Introduction to Nutrition and Cancer Patients

The following is adapted from NUTRITION and CANCER: EVERYBODY'S BUSINESS developed in partnership with Abbott Nutrition and the Rarer Cancer Forum via an unrestricted educational grant from Abbott Nutrition.  © Rarer Cancers Forum 2007.

INTRODUCTION TO NUTRITION AND CANCER

Not everyone with cancer will have problems that cause them to lose weight. For some people weight loss is temporary and weight will be easily regained once treatment has finished, but for many the loss of weight before diagnosis, during treatment and subsequently can be severe.

Recommendations about food and eating for cancer patients can be very different from the usual suggestions for healthy eating. This can be confusing because the new suggestions may be the opposite of how your patients have previously tried to eat.  People with cancer often have a poor appetite and are only able to eat small amounts of food, so recommendations for cancer patients usually focus on encouraging people to eat foods that are higher in calories and nutrients, such as protein.  That way they get the energy and nutrients they need in a smaller volume of food.  Supplements like Ensure and ProSure www.prosure.com can also play a key role in making sure patients get the nutrition they need to get back to good health.

Be aware of the difficult situation your patient is in.  During cancer treatment, the patient's entire life feels out of control.  Everything is taken over by the treatment, and the patient can do very little for themselves.  This loss of power and control over one's life can be extremely challenging.  In talking with cancer patients, one thing we have learned is that nourishment can be one of the last remaining areas where a patient feels they have choice and control.  Nutritional supplements can play a very important role both physically and psychologically, enabling a patient with lost weight and difficulties eating to make a positive choice to nourish themselves and get back on the path to good health.

TOP TIPS FOR PEOPLE WITH CANCER AND THEIR CARE GIVERS

The following tips have been produced by the Rarer Cancers Forum with information from practicing healthcare professionals who look after people with cancer. The tips have helped some cancer patients at some stage of their illness.  However, it's important to remember that different things work for different people at different times.  The tips may help your patients with their particular problem – we certainly hope so. But whatever happens, please encourage them ignore pay attention to symptoms. Make sure they come to you or other qualified health care professionals for help.  Be sure you know if your patient is on a particular diet that affects what they eat.  Examples of this would include a vegan or vegetarian diet, or if they are diabetic.

The following are tips written for the patient.  At the end of this section, a printable version is provided.

Weight Loss

How much weight you may lose can depend on the type of cancer you have. About six out of ten people with lung cancer and eight out of ten people with stomach cancer, pancreatic cancer or oesophageal cancer have lost a significant amount of weight by the time they are diagnosed. People with breast cancer or prostate cancer don't tend to have lost weight at diagnosis and their treatment may even encourage a weight increase.

Many people do not have scales to be able to judge their weight loss. However, you can ask your nurse or GP or consultant to weigh you. If you know approximately what your weight was before you had cancer it will be possible to work out whether or not you have lost weight.

Another way to judge any weight loss is to look at how your clothes fit. Are they looser? Can you notch in your belt tighter? What about your collar size, has it got smaller? And are your jewelry and rings looser? These are all important signs of weight loss. Don’t be afraid to tell your health professionals about the loss of weight – it’s an important sign and stopping any further weight loss can help you in your recovery.

Feeling low

We know that feeling low, out of control and depressed is a side effect of having cancer and undergoing treatment. These feelings can remove any interest in food. It's important to discuss this with the healthcare professional who is managing your care.  

Nausea and sickness

There are many reasons why a person with cancer may experience feelings of nausea and vomiting.  Some types of chemotherapy can affect the vomiting centre in the brain. Radiotherapy, if given close to the brain, stomach, bowel or liver, can also affect the vomiting centre. Hormonal therapies have been known to cause feelings of nausea, as have morphine-based medicines. Physical factors may also have an impact. This may be due to changes in body chemistry, damage to the liver, a bowel blockage or severe constipation. There are many things you can do to try to counteract feelings of nausea. Some suggestions are given below. If one idea doesn’t work for you, it's always worth trying another.

• Don’t force yourself to eat if the feelings are bad.
• Choose foods that are bland, such as dry crackers.
• Eat frequent small snacks whenever you feel hungry – don’t wait for meal times.
• Use nutritional drinks to add extra calories and protein to a drink, and sip it slowly. Ask your Healthcare Professional for advice.
• Cut back on fluids with meals as they may make you feel full and worsen the nausea.
• Ask someone else to prepare your meals.
• Avoid the smells of cooking as these may make you feel worse, you may find you prefer cold foods.
• Eat in a cool room.
• Sit and eat with someone, lay a table, listen to music, watch television.
• Wear comfortable, loose fitting clothes.
• Sit up with your head up after eating.
• Suck popsicles, sip cool water, juices and clear soup. It is important to make sure that you keep your fluid intake up because dehydration will worsen the problem.
• Use a mild mouth wash.
• Suck on boiled sweets or peppermints.
• Foods such as ginger ale or ginger-nut biscuits may help.

