• COURSE NAME: CC &EN

• COURSE CODE:SHS.514 lec.18

• INSTRUCTOR: Saba Nadeem Dar

School of Health Sciences

University of Management and
technology
Enteral feeding- Cancer
 Learning outcomes
• Macronutrients requirement
• Nutrition assessment & diagnosis
• Nutrition intervention
• Nutrition support
• Case study
 Introductio
n
• Carcinogenesis is the origin or development of cancer.

• A carcinogen is a physical, chemical, or viral agent that induces cancer.

Phase
s
• Involves transformation of cells produced by the interaction of
chemicals, radiation or viruses with cellular (DNA)
Initiation

• Cells multiply and escape the mechanisms set in place to protect

the body from the growth and spread of such cells.
• Neoplasm, new and abnormal tissue with no useful function, is
Promotion established

• Tumor cells aggregate and grow into a fully malignant neoplasm

or a tumor.
Progression
 Weight
Diarrhea & mucositis Xerostomia loss Anemia
Vomiting constipation
Nausea Dysgeusia
• All of these side effects have the potential to place the individual at
nutritional risk, and, if not successfully treated, may result in
malnutrition
• Nutritional treatment relies heavily on careful screening and
assessment of patients who are at high risk for developing
malnutrition, which may result from either the cancer itself or the
medical treatment, including surgery, chemotherapy, and/or radiation
• Pharmacologic agents, such as appetite stimulants, prokinetics,
antiemetics, may be useful for control of symptomatic treatment
in combination with nutrition therapy

• Malnutrition - common cause of morbidity and mortality in cancer

patients, especially with certain types of cancer including lung,
pancreatic, GI cancers, head and neck cancers, and ovarian cancer
Nutrition
Assessment
• Subjective global assessment (SGA) is one such method that has been
successfully used for the cancer patient population

• The Patient Generated SGA (PG-SGA) and the Scored PG-SGA are
recent modifications to the original SGA.

• The health care professional completes the SGA, while the patient
completes the PG-SGA
• It is important to conduct a comprehensive nutrition assessment
examining data from nearly all of the assessment domains:
Anthropometrics, Biochemical Data, Medical Tests and Procedures,
Nutrition- Focused Physical Findings,
Treatments/Therapy/Alternative Medicine, and Food/Nutrition-
Related History.
• A chair scale can be employed if a
cancer patient is physically weak
and lacks the strength to stand on
a scale.
• In patients with ovarian cancer, for example, a significant amount of lean
body mass may have been lost due to anorexia and poor food intake due to
early satiety (usually as a result of the growing tumor that pushes up
against the stomach wall)

• However, ovarian cancer metastases to the liver may cause significant

ascites, and thus weight gain due to fluid retention.
• Serum albumin levels are affected by many factors. These include:
• Changes in plasma volume
• GI bleeding,
• Severe diarrhea,
• Renal and liver disease,
• Burns,
• Massive trauma,
• Blood losses (such as those that occur during surgery or with
trauma)
• Chemotherapy
• Serum albumin is affected by so many different factors, some or all of
which may be present in the cancer patient, it may not be the best
biochemical tool with which to assess nutritional status in these
patients.
• C-reactive protein (CRP) is the most sensitive indicator of
inflammation because it increases in serum concentration as much as
1,000-fold
Energ
y
• Obese patients: 21–25 kcal/kg

• Non-ambulatory or sedentary adults: 25–30 kcal/kg

• Slightly hyper metabolic patients or those patients who need to gain

weight, or are anabolic: 30–35 kcal/kg

• Hyper metabolic or severely stressed patients or those with

malabsorption: 35 kcal/kg or greater as needed
 Protei
•n
Normal or maintenance protein needs: 0.8–1.0 g/kg
• Non-stressed cancer patients: 1.0–1.5 g/kg
• Bone marrow transplant or HSCT patients: 1.5 g/kg
•Increased protein needs (protein-losing enteropathy, hypermetabolism,
extreme wasting): 1.5–2.5 g/kg
•Hepatic or renal compromise including BUN approaching 100 mg/dL or
elevated ammonia: 0.5–0.8 g/kg
 Flui
•d
Many cancer patients, especially those undergoing chemotherapy and/or
radiation, can become dehydrated easily. Those patients receiving
chemotherapeutic agents that damage the GI mucosa and cause diarrhea
are at particularly high risk for developing dehydration.
• Patients undergoing radiation to the head and neck area are also at high
risk for dehydration due to their inability to take adequate oral fluids
secondary to pain and inflammation of the mouth, throat, and esophagus.
• High-risk patients need to be assessed frequently for signs and
symptoms of dehydration (dark, concentrated urine, decreased
urine output, dry mouth, acute weight loss).

