Post-Graduate Institute of Agriculture- University of Peradeniya

M.Sc. Food & Nutrition

Dietetics FT 5217

MID- TERM ASSIGNMENT

Raaidah Wahab

ID: 19412- CMB

January 31, 2021.

Words: 3125 without references

No. of References: 14

I declare that the attached work is entirely my own and that all sources have been acknowledged.
 Raaidah Wahab: 19412-CMB

INTRODUCTION

Colorectal cancer (CRC) is now known to be the third most common type of cancer for women
and the fourth most common type of cancer in men globally1. Although CRC was primarily
observed in longstanding developed countries, it has now become prevalent in newly developed
countries as well due to dietary modifications, increased consumption of high calorie highly
processed foods, decreased physical activity and lifestyle-related factors (such as smoking)1,2.

Recent studies show the importance of proper nutrition and how it is essential for better recovery
and decreased mortality for people with cancer3. A study by Ravasco et al.3 showed that under
nutrition is a major source of morbidity and mortality in cancers of the colon and rectum. Novelli
et al.4 suggests that surgery is the main treatment for CRC and the only curative factor is
nutritional status which has a large impact on post-operative recovery.

Good nutrition can help to manage the side effects of treatment (e.g. fatigue, loss of appetite)
and speed up recovery, heal wounds and rebuild damaged tissues (this is important after surgery,
radiotherapy, chemotherapy or other treatment), improve your body’s immune system and ability
to fight infections and reduce the risk of recurrence4,5. A nutritional counseling protocol for
patients who require surgery (with or without chemotherapy and radiotherapy) was found to have
a positive effect in post-operative prognosis and risk of recurrence as well4,5.

A 2012 meta-analysis evaluating 11 prospective cohort studies of dietary guideline adherence

and cancer-specific mortality indicated that, on average, cancer mortality was 22% lower in
adults who reported greater adherence to dietary guidelines6.
The American Cancer Society Guidelines on Nutrition and Physical Activity for Cancer
Survivors include the following7:

 Achieve and maintain a healthy weight.

 If overweight or obese, limit consumption of high-calorie foods and beverages and increase physical activity to promote
weight loss.
 Limit intake of processes meat and red meat.
 Engage in regular physical activity. (150 min/week and strength training exercises at least 2 days/week)
 Achieve a dietary pattern high in fruits, vegetable and whole grains-at least 2.5 cups of vegetables and fruits daily and avoid
refined grain products.
 If alcohol is consumed- limit to no more than 1 drink daily for women and 2 drinks daily for men.
 foods and drinks high in simple sugars (sugary desserts and candy), foods high in saturated fats and trans fats (like pork,
lamb, butter, and processed snacks), greasy and fried foods, carbonated drinks and soda, caffeine
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CASE STUDY

In our case study, the 45-year-old male experienced a loss of weight of 10kg during a period of 2
months, following which he underwent a colectomy and is now under-going adjuvant
chemotherapy to prevent recurrence. He is also reporting symptoms of loss of appetite (LOA),
constipation and associated abdominal discomfort. His current weight is 50 kg (previous weight
was 75 kg) and height is 165 cm.
His daily diet provides an average of 342 g of carbohydrate, 110 g of protein and 25 g of fat.
His biochemistry is as follows: Albumin = 1.5 g/ dL (Decreased)
Protein = 4.5 g/dL (Decreased)

Normal Albumin9 = 3.4 ~ 5.4

Normal Protein9 = 6 ~ 8.3
 According to the above information we can gather the following information:
Previous BMI = 27.5 (over-weight) Current BMI = 18.4 (underweight)

 To calculate patient’s BMR, we use Harris Benedict Equation for BMR of men:
BMR = 66.5 + (13.7 × weight in kg ) + ( 5 × height in cm ) – ( 6.8 × age in years )
BMR = 66.5 + (13.7 × 50 ) + ( 5 × 165 ) – ( 6.8 × 45 )
BMR = 1270.5 kcal/day

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 Then we calculate Total Daily Energy Expenditure (TEE) taking Injury/ Stress factor and
Activity factor into account:
Injury/ stress factor for major surgery considered – 1.4
Activity level factor considered – 1.2
TEE = BMR × 1.4 × 1.2
TEE = 2134.4 kcal/day

 Based on the information above it is noted that the patient is underweight and has to increase his
total daily energy intake above the expenditure (TEE).

