgWeight loss
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Nutrition Care Process2- DiagnosisBehavioral – Environmental Domain11
Problem Etiology Sign/SymptomsLimited access to nutrition-related supplies
Lack of insurance & financial resources
-Not using the prescribed amount of tube feeding formula-Continued weight loss to 80% of usual weight
Intake of unsafe food
Exposure to contaminated food while neutropenic
-hospitalization-Diarhhea-Positive stool culture for Salmonella
Undesirable food choices
An unwilling to apply nutrition information
-Ongoing Diarrhea -Diet history of continued high fiber food intake while undergoing pelvic radiation therapy.
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Nutrition Care Process The NCP consists of Four
distinct, inter-related steps:
1)Assessment2)Diagnosis3)Intervention4)Monitoring and
Evaluation
فرودگاه کانزای)ژاپن(
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Nutrition Care Process3- Intervention
Nutrition interventions are to the specific actions, taken intended to address and correct the nutrition diagnosis.
The aspects of intervention are10 :
1. What are the Goals of nutrition intervention for patients with cancer cachexia?
2. What is the nutrition Prescription to achieve these goals?
3. What are effective methods of Implementation to ensure positive outcomes?
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1. What are the Goals of nutrition intervention for patients with cancer cachexia? Traditionally, Treatment has focused on
Weight Gain.19
Recently, Weight Stabilisation is an appropriate goal for weight losing cancer patients.20
2. What is the nutrition Prescription to achieve these goals? Energy Requirement Protein Reqiurement Fluid Requirement Eicosapentaenoic Acid (EPA)
3. What are effective methods of Implementation to ensure positive outcomes? Counselling to maximise food intake.
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Comunicación y Gerencia
What is the nutrition Prescription to achieve goals 4?
The following guideline are recommended for estimating Energy Requirement for cancer patients:
• Cancer –specific (bedridden): 20-25 kcal/kg/day
• Obese patient :21-25 kcal/kg/day• Normo-metabolic patient : 25-30
kcal/kg/day• Hyper-metabolic patients: 30-35
kcal/kg/day• Cancer-specific(Ambulant): 30-35
kcal/kg/day.
What is the nutrition Prescription to achieve goals 4?
Guidelines for protein requirements are as follows:
• Cancer- specific(Ambulant): 1 g/kg per day.
• Cancer-specific(bedridden): 1.2-2 g/kg per day.
• Non-stressed: 1-1.5 g/kg per day.• Hypermetabolic or protein-losing
enteropathy conditions: 1.5-2.5 g/kg per day.
In cancer , there is a severe Fall in plasma leucine and glutamate level and Rise in plasma phenylalanine and tryptophan level.
What is the nutrition Prescription to achieve goals 4?
Fluid Requirement
Dehydration is prevalent in many cancer patients, especially those who Receive chemotherapy and/or radiation therapty.
The fluid needs of cancer patients are similar to those of other patient population without renal disease(30-35 ml/kg/day).
Although, fluid needs may also be greater in the face of increased fluid losses.
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Nutrition Care Process Nutrition interventions should be
recognised as an integral part of cancer therapy to improve clinical outcomes and quality of life21.
A Specific Nutritional Ingredients has developed to support the immune system , modulate weight, Lean Body Mass loss , change anorexia, in cancer cachexia21.
The active nutritional ingredients is :1. Fish Oil 2. Branch Chain Amino Acid (Leucine)3. High Protein4. Specific Oligosaccharide Mixture
(SOM)
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Authors Study Population LBMassessment
Result
Murphy et al)2011(22
-16 Intervention , 4 capsules per day )2.5 g EPA + DHA(- 24 Control : no intervention-duration 10 weeks
CT I:maintenance of weight &skeletal muscle, -69% gained muscle.C: weight loss )2.3 kg( muscle loss )1 kg(
Weed et al)2011( 23
-31 Weight-losing patients )Two cans enriched-oral nutritional supplement per day )2.2 g EPA(./ Duration 5 week
BIA - Significant increase in LBM )+3.2 kg(
van der Meijet al )2010(24
19 patient with cancer- Two cans of enriched-ONS perday )2 g EPA + 0.9 g DHA(14 in control: Mean intake: 1.0 can perday.- Duration 5 weeks.
BIA, MUAC
I:- Weight maintenance, - increased MUAC, - decreased serum IL-6& CRP-Greater decrease of REE in I vs C. -Milderdecrease of FFM in I vs C.
Ryan et al )2009( 25
28 in intervention EPA-enriched enteral feed )2.2 g EPA per day(25 in control: iso-caloric, iso-nitrogenousstandard feed.Duration: 26 day.
BIA I: Maintenance of LBM.-Muscle loss >5% of body weight 8%)vs 39% in C.)No difference in CRP, albumin or IL-6 between groups
Summary of recent Clinical Trials on the effect of EicosaPentaenoic Acid (EPA)on Lean Body Mass(LBM).
