Medical Nutrition Therapy
Cancer Guidelines And
How To Use Them
Ms Tah Pei Chien
Clinical Dietitian
University Malaya Medical Centre
(Chairperson of MNT Cancer
Guidelines)
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MDA Scientific Conference 2013 – Sunway Putra Hotel
Outline • How To Identify At Risk Patients
• How To Do Nutritional Assessment
• How To Give Nutrition Prescription
• How To Estimate Energy Requirement
• How To Estimate Protein Requirement
• Indication of EPA
• How To Do Nutrition Diagnosis
• Determining Route of Nutritional Support
• Nutrition Monitoring & Evaluation
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Nutrition Screening and NCP Flow Chart
MST
SGA &
PGSGA
Adapted from: The American Society for Parenteral and Enteral Nutrition (ASPEN) 2011
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How To Identify At Risk Patients?
• Screening for at nutritional risk patients
– Malnutrition Screening Tool (MST) –
Appendix 1
• Nurses and other healthcare team
members
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1. 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 (4)
2. Have you been eating poorly because of a decreased appetite?
No ( 0)
Yes (1)
If score 0 or 1 not at risk of malnutrition
≥ 2 at risk of malnutrition
Ferguson M, Bauer J, Banks M, Capra S. 1999. Development of a valid and reliable
malnutrition screening tool for adult acute hospital patients. Nutrition. 15: 458–464.
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Malnutrition Screening Tool (MST)
Malnutrition Screening Tool (MST) • MST is a reliable nutrition screening tool which can be
incorporated into admission forms or patient information
sheets.
• Score ≥2 (at risk of malnutrition) → refer to dietitian
• Score < 2 (not at risk of malnutrition) → re-screened
weekly / next attending clinic to detect changes.
• Nutrition screening is unnecessary if a patient is referred
to dietitian by other methods, e.g. direct referral from an
oncologist; straight away proceed to nutrition
assessment (DAA, 2006).
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How To Do Nutritional Assessment?
• Table 2 (Page 7 and 8)
– Target group
– Assessment tools
– Assessment parameters
• Combination method (Tools and Assessment
Parameters) is best suggested for nutritional
assessment (Grade C). (Davies, 2005)
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Table 2: Nutrition Assessment Criteria Criteria Recommendation Grade Reference
Target Group Suggested for all patients who are identified to be at nutrition
risk (after conducting) nutrition screening C ASPEN, 2011
Tools
Use a validated nutrition assessment tool to assess
nutritional status
1. The Scored Patient Generated–Subjective Global
Assessment (Appendix 2)
- A gold standard assessment tool for oncology patients
(Leuenberger et al., 2010)
2. Subjective Global Assessment (Appendix 3)
- Validated in a variety of patient population
- Incomplete list of cancer specific nutritional impact
symptoms, and it does not include a triage component
B
Arends et al.,
2006
DAA, 2006
DAA, 2008
Kwang &
Kandiah, 2009
COSA, 2011
Mccallum, 2006
Assessment
Parameters
Medical history
- Diagnoses
- Past medical history
- Sensory limitation(s)
Anthropometric data
- Current weight
- Weight history: usual body weight, recent weight changes
(incorporated in the scored PG-SGA)
- Height (measured, recumbent, knee height, or arm span)
- BMI
- TSF;MAC – calculation of upper arm muscle area; lean body
mass
Biochemical assessment
- Indicators of protein status: albumin, pre-albumin, total
protein, nitrogen balance, CRP
- Hematological assessment: hemoglobin, HCT, platelet, total
lymphocyte count, white blood cell
- Renal profile: sodium, potassium, magnesium, phosphate,
urea, creatinine
C Charney &
Cranganu, 2010
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Assessment Parameters
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Medical history
• Diagnoses
• Past medical history
• Sensory limitation(s)
Anthropometrics data
• Current weight
• Weight history: usual body weight, recent weight changes (incorporated in the scored PG-SGA
• Height (measured, recumbent, knee height, or arm span)
• BMI
• TSF;MAC – calculation of upper arm muscle area; lean body mass
Source: Charney & Cranganu, 2010
Assessment Parameters
