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People Living with Cancer

Nutritional Care of the Cancer Patient

Friday, September 13, 2013

JEAN MILLS, CLAIRE MCMAHON & GINA FOURIE Consultant Dieticians RD(SA) PR No. 502

EATING PROBLEMS ASSOCIATED WITH CHEMO AND RADIOTHERAPY

Although nutrition cannot cure cancer, it does play an essential supportive role in cancer therapy. Nutritional support can help prevent or reverse poor nutritional status and its associated complications. Weight loss and malnutrition may interfere with anticancer treatment, and individuals who lose weight may have a reduced tolerance to treatment (including poor recovery after surgery) owing to poor wound healing and an increased susceptibility to infection.  Weight loss may also contribute to a poor quality of life. Additionally, cancer and its treatment tax the immune system, increasing the likelihood of infections, which raise energy and nutrient needs even further. Nutritional support of persons with cancer should be an integral part of any treatment.

Individuals with cancer can suffer from numerous eating difficulties, arising from the presence of the disease and/or treatments.  If attention is paid to these problems by early dietary intervention, some symptoms can be relieved and excessive weight loss prevented.  A person with cancer who has a good nutritional status, when compared to a similarly afflicted malnourished person, feels better, eats better, is more active and stronger, resists infection better and enjoys a better quality of life.

Early nutritional intervention (soon after a diagnosis has been made) can address dietary problems and is extremely beneficial in long-term management. People with cancer have vastly increased needs for both energy (calories) and protein, as well as for certain vitamins and minerals. Requirements for specific vitamins and minerals are highly variable and depend on the type of therapy used and the presence and severity of complications e.g. vomiting and malabsorption.  All individuals should be carefully monitored for early signs of nutrient deficiencies.  Although it is generally prudent to recommend a multivitamin/mineral supplement in most persons with cancer, one should guard against excessive supplementation, which could be harmful. Vitamin supplements should be stopped during cancer treatments (radiation or chemotherapy) as well as for three days before and 3 days after treatment, as they may interfere with the treatments.

Nutrition plays an important role during treatment for a variety of reasons:

• It enables one to tolerate the treatment, and any side effects of the treatment, better.
• It prevents healthy body tissues from being damaged.
  • It helps to rebuild normal tissue that has been affected by treatment.
• It boosts immune function.
• It reduces the risk of infection.

HOW DOES CANCER AFFECT NUTRITIONAL STATUS?

The physiological effects of cancer can cause increased nutritional requirements and a reduced food intake. The nutritional consequences depend on the severity, location and treatment of the cancer.  These consequences can be severe and may be worsened by the effects of the cancer treatment.  The result is often a profound depletion of nutrient stores.  

CANCER CACHEXIA

This syndrome affects about two-thirds of persons with cancer and is characterized by loss of appetite, inadequate food intake, progressive weight loss, malnutrition, increased and altered metabolism and wasting (loss of muscle).  Poor food intake combined with increased nutrient requirements lead to muscle wasting and general poor health, which diminishes food intake further.  The body continues to deplete its nutrient stores at an accelerated rate and the resulting malnutrition compromises the quality of life and may lead to complications. 

CANCER TREATMENTS AND ASSOCIATED NUTRITIONAL CONSIDERATIONS  

The main aim of cancer treatment(s) is to annihilate cancer cells, relieve pain and prevent further tumor growth.  Through the use of available treatment regimens, cancer can sometimes be arrested, but ironically, these treatments can also threaten the health and nutritional status of the individual by interfering with the their ability to ingest, digest and absorb their food adequately. Treatments that are used include radiation therapy, chemotherapy, surgery, or any combination of the three.

RADIATION THERAPY

Radiation therapies prevent cells from dividing. Radiation damages all actively dividing cells (normal body cells as well as tumour cells), but cancer cells are damaged more severely and recover more slowly, as they divide more rapidly than normal cells. Side effects associated with radiation therapy vary according to the region irradiated; usually occur within 10 - 17 days after initiation of therapy and are usually temporary, resolving within 2 - 4 weeks after completion of the treatment. 

