Issue 140 Nutrition through cancer treatment

CONDITIONS & DISORDERS

NUTRITION THROUGH CANCER TREATMENT Erin Kelly Student, Nutrition and Dietetics, University of Surrey Erin is currently in her final year at the University of Surrey after successfully completing two 12-week clinical placements.

She has a strong interest in oncology, cystic fibrosis and inherited metabolic disorders.

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This article looks at the difficulty in meeting nutritional requirements during cancer treatment, the changes and effects of taste and appetite and the development of Enhanced Recovery After Surgery (ERAS).

Every two minutes, someone in the UK is diagnosed with cancer.1 A startling fact, but one which is becoming ever more present, with cancer causing one in eight deaths worldwide. It is now predicted that, by 2030, there will be 21.7 million new cases of cancer globally and 13 million cancer deaths, as we have an increasingly ageing population.2 Nutrition plays a major role in cancer treatment and ensuring that nutritious foods are eaten before, during and after cancer treatment can help patients feel better and stay stronger.

It can sometimes be difficult to meet our own nutritional requirements, but what about if you have cancer and are having treatment? People with cancer are at a higher risk of malnutrition due to both the psychological and physical effects of a diagnosis. Psychological effects can result in anxiety and/or depression which can affect appetite, whilst physical symptoms of cancer, including pain, dysphagia, vomiting and diarrhoea, can also impair appetite, affect nutrient absorption and increase nutrient losses.3 WEIGHT LOSS

A prolonged catabolic response to a tumour can cause unplanned weight loss and wasting muscle.4 It is extremely important to eat well during cancer treatment as it affects the way cells grow and divide, which may also affect normal cells and can result in the patient feeling unwell. Patients often complain of taste changes, a loss of appetite and fatigue/tiredness. Research has shown that people who remain a stable

weight during cancer treatment often have a better quality of life and live longer, which is why, even if a person is overweight, it is recommended that all patients keep their weight stable. Any weight loss can cause the medical team to delay treatment if they deem the patient is not well enough, as it can increase side effects and is more likely due to muscle loss which can hamper motility.7 So, what can we as dietitians do to help support our patients and help ensure we minimise any weight loss whilst patients are receiving treatment?

A healthy balanced diet is recommended for people who, through treatment, are coping well, have minimal side effects and are not losing any weight. If a patient is finding it difficult to meet their nutritional requirements and, hence, are losing weight, there are several firstline dietary interventions which can be encouraged: • Choose richer foods, ie, high energy foods and full fat products such as cakes, biscuits, milk and cheese.

• Fortify foods by adding extra ingredients to increase energy content without increasing portion size, for example, adding full cream to soups, smoothies, or adding cheese to mashed potato.

• Eat regular bitesize high energy snacks, such as cheese and crackers, mini sausage rolls and nuts.

• Drink nourishing fluids including full fat milk and milkshakes.

If a patient continues to lose weight despite food fortification advice, they may be offered ONS.

www.NHDmag.com December 2018/January 2019 - Issue 140

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CONDITIONS & DISORDERS INTERVENTIONS AFTER SURGERY

EFFECTS OF TREATMENT

Chemotherapy and particular medications can cause patients to become nauseous and experience vomiting, that can have a severe impact on their appetite. There are different anti-sickness medications that patients can try; however, it may also be useful to suggest patients have dry, bland foods first thing in the morning to help settle their stomach, to eat little and often throughout the day and to eat cold foods if cooking smells cause the patient to experience nausea.6 Patients having cancer treatment often complain of taste changes, for instance, sweet and salty foods often become stronger; some develop a metallic taste, whilst others may lose all of their taste senses.6 To overcome these taste changes, it is often recommended to add herbs and spices to try to enhance flavours. Sharp tastes such as fruit juices can be refreshing, whilst using plastic cutlery can sometimes help with metallic taste.6 People also can experience dry mouth during treatment and in order to cope with these changes, patients are recommended to drink at least two litres of water a day, eat softer foods which are easier to chew and swallow and to add lots of gravy and sauces to foods.7 Using sugar-free gum and/or sucking on boiled sweets can also help to stimulate salivary glands to help with dry mouth.

General tiredness and fatigue is a common side effect of cancer treatment and can affect a person’s appetite and/or motivation to eat.

Being prepared and planning ahead by cooking batch meals and bulk freezing them when the patient feels well, can be a great option for when the patient is not feeling so good. Ready meals, tinned and frozen foods can also be a great nutritious option.

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One of the main treatments for cancer is to have surgery to remove tissue from the body. For patients undergoing surgery, the avoidance of any post complications is the main objective and whilst there are many influences which can affect recovery, nutritional intervention can play a vital role. Malnutrition can have a negative effect on wound healing by delaying the process and in patients who are undernourished before surgery, there is a higher risk of postoperative complications such as morbidity and mortality.

More than three million people in the UK are malnourished at any one time, with an estimated 30% of people admitted to acute hospitals or care homes at risk of becoming malnourished.7 In the past, nutritional support was used postoperatively. However, many patients would remain nil by mouth for a week after surgery.

Parenteral nutrition (PN) was also used to provide nutritional support after surgery, but it tended to be delayed and only used after major surgical complications.3 The development of ERAS has since revolutionised the care of major elective surgical patients across the UK and Europe.3 The aim of ERAS is to improve the quality of care to all patients who undergo major elective surgery, as it is thought that improved care and reduced harm will shorten length of hospital stays and, therefore, also free up bed space.5

Enhanced recovery principles include: • optimising the patient’s health/medical condition preoperatively; • assessing risk and fitness for surgery at preoperative assessment; • reducing starvation by using carbohydrate loading drinks up to two hours before surgery; • using minimally invasive surgery where possible; • using a clear and structured approach to postoperative management, including pain relief; • early mobilisation and early nutrition.3 CONCLUSION

Having a cancer diagnosis can be an extremely difficult time for a patient and their families. The role of a specialist oncology dietitian is to give specific tailored nutrition evidence-based advice in order to optimise the patient’s nutritional status and quality of life and to provide support.

www.NHDmag.com December 2018/January 2019 - Issue 140