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Proteolysis:Reduced muscle apoptosis and necrosisDown regulation of ubiquitin
proteosome pathwayDecreased production of pro-
inflammatory cytokines
Protein synthesis:Improved insulin sensitivityIncreased protein and caloric intake
Indirect effects :Reduced side effects from
chemotherapyEnhanced response to chemotherapy
EPA affects LBM via several diverse mechanisms26:
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2. Branch Chain Amino Acid (Leucine)Authors Objective Study
PopulationResult
Gomes-Marcondes27 MC. et al )2003(
- Effect of A leucine-supplemented diet on protein content of skeletal muscle in young tumor-bearing rats.Duration: 12 day.Control: 18% proteinIntervention:15% protein+3% leucin
Wistar rats )25 days old( N = 36,
-a small reduction in myosin content in I vs C.-Body fat was especially reduced) I group(- Body weight was reduced too )I group(- leucine-supplemented diet could prevent, in part, the more expectedWeight & LBM loss.-prevent hypoglycemia
Cangiano C. et al 28)1996(
- Effects of oral BCAA on anorexia and caloric intake in cancer patients- BCAA supplement [14.4g/day)7.1 g Leucine( ]for 7 consecutive days.
cancer patients )n = 28(
-increased plasma BCAA-Decreased tryptophan-45 % decreased in anorexia
Skeletal muscle was the tissue most severely affected in terms of wasting.
The Branched Chain Amino Acids(BCAA)29: –act as substrates for protein synthesis–modulate several elements of the protein
synthetic machinery.
BCAA have a clear inhibitory action on proteolysis in skeletal muscle30.
Leucine is the most potent of the three branched chain amino acids in this regard.
Leucine supplementation could better preservation of body weight gain, food intake and muscle protein31.
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Comunicación y Gerencia
Leucine supplementation increases protein synthesis through insulin-dependent pathway which lead to activation of mTOR pathway32.
Gallagher P. et al, 2007 . . FASEB J. 21:895.10
p70S6K: Ribosomal protein
4E-BP1: Elongation factoreIF4G: Initiation factor
PKB/Akt: protein kinase B
mTOR: mammalian Target Of Rapamycin
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Authors
Objective Result
Faber J. et al )2008(5
- Beneficial immune modulatory effects of a specific nutritional Combination for cancer cachexia-26 rat.-Duration: 20 day.-Control Diet:
• 126 gr Protein(Casein)• 699 gr CHO• 52.5 gr Fat( corn oil)
–Experiment Diet:• 210 gr protein(189 g casein+ 21g
Leucin)• 561 gr CHO• 52.5 gr fat
20.2 g corn10.2 gcanola22.1g Fish oil provide 6.9g EPA
, 3.1g DHA(• 18 g short-chain galacto-
oligosaccharides• 2g short-chain fructo-
oligosaccharides
Experimen Diet show:
-Improved Th1 immuno response.
-Significantly Increased in :-Weight of Skelatal Muscle-Epididymus Fat Weight-Body Weight-- Significant decreased in :
- PGE2- TNF-a- IL-6
Combine effect of Specific nutrition ingredients:
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Comunicación y Gerencia
Authors
Objective Result
Faber J. et al )2008(5
–Experiment Diet:• 210 gr protein(189 casein+ 21
Leucin)• 561 gr CHO• 52.5 gr fat
20.2 g corn10.2 g canola22.1 g Fish oil provide
6.9 g EPA , 3.1 g DHA)
When Fish Oil in combination with high protein/leucine was added to the diet, BW, weights of epididymus fat and the skeletal muscle improved significantly
Norren K Van. et al.(2009)9
Dietary supplementation with a specific combination of high protein, leucine, and fish oil on muscle function in cachectic mice.Duration :20 day-Control Diet :
• 126g protein(casein)• 727 g CHO• 40 g Fat(soy oil)
– Experimental Diet:– 151 gr Casein + 16 gr leucin– 22 g Fish oil(provided 6.9 g EPA,
3.1 g DHA)
-Reduction of inflammatory state by fish oil
-Improve sensitivity of cachectic mice to anabolic stimuli like Leucine
-High protein Diet , resulting in improved maintenance of Muscle protein Mass.
It is important to provide nutritional intervention with immuno-modulating properties;
Because, impaired immune function is affected before the onset of weight loss, in Cancer Cachexia.
High protein –high leucine did not result in significant weight gain, Unless FISH OIL was added.
Reduction of inflammation by Fisah Oil 33, improved the sensitivity of the muscle to anabolic stimuli like ,Leucine.
Also better immuno responses against infection , achieved through Specific oligosaccharid Mixture(SOM)9.
Overally
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What are effective methods of Implementation (اقدامات) to ensure positive outcomes? Counseling to Encourage high
protein/energy supplements as an essential component of treatment34.
Try serving 6 smaller meals/snacks per day.
Discuss good sources of protein in the diet
If vegan/vegetarian ensure adequate alternative sources of protein.
Fortify foods by adding milk powder, cream, cheese
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What are effective methods of Implementation (اقدامات) to ensure positive outcomes? Patients with chewing and
swallowing difficulties, modified protein mixture: e.g. minced meats, pureed meat/chicken/fish , scrambled or poached eggs, mashed beans, peanut paste, lentil/bean soups10.
