Nutrition in Cancer, AIDS, and Other Special Problems

Chapter 22
Role in Wellness
Physical health dimension

Challenge to halt or minimize malnutrition often

associated with symptoms or treatments
Intellectual health dimension

To maintain optimal nutrient intake while dealing

with serious illness requires intellectual capability to
comprehend aspects of treatment and
rehabilitation
Emotional health dimension

Fearing death from AIDS or cancer stresses ability to

cope
Social health dimension

Prejudice against (and fear of) clients with HIV/AIDS

and cancer affects potential for individuals to
continue social and work relations as in past
Spirituality health dimension

Faith can provide personal insight for gathering

strength to heal
Cancer

Cancer

Characteristics of cancer cells

Uncontrolled cellular reproduction

Cells become independent of

normal growth signals

Cells contain abnormal nucleus and

cytoplasm

Mitosis rate generally increases

Nucleus of cells may be abnormal shape

with clearly abnormal chromosomes

Carcinogenesis

Process resulting in abnormal cell

production

Abnormalities in cell replication

Initiation

Results in mutation of
deoxyribonucleic acid (DNA)

Exact causes not clear for all

malignancies

Physical and chemical

agents or exposure to
microorganisms may
cause mutation

Promotion

Replication of mutated cell

promoted

Abnormal cell growth results

Factors in some malignancies

include:

Estrogen

Testosterone

Nitrates

Cigarette smoke

Alcohol
Progression

Abnormal cells outside original

location of cell

Second leading cause of death in U.S.

Most diagnoses of cancer occur in older individuals

Most common types of cancer include lung,

prostate, and colorectal

50% to 75% of all cancer deaths linked to human

behaviors and lifestyle factors

Nutrition factors considered important

environmental and lifestyle factors in etiology and
prevention of cancer

Nutrition and dietary factors may interact

within process of carcinogenesis in all three
stages: initiation, promotion, and
progression

National Cancer Institute guidelines

Do not smoke cigarettes or use other

tobacco products

Do not drink too much alcohol

Eat five or more daily servings of fruits and

vegetables

Eat a low-fat diet

Maintain or reach a healthy weight

Be physically active

Protect skin from sunlight

Nutrition and the diagnosis of cancer

Cancer cachexia

Complex syndrome resulting in severe

wasting of lean body mass and weight loss

Hypothesized that cytokines drive altered

metabolic response in cachexia

Results in weight loss, anorexia,

hypermetabolism, skeletal muscle
mass wasting, and increased lipid
breakdown

Cachexia affects almost 50% of all cancer

patients

Present even at beginning stages

of tumor development before
actual weight loss observed

Aggressively approaching nutrition support

as major component of medical care assists
with minimizing nutritional complications
of cancer
Benefits of nutritional adequacy

Maintenance of nutritional status

Decreases risk of surgical complications

Ensures patients able to meet increased

energy and protein requirements

Helps to repair and rebuild normal tissues

affected by antineoplastic therapy

Promotes increased tolerance to therapy

Assists in promoting enhanced quality of

life

Nutritional effects of cancer treatments

Surgery

Depends on type and extent of surgical

resection

Resections of any portion of

gastrointestinal (GI) tract

Alterations in nutrition intake and

nutrient absorption

Energy and protein requirements may need

to be increased

To promote optimal wound

healing postoperatively

Malabsorption tends to be primary

nutritional problem

Many patients enter surgery

already experiencing protein-kcal
malnutrition

Higher risk for complications

Chemotherapy

Most protocols include combination of

chemotherapy agents

Act by:

Inhibiting one or more steps of

DNA synthesis in rapidly
proliferating cells characteristic of
malignant cell

Or by enhancing hosts immune

system to allow for improved
response to therapy

Cells of bone marrow and lining GI tract

tend to be susceptible to damage from
chemotherapy

Rapid cell turnover rate

Severity and manifestation of side effects

determined by:

Chemotherapy agent

Dosage

Duration of treatment

Rates of metabolism

Accompanying drugs

Individual tolerance

Radiation therapy

Ionizing radiation used to kill cells by

altering DNA of malignant cell

Interferes with factors controlling

replication

Used to treat tumors sensitive to radiation

exposure or tumors that cannot be
surgically resected

Some normal cells within treatment range

also in stage of cell replication also may be
damaged

Complications may develop during

radiation treatment or become chronic and
progress even after treatment completed