 In accordance with WHO criteria8, the Asian criteria-based BMI was used as follows: <18.5 for
underweight, 18.5-23 for normal-weight, 23.0-27.5 for overweight, and >27.5 for obese.
Therefore, for this patient, an ideal weight would be 68 kg.

If the patient is to maintain a normal BMI, then the healthy weight

target would be around 68 kg.

Therefore, at 68 kg the patient’s TEE is:

BMR = 66.5 + (13.7 × weight in kg ) + ( 5 × height in cm ) – ( 6.8 × age

) BMR = 66.5 + (13.7 × 68 ) + ( 5 × 165 ) – ( 6.8 × 45 )
BMR = 1517.1 kcal/day

TEE = BMR × 1.4 × 1.2

TEE = 2548.7 kcal/day

 Given the information above, there is an energy deficit of: 2548.7 KJ - 2134.4 KJ = 414.3 KJ

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 A healthy normal diet contains 60% carbohydrate, 25% fat and 15% protein. Based on this, we
are able calculate the daily intake require in grams10:

Carbohydrate = 2548.7 × 60 = 1529.2 Kcal = 382 g (1592.2 ÷ 4)

100

Fat = 2548.7 × 25 = 637.1 Kcal = 70.7 g (637.1 ÷ 9)

 From all the100
information above we can now compare the quantities of current intake of
macronutrients versus target intake to achieve a healthy weight.
Protein = 2548.7 × 15 = 382.3 Kcal = 95.5 g (382.3 ÷ 4)
100 Carbohydrate Fat Protein
Current daily intake 342 25 110
However, as the patient’s albumin and protein levels are below normal it is important to introduce a
(g/day)
diet with higher amount of protein. Therefore, we also include the increased metabolic need of 1.5
Target daily intake 382 70.7 143.6
kg
(g/day)
/body weight, bring the total protein content
to: Protein = 95.5g × 1.5 =. 143.6 g
Now that we have a basic understanding of the patient’s current TEE and his nutritional
requirements to achieve normal weight, we can further look into his dietary requirements based
on his symptoms as well, before giving a suitable management plan.
It is important to remember that each individual will respond to food differently and he can try
out different foods more than once to check on his tolerability.

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POST- COLECTOMY NUTRITIONAL REQUIREMENTS

Studies11 show that proper dietary adjustments along with behavioral adjustments (due to bowel
irregularities) as well as exercise are all key elements in post-colectomy recovery.

It is vital to avoid food that might carry a risk of infection such as non-pasteurized soft cheeses,
under cooked meat, uncooked fish, raw eggs in uncooked items, etc. Studies 12 show that surgery
induced immuno-suppression can result in increasing susceptibility to infection.

POST- CHEMOTHERAPY NUTRITIONAL REQUIREMENTS

 Hydration, both pre- and post-chemotherapy is extremely important.
 Five to six small meals a day are recommended to avoid feeling nauseous and bloated. Room
temperature or colder foods and drinks will also help with nausea.
 Chemotherapy induced neutropenia leads to an immune system compromise. Therefore, care
must be taken to prevent food borne illnesses: avoid raw or undercooked meat, poultry,
seafood, and eggs.

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 An increase in protein intake as also recommended by The American Cancer Society to help
heal tissues and fight infection and it is recommended to eat at least 1.1 g of protein/ kg of
body weight7.

EATING WITH A LOSS OF APPETITE (LOA)

LOA is a very common side effect of cancer and its treatment.
The following steps can be taken to help in dealing with LOA:
 Small amounts of exercise such as a gentle walk before meals can increase your appetite
 Eat by the clock- Eating at similar times each day will help to regulate your appetite.
 Eat five or six small meals and snacks rather than two or three larger meals.
 Adding herbs, spices and seasonings can make food taste better and increase your appetite to
eat.
 Avoid water, tea, coffee, diet soda, or other non-caloric beverages with meals. They can fill
you up and replace the food your body truly needs.
 Include protein foods, such as eggs, nuts or nut butter, tuna, or chicken with every meal and
snack.