CHEMOTHERAPY

Chemotherapy, also used to interrupt cell division, is often effective but also has undesirable side effects.   Chemical agents or medications are used and affect the whole body, as opposed to radiation therapy and surgery, which are used to treat the cancer locally (i.e. at the site of the cancer).  As a result, chemotherapy can have many adverse side effects, and dietary and nutritional status may be severely affected.  Side effects are dependent on the specific agent used, dosage, duration of treatment, accompanying drugs and individual response. 

SURGERY

Surgery is the primary mode of treatment for patients with gastrointestinal cancers (cancers of the stomach or intestine). Surgery may be combined with chemo- or radiation therapy before or after surgery to prevent new tumor growth.  The side effects depend on the location of the tumor and its size, as well as the surgical procedure. 

SIDE EFFECTS OF TREATMENT: DIETARY RECOMMENDATIONS

NAUSEA AND VOMITING

Nausea and vomiting may be due to the illness and/or the treatment prescribed. The degree varies from individual to individual, and may last for only a few hours, or for much longer. Ask your oncologist to prescribe an anti-nausea medication that is suitable for your treatment regime if you need it. If the nausea lasts for only a few hours after the treatments, avoid food during that time and only consume clear liquids. Once nausea is over, continue to eat a healthy balanced diet. If the nausea persists, try some of the following:

• Small, frequent, dry meals of easily digested carbohydrate (e.g. Provita, cream crackers, toast and marmite/honey/jam, corn thins, rice crackers, pretzels) are tolerated best.
• Eat an easily digested source of carbohydrate before getting up in the morning e.g. dry biscuits like Salticrax or dry toast.
• Eat smaller, more frequent meals rather than three big meals a day.
• Eat small portions at a time. Large meals that make you feel too full can aggravate nausea.
• Avoid strongly flavoured foods and rich creamy meals/desserts. They often make the nausea worse.
• Salty/savoury foods (e.g. marmite on toast) are often tolerated better than sweet foods.
• Liquids are best taken between meals rather than with meals (wait 30-60 minutes before or after eating). Sip slowly or consume through a straw (this slows down the rate at which you can drink.)
• Clear, cool beverages are recommended e.g. apple juice, Appletizer, Grapetizer, grapefruit flavoured ‘Just Juice’.
• Sour liquids (e.g. sour sweets and lemon Lucozade) as well as acid flavours (e.g. grapefruit or dill pickle) help to clear your palate. Ginger Beer or a slice of ginger in hot water can help too.
• Frozen fruit lollies and iced fruit sorbets in sour flavours like grapefruit or lemon are useful.
• Avoid very fatty or fried foods because they can aggravate the nausea.
• Try to avoid eating too many of your favourite foods: if you vomit, you may be put off these foods in future.
• Eat slowly and chew your food well.
• Eat sitting upright.
• Do not lie down for at least one hour after eating. Rather sit upright in a chair, or use a few pillows to prop yourself up.
• Wear loose clothing and get plenty of fresh air.
• Nausea often gets progressively worse during the day. Try to eat early in the day, when you are still feeling all right.

CHEWING PROBLEMS/DRY MOUTH/SORE MOUTH/MUCOSITIS

Both swallowing and/or chewing problems may occur for a variety of reasons:

A growth in the mouth may interfere with chewing.

A growth in the oesophagus may interfere with swallowing.

A sore mouth or throat may result from the illness and/or effects or treatment.

Dentures may no longer fit well due to weight loss.

Radiotherapy to the head and neck area may reduce the flow of saliva or cause saliva to be thicker than usual.