Primary radiation sites resulting in nutrition

problems include:

Head and neck

Abdomen and pelvis (GI tract)

Central nervous system (CNS)

Bone marrow transplantation

Used to treat certain hematologic

malignancies (acute and chronic leukemia
and some forms of lymphoma)

Used as adjunct therapy for solid tumors

such as breast cancer

Types of transplant include autologous,

allogeneic, and syngeneic

Treatment of solid tumor

Patients own bone marrow

harvested and saved before
initiation of chemotherapy or
radiation therapy

Patient then receives high-dose

chemotherapy and possibly total
body irradiation to eradicate
cancer

Patients own bone marrow then

infused as rescue from effects
of both chemotherapy or
radiation

Hematologic malignancies

Patient receives bone marrow

from genetically matched donor
(allogeneic) or in some cases
from twin (syngeneic)

Ability to maintain adequate oral intake

difficult because of nausea, vomiting, and
mucositis

Antineoplastic regimens and BMT result in

immunosuppression

Places BMT patient at high risk

for infections from bacterial and
fungal pathogens

Pathogens commonly in
environment including fresh fruits
and vegetables ordinarily not
hazard to healthy people

Low-bacterial diet indicated whenever

3
plasma neutrophil count <1000 mm

Food safety guidelines for patients with low

immune function or are neutropenic

Avoid undercooked meats and

eggs

Ensure raw fruits and vegetables

washed well and/or peeled
(including salads and garnishes)

Follow appropriate sanitation

guidelines for food preparation
and storage
Graft versus host disease (GVHD)

Major complication with allogeneic BMT

Best described as reverse rejection

Grafted tissue or organ

recognizes hosts cells as foreign

May result in multiple organ damage, but

skin, GI tract, and liver of particular concern

Nutritional management complicated

May require intense therapy for

as long as 1 to 2 years
posttransplant
Nutrition therapy

Cancer patients at high risk for malnutrition

Recognizing clinical signs and treating

symptoms early helps prevent protein-kcal
malnutrition

Nutrition essential component of total management

of cancer

Nutrition support must be individualized

Prognosis considered to appropriately adjust

aggressiveness of nutritional intervention

Supportive

Adjunctive

Definitive
Anorexia caused by cancer or its treatment

Etiology generally multifactorial

Changes in taste and smell

Decreased transit time and subsequent

early satiety

Opportunistic infections

Therapy and other medication side effects

Pain

Emotional and psychologic effects

Treatment options

Essential to promote adequate nutritional

intake

Many cancer patients feel loss of control

after diagnosis

Managing their nutritional intake

assists in regaining control

Essential nutrient density of food stressed

Small, frequent meals

Use of high-kcal supplements

Pleasant eating environment

Medications successfully stimulate appetite

Megestrol (Megace)

Dronabinol (Marinol)
Nausea and vomiting

Nausea and vomiting may result from:

Delayed transit time

Physiologic symptoms such as

hypercalcemia or central nervous system
(CNS) involvement

Medications

Anticipation on part of patient

Treatment options

First line of treatment

Adequate and aggressive

antiemetic therapy

Essential to give
medication 60 to 90
minutes before meals

If nausea and vomiting prevented, reduced

risk of anticipatory nausea and vomiting

Cold foods without odor better tolerated

Behavioral strategies such as guided

imagery and relaxation techniques
successful
Taste abnormalities

Taste alteration causes

Changes or destruction of oral mucosa

Presence of tumor by-products systemically

Changes in quantity or quality of saliva

Inadequate mouth care

Drug-related taste changes

Treatment options

Appropriate to avoid foods that taste bad

Important to provide alternate food

choices to maintain adequate nutrient
intake

Tart or spicy foods may enhance intake

Guidelines for mouth care essential

Principles of nutrition therapy

Nutrition should be essential component of every

treatment plan for cancer patient

Expected outcomes for nutrition therapy

Weight and lean body mass maintained

within established goal range

Consumption of adequate energy

and protein or appropriate
nutritional support

Hydration adequate as measured by clinical

and physical assessment

Adequate energy and protein consumption

to perform ADL

Comprehension by patient of neutropenic

precautions

Appropriate and safe use of

complementary nutrition therapies by
patient
AIDS
Acquired immunodeficiency syndrome (AIDS)