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Biochemical assessment
• Indicators of protein status: albumin, pre-albumin, total protein, nitrogen balance, CRP
• Hematological assessment: hemoglobin, HCT, platelet, total lymphocyte count, white blood cell
• Renal profile: sodium, potassium, magnesium, phosphate, urea, creatinine
Clinical assessment
• Gastrointestinal (GI) symptoms (nausea, vomiting, constipation, diarrhea, steatorrhea, early satiety) – can use the PG-SGA to identify barriers to food intake
• Appetite and taste changes – can use the PG-SGA to identify barriers to food intake
• Presence of pain
• Mood change
• Review medications and note if patients is taking analgesics, enzymes, laxatives, antiemetics, alternative therapies
Source: Charney & Cranganu, 2010
Assessment Parameters
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Dietary Information
• Dietary intake, especially energy & protein, quantitatively
• Food/supplement intake: checklist on vitamin/mineral supplements and complementary medicines (herbal/traditional products)
• Food allergies
• Food restrictions and belief
Functional status and QoL
• To determine physical functional status and level of fatigue, using Karnofsky Performance Scale (KPS) (Karnofsky & Burchenal 1949). The KPS scale is typically used in general oncology care (Ma et al. 2010)
• To measure QoL using The European Organisation for Research and Treatment of Cancer Care Quality of Life Questionnaire (EORTC QLQ-30) (Aaronson et al. 1993)
• Hand-grip strength Source: Charney & Cranganu, 2010
How To Give Nutrition Prescription?
• Energy
• Protein
• Fluid
• Eicosapentaenoic acid (EPA)
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How To Estimate Energy Requirement?
• Individualized and based on clinical judgement
– Planned antineoplastic therapy, anticipated side effects, current nutritional status, tumor burden, body weight and composition changes (ADA 2006).
• Table 3 (page 9 to 11) – 5 formula for energy estimation
– Normal weight
– Overweight/obese
– Underweight
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Table 3: Formulas for Calculation of Energy Requirement
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Table 3: Formulas for Calculation of Energy Requirement
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Table 3: Formulas for Calculation of Energy Requirement
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How To Estimate Protein Requirement?
• Protein requirement are difficult to determine. Nitrogen balance is affected by many variables including the stress of treatment modalities such as Chemotherapy & Radiation (ADA 2006).
• Table 4 (Page 12)
– Non surgical cancer patients
– Peri operative cancer patients
• Without renal disease
• With renal disease
– Cancer cachexia
– Cancer patients with hepatic disease
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Table 4: Estimating Daily Protein Needs in Cancer Patients
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Table 5: Estimating Fluid Needs in Cancer
Patients
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Age (years) Fluid Requirement,
ml/kg
16-30, active 40
31-55 35
56-75 30
76 or older 25
These recommendations are just for
maintenance needs. Fluid requirement in fluid
overload or dehydration patients need to be
adjusted.
Source: ADA, 2000
Indication of EPA • Page 13
• Cachexic cancer patient
• Unintentional weight loss cancer patient
• Pancreas and upper digestive tract cancer patient
• A total of 2 g EPA/day is recommended (ASPEN 2009)
• Be wise with the use on Omega 3 capsule
supplementation and oily fish consumption in view of its
practicality such as amount required, large size, side
effects (burping, fishy aftertaste, tolerance)
21
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How To Do Nutrition Diagnosis?
• Based on 18 common nutritional diagnoses
of Cancer Patients
• Table 6 (Page 14 to 19)
– Sample PES statement: NI-2.1
• Problem: Inadequate oral intake
• Etiology: Related to mucositis post-radiation
• Signs/symptoms: As evidenced by dietary history
suggesting intake of less than 50% of estimated
needs
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Source: ADA (2011) Third edition, International dietetics & nutrition
terminology (IDNT) reference manual.