DEALING WITH CONSTIPATION

Constipation is another common side effect following bowel resection. Most studies show that
palliative care patients are at a high risk of constipation, and while general principles of
prevention should be followed, pharmacological treatment is often necessary. The combination
of a softener and stimulant laxative is generally recommended, and the choice of laxatives should
be made on an individual basis13,14.
 In nutritional management of constipation, the key is to balance intake of soluble (oats) and
insoluble fiber (whole wheat flour, beans). Increase you amount of fiber gradually and in
small portions to avoid wind and bloating.
 Increase fluid intake, especially water as this will also help.
 Consume fruit that is high in a natural laxative called sorbitol (prunes, strawberries, raisins,
apples). Avoid bananas.

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GAINING WEIGHT SAFELY

As the patient in this case study is underweight, it is important to gain weight safely and with
proper nutritional guidance. Weight loss may be due to the cancer itself and/or its treatment
which both result in loss of appetite and eventually loss of weight. The mental well-being of a
cancer patient also plays a role in eating.
Some things to remember when gaining weight safely are:
 Eating four to six small meals rather than three large ones a day can help you to eat more
calories and digest your food more easily.
 Include energy-rich foods, (avocado, coconut milk/cream) and high protein foods with your
meals or snacks.
 Treat food like medicine: something you have to have. Set times for meals and snacks rather
than waiting until you’re hungry.
 Try liquids that add calories do your diet (Sustagen). Drink liquids between meals rather than
during meals to avoid being full quickly.
 Exercise- Recent research suggests that regular gentle/light physical activity can help with
stimulation appetite and to build up your muscle strength 6,7,12,13. (With professional advice
and care)

HAVING HYPOPROTENEMIA / HYPOALBUMINEMIA

Hypoalbuminemia in this patient indicates the presence of inflammation independent of a
nutritional issue15,16. Studies show that it is an indicator of outcome and is accelerated by
undernutrition and lack of exercise15,16. Therefore, the pro-inflammatory phase of inflammation
in this patient needs to be clinically addressed; while also improving nutrition intake with high
protein content to prevent/slow down the loss of muscle mass and function.

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MACRONUTRIENT REQUIREMENTS OF THE PATIENT

Current Intake Target Intake Ways to add it to your diet

Carbohydrates 342 382 A diet with starchy vegetables is a good source of

carbohydrates and will provide the extra calories that the
body requires- Potatoes, breadfruit, jackfruit
Wholegrain bread, pastas, cereals.

Proteins 110 143.6 Choose high protein lean meat like chicken and fish.
Some examples of other protein-rich foods include eggs,
meat, milk, yogurt, cheese, beans, nuts, and peanut butter.

Fat 25 73.7 Fats have more calories per gram than carbohydrates or
proteins. Therefore, it is important to add healthy fats to
the diet such as avocado, olive oil, coconut oil, nuts,
butter, full cream milk to the diet.

Fiber Unknown 25~35 g Healthy adults need at least 25~35 g per day. Its best to
start in small quantities and then gradually increase
according to tolerability and other symptoms (such as
constipation)
Whole grain- Whole grain cereals (oats), whole grain
basta/bread
Pulses- Lentils, chickpeas, red kidney beans
Vegetables- Cauliflower, peas, carrot, sweet potato,
spinach, green leafy vegetables
Fruit- Apples, prunes, raisins
*it is important to add a good balance of both soluble and
insoluble fiber.
Fluid Unknown 1800~2000 Stay hydrated to avoid cancer treatment-related
ml /day dehydration.
Avoid caffeinated beverages.

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Diet plan
Based on the information above, it is best that the management plan for the individual includes
components to help with gaining weight safely, dealing with hypoproteinemia, LOA and
constipation.
Gaining weight safely can be addressed over a span of 3 months with a target weight gain of 6
kg per month so that the individual reaches a healthy weight of 68 kg.
The issue of hypoproteinemia has to also be clinically assessed since it is a sign of inflammation.

Monthly management plan- (1 week given)

The subsequent nutritional information has been gathered from the following sources:
 Biodiversity for food and nutrition Sri Lanka: https://bfnsrilanka.org/nutrition-facts
 Indian food composition table 2017: http://www.ifct2017.com/frame.php?page=home
 Food labels
 MyFitnessPal.com: https://www.myfitnesspal.com/

Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7

If having tea or coffee (preferable to avoid): add full cream milk and 1 or 2 teaspoons sugar
(white/brown).
1 glass of Sustagen is preferable.
Breakfast 6 white Steel/ rolled Boiled and Mung milk 3 atta Boiled green Cheese &
flour cut oats tempered rice (with roti gram spinach
string + full cream chickpeas white chapati + scraped omelet
hoppers milk (1 cup) samba) (157.5 kcal- coconut (78.65 kcal-
Carbs: Carbs-1.6g,
+ green (245 kcal- (268.9 kcal- + 35.73g, Fat: +lunumiris Fat-6.06g,
Carbs: 40g, Carbs: 45g,
gram Fat: 5g, Fat: 4g, lunumiris 1.35g, with maldive Protein- 4.94g)
Protein: 5.4g
curry Protein: 10g) Protein: 15g (213 kcal- fish
Fiber: 12g) Carbs: 32.1g,
Fiber: 11.28g) + 2 slices
+ coconut (345 kcal-
+1
Fat: 7.2g,
+ dhal Carbs: 42.2g, of whole
sambol + added Protein: 6.9g Fat: 11.3g,
(968 kcal- tablespoon Fiber: 12g) curry (½ Protein: 21.4g) wheat
Carbs: 120.5g, coconut bread
Fat: 49.2g, chopped shavings + Fish cup) (102 kcal-
Protein: 18.1g) cashew nuts (78 kcal- + 1 tbsp Carbs: 20.68g,
curry Carbs: 11g,
(82.95 kcal)
(132 kcal- Fat: 3g, butter Fat: 0.26g,
+ 1 cup + added Carbs: 1g, Protein: 2g) (102 kcal) Protein: 1.94g)
fish curry + 1 tsp honey maldive fish Fat: 10g, + 1 tbsp
(132 kcal- (12.8 kcal)
Protein: 10g) + fish butter
Carbs: 1g,
Fat: 10g, + 1 cup of curry (100 kcal-
Carbs: 0g,
Protein: 10g) (132 kcal-
+ cut mango/ rice conjee Carbs: 1g,
Fat: 11g,
Protein: 0g)
strawberry (264 kcal-
Carbs: 29g,
Fat: 10g,
Protein: 10g)
Fat: 10g,
Protein: 13g)

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+ + glass
coconut orange
sambol juice
(1 tbsp) (111.6 kcal-
(79 kcal- Carbs: 25.7g,
Carbs: 1.78g, Fat: 0.5g,
Fat: 7.55g, Protein: 1.74g)
Protein:
1.04g)

Mid- Papaya 1 full fat Dried fruits- Woodapple Papaya 1 cup Dried
morning juice yoghurt (dates, juice juice mulligatawny fruits-
(114 kcal- (Highland) prunes) (114 kcal- soup dates,
snack Carbs: 29.9g,
Fat: 0.05g,
(159 kcal-
+ 2 cream
Carbs: 29.9g,
Fat: 0.05g,
(180.5 kcal-
prunes)
Carbs: 13g, Carbs: 21g,
Protein: 0.3g) Protein: 0.3g)
Fat: 2g, + 1 tbsp crackers Fat: 26g,
Protein 3g) Protein: 12.g)
Cashew (74 kcal- +1 tbsp
+ 2 cream nuts/
Carbs: 4g,
Fat: -,
+2 Cashew
crackers + chopped peanuts Protein: -) cream nuts
(74 kcal-
Carbs: 4g,
dates/ prunes (82.95 kcal) crackers (82.95 kcal)
(74 kcal-
Fat: -,
Carbs: 4g,
Protein: -)
+ nuts if Fat: -,
Protein: -)
possible
(Cashew
nuts/
peanuts)

Lunch Rice & curry

One cup of white rice/ red rice
+ alternate with fish or chicken curry
+ selection of two/three vegetables curries cooked in coconut milk (green/long/winged beans,
beetroot, pumpkin, carrot, bittergourd, okra, beetroot, jakfruit, breadfruit:1 ~ 2 tablespoons each)
+ chickpeas/ Dhal curry (Parippu)/ green gram curry
+ pol sambol or any green mallum (gotukola, kathurumurunga, mukunuwenna, saarana, thebu,
mixed)
(700 ~ 900 kcal)

Dessert
Mixed fruit salad-Pineapple, Starfruit, Mango, Sweet melon, Papaya (250g) (87 kcal- Carbs: 20.4g, Fat: 0.5g,
Protein: 1.3g)