Retrovirus human immunodeficiency virus (HIV)

causes acquired immunodeficiency syndrome (AIDS)

Retrovirus injects its ribonucleic acid (RNA)

into target cell

Then transcribes RNA into deoxyribonucleic

(DNA) using reverse transcriptase enzyme

Target cells for HIV include:

T4 or CD4 lymphocytes

B-lymphocytes

Monocytes

Macrophages


Other cells of immune system
Initial infection with HIV may include symptoms
such as fever and malaise

Antibodies produced against virus detectable within

2 to 4 months after exposure

Replication of infected cell results in a steady

depletion of CD4 cell count

Causes severe depression of immune

function

Increases risk for opportunistic infections

and malignancies

Diagnosis of AIDS includes:

Positive antibody test for HIV

3

CD4 cell count of <200 mm or <14% of

total white blood cell count

Clinical diagnosis of 1 of 25 AIDS-defining

diseases

Progression from HIV to AIDS varies for each

individual

May not be evident for several years

Two major prognostic factors for HIV

CD4 T-cell count

Measurement of plasma HIV RNA (viral

load for HIV)

HIV bloodborne and sexually transmitted infection

Contaminated blood

Semen

Vaginal secretions

Breast milk

Crosses placenta from mother to baby

Highly active antiretroviral therapy (HAART)

Combinations of:

Fusion inhibitors

Integrase inhibitors

Nucleoside/nucleotide reverse
transcriptase inhibitors

Nonnucleoside reverse
transcriptase inhibitors

Protease inhibitors

Goal of treatment regimens

Maintain viral load of <50 copies/mL

Adherence to these regimens often difficult

Number and complexity of

medications taken daily

Drug resistance can develop if adherence

not maintained

Other side effects

Nausea

Vomiting

Diarrhea

Other metabolic
changes
Malnutrition in HIV/AIDS

Documented in all stages of HIV infection

Malnutrition in HIV/AIDS multifactorial

Most nutritional problems coincide with:

Incidence of high viral loads

Opportunistic infections

Development of viral resistance

AIDS-related wasting syndrome

Involuntary weight loss of >10% in 1 month

with presence of chronic diarrhea,
weakness, or fever for >30 days in absence
of concurrent illness or condition

10% weight loss a strong

predictor of survival in HIV
infection

Even <5% weight loss may be risk

factor for mortality

Malnutrition in HIV/AIDS multifactorial

Contributors include:

Altered nutrient intake

Weight loss and body

composition changes

Physical impairment

Endocrine disorders

Metabolic changes

Malabsorption

Presence of opportunistic
infections

Psychosocial issues

Economic conditions
Altered nutrient intake

Anorexia frequent symptom may be caused by:

HIV infection

Presence of opportunistic infections

Fatigue

Fever

Medication side effects

Physical impairment

Mucositis, esophagitis, pain,

nausea, and vomiting

Depression, loneliness, fear, anxiety, or

other psychosocial issues

Economic availability of adequate food

supplies
Weight loss and body composition changes

Changes may occur as a result of:

Decreased nutrient intake from physical

impairment

Symptoms that impair appetite

Chronic weight loss

Accompanied by decrease in metabolic rate

Reliance on fat stores for energy

Acute weight loss

Accompanied by increase in metabolic rate

Reliance on glucose as fuel

Depletion of lean body mass

Changes commonly seen in wasting syndrome

Often coincide with increases in viral load

Body composition changes also noted in

lipodystrophy (fat redistribution syndrome)

Medications to treat weight loss

Megestrol acetate (Megace)

Dronabinol (Marinol)

Antiemetic

Appetite stimulant

Side effects include

euphoria, dizziness, and
impaired thinking

Oxandrolone (Oxandrine) or oxymetholone

and testosterone

Increases lean body mass, mood

elevation, and increased libido

Dehydroepiandrosterone (DHEA) and

human growth hormone (r-hGH)

