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

Slide 2

Fearing death from AIDS or cancer stresses ability to cope

ROLE IN WELLNESS,
CONTD
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

Slide 3

Faith can provide personal insight for gathering strength to

heal

CANCER
Cancer
Characteristics of cancer cells

Slide 4

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

CANCER, CONTD
Carcinogenesis
Process resulting in abnormal cell production

Abnormalities in cell replication

Slide 5

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

CANCER, CONTD

Slide 6

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

CANCER, CONTD

Slide 7

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

CANCER, CONTD
Nutrition factors considered important environmental and
lifestyle factors in etiology and prevention of cancer

Slide 8

Nutrition and dietary factors may interact within process of

carcinogenesis in all three stages: initiation, promotion, and
progression

CANCER, CONTD
National Cancer Institute guidelines

Slide 9

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

CANCER, CONTD
Eat a low-fat diet
Maintain or reach a healthy weight
Be physically active
Protect skin from sunlight

Slide 10

CANCER, CONTD
Nutrition and the diagnosis of cancer
Cancer cachexia

Slide 11

Complex syndrome resulting in severe wasting of lean body

mass and weight loss

CANCER, CONTD

Slide 12

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

CANCER, CONTD

Slide 13

Aggressively approaching nutrition support as major

component of medical care assists with minimizing nutritional
complications of cancer

CANCER, CONTD
Benefits of nutritional adequacy
Maintenance of nutritional status

Slide 14

Decreases risk of surgical complications

Ensures patients able to meet increased energy and protein
requirements

CANCER, CONTD

Slide 15

Helps to repair and rebuild normal tissues affected by

antineoplastic therapy
Promotes increased tolerance to therapy
Assists in promoting enhanced quality of life

CANCER, CONTD
Nutritional effects of cancer treatments
Surgery

Slide 16

Depends on type and extent of surgical resection

Resections of any portion of gastrointestinal (GI) tract
Alterations in nutrition intake and nutrient absorption

CANCER, CONTD

Slide 17

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

CANCER, CONTD
Chemotherapy

Slide 18

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

CANCER, CONTD

Slide 19

Cells of bone marrow and lining GI tract tend to be

susceptible to damage from chemotherapy
Rapid cell turnover rate

CANCER, CONTD

Slide 20

Severity and manifestation of side effects determined by:

Chemotherapy agent
Dosage
Duration of treatment
Rates of metabolism
Accompanying drugs
Individual tolerance

CANCER, CONTD
Radiation therapy

Slide 21

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

CANCER, CONTD

Slide 22

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)

CANCER, CONTD
Bone marrow transplantation

Slide 23

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

CANCER, CONTD

Slide 24

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

CANCER, CONTD

Slide 25

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

CANCER, CONTD

Slide 26

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 plasma neutrophil
count <1000 mm3

CANCER, CONTD

Slide 27

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

CANCER, CONTD
Graft versus host disease (GVHD)

Slide 28

Major complication with allogeneic BMT

Best described as reverse rejection
Grafted tissue or organ recognizes hosts cells as foreign

CANCER, CONTD

Slide 29

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

CANCER, CONTD
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

Slide 30

Nutrition support must be individualized

CANCER, CONTD
Prognosis considered to appropriately adjust aggressiveness
of nutritional intervention

Slide 31

Supportive
Adjunctive
Definitive

CANCER, CONTD
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

Slide 32

CANCER, CONTD
Treatment options

Slide 33

Essential to promote adequate nutritional intake

Many cancer patients feel loss of control after diagnosis
Managing their nutritional intake assists in regaining control

CANCER, CONTD

Slide 34

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)

CANCER, CONTD
Nausea and vomiting
Nausea and vomiting may result from:

Slide 35

Delayed transit time

Physiologic symptoms such as hypercalcemia or central
nervous system (CNS) involvement
Medications
Anticipation on part of patient

CANCER, CONTD
Treatment options

Slide 36

First line of treatment

Adequate and aggressive antiemetic therapy
Essential to give medication 60 to 90 minutes before meals

