CHAPTER 9. NUTRITION
Suzanne W. Dixon
The issue of nutrition support in the palliative care environment is controversial. Between the extremes of solely appetite-driven dietary intake and feeding aggressively with enteral or parenteral nutrition until death lies the gray area of if, when, and how much to feed individuals with known terminal disease. Further complicating this issue are discrepant perceptions of the patient, family, and the clinician, as well as the cultural context in which death occurs. Many families equate feeding and nourishment with love (Poole & Froggatt, 2002), leading to a desire to aggressively feed the patient, even if this is not likely to improve comfort or length of life. For other families, past negative experiences with aggressive nutrition interventions lead to a rejection of nutrition support under all circumstances (Back & Arnold, 2005). And a study of advanced cancer patients in Europe has demonstrated that cultural values likely affect the decision to aggressively implement nutrition support (McKinlay, 2004).
The role of the clinician is to help patients and families navigate through this difficult and emotionally fraught time, while respecting patient autonomy, desires, and needs. The clinician is in the unique position to help involved individuals weigh the risks and benefits of various nutrition interventions and to determine whether aggressive intervention is likely to improve comfort, pain, and length of life in a meaningful way (Fine, 2006; Fuhrman & Herrmann, 2006).
DEFINITIONS
It is vitally important for the clinician to understand the difference between anorexia and cachexia. These terms often are used interchangeably, but they are not the same. Anorexia is a lack of appetite. Cachexia is the term used to describe the disordered metabolism characteristic of certain diseases and/or conditions including, but not limited to, cancer, sepsis, chronic infections, HIV/AIDS, congestive heart failure, chronic obstructive pulmonary disease, and other conditions resulting in systemic inflammation (Delano & Moldawer, 2006). Anorexia is a feature of cachexia, but anorexia does not cause cachexia. Cachexia and subsequent anorexia can lead to weight loss, loss of muscle mass, loss of functional status, and decline in length and quality of life for patients with advanced illnesses.
PATHOPHYSIOLOGY
The weight loss associated with simple anorexia can be ameliorated with appropriate energy and protein, because this condition is not characterized by the metabolic aberrations that underlie cachexia. The loss of weight, muscle mass, and functional status characteristic of cachexia cannot be addressed with calories and protein alone. If the underlying metabolic derangement of cachexia is not addressed, nutrition support is unlikely to halt weight loss, although it may improve quality of life. In this circumstance, nutrition intervention risks, such as increased discomfort and infection, and benefits, including improved quality of life, must be carefully considered.
The cause of cachexia is not completely understood, but it is thought to result from the overproduction of proinflammatory (procachectic) mediators called cytokines and interferons. Tumor necrosis factor, interleukins 1 and 6, interferon γ, and proteolysis-inducing factor are believed to be among the most important mediators in the cachexia response (Argiles, Busquets, & Lopez-Soriano, 2005; Deans, Wigmore, Gilmour et al., 2006; DeJong, Busquets, Moses et al., 2005; Delano & Moldawer, 2006; Tisdale, 2005). Current research is focusing on additional novel molecules and pathways that may play a role in the development and progression of cachexia, including ghrelin, leptin, myostatin, and the ubiquitin-proteasome pathway (Akashi, Springer, & Anker, 2005; Filippatos, Anker, & Kremastinos, 2005; Jespersen, Kjaer, & Schjerling, 2006; Wolf, Sadetzki, Kanety et al., 2006).
The presence of these mediators can result in anorexia, hypermetabolism, and alterations in normal metabolic pathways. In simple starvation, the healthy body readily adapts to a calorie deficit by decreasing metabolic rate and shifting to fatty acids as a primary energy source, thereby preserving lean body mass. In cachexia, the body fails to make this adaptation, which can lead to disproportionate wasting of lean body mass and loss of strength and functional status. This can lead to a decline in quality of life, comfort, and functionality of the patient who is terminally ill (Anker, Steinborn, & Strassburg, 2004; Cox & McCallum, 2000; Muscaritoli, Bossola, Aversa et al., 2006; Strasser & Bruera, 2002; Van Cutsem & Arends, 2005).
MANIFESTATIONS OF CACHEXIA
The primary manifestations of cachexia include, but are not limited to, anemia, anorexia, dehydration, early satiety, electrolyte imbalances, fatigue, loss of lean body mass, malaise, micronutrient deficiency, taste alterations, weakness, and weight loss. In the palliative care setting, the goal of nutrition intervention for cachexia is to address as many of these issues as possible to improve the quality of life and functionality without increasing discomfort, pain, fluid retention, or other symptoms.
