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Fiber: It Does A Colon Good

A Case Study by:Cheryl ReiningMay 20, 2011

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Colon Cancer Prevalence

The CDC estimated that approximately 102,900 new cases of colon cancer would be diagnosed in the U.S. in 2010 Annually, approximately 51,370 Americans die of colon cancer; equates

to ~ 9 % of all cancer deaths. 90 percent of all colon cancer cases occur after age 50 years. In the U.S., the risk to age 80 is 1 in 10 for males, and 1 in 15

for females, with an increased risk over the age of 80 Gradual shift downward of right-sided or proximal colon

cancers in the U.S. May be related to improvements in diagnosis and

treatment, increased screening and the removal of polyps in the colon

True increase in the incidence of ascending colon and cecal cancers (2)

1. Jemal A, Siegel R, Xu J, Ward E. Cancer statistics, 2010. CA Cancer J Clin 2010; 60:277. 2. Troisi RJ, Freedman AN, Devesa SS. Incidence of colorectal carcinoma in the U.S.: an update of trends by gender, race, age, subsite, and stage, 1975-1994. Cancer 1999; 85:1670.

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Colon Cancer Statistics, 2007

• Significantly different incidence rates between men and women• Black men – highest rates• White men – second highest rates

3. Colorectal (Colon) Cancer Incidence Rates. Available at: http://www.cdc.gov/Features/dsColorectalCancer/. Accessed May 9, 2011.

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Demographic Incidence Rates

XX

XX

X

X

XXX

X

4. Cancers Diagnosed at Late Stages Despite Available Screening Tests. Available at: http://www.cdc.gov/cancer/colorectal/what_cdc_is_doing/tests_article.htm. Accessed May 9, 2011.

Late-stage colon and rectum cancerIncidence rates ranged from 51.0 to 86.5 and were highest In these 10 states.

Adenomatouspolyps

(Pre-malignant)

Small noduleson bowel wall

Deletion of tumorsuppressor genes on

Chromosome 18

Impaired cell cycle

Oncogene

Colon Cancer(Cecal)

Tumor proliferation

Increased basal metabolic rate

Cancer cachexia

Increased recuperationtime from illness &

infection

Obstruction in colon

Change in bowel

Pain

Death

Malnutrition

Pathophysiology of Colon Cancer

5. Colon Adenocarcinoma: Pathophysiology. Available at: http://emedicine.medscape.com/article/277496-overview#a0104. Accessed April 25, 2011.

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Nutritional Implications and Pathophysiology of Colon Cancer

Malnutrition: Loss of appetite Pronounced weight loss w/o dieting Listlessness or apathy Hair and skin changes Swollen abdomen Decreased protein stores → ↓zinc stores → ↓ immuno-

competence → ↑ susceptibility to infection General muscle wasting

Decreased intestinal function Decreased kidney function Decreased cardiac muscle

Decreased gastrointestinal motility6. Pathophysiology of Malnutrition in the Adult Cancer Patient. Available at: http://onlinelibrary.wiley.com/doi/10.1002/1097-0142(19861015)58:8%2B%3C1867::AID-CNCR2820581413%3E3.0.CO;2-A/pdf. Accessed April 25, 2011.

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Preventative Methods

Colorectal screening Low saturated fat intake High fiber intake!!!

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Preventative Methods Cont.

Colorectal Cancer Screening: Detects pre-cancerous polyp(s)

Removal of polyp(s) – stops cancer from devloping Detects cancerous polyp(s)

Surgery required for cancer removal – additional treatment (chemo/radiation) may be required

Saves lives Many people at risk for colorectal cancer not

being screened Estimated that as many as 60% of colorectal cancer

deaths could be prevented if persons aged 50 years and higher were screened routinely

7. Colorectal Cancer Screening. Available at: http://www.cdc.gov/cancer/colorectal/basic_info/screening/. Accessed May 7, 2011.