Improve lean body mass with less

abdominal adiposity

DHEA used to treat depression in

patients with HIV/AIDS

Physical impairment

Nausea, vomiting, mouth, and esophageal

lesions, and impaired dentition may result
from:
Opportunistic infections such as
candidiasis and gingivitis
Side effects of antiretroviral
therapy
Prophylactic treatment to
prevent opportunistic infections
Medication for pain management

Determining causes of impaired intake

crucial to successful intervention
Endocrine and metabolic disorders

Hypogonadism identified with HIV/AIDS

Condition associated with fatigue,

decreased libido, loss of muscle mass,
muscle weakness, impotence, and body
hair loss

Adrenal insufficiency may contribute to

changes in appetite, loss of fuel storage,
and changes in metabolism

Fat redistribution syndrome (lipodystrophy)

Syndrome of body composition changes

and metabolic disturbances

Shift in adiposity with increase in

abdominal obesity

Accompanied by increase in
serum triglycerides, cholesterol,
glucose, and insulin resistance

Etiology of fat redistribution syndrome

associated with protease inhibitors as well
as nucleoside analog therapy
Malabsorption

Malabsorption result of:

Opportunistic infections that damage GI

tract

Effects of malnutrition on villus height and

enterocyte function

Disease itself

Treatment of malabsorption

Treating underlying cause crucial in

reversing malnutrition caused by
malabsorption

To assist control of malabsorptive

symptoms and diarrhea:

Restriction of fat and lactose

common

Lactose-free supplements and

supplements containing mediumchain triglycerides frequently
prescribed

Probiotics and prebiotics,

glutamine and arginine in enteral
products or given separately as
supplement

Ensure adequate caloric and protein intake

as fat and lactose restricted

Prevent dehydration

Fluid losses may be high from

diarrhea

Supplementation with vitamins

and minerals priority
Cycle of malnutrition and wasting

Complex causes

Interventions must be integrated early

Conducting nutrition assessment and

providing counseling result weight
maintenance or gain
Nutrition assessment in cancer and HIV/AIDS

Initial step evaluate anthropometric data

Body weight compared with the clients

usual body weight

Unexplained weight loss concern

Weight loss >10% in 6

months places client at
risk

Body mass index (BMI) identifies

nutrition risk

BMI <18 associated

with malnutrition

Loss of lean body mass characteristic of

malnutrition of AIDS

Weight may initially be stable

Bioelectrical impedance (BIA)

evaluates changes

Calculation of upper arm muscle

area can provide baseline
measurement for monitoring
over time

Biochemical indices

Monitoring disease progression (CD4 or

viral load)

Acute phase proteins measuring

inflammatory processes (C-reactive

protein)

Overall visceral protein stores (serum

albumin and prealbumin)

Other measures such as transferrin not

applicable (possible bone marrow
suppression present)

Dietary assessment

Dietary evaluation by:

24-hour recall

Food frequency

Food diary

Careful attention

Gastrointestinal function

Presence of steatorrhea and

diarrhea

Other physical symptoms that

might interfere with adequate
oral intake
Nutrition therapy

Overall goals of nutrition management

Preserve lean body mass and gut function

Prevent development of malnutrition

Minimize symptoms of malabsorption

Provide adequate levels of all nutrients to

maintain daily physical and mental
functioning

Prevent nutrition-related
immunosuppression

Improve quality of life

Objectives of nutrition care

Realistic and individualized objectives

Interventions designed based on:

Nutritional assessment

Current medical treatment for

client

To determine energy and protein

requirements

Harris-Benedict equation to
determine resting energy
expenditure (REE)

1.3 to 1.5 REE should

meet most clients
energy requirements
for maintenance and
weight gain

MifflinSt. Jeor
equation may better
predict energy
requirements for
hospitalized patient
MifflinSt. Jeor Equation
Females: 10 W + 6.25 H 5 A 161
Males: 10 W + 6.25 H 5 A + 5
W = Weight (in kg)

H = Height (in cm)

A = Age (in years)

Protein requirements

1 to 1.5 g protein/kg of
actual body weight
based on patients
current nutritional
status