CANCER, CONTD

Slide 37

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

CANCER, CONTD
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

Slide 38

CANCER, CONTD
Treatment options

Slide 39

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

CANCER, CONTD
Principles of nutrition therapy

Slide 40

Nutrition should be essential component of every treatment

plan for cancer patient

CANCER, CONTD
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

Slide 41

Hydration adequate as measured by clinical and physical

assessment

CANCER, CONTD

Slide 42

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)

Slide 43

Retrovirus injects its ribonucleic acid (RNA) into target cell

Then transcribes RNA into deoxyribonucleic (DNA) using
reverse transcriptase enzyme

AIDS, CONTD
Target cells for HIV include:
T4 or CD4 lymphocytes
B-lymphocytes
Monocytes
Macrophages
Other cells of immune system

Slide 44

AIDS, CONTD
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

Slide 45

Causes severe depression of immune function

Increases risk for opportunistic infections and malignancies

AIDS, CONTD
Diagnosis of AIDS includes:

Slide 46

Positive antibody test for HIV

CD4 cell count of <200 mm3 or <14% of total white blood cell
count
Clinical diagnosis of 1 of 25 AIDS-defining diseases

AIDS, CONTD
Progression from HIV to AIDS varies for each individual
May not be evident for several years

Two major prognostic factors for HIV

Slide 47

CD4 T-cell count

Measurement of plasma HIV RNA (viral load for HIV)

AIDS, CONTD
HIV bloodborne and sexually transmitted infection
Contaminated blood
Semen
Vaginal secretions
Breast milk
Crosses placenta from mother to baby

Slide 48

AIDS, CONTD
Highly active antiretroviral therapy (HAART)

Slide 49

Combinations of:
Fusion inhibitors
Integrase inhibitors
Nucleoside/nucleotide reverse transcriptase inhibitors
Nonnucleoside reverse transcriptase inhibitors
Protease inhibitors

AIDS, CONTD
Goal of treatment regimens

Slide 50

Maintain viral load of <50 copies/mL

Adherence to these regimens often difficult
Number and complexity of medications taken daily

AIDS, CONTD

Slide 51

Drug resistance can develop if adherence not maintained

Other side effects
Nausea
Vomiting
Diarrhea
Other metabolic changes

AIDS, CONTD
Malnutrition in HIV/AIDS
Documented in all stages of HIV infection
Malnutrition in HIV/AIDS multifactorial
Most nutritional problems coincide with:

Slide 52

Incidence of high viral loads

Opportunistic infections
Development of viral resistance

AIDS, CONTD
AIDS-related wasting syndrome

Slide 53

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

AIDS, CONTD
Malnutrition in HIV/AIDS multifactorial
Contributors include:
Altered nutrient intake
Weight loss and body composition changes
Physical impairment
Endocrine disorders

Slide 54

AIDS, CONTD
Metabolic changes
Malabsorption
Presence of opportunistic infections
Psychosocial issues
Economic conditions

Slide 55

AIDS, CONTD
Altered nutrient intake
Anorexia frequent symptom may be caused by:
HIV infection
Presence of opportunistic infections
Fatigue
Fever
Medication side effects

Slide 56

AIDS, CONTD

Slide 57

Physical impairment
Mucositis, esophagitis, pain, nausea, and vomiting
Depression, loneliness, fear, anxiety, or other psychosocial
issues
Economic availability of adequate food supplies

AIDS, CONTD
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

Slide 58

Accompanied by decrease in metabolic rate

Reliance on fat stores for energy

AIDS, CONTD
Acute weight loss

Slide 59

Accompanied by increase in metabolic rate

Reliance on glucose as fuel
Depletion of lean body mass

AIDS, CONTD
Changes commonly seen in wasting syndrome
Often coincide with increases in viral load

Slide 60

Body composition changes also noted in lipodystrophy (fat

redistribution syndrome)

AIDS, CONTD
Medications to treat weight loss

Slide 61

Megestrol acetate (Megace)

Dronabinol (Marinol)
Antiemetic
Appetite stimulant
Side effects include euphoria, dizziness, and
impaired thinking