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Screening

8. Illinois – 2008 Colorectal Cancer Screening. Available at: http://apps.nccd.cdc.gov/brfss/display.asp?cat=CC&yr=2008&qkey=4425&state=IL. Accessed May 7, 2011.

59.1 = yes 40.9 = no

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Preventative Methods Cont.

Low saturated fat diet Studies dating as far back as 1986 show that

colorectal cancer is associated with high dietary consumption of red and processed meats

9. Rose DP, Boyar AP, Wynder EL. International comparisons of mortality rates for cancer of the breast, ovary, prostate, and colon, and per capita food consumption. Cancer 58 (11): 2363-71, 1986.

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Preventative Methods Cont.

Fiber!!! Dietary fiber (soluble and insoluble) exerts a

protective role in reducing the incidence of colon cancer Potential mechanisms that modify carcinogenesis in

the colon – Fiber: binds to bile acids increases fecal water (possibly diluting carcinogens) acts as a substrate for bacterial fermentation, increasing

bacterial mass and SCFAs, as typified by butyrate Butyrate – important fuel for the colonic epithelium

10. Howe GR, Benito E, Castelleto R, et al. Dietary intake of fiber and decreased risk of cancers of the colon and rectum: evidence from the combined analysis of 13 case-control studies. J Natl Cancer Inst 84 (24): 1887-96, 1992.

Diet High in Fiber

High Levels of Butyrate

Induction of p21(p53-independent manner)

Growth Inhibition

Protection against Colorectal Cancer

ApoptosisDifferentiation

Butyrate

11. Shankar E, Basu C, Adkins B, Siede W, Basu A. NSC109268 potentiates cisplatin-induced cell death in a p53-independent manner. J Mol Signal. 2010 May 10;5:4.

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Sources of fiber

Grains – soluble and insoluble fiber Moves material through the digestive tract Decreases mutagenic activity of fecal contents

Vegetables Cruciferous sources also contain isothiocyanates and indoles Onions and garlic also contain sulfides

Fruits Also contains flavones

Beans Contains phenols

Supplements – do not contain additional cancer-fighting constituents

Fiber-enriched foods (cereal, bread, pasta)

12. Potter JD: Epidemiology of diet and cancer: evidence of human maladaptation. In: Micozzi MS, Moon TE, eds.: Macronutrients: Investigating their Role in Cancer. New York: Marcel Dekker, 1992, pp 55-84. 

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Dietary Fiber Intake for Americans

Usual intake of dietary fiber for adults in the United States is only 15 g/day.

13. Health Implications of Dietary Fiber. Available at: http://www.eatright.org/About/Content.aspx?id=8355&terms=adult+daily+fiber+intake. Accessed May 7, 2011.

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Fiber Intake Needs

25 grams/day for women 38 grams/day for men After age 50

21 grams/day for women 30 grams/day for men.

14. Fiber. Available at: http://www.eatright.org/Public/content.aspx?id=6796&terms=fiber+needs. Accessed May 7, 2011.

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Risk Factors

Heredity Age Smoking Diet Obesity Heavy alcohol use Lack of physical activity

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Patient Profile: Mr. Z

83 y/o Caucasian male History of tobacco use (65 yrs) Alcohol consumption – 1 beer per week Retired and lives at home with his wife Sedentary lifestyle

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Current Problem List

Stable UGI bleed Vomiting Unintentional weight loss Abdominal pain (right side) Bowel obstruction Alternating constipation and diarrhea Feeling very weak and fatigued

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Mr. Z’s Diagnoses

Ulcer (possibly duodenal), causing UGI bleed Initial reason for hospital admittance

Colon (Cecal) Cancer Diagnosed with stage 1 colon cancer on 11-02-

2007(after colonoscopy w/biopsy done on 10-31-2007)

Hemicolectomy (18 inches of colon) 11-02-2007 Malnutrition

Severely compromised status prior to surgery Moderately compromised status after surgery

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Past Medical History

Chronic medical Hx: Denies Previous surgeries: Denies Medications: Denies Allergies (food or drug): Denies

