Side Effect Management through Diet and Nutrition

1/15/2013
Alexandra Vermillion MS, RD, LD/N
Moffitt Cancer Center
Prevent or reverse poor nutrition
Maintain dose and schedule of cancer
treatments
Manage symptoms
Maintain or improve weight and strength
Maximize quality of life
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1/15/2013
Digestive insufficiency (pancreatic exocrine
insufficiency)*
Diarrhea/steathorrea
Glucose intolerance/diabetes*
Nausea and/or vomiting
Loss of appetite
Weight loss
* more common after surgery
Taste changes
Early satiety
Pain with eating
Fatigue
Constipation
Dumping syndrome*
* more common after surgery
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1/15/2013
Endocrine and Exocrine
Exocrine functions: exocrine cells
produce enzymes that help with digestion of
carbohydrates, fats and proteins
Endocrine function: involves the production
of hormones
Pancreatic hormones: insulin and glucagon
Work to maintain proper level of glucose (sugar)
in the blood
Feelings of indigestion
Cramping after meals
Large amounts of gas
Foul smelling gas or stools
Floating stools or greasy/fatty stools
(steatorrhea)
Frequent stools
Loose stools/diarrhea
Unexplained weight loss
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1/15/2013
PANCRELIPASE
Amylase Protease Lipase
Digests
Digests
Digests
Carbohydrates Protein Fat
Pancreatic or duodenal tumors
Following the Whipple procedure or total
pancreatectomy
Obstruction of pancreatic or biliary ducts
Pancreatitis
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1/15/2013
Amount needed depends on disease,
treatment, and amount of fat in the
diet/meal
Start with smallest dose necessary- adjust as
needed
Starting dose
Meals: 16,000-36,000 units of lipase
Snacks: 8,000-12,000 units of lipase
Should not exceed 2,500 lipase units per kg of
body weight
Trial of different brands
Take at the beginning and throughout the
meal/snack
Don’t take at the same time as antacids or
iron supplements
Don’t crush/chew tablets
If prescribed by your doctor, take acid
reducing medication daily.
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1/15/2013
Constipation (most common- don’t confuse
with narcotic induced)
Nausea
Abdominal Cramps
Diarrhea (Careful not to confuse with
symptoms of inadequate enzyme use or
chemotherapy or radiation treatment)
Work closely with medical team (multiple
causes of diarrhea)
Treatment induced
Hormone producing tumors (including certain
types of neuroendocrine tumors)
Lactose intolerance
Pancreatic/digestive insufficiency
Bacterial overgrowth
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1/15/2013
Limit or avoid:
Insoluble fiber
Irritants such as Mg, caffeine, peppers, coffee
Foods creating osmotic pull: dairy/lactose, sugar
alcohols, concentrated sweets
Increase:
Soluble fiber
Fluids: water, electrolyte drinks
Psyllium fiber, guar gum
Food sources of probiotics: tempeh, kimchi,
kefir, yogurt
Over the counter brands
Aim for at least 6-10 billion CFUs (colony forming
units) daily
Lactobacilli and bifidus with FOS
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1/15/2013
Eat small amounts frequently- 5-6 small
meals
Schedule meals/snacks
Big plate, small portion
Use liquid supplements/smoothies/shakes
Light exercise
May benefit from appetite stimulant
Be active
Adequate hydration
Choose foods that are less cumbersome to
chew and swallow
Purchase ready to eat snacks to have on hand
Do not increase caffeine
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1/15/2013
Avoid high fiber foods
Chew food well
Take pain medication proactively
Avoid constipation
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1/15/2013
10-12 cups fluids daily (warm fluids may
help)
Gradually increase high fiber foods
Engage in light exercise such as walking
Limit gas forming foods, carbonated
beverages, straws, chewing gum
Discuss with MD use of stool
softeners/laxatives
May be induced by: treatment, oral infection
Good oral hygiene
Rinse mouth with baking soda/salt rinse
Metallic taste: use plastic utensils and
serving ware
Enhance dull taste-use tart flavors
Try new foods or foods previously disliked
Cold food may taste better than hot
Zinc
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1/15/2013
Eliminate offending odors
Dry crackers/toast
Avoid overly sweet, greasy/fried, or highly
spiced foods
Use room temp foods
Peppermint/ginger tea
Oral care
Eliminate stress
Medication
May be temporary
Individuals who were not previously
intolerant may become intolerant
May be able to tolerate lower lactose foods
Provide lactase enzymes prior to a meal or
use specially marked products already
containing lactose
Cultured dairy products- yogurt, buttermilk
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1/15/2013
Most common surgery for pancreatic cancer
Typically stage 1
Eliminate diarrhea
Restore adequate nutrition
Prevent weight loss
Manage symptoms
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1/15/2013
About 25% of patients will experience
malabsorption after Whipple
Higher enzyme doses
Common to have j-tube-feeding generally cycled
at night
Clear liquids advanced to solids
Small, frequent meals
Avoid greasy/fried foods
May need to limit raw fruits and vegetables and
gradually increase as tolerated
o Medication
o Customize diet
o Limit refined carbohydrates
o Eat carbs in combination with protein, fiber,
and fats
After treatment/surgery complete:
Carbohydrate controlled diet
Use high fiber carb foods as tolerated
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1/15/2013
Tumor induced weight loss/cancer cachexia
Appetite suppression
Altered metabolism of Carbohydrates, fats
and protein
Alleviate through symptom management
Use of Medium Chained Triglyceries (MCT),
Eicosapentaenoic acid (EPA)
Oral nutrition supplements
Boost Plus/Ensure Plus
Boost Glucose Control/Glucerna
Muscle Milk
Carnation Instant Breakfast
Myoplex
Isopure
Scandishake
Resource Breeze
Ensure Clear
Make your own
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1/15/2013
Alleviate gas and bloating
Liquids between meals
Small servings, more often
Limit high fat or fried foods
High fiber foods may be problematic
Medications
Rapid emptying of stomach shortly after
eating
Generally occurs within 2 hours of eating
Flushed skin, dizziness/lightheadedness,
weakness, abdominal pain, nausea, vomiting
and/or diarrhea
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1/15/2013
o Limit portion sizes-6 to 8 small meals
o Liquids between meals
o Avoid foods high in simple sugars
o More complex carbs
o Add soluble fiber
Eat small frequent meals (6-8/day)
Plan meals/snacks the day before
Get plenty of fluids (10-12 cups per day of
non-alcoholic fluid)
Limit use/portions of fat containing foods
Choose nutrient dense foods
Be active
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1/15/2013
Plant based diet
2 ½ cups of fruits and vegetables per day. –
Even better: 3 ½-4 ½ cups per day. (If raw
vegetables hard to digest, use cooked or
juiced)
Healthy Fats
Limit red meat
Be active- at least 30 minutes per day
Take enzymes
Take acid reducing medication (if prescribed
by your surgeon)
Follow with primary doctor for diabetes
management and bone health
“One a day” multivitamin and mineral
supplement
Calcium with vitamin D
Fish oil/omega-3’s
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1/15/2013
www.aicr.org
www.pancan.org
Maria Petzel RD, CSO, LD, CNSD
MD Anderson Cancer Center
Heather Bell-Temin, MS, RD, CSO, LD
Moffitt Cancer Center
Colleen Gill, MS, RD, CSO
University of Colorado
Jeannine B. Mills MS, RD, CSO, LD
Dartmouth Hitchcock Medical Center
Julie Meddles, RD, LD
The Ohio State University Medical Center
Alexandra Vermillion
Contact: Alexandra.Vermillion@moffitt.org
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