Some of the following tips may make eating a little easier:

• Prepare food without spices and salt – these can be added at the table as tolerated.
• Avoid tart (acid tasting) or salty foods.
• Do not use hot spices (chilli powder, curries, peppers, nutmeg, cloves) as these may irritate the lining of your mouth.
• Avoid rough or course textured foods such as raw vegetables, whole-grain products, toast, bran etc.
• Small frequent meals are more acceptable. Try and eat at least six small meals a day.
• Eat foods with lots of gravy or sauce.
• All foods must be soft, moist and easy to swallow.
• Change to soft or liquid foods if you tolerate these better than solid food.
• Serve meals cold or at room temperature.
• Ice cold drinks and ice cream tend to lessen the pain of a sore mouth or throat.
• Add cream, milk, milk powder, sugar, honey and butter to food to increase the energy value.
• Citrus fruit or fruit juices (orange, grapefruit, tomato, guavas) can sting your mouth. Less acidic fruits like banana, apple, pears and paw-paw are easier to swallow.
• Use a straw and drink liquids or soft, sloppy foods from a cup rather than using a spoon.
• Smoking and alcohol can irritate your mouth and throat: avoid these.
• Have liquids at mealtime with the food.
• Drink extra liquids between meals.
• Sugarless chewing gum or mints to suck may offer relief.
  • Rinse your mouth out often, especially after eating sweet foods or drinks. Lack of saliva reduces your mouth’s resistance to bacteria. (Concentrate on good oral hygiene).

Ideas for meals

• Bland fruit juices e.g. apple, grape, paw-paw.
• Mashed potato with butter/cream.
• Soft vegetables e.g. squash, butternut, sweet potato.
• Custard, ice cream, fruit sorbet.
• White bread with luke-warm soup.
• Milky drinks e.g. Build Up, Ovaltine, Milo, hot chocolate made with milk (preferably full cream).
• Yoghurt (double cream or Greek Yoghurt if you need to gain weight) or buttermilk.
• Soft biscuits: keep these uncovered and allow to soften e.g. Marie biscuits, shortbread and tennis biscuits.
• Smooth cream cheese or cottage cheese.
• Thin porridge with sugar/honey and milk/cream.
• Scrambled, soft boiled or poached eggs.
• Finely minced meat or soft-boiled meat, fish or chicken. Cut into small pieces and serve with lots of gravy.
• Soft puddings e.g. cheesecake, jelly and cream, chocolate mousse (be careful of raw eggs if your white cell count is low), rice pudding.
• Pureed stewed fruit, baked apple and custard, mashed banana and cream, canned fruit.

CONSTIPATION

Certain medications, as well as diet low in fibre, may lead to constipation. Try to increase the amount of fibre you consume. Fibre is the "roughage" in your diet. It softens stools and makes them easier to pass. A high fluid intake is needed to soften the fibre in your diet (at least 6-8 glasses a day). Regular exercise, rest and enough sleep are also important in the management of constipation.

SOURCES OF FIBRE

Protein sources

Dried beans (broad, butter, baked, haricot, kidney, sugar beans, soya beans), dried and split peas and lentils. Since these foods are high in protein, they can be used as a substitute for meat, fish and poultry.

All nuts and seeds, including peanut butter (especially crunchy).

 

Carbohydrates

Breads

Wholewheat bread, rye bread, high fibre breads.

Biscuits and Baked Goods

Wholewheat biscuits (e.g. Provita, Bran S, bran rusks), bran muffins, wholewheat scones.

Breakfast Cereals

High fibre/bran cereals (e.g. All Bran, Weetbix, Hi-Fibre Bran, muesli).

Cereals/Grains

Oats, oat bran, barley, brown rice, wholewheat pasta, corn on the cob, popcorn, maize rice, wholewheat flour (e.g. Nutty Wheat), cracked wheat.

Starchy Vegetables

Potatoes and sweet potatoes with the skin.