Changes in taste and smell

Cancer and its treatment can cause changes in your senses of taste and smell and may make foods you once loved taste and smell quite unappetising.

There are things you can do which may help.

• Rinse out your mouth frequently with water – this may improve tastes.
• Use plastic cutlery to reduce the sense of metallic flavour.
• Use fresh fruit and vegetables instead of tinned
• Season foods with tart flavours such as lemon, vinegar, pickles. However, be cautious if you also have a sore mouth because they maymake the soreness worse.
• Season foods with spices such as garlic, chilli, basil, oregano.
• Counter a salty taste or a bitter taste with sweetness, and a sweet taste with lemon or salt.
• Serve foods cold or at room temperature as this decreases stimulation of taste and smell.
• Eat foods such as melon, grapes and oranges icy cold, straight from the fridge.
• If red meats taste strange try other high protein foods such as chicken, fish, eggs or cheese or add nutritional drinks to your foods.
• Make a smoothie by blending fruit with ice cream or yoghurt. You can also add nutritional drinks and other supplements to increase the nutritional content.
• Your usual tastes should return after your treatment ends, but it may take a few weeks to get entirely back to normal.

Constipation

Lots of cancer patients experience constipation.  This may be caused by the tumor or it can be due to some medicines taken for pain relief, to relieve nausea or to the drugs used in chemotherapy.  Changes in diet, lack of fluids or being less active can all have an effect. The after effects of surgery often cause constipation as can not being at home in the privacy of your own bathroom. There are a number of things that may help.

• Try to eat at the same time each day.
• Increase the amount of fluids you take – try warm drinks such as tea, or lemonade.
• Check with your doctor or dietitian if it is appropriate for you to eat high fiber foods such as cereals, or fruits and vegetables with the  skins and peel on. Add these slowly to your diet as they can cause bloating and wind if you're not used to them.
• Eating more fiber may not be possible for everyone. If you find it doesn’t agree with you, ask your dietitian to recommend a nutritional drink that is high in calories and protein, and which also contains fiber.
• Try to be as active as you can – even a gentle walk may help.
• Ask your doctor to recommend or prescribe a laxative. 

Diarrhea

Most treatments for cancer have side effects and frequently diarrhea is one of them. This can be the case with some chemotherapy drugs,

radiotherapy to the gut, biological therapy, bone marrow or stem transplant and surgery. Additionally, some cancers, particularly if they are advanced, cause diarrhea. As a cancer patient you may experience reduced immunity – some diarrhea is caused by infection.  Apart from being unpleasant and sometimes painful, diarrhea can lead to severe dehydration.  This can be very dangerous, so the symptoms of diarrhea should be reported to your doctor or chemotherapy nurse. These healthcare professionals have a range of medications that can help you. If you have diarrhea the most important thing is to keep drinking, as dehydration can be a real problem. Sipping drinks all through the day is a good idea. And remember, seek medical advice if you have diarrhea – don’t just put up with it. 

Sore mouth

Many patients develop a sore mouth during cancer treatments i.e. chemotherapy or radiotherapy near the head or neck. Painkillers and mouthwashes or creams provided by your doctor should help within a few days. It’s important not to ignore this symptom, as it is not only painful but will stop you eating and gaining the nutrients your body needs. Try these ideas – they may help.

• When you have a sore mouth you may need to avoid neat spirits, tobacco, hot spices, raw garlic and onion, vinegar and salty food.  Choose foods that have strong flavors (e.g. herbs, spices, marinades and sauces) if all your food tastes the same.
• Clean your mouth and teeth gently every morning, evening and after each meal using a soft bristled, or child's, toothbrush. If you wear dentures, remove and clean them every morning, evening, and after each meal. If your toothpaste stings, or brushing your teeth makes you feel sick, try a mouth wash instead.
• Use dental floss daily but be careful not to harm your gums.
• Choose meals that are moist with gravies and sauces, to make swallowing easier.
• Keep up your fluid intake – tea or coffee, fruit and vegetable juices, soft drinks or water.

Difficulties in swallowing

Difficulties in swallowing may also happen in some cases as a result of surgery or radiotherapy. If you are having difficulties swallowing tell your healthcare professional. They may refer you to an expert in swallowing problems so that you can be assessed on an individual basis. Some of the tips below may also help.

• Eat small and frequent meals.
• Mince, blend, purée or chop your food but try to make it look appetizing on the plate.
• Use nutritional drink supplements such as Ensure or ProSure (www.prosure.com) if you are unable to eat.
• If you need to take thickened drinks to enable you to swallow them safely, your Healthcare Professional will advise you how to do this
• Go for soft, nutritious high protein foods such as thick and creamy milk yoghurt without fruit, soft scrambled eggs, thickened broths and cream soups.
• Try puréed or mashed fruit and vegetables
• Ice cream, custard, thickened juices and thick milk shakes may also be helpful.
• Using a straw to drink may help.
• Moisten foods with sauces and gravies to make them easier to swallow.
• Take small bites and chew your food very well.
• Good dental hygiene, including rinsing the mouth before and after meals can help.