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Pertinent MedicationsMedication and Amount Purpose or Function Nutritional Implications

Protonix 40 g IV daily Decreases acid in the stomach (to treat UGI Bleed)

Diarrhea, stomach upset, nausea

Heparin 5000 units subcutaneous

q 12 hr

Anticoagulant (blood thinner) – prevents blood clots

Swelling of the tongue or lips, difficulty in breathing, closing of the throat

Reglan Increases rate of stomach and intestine movement during digestion. Used for the prevention of post-operative nausea and vomiting

Nausea, diarrhea

Dilaudid .2-.5 IV push every 5 min. to max of 5 mg

Pain reliever Constipation, dry mouth, decreased appetite, nausea, vomiting

Note: An increase in fiber can help to relieve the side effects of constipation.

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Pertinent Lab Values

  10-29-07 11-04-07 Normal Value/Range Interpretation

Glucose 127 mg/ dL 119 mg/ dL 70-110 mg/dL Fasting High-May be due to acute stress reaction

BUN 6.3 mg/ dL 7.7mg/ dL 8-20 mg/dL Low-Possible cachexia or liver damage

Creatinine .7 mg/dL .6 mg/ dL 0.8-1.4 mg/dL Low-Protein starvation or liver disease

Calcium 7.7 mg/ dL  - 8.9-10.3 mg/dL Low-Due to low albumin level

Albumin 2.4 g/dL 2.6 g/dL 3.5-5 g/dL Low- Due to malnutrition and bleeding

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Anthropometrics

Height 5’8” (172.72 cm)

Weight 131 lb (59.4 kg)

UBW 151 lb (68.6 kg)

IBW 154 lb (70kg)

% IBW 85%

BMI 19.9 = Low Risk

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Estimated Needs

Kcals 30-35 kcal/kg

Hospitalized, cancer cachexia, malnutrition 1786 – 2083 kcals/day

Protein 1.2-1.5 gm/kg

Surgery patient UGI bleed

71.5 – 89 gm/kg Fluid

30 cc/kg Elderly adult

1786 cc/day

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Current Diet

Breakfast ¾ cups cereal (whatever is on sale) ½ cup milk 1 cup coffee (black, no sugar)

Lunch 2 slices white bread 2 slices ham (any kind, could be minced ham) Lettuce (iceberg) Tomato slice 1 Tbsp. mayonnaise 12 oz soft drink (cola, regular)

Dinner 1 Pork chop (or meatloaf, pizza, steak) ½ cup Mashed potatoes w/butter or gravy (or French fries,

rice, fried potatoes)

½ cup green beans (or carrots, peas, mixed vegetables) 12 oz soft drink (cola, regular)

Snack Ice cream bar

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Recommended DietBreakfast ¾ cups Cheerios

½ banana 1 cup milk 1 cup coffee (black, no sugar)

Snack ½ can Ensure Plus with 1 small appleLunch 2 slices whole-wheat bread

2 slices lean turkey 2 leaves romaine lettuce 2 tomato slices 1 Tbsp. reduced-fat mayonnaise Iced tea

Snack ½ can Ensure Plus with ½ cup grapesDinner ½ baked boneless, skinless chicken breast

½ cup mashed potatoes w/Smart Balance spread ½ cup green beans & ½ cup carrots (steamed) Iced tea

Snack Ensure Plus

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Additional Recommendation

Add physical activity into daily routine Regular physical activity

is associated with a decrease in the incidence of colorectal cancer

15. Wolin KY, Yan Y, Colditz GA, Lee IM. Physical activity and colon cancer prevention: a meta-analysis. Br J Cancer 100 (4): 611-6, 2009.

