Nutrition for an Immune Compromised Patient

Jyothi PrasadManipal Hospital

1. Evidence based nutrition guidelines for oncology

2. The benefit of Neutropenic diet - fact or fiction?

Why shouldn’t nutrition be a forgotten ingredient in oncology care?

• 20-40% cancer patient deaths are related to cancer induced or treatment related malnutrition

• Malnutrition causes: Diminished tolerance to therapy Lower survival rates Diminished quality of life Longer hospitalization

• Effects of symptoms on dietary intake is profound – 60% of head and neck and GI patients lose weight upon beginning treatment

Impact of malnutrition

• Head and neck ca treated – the strongest predictor of survival was pre treatment weight loss

• Postoperative morbidity and quality of life significantly influenced by preoperative nutrition

• Immuno competence goes down

• Inability to tolerate anti neoplastic treatments

• Postoperative complications

• Surgical insult on post operative patients is well tolerated by nourished individuals

Nutritional issues in Oncology

• Systemic effects of cancer on nutrition

• Localized tumor effects

• Nutritional problems of therapy

• Nutrition intervention and tumor growth

• Efficacy of nutrition support

• Guidelines for nutrition support

• Unproven diet and nutrition claims

Cancer Cachexia Starvation amidst plenty

• The failure of nutritional repletion despite adequate caloric intake in patients with malignancy. This is mediated by pro inflammatory cytokines

• The prominent feature of clinical feature of cachexia is weight loss in adults and growth failure in children. There is competition between the tumour and the host for nutrients resulting in an accelerated starvation state

• Anorexia, inflammation, insulin resistance, and increased muscle protein breakdown are frequently associated with cachexia

• Cachexia is different from Anorexia. Anorexia is EFFECT rather than CAUSE OF cachexia.

• Cachexia is distinct from starvation, age related loss of muscle mass, primary malabsorption and hyperthyroidism and is associated with increased morbidity and mortality

Pathogenesis of Cancer induced Cachexia

Cancer induced cachexia is invariably associated with the presence and growth of tumor

CANCER

Nausea/Vomitting Anorexia

Metabolic changes: Energy, protein, lipid and cho

WEIGHT LOSS

NEOPLASTIC CACHEXIA SYNDROME

The Cachexia Journey

Death

Pre Cachexia Cachexia syndrome

Severe Cachexia

Weight loss Weight lossReduced food intake Systemic inflammation

Severe muscle wastingFat lossImmuno compromised

>6-9 months 3-9 months <3 months

Survival

Changes that occur in metabolism

Carbohydrate

• Insulin resistance• Increased glucose

synthesis• Gluconeogenesis• Increased Cori cycle

activity• Decreased glucose

tolerance

Protein

• Increased protein catabolism

• Decreased protein synthesis

Fat• Increased lipid

metabolism• Decreased

lipogenesis• Decreased activity of

lipoprotein lipase (LPL

Therapy related issues

Radiation related problems

Oropharyngeal AreaLoss of tasteXerostomia & odynophagiaTeeth loss

Lower Neck & MediastinumEsophagitis with dysphagiaFibrosis with esophageal stricture

Abdomen & PelvisBowel-damage syndromes (acute or chronic) with diarrhea, malabsorption, stenosis & obstruction, fistulization

Surgery related problems

Radical Resection of Oropharyngeal Area

Chewing & swallowing difficulties

EsophagectomyGastric stasis & hypochorhydria secondary to vagotomySteatorrhea secondary to vagotomyDiarrhea secondary to vagotomyPremature satietyRegurgitation

Gastrectomy (high subtotal or total)Dumping syndromeMalabsorptionAchlorhydria & lack of intrinsic factor and R proteinHypoglycemiaPremature satiety

……. Contd

Intestinal Resection - Jejunum & Ileum• Decreased absorption efficiency

including fat• Vitamin deficiency with fat-

soluble vitamin malabsorption• Bile salt losses with diarrhea or

steatorrhea• Hyperoxaluria & renal stones• Calcium & magnesium depletion

Massive Bowel Resection• Life-threatening malabsorption• Malnutrition• Metabolic acidosis• Dehydration w/wo salt & water

balance problems

Blind Loop Syndrome• Vitamin B12 Malabsorption

Pancreatectomy• Malabsorption • Diabetes

Drug-related ProblemsNoncytotoxic

Corticosteriods• Fluid & electrolyte problems• Nitrogen & calcium losses• Hyperglycemia

Sex hormone analogues• Fluid retention• Nausea• Megesterol acetate -

glucocorticoid effects

Chemotherapy• Nausea• Vomitting• Loss of appetite• Diarrhea• Anorexia • Mouth ulcers• Diarrhea/Constipation

Appetite

Food intake

Intermediary metabolites

Endocrine abnormalities

Secondary infections, malignant lesions

Medications

Cytokines

Nutritional abnormalities

Neurological influences

Psychiatric, psychological

influences

Learned aversions to therapy

Social, cultural & economic factors

Physical factors

Nutritional support – how to go about?