Loss of appetite

Many people lose their appetite as a result of cancer and its treatment. These hints may help if this happens to you.

• Eat smaller meals more frequently, and eat when you are hungry, not just at mealtimes.
• Eat favorite foods whenever you feel like them.
• Have high calorie snacks when you want them.
• Try not to fill up on fluids when you are eating, instead try to drink between your meals.
• Use nutritional drinks such as Ensure or Prosure to boost your calorie intake.

Nutritional drinks

Our lack of appetite can be a signal to our not being in good health.  But, it is more difficult to get back to good health when we are not taking in the nutrition we need.  Ask your healthcare professional to recommend supplement drinks like Ensure to boost your calorie and protein intake if you are unable to eat enough food. Nutritional drinks like Ensure can help bridge that nutrition gap to help put you back on the path to good health.  Ensure is Complete (meaning it has all the essential vitamins, minerals, and nutrients you need) and Balanced (meaning it has the proper proportion of Protein, Carbohydrates, and Fat for a healthy diet.  Ensure is an excellent solution for those needing to increase their nutritional intake while being certain that the nutrition they are getting is properly balanced and complete.  Remember there are lots of ways to drink Ensure, and it can also be used in cooking. 

For cancer patients engaged in active treatment, ProSure is the only therapeutic nutritional supplement with clinically demonstrated results.   It has been shown to improve appetite and dietary intake, promote weight gain, increase lean body mass and strength, attenuate pro-inflammatory response, and improve physical activity and quality of life in people with cancer.  To learn more about ProSure, please go to www.prosure.com.   

Top tips for using nutritional drinks

• Ensure vanilla flavor can be used as a substitute for milk on cereal, or in rice pudding, instant whips or soups.
• Chocolate flavor milkshake-style drinks like Ensure can also be gently warmed to make a delicious hot drink – but do not boil as this may affect some of the nutrients.
• Ensure vanilla flavor can also be enhanced easily with Your own flavor additives.  Adding a small amount of Lemon Extract, Mint Extract, Cinnamon – even Instant Coffee for example can create your own unique flavor and add variety. 

Feeling tired

Tiredness is another common symptom. Try not to let it stop you eating – you need to keep up your energy levels. These tips may help.

• Eat small amounts throughout the day even if you are not too hungry.
• Eat when you have the most energy.
• Use quick and easy-to-prepare meals and snacks and supplemental nutritional drinks.

Food cravings or dislikes

Lots of cancer patients develop food cravings and dislikes. Don’t worry, these will usually pass. The following hints may be useful. 

• Try not to eat your favorite foods when you are feeling nauseous. This will help you not associate those foods with feeling sick in the future.
• Use food cravings to your advantage where possible. For example, if you crave chocolate, try a chocolate flavored nutritional drink.
• Get someone else to cook your food if possible.
• Avoiding the smell of fatty foods can sometimes help. 

Dry mouth or thick saliva

Dry mouth or thick saliva can be the result of some types of radiotherapy or medications. If you have difficulties with a really dry mouth, talk to your healthcare professional.

• Try to keep your mouth moist – take sips of water regularly.
• Add gravy, butter, creams and sauces to your food. 
• Eat soft foods that are cool or at room temperature.
• Suck on boiled sweets, popsicles and ice cubes.
• Rinse your mouth before and after eating.
• Keep drinking.

 Heartburn and reflux

This causes a burning feeling in your throat and upper stomach and can make your mouth taste sour. It is very common in cancer treatments. There are medications that will help with the problem. Ask your healthcare professional for help. The following tips may also help.

• Acidic citrus fruits and spicy foods may make the problem worse.
• Some people find that avoiding foods high in fat may help.
• Don’t drink immediately before eating, and wait 30 minutes after eating before you have a drink.
• Try not to lie down immediately after eating.
• Limit your intake of alcohol, colas, coffee and tea.

Gas, bloating or cramping

Certain treatments may increase gas, bloating or cramping. There are a number of medications that can help these symptoms, so ask your health professional. Here are some other ideas that may help.

• Eat small and frequent meals.
• Limit the fizzy drinks you take.
• Avoid drinking through a straw.

Food safety

Cancer and its treatment can adversely affect the immune system making your body less able to fight infections. Apart from the usual precautions of hand washing and washing salads and fruit before you eat them, it is also considered sensible to avoid certain foods.

• Blue cheese.
• Unpasteurized cheeses and pâté.
• Shellfish.
• Sushi.

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