Nutrition and Living with Neuroendocrine Tumors:

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Nutrition and Living with Neuroendocrine Tumors: Leigh Anne Kamerman Burns MS, LDN, RD Nutritionist LSUHSC New Orleans Ochsner Kenner Neuroendocrine Tumor Clinic Objectives Identify recommendations for
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Nutrition and Living with Neuroendocrine Tumors: Leigh Anne Kamerman Burns MS, LDN, RD Nutritionist LSUHSC New Orleans Ochsner Kenner Neuroendocrine Tumor Clinic Objectives Identify recommendations for Cancer Survivors Identify problems and symptoms affecting the nutritional status of among patients living with NETs Provide information to improve the symptoms and complications related to foods and beverages consumed. 2 nd Expert report: Food, Nutrition, Physical Activity, and the prevention of cancer Recommendations Weight Management Diet Physical Activity Source: American Institute for Cancer Report background Developed over 5 years 9 teams of researchers 21 experts and 82 peer reviewers 7,000 studies 17 different cancers 517 pages and graph Unanimously agreed on recommendations ACIR second expert report Nov. 2007 ACIR Nutrition recommendations for Americans Scientific Evidence Convincing Probable Suggestive No link Convincing Overweight and obesity increased 8 different cancers breast, colon, rectum, Red meat GI, colorectal Cured and processed meat- colorectal Alcohol colorectal, breast, esophageal, mouth, larynx and pharynx Insufficient exercise - colon AICR recommendations Be as lean as possible without becoming underweight. Be physically active for at least 30 minutes every day. Avoid sugary drinks. Limit consumption of energy-dense foods. Eat more of a variety of vegetables, fruits, whole grains and legumes such as beans. ACIR recommendations cont. Limit consumption of red meats (such as beef, pork and lamb) and avoid processed meats. If consumed at all, limit alcoholic drinks to 2 for men and 1 for women a day. Limit consumption of salty foods and foods processed with salt sodium. Don't use supplements to protect against cancer. American Institute of Cancer Research Recommendations for Cancer Survivors Keep An Eye On Portions After treatment, cancer survivors should follow the recommendations for cancer prevention. Anatomy of My Pyramid One Size Doesn t Fit All Activity Gradual Improvement Moderation Variety Personalization Proportionality Nutritional problems Among Carcinoid Cancer patients Involuntary Weight loss Muscle mass reduced / Protein loss Reduction in amounts consumed and absorption of nutrients Decreases in patients immune system Decrease in control of bowel movements Reduction in QOL Critical Weight Loss: Definition Time Course Severe* Weight Loss (%) 1 week 2 1 month 5 3 months months 10 Blackburn GL et al. JPEN J Parenter Enteral Nutr. 1977;1: *Associated with increased risk for complication and death. Weight Loss: Implications Risk for complication and death 1 Treatment response 1 Hospital length of stay, rehospitalization 2 QOL, self-appearance, patient satisfaction with care 2 1 DeWys WD et al. Am J Med. 1980;69: Sproat KV, Russel CM eds. Malnutrition. A Hidden Cost in Health Care. Ross Products Division, Abbott Laboratories; Zhang W et al. Eur J Drug Metab Pharmacokinet. 1999;24: ; 4 Murry et al. Int J Cancer Suppl. 1998;11: Walter-Sack I, Klotz U. Clin Pharmacokinet. 1996;31:47-64; JCAHO, 1996. Most Prevalent QOL Concerns for NET Patients Fatigue Diarrhea Worry about illness getting worse Also considered the worst aspects of physical distress and most common reasons for social restrictions Most prevalent and worst aspect of emotional distress Frojd et al. Health and Quality of Life Outcomes 2007, 5:18 Symptoms requiring dietary adjustments Carcinoid syndrome Flushing Fatigue Nausea Vomiting Diarrhea Gas Fatigue Most common side effect of cancer and its treatment Causes: cancer /stress /dehydration / diarrhea /surgery/ chemo/rad treatment /Anemia / abnormal electrolytes / K+ / Mg+ Suggestions: Rest/ Nap/ stock easy to prepare foods/ supplements / Hydrate / small frequent feedings / avoid sugary foods and fluids Basic Mechanisms Responsible for Clinically Osmotic diarrhea Significant Diarrhea Secretory diarrhea Decreased contact time / surface area Probable combination of the above Causes of Non-Secretory Diarrhea Drug induced (SMS analogs) Short Bowel Syndrome Inflammatory Bowel Disease Bacterial Overgrowth Non- Secretory Diarrhea Celiac Sprue Bile acid colitis Pancreatic Insufficiency Intestinal Surgery Gallbladder Removal Contributing Factors of Osmotic Diarrhea Malabsorption such as lactose intolerance Ingestion of poorly absorbed substrates such as: sorbitol, mannitol, Epson salt or antacids Diarrhea will stop Causes of Secretory Diarrhea Vipomas: VIP (Vasoactive intestinal peptide) Gastrinomas: Gastrin Tumor Associated: Secretory Diarrhea Carcinoid: Histamine, Serotonin, Polypeptides Nutrition Strategies and Diet Management Information and screening tools sent with visit packet. Scored Patient Generated Subjective Global Assessment (PG-SGA) Web page Nutrition Information and resources * Based on Standards of Practice for Oncology Nutrition website and Clinical Guide to Oncology Nutrition 2 nd edition ONDPG Elliot, L. et, al. 2006 Determining Who Is at Risk Risk based on: % Weight loss Rate of loss Albumin levels Cholesterol level Critical weight loss categories Laboratory assessments History and physical exam Weight loss history Height and weight Nutritional assessment