Assess: Patient history, look for signs, weigh regularly and know the lab values

Plan: Nutritional requirements - set short term and long term goals

and individualize needs

Intervene: Symptom management - strategies for patients, enteral

and parenteral nutrition

Evaluate: Effectiveness of intervention, achievement of long and short term goals

Evaluation : Before beginning intervention

• Cardinal principle:

Individualize to needs of patient

• Short-term goal:

Improve nutritional status

• Long-term goal:

Normalize Nutrient IntakeAlleviate disease symptoms

• Outcomes???

Better Quality of life / VigorFewer Crisis / Improved Treatment Response

Screening Vs Assessment

Screening

• Done to detect the possibility of nutrition risk

• All patients in all settings require it

• Required to be stored in the medical file

• Patient generated SGA is often used and is useful and easy to score

• Score generated guides nutrition intervention

• If screen indicates risk, full assessment must be done

Assessment

• More intensive and thorough• Needs intervention, follow up

regularly• Assessment must have weight

history, appearance, functional status, diet history, biochemical parameters, medication and planned treatment

• Assessment can include financial and psychosocial aspects is possible

• Has to be done by a dietician or doctor only

Minimum, immediate measurements, least expense, concise information

Longer time, more measurements, a bit more expensive, indepth information

Nutritional assessment criteria

1. Anthropometry: Weigh regularly BMI Severe weight loss Mid – arm circumference2. Laboratory data: Not always the most accurate when

viewed alone Serum albumin : Level falls only after significant depletion has

occurred

Serum pre albumin: Can be used for assessment

Serum transferrin: More sensitive marker for marginal protein depletion

Total iron binding capacity Delayed hypersensitivity skin testing to a recall

antigen Total lymphocyte count3. Diet history 24 hour recall, Food frequency etc

Who is severely malnourished?

• Weight loss more than 10%

• Poor intake for 2 weeks or more

• BMI less than 18.5

• Mid arm circumference: Male <17.6cms Female <17.1 cms

• Subjective global assessment score – “C”

• Mini nutritional assessment score - <25

• Albumin on entry <3gm %

• Total lymphocyte count <1500

Nutrition requirement guidelines Calories (Harris-Benedict formula)

• Obese patients: 21-25 kcal/kg• Non-ambulatory/sedentary adults: 25-30 kcal/kg• Sepsis: 25-35 kcal/kg• Slightly hypermetabolic or those in need of weight gain or those with

stem cell transplant: 30-35 kcal/kg• Hypermetabolic or severely stressed: ≥35 kcal/kgProtein needs

• Normal or Maintenance: 0.8-1.0 g/kg• Non-stressed cancer patient: 1.0-1.5 g/kg• Bone marrow transplant or HSCT patients: 1.5 g/kg• Increased protein needs: 1.5-2.5 g/kg• Hepatic or renal compromised or elevated ammonia: 0.5-0.8 g/kg

• Vitamins Minerals Folate Magnesium Vit C Zinc Retinol Copper Iron

Fluid requirements

• 16-30 years, active: 40 mL/kg• 31-55 years: 35 mL/kg• 56-75 years: 30 mL/kg• 76 years or older: 25 mL/kg

1 mL/kcal of estimated energy needs

Managing symptoms

• Nutrition can help manage symptoms. The key is to start early

• Specific diet modifications will help minimize nutrition related side effects

• Each side effect has numerous approaches for management

• Strategies for patients include teaching and trial and error pragmatism

• Screening and assessment will identify those who require aggressive intervention

• For others enteral and sometimes parenteral support is a must

When Is Initiation of Enteral Nutrition Indicated?