• Fluid needs can be calculated using the same formulas used for most
other patients without renal disease (30–35 mL/kg).
• Deficiencies of vitamins (especially folate, vitamin C, and retinol) and
minerals (magnesium, zinc, copper, and iron) can occur in cancer patients
due to the direct effects of the tumor, effects of cytokines, infectious
processes, chemotherapy, radiation, or inadequate food intake

• Micronutrient requirements have not been established for those

individuals
• Use of a daily multivitamin and mineral supplement that contains
<150% of the DRI may be beneficial for most patients undergoing
chemotherapy and/or radiation therapies.
Nutrition
Diagnosis
It may include
• Involuntary weight loss;

• Increased energy and protein needs;

• Altered GI function; or

• Inadequate oral food/beverage intake.

 Nutrition
• Intervention
Nausea/vomiting is one of the most common side effects that occurs as a result of
oncologic therapies and can be debilitating. Causes of nausea and vomiting in
cancer patients include
• Chemotherapy,
• Radiation,
• Narcotic analgesics,
• Odors (including food odors, perfumes), and
• Delayed gastric emptying.
• Nausea and vomiting associated with chemotherapy can be classified
as acute, delayed, or anticipatory

• Acute nausea and vomiting occur within 24 hours of administration

of chemotherapy.

• The most emetogenic chemotherapeutic agents include cisplatin,

methotrexate, doxorubicin, and cyclophosphamide
• Delayed nausea and vomiting usually begin 24 hours after the
chemotherapy has been administered and may last up to a week.
• Delayed nausea and vomiting are most commonly seen after
the administration of cisplatin, carboplatin, cyclophosphamide,
or doxorubicin
• Anticipatory nausea and vomiting most commonly occurs before the
initiation of chemotherapy, but may also occur during or after the
initiation of chemotherapy.

• This type of nausea and vomiting often results from inadequate

prevention and/or poorly controlled nausea and vomiting during the
first chemotherapy and is more commonly seen in pediatric patients
• Nausea and vomiting related to RT are dependent on the field being irradiated.

• Almost 100% of patients undergoing total body irradiation (TBI) during bone
marrow transplantation experience emesis,

• While radiation of the cranium only is considered low risk (about 10% to 30% of
patients experience emesis).

• Upper- and mid-abdominal RT can also result in nausea and vomiting starting one
to two hours after treatment and persisting for several hours.
• Patients who are experiencing nausea and vomiting due to certain
odors are encouraged to take precautions in avoiding noxious odors.
• Nausea from cooking odor can be minimized by
• Opening windows when cooking,
• Taking a walk when meals are being cooked, and
• Avoiding frying of foods, which emits more odors than most other forms of
cooking
• Patients should ask friends and family members to avoid
perfumes when they are visiting

• A common cause of nausea and vomiting is the use of narcotic

analgesics (morphine, codeine, fentanyl), which are prescribed for
many cancer patients for chronic pain
• Delayed gastric emptying can result in nausea and vomiting.

• Small, frequent meals may be helpful, as well as the administration of

prokinetics
• The most common cause of nausea and vomiting in cancer patients
is chemotherapy; this is referred to as chemotherapy induced nausea
and vomiting (CINV).
• The patient should be advised to eat only a small, low-fat meal the
morning of the first treatment and to avoid fried, greasy, and favorite
foods for several days following the treatment.

• A clear liquid diet for the first few days after therapy may
be indicated
• To provide calories and maintain hydration, consumption of
electrolyte-fortified beverages such as Gatorade, nutritional fruit
beverages such as Resource Breeze (Nestlé Nutrition) and Enlive
(Abbott Nutrition) and non-acidic fruit drinks (apple and grape juice,
nectars) should be encouraged
• To encourage adequate intake and maximal control of nausea and
vomiting, antiemetics should be taken at least 30–45 minutes before
a meal is consumed.

• Patients should be encouraged to take their antiemetics even if they

do not feel nauseated at the time, especially while actively receiving
treatment
Early
satiety
• A common complaint expressed by cancer patients is “I just can’t eat as
much as I used to” or “I get full right after I start eating.” This describes the
symptom of early satiety, which is caused primarily by delayed gastric
emptying.

• Eat small nutrient dense meals

• Beverages should also contain nutrients and should be consumed between

meals rather than with meals so as not to add to the feeling of fullness.
• Consumption of raw vegetables, such as salads, and other high-fiber
foods should be avoided

• Prokinetics, medications that increase gastric emptying, may be useful.