Ensure adequate quantity consumed of High protein energy nutrition supplements enriched with EPA10.
To develop gastrointestinal tolerance, fish oil and high protein energy supplements should increase gradually.
Consumption of high protein energy supplement enriched with EPA over a period of at least 8 weeks10.
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Nutrition Care Process The NCP consists of Four
distinct, inter-related steps:
1)Assessment2)Diagnosis3)Intervention4)Monitoring and
Evaluation
شهر پالمیرا)سوریه(
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Nutrition Care Process4- Monitoring & Evaluation Nutrition intervention may lead to a
variety of outcomes10.
Intermediate outcomes include – changes in dietary intake, – changes in symptoms, – changes in biochemistry,
anthropometric measures – changes in nutrition status
Clinical/Cost/patient outcomes include: – Mortality( length of hospital stay +
quality of life)– Morbidity(Complication)
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Agenda
Section I: IntroductionSection II: Cancer-related MalnutritionSection III: Nutrition Care process Section IV: Practice RecommendationQuestions & Answers
Libya
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Practice Recommendation:
Screening :–Malnutrition Screening Tool has been validated.
Assessment :–The PG-SGA should be used in patients with cancer cachexia.
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Practice Recommendation:Intervention:–To Improve Immune System Function–To Maintain Lean Body Mass–Stabilisation of Weight
•provide Specific Nutritional Combination.
•Fish Oil (Generally Recognised As Safe(GRAS1) = 3g/day )+ High protein Diet+ Leucine+ Specific Oligosaccharid
•CounselingMonitoring & Evaluation:–The outcome of intervention should be Monitoring
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And finally This is our planet……
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References:1.Marian m., [book].[Cancada].Jones and Bartlett Publishers; (2009) 461p.2.Bray F, et al. Lancet Oncol. (2012)3. Ferlay J, et al. GLOBOCAN (2008)4. Shaw C, .[hardcover book].[(2011) 1.398p.5.Faber J., et al . British Journal of Cancer (2008) 99, 2029 – 2036. 6.Evans WJ et al. Clin Nutr, (2008)7.Kenneth Fearon et al.Lancet Oncol (2011) 12: 489–95 8.Laviano A., et al. .Nature Clinical Practice Oncology, (2005) 2;3-158-1659.Norren van K. et al.. British Journal of Cancer (2009) 100, 713 – 72210.Linda Tapsell et al..Nutrition & Dietetics (2006); 63 )Suppl. 2(: S5–S32.11.L. Kathleen Mahan.[text book] (2012).1227p. 12.Ravasco,p. et al. Clinical oncology (2003) 15)80, 443-450. 13.Read, J.A. et al. Nutrition and Cancer (2005) 53)1(,51-56.14.Slaviero K.A., et al. Nutrition and cancer (2008) 46)2(, 148-157.15.Ferguson M.L. Australasian radiology (1999) 43)30, 325-327.16.Ferguson, m., et al .Nutrition (1999) 15)6(, 458-464.17.Bauer, J.A., European journal of Clinical Nutrition (2009) 56, 779-785.
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References:18.Thoresen, L., et al. Palliative Medicine (2002) 16)10,33-42.19.Bruera E, et al . J Clin Oncol (2008); 21: 129–34. 20.Jatoi A, et al. J Clin Oncol (2004); 22: 2469–76.21.van Bokhorst-de et al. Eur J Oncol Nurs (2005) 9)Suppl
2(:S74–S83. 22.Murphy RA, et al.Cancer (2011) 117: 1775–1782.23.Weed HG, et al. Head Neck (2011) 33)7(: 1027–1033.24.van der Meij BS,et al. J Nutr (2010) 140: 1774–1780.25.Ryan AM, et al. Ann Surg (2009) 249: 355–363 .26.Murphy RA. et al. British Journal of Cancer (2011) 105, 1469
– 1473.27.Gomes-Marcondes MC, et al. Braz J Med Biol Res (2008) 36:
1589–1594.28.Cangiano C, et al. J Natl Cancer Inst (1996) 88: 550–552.29.Kobayashi H, et al. J Nutr (2006) 136: 234S–236S.30.Busquets S, et al. Journal of Cellular Physiology, (2000) 184:
380-384. 31.Anthony JC, et al. J Nutr (2000);130: 2413–2419.32.Gallagher P, et al. FASEB J. (2007) 21:895.10.33.Tisdale M. J. et al . Nutr Clin Pract (2006) 21: 168-174.34.Bauer j. European Oncological Disease (2007),12-14
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– Dr Bauer has presented research related to nutrition screening, assessment and cancer at national and international conferences .
– She is also an Adjunct Associate Professor in the School of Public Health,Queensland University of Technology.
– Dr. Judy Bauer she has over 40 publications in national and international journals.
–
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L. Kathleen Mahan
20082012
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Thank s a Million for
Your Attention and Attendance
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Agenda
Section I: IntroductionSection II: Cancer-related MalnutritionSection III: Nutrition Care process Section IV: Practice RecommendationQuestions & Answers