• Actual or anticipated inability to meet 50% of needs for 7 or more days

• Contributes to Quality/Length of life in meaningful way

• Can improve tolerance to treatment and/or ultimate outcome

• A functioning gut (to some degree) is present

• Is not contraindicated• Obstruction?• Gastroparesis?

• NG tube or PEG depends on the length of stay

Advantages

Food in liquid form

Keeps the stomach and intestines working normally

Fewer complications than parenteral nutrition

Nutrients used more easily by the body

Can be administered at home

Parenteral Nutrition• Appropriate for patients who are severely malnourished or have

contraindications to enteral feeding – severe nausea or vommitting, fistulas in intestines, loss of body weight with enteral nutrition, stomach and intestines removed etc

• Requires central venous line and daily laboratory evaluation and composition adjustments

• Complication include Hypoglycemia, Hyperglycemia Hypokalemia,Blood clots,Infection at site of insertion, Elevated liver enzymes

• In transplant patients TPN is not used as the patients are nourished prior to transplant to withstand the procedure as the mortality & morbidity is high

• TPN is reserved for patients with unintentional weight loss prior to transplant and possess non functioning GI tracts.

ORAL NUTRITION ENCOURAGED, ENTERAL NUTRITION ATTEMPTED AND TPN DISCOURAGED!

Complementary Cancer Therapies

Glutamine: Neutral, gluconeogenic, non essential aa. May help decrease symptoms, but not consistently documented.

Eicosapentanoic acid (Omega 3 fatty acid): Potential role in inflammation, may help cachexia

Probiotics: Healthy bacteria, may decrease opportunistic infections, improve nutrient absorption etc

Zinc, Co-enzyme 10 etc . . . . . . . . .

Neutropenia and neutropenic diet?

• Neutropenia is defined as the neutrophil count below 1.5 x 10 9/1

• Neutrophils are needed against defense and when the neutrophil count falls below the risk of developing an infection greatly increases

• In bone marrow transplant patients it falls below 0.5 and is called profound neutropenia

• Many food contain food borne pathogen which may be harmful for a person with very low immunity

• A diet that limits certain types of foods to limit the exposure of certain types of bacteria and limit food borne infection in an already immune compromised patient

Neutropenic diets - demystified

• Neutropenic diets restrict many foods especially fresh fruits, veg, juices, curd etc.

• Patients, especially paed find it difficult as it excludes many foods, importantly fresh fruits and veg

• Though foods contain harmful bacteria and bacterial translocation is possible, recent studies have been unable to obtain significant differences between placebo and intervention groups

• Unanswered questions in regard to the neutropenic diet include

the following: (a) which food should be included; (b) which food preparation techniques improve patient compliance; (c) which patient populations benefit most; and (d) when should such a diet be initiated

• Without scientific evidence, the best advice for neutropenic patients is to follow food safety guidelines as indicated by government entities.

Food safety guidelines – A common sense approach

All patients need to follow 4 basic steps to food safety

Clean: Wash hands, surfaces, produce and clean lids for canned produce

Separate: Don’t cross contaminate. Separate foods and cutting boards. Especially true for flesh foods

Cook: Cook to proper temperatures. Use a food thermometer to check internal temperature

Chill: Refrigerate promptly. Cold temp slows the growth of harmful bacteria

• While shopping be careful and read all the labels for expiry date

• Be smart while eating out and transport food carefully and go by rules

• Be aware of food borne illnesses and know the symptoms!!

Future directions in oncology nutrition

• We have a knowledge base with cancer survivors

• We know about potential carcinogens thru food and water – prevention is the key

Practice issues:• Development of cancer rehab programmes. Evaluation of

intervention is needed

• Benefit of nutrition intervention to be documented – outcome research

• Oncology nutrition to be a special field and a oncology nutritionist to be a part of the multi disciplinary team

All patients undergoing HSCT with myeloablative conditioning regimens are at nutrition risk and should undergo nutrition screening, assessment if required and a proper nutrition plan

Nutrition support therapy is appropriate in patients undergoing HSCT who are malnourished . When PN is used, it should be discontinued as soon as toxicities have resolved

Enteral nutrition should be used in patients with a functioning GI tract in whom oral intake is inadequate to meet nutrition requirements

Pharmocological doses of Glutamine may benefit patients

Patients should receive couselling regarding food safety guidelines as they may pose a infectious risk

Nutrition support therapy is appropriate for patients who develop moderate to severe GVHD accompanied by poor oral intake

To conclude . . . . . .

Thanks for your attention!