Vegetables

Any vegetable that contains pips and seeds. Eat the skin where possible. Good sources of fibre include: peas, carrots, corn, cabbage, celery, beans and sprouts. Cook for the minimum period required eg. lightly steamed.

Fruit

All types, including skins, pips and membranes wherever possible. Apples with skin, pears and citrus fruits are especially good sources of fibre.

Dried fruit e.g. prunes, apricots, figs, and raisins.

Miscellaneous

Digestive Bran, high fibre/muesli health bars, peanut brittle, dried fruit sweets.

Good ideas for high fibre snacks

1. Dried fruit e.g. prunes, mebos.
2. Nuts and raisins.
3. Muesli and high fibre bars e.g. Granola bars.
4. Wholewheat rusks and biscuits.
5. Popcorn.

DIARRHOEA

Radiation to the lower bowel can result in either diarrhoea or cramps. Diarrhoea may sometimes be caused by a lactose intolerance induced by radiation therapy. (Lactose is the sugar found in milk and dairy products).

• Avoid foods high in roughage e.g. whole-wheat bread, skins of fruit, and pips of fruit. Use white bread instead of brown bread, rice crispies or cornflakes instead of All Bran and Weetbix etc.
• Peel all fruit and vegetables.
• Avoid very fatty foods e.g. fried foods, fatty meats, oils, salad dressings, chocolate etc.
• Eat smaller, more frequent meals.
• Drink enough fluid to replace losses. Dilute fruit juices (concentrated juices may worsen diarrhoea). Try Bovril or Oxo. Fluid replacement is very important to prevent dehydration. Try and drink water or re-hydration drinks after every loose stool (see recipe).
• REHYDRATION FLUID:(remember hygiene) 1 liter of cooled boiled water, 8 teaspoons of sugar and 1/2 teaspoon of table salt. Drink this frequently whilst you have diarrhoea.
• Eat bland foods rather than those that are strongly spiced.
• Avoid milk and dairy products if you have severe diarrhoea, as lactose may worsen the condition. You may reintroduce these foods once your diarrhoea resolves.
• Concentrate on soluble fibre. Oat Bran can help to bind the stools (use under guidance from a dietician).
• Avoid alcohol and caffeine, since both may have a dehydrating effect.
• Avoid gas forming foods and drinks (e.g. peas, lentils, cabbage, cauliflower, broccoli, onion, nuts, cucumber, beans, bran, garlic and beer).
• Limit the intake of fructose (fruit sugar) by avoiding apple and pear juice as well as grapes, honey, dates, nuts, figs and soft drinks. Do not eat too much fruit – only have one piece at a time.
• In order to replenish sodium (salt) and potassium: eat bananas, potatoes, fish, and meat and drink apricot and tomato juice.

FOOD AROMAS/SMELLS

Certain odors can sometimes also make you nauseous.

• Some foods and beverages have a strong odour/aroma when cooking. Avoid these foods and beverages e.g. fish, brewing coffee, cabbage.
• Allow the food to cool down to room temperature before serving as this reduces the aroma.
• Fried foods and oily foods are often offensive.
• Stay away from the kitchen if cooking is in progress – go for a walk or move to another room to avoid the smell. Let someone else do the cooking if the smell is offensive.
• Use prepared foods/convenience foods that are frozen and can be quickly reheated in an oven/ microwave.

DECREASED APPETITE/ EARLY SATIETY

Factors that contribute to a loss of appetite in persons with cancer include: nausea, fatigue, pain, fever, psychological stress, obstruction in the mouth or oesophagus by the tumor and changes in taste / smell. 