Mid- 1 glass of 1 cup 1 glass of 1 full fat 1 glass 2 cream 1 glass of

afternoon Sustagen mulligatawny Sustagen yoghurt of crackers Sustagen
(244 kcal- soup (244 kcal- (159 kcal) Sustagen (74 kcal) (244 kcal-
snack Carbs: 41.3g,
Fat: 3.3g,
(180.5 kcal-
Carbs: 41.3g,
Fat: 3.3g,
(244 kcal-
Carbs: 41.3g,
Fat: 3.3g,
Protein: 12.5g)
Carbs: 21g,
Fat: 26g,
Protein: 12.5g) + chopped Carbs: 41.3g,
Fat: 3.3g,
+ 1 tbsp Protein: 12.5g)
Protein: 12.g) dates Protein: peanut butter
+Dried + 1 milk 12.5g) (94 kcal) + 2 milk
pitted (Marie) + nuts if (Marie)
prunes (5) biscuit possible + 1 milk + 2 slices of biscuits
(115 kcal)
(19 kcal- (Marie) apple (38 kcal-
Carbs: 3g,
Fat: -,
biscuit Carbs: 6g,
Fat: -,
(19 kcal-
Protein: -) Protein: -)
Carbs: 3g,
Fat: -,
Protein: -)

Dinner Grilled Coconut roti Whole Grilled fish 6 white Thosai Macaroni
(~175 kcal)
chicken (227 kcal-
Carbs: 39.9g,
wheat / flour +saambar stir fry
breast-no Fat: 6.3g, white rice + steamed string +coconut with egg
Protein: 5.1g)
skin noodles stir vegetables hoppers sambol
(137.3 kcal- (319 kcal-

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Carbs: 0g,
Fat: 3g,
+ fish curry fry with egg (carrot, + green Carbs: 46.9g,
Fat: 13g,
&
(132 kcal-
Protein: 25.7g)
Carbs: 1g,
& beans, gram Protein: 6.6g) vegetables
Fat: 10g, vegetables spinach, curry (137.3 kcal-
Carbs: 0g,
+ Protein: 10g)
potato) + +fish/chicken Fat: 3g,
steamed + chicken/ (225 kcal-
coconut curry Protein: 25.7g)

vegetables + dhal curry Carbs: 32.73g, (132~160 kcal)

(78 kcal-
fish curry Fat: 9.05g, sambol
(carrot, Carbs: 11g, Protein: 5.25g) (968 kcal- + baked
beans, Fat: 3g, Carbs: + boiled egg chicken
Protein: 2g) + cucumber, 120.5g, Fat: (155 kcal) (137.3 kcal)
spinach, tomato salad 49.2g,

potato, with + 2 slices Protein:

+ tomato & 11.2g) +
cabbage) yoghurt/ of whole
(225 kcal-
onion salsa wheat + 1 cup cucumber,
Carbs: 32.73g, curd tomato
Fat: 9.05g,
bread fish
Protein: 5.25g) (102 kcal- curry (132 salad with
Carbs: 20.68g,
Fat: 0.26g,
kcal- yoghurt/
+ 1 slice Protein: 1.94g)
Carbs: 1g,
curd
Fat: 10g,
of whole Protein: 10g)
wheat
bread + 1 tbsp
(51 kcal-
Carbs: 10.34g,
butter
(100 kcal-
Fat: 0.13g,
Carbs: 0g,
Protein: 0.97g) Fat: 11g,
Protein: 0g)
+ 1 tbsp
butter
(100 kcal-
Carbs: 0g,
Fat: 11g,
Protein: 0g)

Fluid Hydration is extremely important with fluid intake of at least 1800~2000 ml /day

Other  For dealing with constipation: it is also beneficial to take laxatives such as
remarks ‘Fybogel/ Ispaghula husk’: 1 sachet 2 times/day after meals. Or a stool
softener such as Dulcolax syrup 5ml tds.

 Sustagen has been included as in it can provide a significant number of

calories.

 Fruits such as Papaya, Wood apple and prunes have been chosen as they may
help relieve constipation. Papaya is known to be a good source of fiber.

 Animal proteins such as fish (they help to decrease inflammatory cytokines)

and chicken have been included in almost every main meal in order to assist
with the nutritional management of hypoproteinemia.

 Lentils, poultry, fish, eggs, dairy, nuts and seeds have been included because
they contain BCAA: as they will quickly metabolize in muscle providing
direct energy.

 Coconut has also been included in most main meals in various forms (scraped,
coconut sambol, coconut milk) as it is high in fat content.

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