AIDS, CONTD

Slide 62

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

AIDS, CONTD
Physical impairment

Slide 63

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

AIDS, CONTD
Endocrine and metabolic disorders
Hypogonadism identified with HIV/AIDS

Slide 64

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

AIDS, CONTD
Fat redistribution syndrome (lipodystrophy)

Slide 65

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

AIDS, CONTD

Slide 66

Etiology of fat redistribution syndrome associated with

protease inhibitors as well as nucleoside analog therapy

AIDS, CONTD
Malabsorption
Malabsorption result of:

Slide 67

Opportunistic infections that damage GI tract

Effects of malnutrition on villus height and enterocyte function
Disease itself

AIDS, CONTD
Treatment of malabsorption

Slide 68

Treating underlying cause crucial in reversing malnutrition caused

by malabsorption

AIDS, CONTD

Slide 69

To assist control of malabsorptive symptoms and diarrhea:

Restriction of fat and lactose common
Lactose-free supplements and supplements containing
medium-chain triglycerides frequently prescribed
Probiotics and prebiotics, glutamine and arginine in
enteral products or given separately as supplement

AIDS, CONTD

Slide 70

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

AIDS, CONTD
Cycle of malnutrition and wasting
Complex causes

Slide 71

Interventions must be integrated early

Conducting nutrition assessment and providing counseling
result weight maintenance or gain

AIDS, CONTD
Nutrition assessment in cancer and HIV/AIDS
Initial step evaluate anthropometric data

Slide 72

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

AIDS, CONTD

Slide 73

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

AIDS, CONTD
Biochemical indices

Slide 74

Monitoring disease progression (CD4 or viral load)

Acute phase proteins measuring inflammatory processes (Creactive protein)
Overall visceral protein stores (serum albumin and
prealbumin)
Other measures such as transferrin not applicable (possible
bone marrow suppression present)

AIDS, CONTD
Dietary assessment

Slide 75

Dietary evaluation by:

24-hour recall
Food frequency
Food diary

AIDS, CONTD

Slide 76

Careful attention
Gastrointestinal function
Presence of steatorrhea and diarrhea
Other physical symptoms that might interfere with
adequate oral intake

AIDS, CONTD
Nutrition therapy
Overall goals of nutrition management

Slide 77

Preserve lean body mass and gut function

Prevent development of malnutrition
Minimize symptoms of malabsorption

AIDS, CONTD

Slide 78

Provide adequate levels of all nutrients to maintain daily

physical and mental functioning
Prevent nutrition-related immunosuppression
Improve quality of life

AIDS, CONTD
Objectives of nutrition care

Slide 79

Realistic and individualized objectives

Interventions designed based on:
Nutritional assessment
Current medical treatment for client

AIDS, CONTD

Slide 80

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

AIDS, CONTD
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)

Slide 81

A = Age (in years)

AIDS, CONTD

Slide 82

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

AIDS, CONTD

Slide 83

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

AIDS, CONTD
Antiretroviral therapy

Slide 84

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

AIDS, CONTD

Slide 85

Specific nutrition recommendations include:

Efavirenz (Sustiva)
Avoid taking with high-fat meals
Lopinavir (Kaletra) + ritonavir (Norvir)
Moderate-fat meals increase availability of capsules
Take with food

AIDS, CONTD

Slide 86

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

AIDS, CONTD

Slide 87

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

AIDS, CONTD
Prevention of foodborne illness
Crucial component of nutrition therapy and education for
HIV/AIDS
As CD4 counts fall, higher risk for infections from foods

Slide 88

Nutrition education focus on safe methods for food

purchasing, preparation, and storage

AIDS, CONTD
Low microbial diet prescribed with recommendations to avoid:

Slide 89

Undercooked meats and eggs

Raw vegetables
Fruits

AIDS, CONTD
Physical activity
Regular aerobic exercise and resistance training assist with:
Lipid abnormalities
Fat redistribution syndrome
Other body composition changes

Slide 90

Recommendations individualized and initiated slowly after

physicians approval

AIDS, CONTD
Benefits of physical activity

Slide 91

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

AIDS, CONTD
Multidisciplinary approach

Slide 92

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