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Dietary Goals

Consume at least 75% of meals (short term) Increase vegetable intake (5 per day) Increase whole grain intake (make half of

the grains whole) Add fruit into daily diet (3 per day) Consume lean protein sources Limit intake of processed and red meats Limit intake of saturated fats

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In Summary

Plant foods high in fiber reduces the risk of colon cancer

Dietary fiber increases transit time – waste product has less carcinogen contact within the colon and the mucosal lining

Regular physical activity is associated with a decrease in the incidence of colorectal cancer

Colorectal cancer screening saves lives

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A Bit of Trivia

Did you know that… there are 70 million Baby Boomers (age

50 & older) in the United States? this equates to 20% of all Americans? only 59% of this population will be

screened for colorectal cancer? a large percentage of this population is

seeking nutritional guidance? (What a great opportunity for Dietitians!)

16. The State of Aging and Health in America, 2004. Available at: http://www.cdc.gov/aging/pdf/State_of_Aging_and_Health_in_America_2004.pdf. Accessed May 7, 2011.

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References1. Jemal A, Siegel R, Xu J, Ward E. Cancer statistics, 2010. CA Cancer J Clin 2010; 60:277.

2. Troisi RJ, Freedman AN, Devesa SS. Incidence of colorectal carcinoma in the U.S.: an update of trends by gender, race, age, subsite, and stage, 1975-1994. Cancer 1999; 85:1670

3. Colorectal (Colon) Cancer Incidence Rates. Available at: http://www.cdc.gov/Features/dsColorectalCancer/. Accessed May 9, 2011.

4. Cancers Diagnosed at Late Stages Despite Available Screening Tests. Available at: http://www.cdc.gov/cancer/colorectal/what_cdc_is_doing/tests_article.htm. Accessed May 9, 2011.

5. Colon Adenocarcinoma: Pathophysiology. Available at: http://emedicine.medscape.com/article/277496-overview#a0104. Accessed April 25, 2011.

6. Pathophysiology of Malnutrition in the Adult Cancer Patient. Available at: http://onlinelibrary.wiley.com/doi/10.1002/1097-0142(19861015)58:8%2B%3C1867::AID-CNCR2820581413%3E3.0.CO;2-A/pdf. Accessed April 25, 2011.

7. Colorectal Cancer Screening. Available at: http://www.cdc.gov/cancer/colorectal/basic_info/screening/. Accessed May 7, 2011.

8. Illinois – 2008 Colorectal Cancer Screening. Available at: http://apps.nccd.cdc.gov/brfss/display.asp?cat=CC&yr=2008&qkey=4425&state=IL. Accessed May 7, 2011.

9. Rose DP, Boyar AP, Wynder EL. International comparisons of mortality rates for cancer of the breast, ovary, prostate, and colon, and per capita food consumption. Cancer 58 (11): 2363-71, 1986.

10. Howe GR, Benito E, Castelleto R. Dietary intake of fiber and decreased risk of cancers of the colon and rectum: evidence from the combined analysis of 13 case-control studies. J Natl Cancer Inst 84 (24): 1887-96, 1992.

11. Shankar E, Basu C, Adkins B, Siede W, Basu A. NSC109268 potentiates cisplatin-induced cell death in a p53-independent manner. J Mol Signal. 2010 May 10: 5:4.

12. Potter JD. Epidemiology of diet and cancer: evidence of human maladaptation. In: Micozzi MS, Moon TE, eds. Macronutrients: Investigating their Role in Cancer. New York: Marcel Dekker, 1992, pp 55-84. 

13. Health Implications of Dietary Fiber. Available at: http://www.eatright.org/About/Content.aspx?id=8355&terms=adult+daily+fiber+intake. Accessed May 7, 2011

14. Fiber. Available at: http://www.eatright.org/Public/content.aspx?id=6796&terms=fiber+needs. Accessed May 7, 201.

15. Wolin KY, Yan Y, Colditz GA, Lee IM. Physical activity and colon cancer prevention: a meta-analysis. Br J Cancer 100 (4): 611-6, 2009.

16. The State of Aging and Health in America, 2004. Available at: http://www.cdc.gov/aging/pdf/State_of_Aging_and_Health_in_America_2004.pdf. Accessed May 7, 2011.