Nutrition Care process for Oncology Patients

Nutrition Care Process for Oncology Patients

Comunicación y Gerencia

Presented by:Salmeh Bahmanpour

Nutritionist(PhD)

Praise be to ALLAH the Merciful

PhD’s Seminar

Agenda

Section I: IntroductionSection II: Cancer-related MalnutritionSection III: Nutrition Care process Section IV: Practice Recommendation Questions & Answers

Agenda

Section I: IntroductionSection II: Cancer-related MalnutritionSection III: Nutrition Care process Section IV: Practice RecommendationQuestions & Answers

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.

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)

Click to add Title Click to add Text

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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

http://www.who.int/

Cancer Mondial report:

Agenda


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.

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.

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

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

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

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

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)

Persistent activation of POMC, which Suppress the activity of NPY/AgRP, were seen in Cancer Cachexia8.

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.

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.

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.

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.

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 .

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.

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.

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).

Agenda


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.

Nutrition Care Process The NCP consists of four

distinct, inter-related steps11:

1)Assessment2)Diagnosis3)Intervention4)Monitoring and

Evaluation

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.

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)

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.

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


Slaviero et al(2003)14

Compare the MNA against unintentional weight loss of greater than 10% in 3 month


Several Studies evaluated the use of the scored Mini Nutritional Assessment(MNA) in cancer patients

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


Isenring et al(2006)

Compare the MST against against PG-SGA in patients undergoing chemotherapy


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.

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

Nutrition Care Process The NCP consists of Four

distinct, inter-related steps:


Evaluation

کوه هایp آتشفشانی پِیتون

(ایسلند)

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?

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

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.

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


Bauer et al(2002)17

Compare the PG-SGA against SGA

71 patients

11 month


Ravasco et al (2003)12

Calculating Sensitivity & Specificity

200 patient attending radiotherapy

80% Sesnitivity89% Specificity

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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Evaluation

چیچن ایتزا(تمدن مایا)/مکزیک

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.

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.

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

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

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.




Evaluation

فرودگاه کانزای)ژاپن(

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?

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.


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.


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.


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.

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)

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).

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:

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.


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

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:


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

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

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.




Evaluation

شهر پالمیرا)سوریه(

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)

Agenda


Libya

Practice Recommendation:

Screening :–Malnutrition Screening Tool has been validated.

Assessment :–The PG-SGA should be used in patients with cancer cachexia.

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

And finally This is our planet……

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.

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

– 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.

–

L. Kathleen Mahan

20082012

Thank s a Million for

Your Attention and Attendance

Agenda


Nutrition Care process for Oncology Patients

Health & Medicine