Table 6: Common Nutrition Diagnosis for Cancer Patients
Source: ADA (2011) Third edition, International dietetics & nutrition terminology (IDNT) reference manual.
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Algorithm of Nutritional Support for Cancer
Patients
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When to initiate ONS
• 60-75% of energy requirement
– Based on MST score
– Table 7 (Page 21)
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Diet and Counseling
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Recommendation Grade References
• At low nutritional risk patients (MST = 0-1)
-Recommend a well balanced diet
-Recommend healthy traditional diet
according to needs, preferences and
symptomatology
-Healthy, balanced, assorted, appetizing and
adequate amount of food and nutrients
C Bauer, 2007;
FESEO, 2008
Diet and Counseling
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Recommendation Grade References
• At moderate nutritional risk patients (MST = 2)
- Recommend high protein-energy diet
- High protein and high energy diet
- Try 6 smaller meals/snacks per day
- Include 3-4 servings of energy and protein
rich foods or drinks daily
- Oral nutritional supplements 2-3 servings per
day
C Bauer, 2007
• At high nutritional risk patients (MST = 3-5)
- Recommend high protein high energy diet
- Recommend high protein high energy
supplements 2-3 times per day
- Consider intensive nutrition support
C
Bauer, 2007
When To Initiate Enteral Feeding?
• Less than 60% of energy intake via oral route for
more than 10 days
• Unable to eat for more than 7 days.
• Based on Nutrition Intervention EN (page 22-24)
– General
– Perioperative
– During Chemo/Radiotherapy
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When To Initiate Parenteral Nutrition?
• Less than 60% energy intake from oral or
enteral nutrition for more than 10 days
– Not tolerating to EN eg persistently high GRV
• Prolonged NBM
– UGIB
• When the gut is not functioning
– Paralytic Ileus (intestinal failure)
• Expected survival longer than 2-3 months
• Nutrition Intervention PN (page 24)
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How To Manage Immunosuppressed
Patients? • Nutrition during transplantation of
hematopoietic precursor cells (pg 25)
• Dietary Guidelines (pg 27)
– Food safety education
– High risk food restriction (raw, semi cooked
food, unpasteurized dairies, mouldy and
expired food) (ADA 2006)
– The use and effectiveness of neutropenic diet
is not scientifically proven (Steven 2011)
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How to use the sample menu and
modify the diet?
• Sample menu – 1500 kcal, 1800 kcal &
2000 kcal (Table 8 - Page 28 and 29).
• Modification for protein and energy (Table
9 - Page 30).
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Table 8: Sample menu of 1500 kcal and modification to
increase calories to 1800 kcal & 2000 kcal
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Table 9: Examples of modification for different food groups
38
How to Variety Food Intake?
• Oil/butter/cream :
vs
Plain porridge porridge with sesame oil
vs
Clear soup cream soup 39
How to Variety Food Intake?