Vitamin and mineral status needs

to be monitored closely because
deficiencies may evolve

Suppressed oral intake

Increased requirements
for certain
micronutrients

General multivitamin supplement

meeting 100% of the
Recommended Dietary Allowance
(RDA) for vitamins and minerals
routinely recommended

In individual situations, other

supplements may be warranted
Antiretroviral therapy

Antiretroviral therapy requires specific

nutrition recommendations

Many antiretroviral medications

result in symptoms such as
nausea, vomiting, diarrhea, or
anorexia that might impair oral
intake

Number of pills taken can

overwhelm patient

Ingestion of food along with

certain medications may affect
absorption of that drug or vice
versa

Specific nutrition recommendations

include:

Efavirenz (Sustiva)

Avoid taking with highfat meals

Lopinavir (Kaletra) + ritonavir

(Norvir)

Moderate-fat meals
increase availability of
capsules

Take with food

Saquinavir (Invirase)

Take within 2 hours of

meal of high-fat foods
or large snack
containing
carbohydrate, protein,
or fat

Ritonavir (Norvir)

Taking with food may

decrease abdominal
cramping and diarrhea
common when this
drug initially prescribed

Symptoms usually
disappear within 8
weeks

Indinavir (Crixivan)

Taken on empty
stomach

Meal can be eaten 1

hour after drug or 2
hours before drug

For some, may be

necessary to eat small
snack with drug, but fat
should be avoided
Prevention of foodborne illness

Crucial component of nutrition therapy and

education for HIV/AIDS

As CD4 counts fall, higher risk for infections

from foods

Nutrition education focus on safe methods for food

purchasing, preparation, and storage

Low microbial diet prescribed with

recommendations to avoid:

Undercooked meats and eggs

Raw vegetables

Fruits
Physical activity

Regular aerobic exercise and resistance training

assist with:

Lipid abnormalities

Fat redistribution syndrome

Other body composition changes

Recommendations individualized and initiated

slowly after physicians approval
Benefits of physical activity

Increased muscle volume, strength, functional

capacity, and quality of life

Decreased abdominal fat

Prevention of glucose abnormalities and improved

insulin sensitivity

Improved circulation

Improved bone metabolism

Multidisciplinary approach

Nutrition assessment, counseling, and support

critical components of medical care

Effective treatment requires multidisciplinary

approach with collaboration of all health care team
members including nurse and dietitian

Early recognition and intervention for nutritional

risk factors keys to effective nutrition support and
related medical therapies

-----------------------NOTES FROM LECTURE------------------Cancer

- it is characterized by uncontrolled growth and spread of abnormal
cells, which continue to reproduce until they form as mass called
tumor
Cancer cells
- uncontrolled cellular reproduction where cells become
independent of normal growth cells
- cells contain abnormal nucleus and cytoplasm
- the mitosis rate fenerally increases
Characteristics of Malignant Cells
1. Differentiation
2. Rate of Growth
3. Spread (Invasion and Metastasis)
Carcinogenesis
- initiation: takes place when a carcinogen like virus becomes
activated in the body and binds to DNA
- promotion: growth of cancer cells
- progression: is the uncontrolled growth of cancer cells until
malignant tumor develops
Malignant versus Benign Tumors
Benign (not cancer): tumor cells grow only locallly and cannot
spread by invasion metastasis
Malignant (cancer): cells invade neighboring tissues enter blood
vessles and metastasuze ti dufferent sites
What causes cancer
- some virus or bacteria
- some chemicals
- radiation
Carcinogen: any substance that is an agent directly involved in the
promotion of cancer or in facilitation of its propagation.
Etiology
- associated with a high intake of saturated fat, polyunsaturated
fatm and excess CHO (sugar)
- associated with other correlates of metabloic syndrome
- certain cancers appear to be related to hyperinsulinemia (eg, forms
of breast, colon, liver, ovarian, and uterine)
- possible excess iron intake (associated with inflammation)
Non-Diet Risk Factors
- associated with low level of physical activity
- smoking/chewing activity
- alcohol intake, especilally excessive
- exposure to UV light
- chronic inflammation with high C-reactive protein (CRP)
Leading Cancer sites
Men: prostate, colorectal, lung, skin
Women: breast, colorectal, lung, skin
Cancer screening for ealry detection
- mammography
- pap smear
- MRI
American institute for cancer research: 30% to 40% reduction in
cancer risk with
- choose diet rich in a variety of plant based foods
- eat plenty vegetables and fruits
- maintain a healthy weight and be physically active

