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)

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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

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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

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Nutrition Monitoring &

Evaluation

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Nutrition Monitoring & Evaluation

52

Nutrition Monitoring & Evaluation

53

Nutrition Monitoring & Evaluation

54

Nutrition Monitoring & Evaluation

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Nutrition Monitoring & Evaluation

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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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