vs
Steamed fish fried fish
Hard boiled egg
vs
scrambled egg with butter
Plain biscuit
vs
cheese/butter added biscuit 40
Hydration - How to Fortify
Beverages
• Plenty of fluids - 8 glass per day
• Honey/sugar (↓ metabolic taste)
– Plain water vs cordial drink
– Plain fruit juice vs sweetened with
honey/sugar
+ 41
Regular Menu
Breakfast Morning
Tea Lunch
Afternoon
Tea Dinner Supper
Bread with
margarine
Served
with
scrambled
egg
Milk tea
Biscuits
with jam
Milk or
honey
Rice with
egg, fried
battered
chicken
Whole fruit
Kuih
Coffee or
milk
Flavored
rice with
battered
fish
Whole fruit
Assorted
biscuits
with
cream
Choc
drink with
milk
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Texture-Modified Menu
Breakfast Morning
Tea Lunch
Afternoon
Tea Dinner Supper
Blended
oat with
milk
Coffee
added with
milk
Flavored
yogurt
Cordial
Blended
porridge
with carrot,
fish and
sesame oil
Sweetened
fruit juice
Mashed
potato
Ice cream
Blended
cream soup
with potato,
chicken
Sweetened
fruit juice
Blended
red bean
paste
Choc
drink with
milk
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Nutrition Education / Counselling
• Surgery and related nutrition impact
symptoms (Table 10 – pg 31-32)
• Systemic therapy and related nutrition
impact symptoms (Table 11 – pg 33)
• Radiation and Related Nutrition Impact
Symptoms (Table 12 – pg 34)
• Tips for Managing Nutrition Impact
Symptoms (Table 13 – pg 35-40)
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Nutrition Impact Symptoms
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Tips for Managing Nutrition Impact Symptoms (16)
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How to use additional info
• Physical activity- page 42-43
• Nutrition Monitoring & Evaluation- Table
17, page 44-49
• Karnofsky Performance Scale – Appendix
4, pg. 62
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How to use additional info
• The European Organisation for Research and
Treatment of Cancer Care QoL Questionnaire
(EORTC QLQ-C30)- Appendix 5, pg 63-64
• Nutritional supplement- Appendix 6, pg 65-66
• Commonly used Drugs interaction –Appendix
7, pg 67-69
• Traditional & Complementary Medicine
(T&CM)- appendix 8-10, pg 70-74
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Physical Activity
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Nutrition Monitoring & Evaluation –
PG-SGA
50
Nutrition Monitoring &
Evaluation
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Nutrition Monitoring & Evaluation
52
Nutrition Monitoring & Evaluation
53
Nutrition Monitoring & Evaluation
54
Nutrition Monitoring & Evaluation
55
Nutrition Monitoring & Evaluation
56
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Appendix 5 -
EORTC QLQ-C30
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Appendix 5 -
EORTC QLQ-C30
• a questionnaire
developed to
assess the
quality of life of
cancer patients
Appendix 5 -
EORTC QLQ-C30
• a questionnaire
developed to
assess the
quality of life of
cancer patients
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Appendix 6: Oral Nutritional Supplement and
Enteral Formula Composition
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Appendix 7: Commonly Used Drug and Dietary Supplement
Interaction
• Antibiotics
• Gastrointestinal
agent
• Diuretic
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Appendix 8: Five categories of T&CM* according to NACCM (The
National Center for Complementary and Alternative Medicine)
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Appendix 8: Five categories of T&CM* according to NACCM (The
National Center for Complementary and Alternative Medicine)
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Appendix 9: Biologically Based Therapies
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Appendix 10: Nutrition (Diet) and Metabolic Therapies
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Summary and Conclusion This medical nutrition therapy is developed to guide dietitians toward a standardised dietary management along the nutrition care process for cancer patients in order to improve patients’ outcomes.
Guidelines are just that, Guidelines
• Not dogma, not absolute, not rules, No guarantees
Clinical judgment and expertise always takes precedent over guidelines
Guidelines will change with ongoing trials, keep an open mind
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MNT Guidelines for Cancer in Adults
Working Group Committee Gaik
Lian Suraiya
Firdaus
Wai
Hong Hidayah Shariza
Pei
Chien
Shafurah
Li Yin
Zalina
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MNT Babies
Acknowledgement We would like to extend out gratitude and appreciation to
the following for their contributions:
•Dietetic Department of University Malaya Medical Centre
for the use of the meeting room
•The Peer Reviewers for their time and professional
expertise
•Healthcare Nutrition Division of Nestle Products Sdn. Bhd.
for the refreshments
•Wyeth Nutrition (M) Sdn. Bhd (formerly know as Wyeth
(M) Sdn Bhd) for the printing of the Cancer MNT book
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THANK YOU
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