Metoclopramide, for example, is a motility agent that selectively stimulates
gastric emptying and may be useful for the patient with early satiety.
• A potential side effect of metoclopramide is diarrhea; therefore, it
should not be used by patients that are already at risk for diarrhea.
Mucositi
s
• Mucositis, also known as stomatitis, is irritation and inflammation
of the epithelial cells of the mucosal membranes lining the
gastrointestinal tract that can occur at any point in the GI tract from
the mouth to the anus
• The patient with oral mucositis should have a thorough assessment of the mouth.
• Alterations in the oral mucosa may include color changes of the tongue, lips,
and gingiva; changes in moisture; and changes in integrity, including cracks,
fissures, ulcers, blisters and lesions.
• The presence of white plaques is generally indicative of fungal infections such as
candidiasis.
• The disruption of the mucosal barrier in the oral cavity increases the risk of
infections.
• Symptoms will include pain and burning with chewing and
swallowing

• Mucositis may be severe enough to cause the patient to completely

forgo any food or fluids, which can lead to dehydration and acute
weight loss
• Good oral hygiene is important for the patient.

• Recommend the intake of softer, moister foods with extra sauces, dressings, and gravies.

• Suggest serving foods at cool or room temperatures.

• Advise the avoidance of alcoholic beverages, citrus, caffeine, tomatoes, vinegar and hot
peppers; and dry, coarse, or rough foods.
• Encourage compliance with medications prescribed to manage oral pain and/or
infection.
Diarrhe
a
• When mucositis is present in the oral mucosa, it can be assumed that it
may also be present in the stomach and in the small and large intestine,
resulting in diarrhea, which may at times become severe
• Dehydration can occur rapidly. The patient with diarrhea should be
encouraged to drink small amounts of fluid frequently throughout the day.
• Large amounts of fruit juices should be avoided as excessive fructose
can exacerbate diarrhea.
• Gatorade®, Pedialyte®, clear liquid nutritional beverages, and
other oral rehydration fluids are recommended

• Instructing the patient to increase their intake of foods high in

soluble fiber may help with the treatment of diarrhea
Dysgeusi
a
• Many chemotherapeutic agents, specifically cisplatin, and radiation
to the head and neck area cause dysgeusia.

• Taste changes that occur include a metallic taste (usually due to the
chemotherapeutic agent cisplatin), no taste sensation (aguesia), a
heightening of certain tastes (especially sweets), or aversions to
foods the patient liked to eat in the past.
• Patients who experience a metallic taste in their mouth should be advised
to avoid metal utensils and instead use plastic utensils.

• To ensure an adequate protein intake, the patient should be encouraged to

incorporate other high-protein foods into the diet, including peanut
butter, cottage cheese, cheese, poultry, and soy meat substitutes.

• Patients with aguesia should be encouraged to use more highly spiced and
flavorful foods, such as marinated foods
• Many homemade drinks and nutritional beverages may be too
sweet for these patients.
• Alternative options may be to have the patient try a nonsweet
supplement such as Osmolite®
Xerostomi
a
• Xerostomia, reduced saliva production, is a common side effect of head and
neck radiation and chemotherapy Xerostomia,

• The severity of xerostomia is correlated with the severity of oral

discomfort, dysgeusia, dysphagia, and dysphonia.

• Drugs used to treat cancer can make saliva thicker, causing the mouth to feel dry.
• Treatment of xerostomia may include use of artificial saliva (saliva
substitutes) and/or mouth moisturizers

• One study found chewing gum to be more effective than artificial

saliva for the treatment of radiation-induced xerostomia

• Denture wearers may not be able to chew gum for the treatment of
xerostomia.
Anorexi
a
Nutrition
Support
• Nutrition support therapy is appropriate in patients receiving active
anticancer treatment who are malnourished and who are anticipated to be
unable to ingest and/or absorb adequate nutrients for a prolonged period
of time.

• Omega-3 fatty acid supplementation may help stabilize weight in cancer

patients on oral diets experiencing progressive, unintentional weight loss.
• Immune-enhancing enteral formulas containing mixtures of arginine,
nucleic acids, and essential fatty acids may be beneficial in
malnourished patients undergoing major cancer operations.

• Enteral nutrition support may be beneficial in malnourished patients

undergoing RT for head and neck cancers
• Providing parenteral nutrition support to cancer patients with
advanced disease has significant ethical implications, increases the
risk of metabolic and infectious complications, and is expensive.
• http://pt-global.org/wp-content/uploads/2014/09/PG-SGA-Sep-
2014-teaching-document-140914.pdf
• https://abbottnutrition.com/perative
• https://abbottnutrition.com/pivot-1_5-cal
Case
study
• Miss L. is a 68-year-old woman. Recently she was diagnosed with
breast cancer. Surgery, followed by concurrent chemotherapy and
biotherapy and then radiation therapy to her breast are planned for
treatment of her disease. Anticipated side effects of her cancer
therapy include treatment-related fatigue, mouth sores, nausea,
vomiting, diarrhea. She is 5’4“ tall, weighs 149 lb, and has a history of
hypercholesterolemia and hypertension that has been managed with
dietary measures.
• Design blanderized diet and also select NG feeding formula
????
Thank
You