Patient Nutrition Assessment Intake calories: food diary / dietary recall Proteins sources, preparation, amounts Fats sources Vitamins / minerals Fluids Dietary Supplements Medication Assessment: Lab / Wt/BMI / Flushing Abnormal stools color, form Frequency, time, time related to meals Runny stools Fatty / Float stools, smells Nutrition evaluation Identify individuals nutritional status Identify recent weight changes, symptoms, recent surgeries et al. Determine patients understanding of nutrition and relationship to disease Determine nutritional plan Begin education Follow up Nutrition Care Plan Pre op Previous surgeries /or pre existing conditions Symptoms Involuntary weight loss Diarrhea / Steatorrhea Protein status Muscle mass Albumin /pre-albumin Medication Life style Activity Support systems Post op Previous surgery nutritional status Projected nutritional needs post op Change diet as post op symptoms change High protein, low sugars soft Complex CHO, fat as tolerated Fiber mix soluble / insoluble with symptoms Dietary intervention High protein High Calorie dense diet Dumping syndrome diet Altered fiber diet Low fat diet Diarrhea reducing diet Lactose free/ Gluten free Low tyramine diet FODMAP Diet ( Gassy Foods) Alterations to improve tolerances to foods Chew foods completely Chop or mash before eating Increase calorie and protein density Avoid foods associated with problems Eat smaller portions but increase frequency 6 small feedings daily Liquids adjust to meet tolerances but don t avoid Adjust diet related to symptoms If diarrhea or gas Diet for diarrhea ( reduce conc. Sweet, fat and insoluble fiber) Rapid transit / Dumping diet ( 6 sm feedings sep. solids and liquid + diarrhea diet) FODMAP diet (gassy foods) If nauseated Avoid red meats and fatty foods avoid smells and color in foods Use Low fat diet If constipated add insoluble fiber and fluids Dietary Factors Caffeine Lactose/Fructose (in quantities surpassing the gut's absorptive capacity) Fats FODMAP diet Coffee, tea, cola, OTC headache remedies Apple juice, pear juice, grapes, honey, dates, nuts, figs, soft drinks (especially fruit flavored), prunes Sugar-free gum, mints, sweet cherries, prunes Milk, yogurt, soft cheeses Margarine, sauces, salad dressing, butter, oils, avocados, palm oils Carbohydrate intolerances Amines Rich Foods and Products [7] (Tyramine, Dopamine) HIGH Aged cheeses (cheddar, Camembert, Stilton) Alcoholic beverages Smoked, salted or picked fish or meat (herring, salami, sausage, corned beef, bologna, pepperoni) Any spoiled protein foods (chicken liver) Yeast extracts and Brewers yeast, hydrolyzed proteins Broad beans, sauerkraut, shrimp paste, some soybean products, miso soup, soy sauce, tofu MODERATELY HIGH Caffeine containing drinks, coffee (in large amounts), soda Chocolate (in large amounts) Some nuts (peanuts, coconuts, brazil nuts) Some pizzas, raspberries, banana, avocado VLW Go Decreasing Motility Activity rest with feet up for 15 min after meals recommend in between meals by 2 hours Stress maintain a relaxed environment at meal Foods avoid concentrated sweets separate solids and liquids avoid extreme hot or cold consider Review tolerances of fiber types Enteral Supplements Only replace when needed related to intake and absorption Standard Carnation instant breakfast, Ensure, boost, breeze Modular Juven, benecal, beneprotein, Medium Chain Triglycerides Specialty Partially elemental -Peptemen, elemental High protein vital, Stress, immune suppression, Maltodextrin/ Glucerna Supplementing Vitamins, Minerals and other Multivitamin 100% Water Soluble vitamins C and B complex Fat soluble vitamins ADEK Magnesium Calcium Herbal No FDA approval Medication for diarrhea symptoms Medication relax smooth muscle in small bowel and colon to decrease motility and increase time allowed for water reabsorption Lomotil Tincture of opiate Medication action increase water absorption by binding water Attupugite Kaopectate, donnagel, Polycarbophols, equadectin, konsyl fiber, polycarb Anti-diarrhea Medications They treat only the symptoms They work by slowing down the movement of the gut This allows more time for water to be absorbed which makes the stool less watery Medications for Steatorrhea Pancreatic enzymes FDA approved medications Creon, Zen pep, Pancreaze Bile binding agents Cholestyramine Welchol Probiotics Cholestyramine Used when bile salts are thought to play a role in the diarrhea Action is to binds bile acids, keeping them from reaching the colon and thereby stopping bileacid-induced diarrhea Common after gallbladder removal or presence of short bowel syndrome Resources for CAM Monitoring Symptom relief Stabilized weight Normal protein markers Increase fat soluble nutrients Increase in food selection Increase in Quality of life Nutrition: Making best choices considering symptoms If normal GI tract no symptoms follow AICR Cancer Survivor recommendations If symptomatic due to condition adjust diet to best fit your situation Remember everyone is different and may need special nutritional considerations Activity 30 to 45 minutes daily Eat high protein foods low in fat sources when building muscle Adjust times of activity away from meals if diarrhea/ steatorrhea Increase activity if constipated Food Labels Look For... Serving Size Calories Fat Sodium Carbohydrates Dietary Fiber Recipes resources Cooking with Cancer Dr. Pineda Betty Crocker Living With Cancer Food for the Fight ACIR Eating Well With Cancer Summary
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