• Smaller more frequent meals:  5-6 instead of three main meals.
  • Meals should be appetizing in appearance and taste and provide enough energy and protein.
• Meat, fish, poultry, eggs, whole milk, cheese, cream soups, ice cream, whole-milk yoghurt, creamed vegetables and rich desserts are good choices.
  • The use of supplements may be necessary. Drinks are easier to consume than solid food if you are feeling unwell.
  • Avoid low fat or nonfat milk products: use full fat dairy products and add 50g milk powder to 500ml full cream milk to make enriched protein milk.
  • Avoid low calorie foods: broth-based soups, green salads, steamed/plain vegetables, and low calorie beverages.
  • Cook meals when you are feeling well and store them in the freezer or fridge.
  • Eat slowly and relax during meals.

 IDEAS FOR INCREASING YOUR CALORIE INTAKE

• Keep grated cheese in the fridge and sprinkle onto meals and snacks.
• Mix cheese with mashed potato.
• Add sugar, honey, nuts, and seeds to cereals, full cream yoghurts, and desserts.
• Liquidize stewed fruit, almonds, cashews, brazils or peanuts and add to yoghurt, custard and ice cream.
• Nibble cheese, crisps, nuts and dried fruit between meals.
• Add cream, evaporated milk, ice cream or custard to fruit.
• Add jam or grated chocolate to puddings.
• Add mayonnaise to sandwiches or salads.
• Snack on biltong or droë wors (if your white cell count is not too low).
• Sugar, vegetable oil, peanut butter, eggs and non-fat milk powder can be used in porridge, soups, gravies, casseroles or milk based drinks to increase the protein and energy content, without adding to the bulk of the meal.
• Add sugar, butter, peanut butter, margarine, cheese, mayonnaise and cream to foods (if tolerated).
• Dairy products are a good protein source. Cultured dairy products like yoghurt are easier to digest than milk.  If milk causes cramps or a feeling of fullness it is best to avoid it in the diet, but it is quite possible that yoghurt and sour milk will be tolerated.
• Beans, seeds and peas are good sources of protein and cheaper than meat, eggs and milk products.

TASTE ALTERATIONS

• Include many cold foods and milk products.
• Experiment with foods.
• Increase use of flavouring and seasoning.
  • Fruit-flavoured supplements often taste better than others.
  • Avoid red meats, chocolate, coffee and tea.
    • Foods should be well cooked - eliminate foods that could potentially be contaminated with bacteria. 
    • Avoid raw fish, meats, mould-containing unpasteurised cheeses, raw unwashed fruit and vegetables, unpasteurised honey, commercial cream-filled pastries requiring refrigeration, dry / fresh spices added after cooking and herbal supplements.
    • Wash hands well before working with food.
    • Keep chilled food well chilled. Frozen foods must be used as soon as they have defrosted: do not re-freeze them.
    • Keep raw and cooked food separate. Use separate chopping boards and knives for raw and cooked food.

FOOD SAFETY

For more information

CANSA

 (Cancer Association of South Africa) can be contacted on a toll-free number: 

AMERICAN CANCER SOCIETY

www.cancer.org

UK CANCER INFORMATION SERVICE

www.cancerbackup.org.uk/info/diet.htm

With thanks to NICUS (Nutrition Information Centre of the University of Stellenbosch) for some of the above information.