- drink alcohol in moderation

- select foods low in fat and salt
- prepare and store foods safely
- do not use tobacco in any form
- Vitamin D intake
Cancer Treatments
- Surgery: resection of the tumor
- Chemotherapy: use of drugs combination to cure or control cancer
- Radiation: idrd ionizing radiation to kill cells by altering the DNA
Benefits of Nutritional Adequacy
- decreased risk of surgical complications
- ensure that patients are able to meet increased energy and CHOn
requirements
- help to repair and rebuild normal tissues affected by antineoplastic therapy
- promote and increased risk of therapy
Nutritional Goals During Cancer Treatment
- short term goal: prevent weight loss
- Long Term goals: achieving and maintaining normal weight
- Replacing nutritional losses from side effects of treatment (eg. fluid
and electrolyte losses from vomiting, diarrhea, and malabsorption
- Providing adequate amounts of kilocalories, protein
Nutrient Needs
1. Increasing CHOn and calories (individualized)
- high CHON diet
- high calorie needs by using gravies, changing cooking methods to
include butter or good oils
25-35/kg weight maintenance
40-50/kg replinish body stores
- add skim milk powder to milk to make double strength milk, chill
before serving
Minimizing Side Effects
Fatigue
- prepare easy meals such as scrambled eggs, toast, and canned
fruits
- eat a good breakfast
- use frozen or canned foods
- drink commercial liquid supplements, milkshakes, or pasteurized
eggnog.
No appetite
- include snaks; emphasized small frequent meals
- include high calorie drinks such as sherbet
- keep sugar based candy by bedside
Nausea and vomiting
- use antiemetic meds before meals
- avoid fatty foods
- avoid concentrated sweers
- sip liquids slows (STRAW)
- avoid foods with a strong odor
Stomatitis or Esophagits
- eat soft foods
- add gravy, butter or sauces to dry foods
- avoid very salty, spiced or acidic foods
- use straw for beverages
- use artifical saliva as prescribed
Diarrhea:

- avoid lactose containing beverage foods

Constipation
- increase water fiber intake
Altered taste (dysgeusia)
- try lemon juice or vinegar on vegetables
- emphasize cold foods such as ice cream
- experiment with spices and marinades for meat
- add bacon bits of flavor
Methods of Feeding
- oral nutrition: preferred whenever possible
- tube feedings/enteral nutrition
- total parenteral nutrition
- used when digestive tract is not functioning
- nutrients are administered intravascularly
Neutropenic Diet
- a diet for people with weakend immune system (>1000mm3
neutrophil)
- helps protect them from bacteria and other harmul organisms
found in some foood and drinks
Guidelines
- avoiding undercooked meats, fish and eggs
- ensuring that raw fruits and vegetables are washed well and or
peeled
- wat or drink only pasteurized milk and dairy products
- follows appropriately sanitation guidelines food preparation and
storage
With Cancer Remission for prevention of Recurrence
Promote lifelong positive nutrition behaviors
- encourage high fiber diet and emphasis on monounsaturated fats
- encourage moderate kcalorie intake to manage weight, as well as
avoidance of excess salt
- encourage high quality diet per Mypyramid food guidance system
Promote positive lifestyle
- encourage regular physical activity
- encourage avoidance of excess alcohol
- encourage avoidance of tobacco
Tube Feedings
- complete products: meal replacements that require digestion and
absorption
- chemically defined products: minimal or no digestion/for
pancreatic cancer patients
- modular products: used in combination with other tube feeding
products to enhance calorie or CHON intake
- Specialty products: vary in terms of specific amino acid, CHO, at
content or for patient with hepatic or renal failure
Guidelines in Cancer prevention
- low fat diet
- avoid alcohol intake or smoking
"Your life is your hands, choose wellness"