GLYCAEMIC INDEX OF SOUTH AFRICAN CARBOHYDRATES

	LOW GI (0 – 55) Eat most of the time.	INTERMEDIATE GI (56 – 69) Eat in moderation.	HIGH GI (70 AND ABOVE) Try to avoid, or eat after strenuous exercise, or when blood sugar levels are low. Try to combine with a low GI food.
DAIRY	Low fat/ fat free milk (plain and flavoured). Low fat/ fat free yoghurt (plain and sweetened). Low fat/fat free custard (sweetened and unsweetened); Low fat ice-cream (sweetened and unsweetened e.g. Dialite ice-cream).	Ice cream. Mega ‘lite’ ice cream bars. Low fat condensed milk.	None.
CEREALS	Pronutro: whole wheat (original and apple bake); Future Life cereal; Special K; High fibre bran; Bokomo Fibre Plus, Fruitful All Bran flakes; some muesli e.g. Fine Form, Nature’s Source low GI muesli, Bokomo Morning Harvest Muesli, Vital muesli. Oats-so-easy Original flavour. Cold mealiemeal. Oat bran (raw), Digestive bran.	Strawberry Pops, Pronutro (original, banana, strawberry, chocolate and honeymelt), Tasty wheat, Corn pops, Frosties, Choco’s, Shredded wheat, All bran flakes. Mealiemeal – reheated. Oats (Bokomo, Woolies, Pick ‘n Pay, Spar) Cooked Jungle oats.	Weetbix, Nutrific, Maltabella, Puffed wheat, Rice Crispies, Cornflakes, Froot Loops. Toasted muesli. Oats (Tiger oats). Instant oats (flavours). Cooked oat bran. Maltabella.
BREAD	Provita. Seed loaf, Pumpernickel. Any other bread made with lots of whole kernels, crushed wheat (e.g. Albany or Duens dumpy, Duens seed loaf, Fine Form, Sasko Nature’s harvest, Uncle Salie’s brown/ whole wheat).	Provita oats and brown sugar Rye bread. Ryvita. Crackermates ‘lites’ (wholewheat and sesame) Pita Bread (wholegrain).	All brown, white and regular whole wheat bread. All bread rolls and anything made with cake flour, bread flour and whole wheat flour. Rice cakes, corn thins, Snack bread, cream crackers, water biscuits, melba toast.
STARCHES	Legumes: all dried and canned beans, peas, lentils, pea dhal, baked beans and butter beans. Boiled barley, Barley wheat, crushed wheat. Bulgur, buckwheat. Quinoa. Pasta (100% Durum wheat /Durum semolina). Sweet potato, Mealies/corn. Brown rice, Tastic rice and wild rice.	Sweet corn (canned – cream style). Basmati rice. Arborio rice (for risotto). Baby potatoes – with skin. Cous cous. Samp and beans.	All boiled, mashed, baked and fried potatoes. Instant and 2-Minute noodles. Samp. Mealie rice. Millet. Pasta (normal wheat flour). Polenta.
FRUIT Watch portions! A potion = fruit the size of a tennis ball	All deciduous fruit, i.e. apricots, cherries, peaches, plums, pears, apples etc. All citrus fruit (oranges, naartjies, grapefruit) Strawberries and other berries, kiwi and grapes (watch portions!)	Tropical fruit, i.e. banana, mango, paw-paw, pineapple and litchis. Dried fruit: sultanas, dates, raisins (watch portions!)	Watermelon and sweet melons. Dried fruit rolls.
VEGETABLES	All those that are not intermediate or high GI e.g. beans, broccoli, cauliflower, cabbage, onion, mushroom, cucumber, lettuce, marrows, peas, peppers, tomato etc.	Beetroot, spinach, marog.	Carrots and carrot juice, pumpkin, Hubbard squash, butternut, parsnips, turnips.
SNACKS AND SUGAR	Fructose: not more than 20g  (4 tsp) per day. Sugar-free sweets. Jepsa low GI rusks. Sugar-free jam e.g. St Dalfour, Naturlite. Homemade low fat popcorn.	Digestive biscuits, Low fat oatmeal crumpets. Ouma Nutri rusks. Low fat biscuits, bran/fruit muffins or pancakes containing oats/oat bran. Raw honey, jam, sugar.	Sweets – boiled and jelly type. Marie biscuits. Most cakes and biscuits made with white flour. Commercial honey, glucose, maltose.
DRINKS	Sugar-free cold drink, Lipton ‘lite’ Iced Tea, ‘lite’ flavoured mineral water. Diluted juice of low GI fruits: only 1-2 glasses per day.	Juice of intermediate GI fruits – only 1 glass of diluted juice. Regular cool drink: cordials and soft drinks.	Sports/energy drinks, eg Energade, Powerade, Lucozade.

 

 

 

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