Metabolic Abnormalities of Cachexia
Ideally, addressing the underlying metabolic abnormalities of cachexia is the first step to improved quality of life, functionality, and symptomatology in the palliative care setting. Unfortunately, pharmacologic interventions for cachexia have had limited success and are only appropriate in carefully selected patients (Strasser & Bruera, 2002; Wilcock, 2006).
The use of omega-3 fatty acids is one intervention designed to ameliorate the underlying metabolic aberrations of cachexia (Elia, Van Bokhorst-de van der Schueren, Garvey et al., 2006). Evidence suggests that the metabolic alterations that contribute to cancer cachexia can be normalized by increased intake of eicosapentaenoic acid (EPA), one type of omega-3 fatty acids (Barber, 2002; Barber & Fearon, 2001; Barber, Fearon, Tisdale et al., 2001; Barber, McMillan, Preston et al., 2000; Barber, Ross, Voss et al., 1999; Burns, Halabi, Claman et al., 1999; Harman, 2002; Jho, Babcock, Helton et al., 2003; Moses, Slater, Preston et al., 2004; Wigmore, Barber, Ross et al., 2000). Research on the benefits of EPA for addressing cachexia has been conducted predominantly in cancer populations. However, given that common pathophysiologic mechanisms appear to underlie cachexia that occurs in various disease states, it is reasonable to assume that administration of omega-3 fatty acids is a useful approach in all of these cases (Coletti, Moresi, Adamo et al., 2005; Hehlgans & Pfeffer, 2005; Witte & Clark, 2002).
Research has indicated that amounts up to 18 g/day of EPA are well tolerated (Barber & Fearon, 2001). The most common dose-limiting symptom is diarrhea (Barber & Fearon, 2001). It is important to note, however, that a dose of 2.2 g of EPA per day is believed to be effective and that this lower dose is associated with minimal risk of side effects (Fearon, Von Meyenfeldt, Moses et al., 2003; Moses et al., 2004).
Patient education is a key component of appropriate use of EPA. Three double-blind, placebo-controlled trials failed to find a benefit from an EPA-enhanced liquid nutritional supplement in cachectic cancer patients. However, in not one of these trials was the therapeutic minimum dose reached of 2.2 g of EPA per day (Bruera, Strasser, Palmer et al., 2003; Fearon et al., 2003; Jatoi, Rowland, Loprinzi et al., 2004). Furthermore, post-hoc analyses indicated a strong correlation between higher EPA intakes and significantly improved outcomes, including halt in weight loss, improved quality of life, and reductions in inflammatory biomarkers. These trials highlight the importance of educating patients on the therapeutic nature of an EPA-containing supplement so that this is not treated as simply “another supplement to try.”
EPA can be incorporated into the diet through specialized oral/enteral formulas such as RESOURCE Support (Novartis Medical Support) and ProSure (Ross/Abbott Laboratories) or EPA-containing fish oil supplements. Fish oil supplements are available in gelatin capsule and deodorized liquid form. For typical gelatin capsule supplements, approximately 8 to 10 capsules per day are required to reach 2.2 g of EPA. Many patients have difficulty swallowing pills, and for this group, the deodorized liquid form of fish oil may be a better option (The Very Finest Fish Oil [Carlson Laboratories] is an example of a liquid product that is well tolerated by many patients). Generally, it has been recognized that food sources of EPA do not provide a dose that is sufficient to halt cachexia.
MANAGEMENT OF NUTRITION IMPACT SYMPTOMS
The nature of appropriate nutrition intervention should be guided by the setting in which it occurs. Suggested interventions that can be used by the clinician when educating the patient and family in the palliative and end-of-life care settings include the following.
Palliative Care Setting
The caregiver must treat and manage the symptoms that may affect nutritional intake and interfere with the patient’s desire to eat, including constipation; bloating; diarrhea; feelings of fullness, early satiety, and poor appetite; altered sense of taste and smell; dry mouth and/or thick saliva; sore mouth and/or throat; nausea and/or vomiting; and pain.
Patient and Family Education Constipation
While many health care professionals dismiss constipation as a relatively trivial problem, resulting in a lack of attention to the subject, constipation is experienced by more than 50% of cancer patients (Smith, 2001), a group that comprises a significant proportion of the palliative care population. Constipation causes physical and emotional distress in patients who experience it, and the frequent use of pain management medications makes constipation common in the palliative care population (Staats, Markowitz, & Schein, 2004). Unfortunately, the need to treat constipation often is due to a failure to prevent it (Smith, 2001).
In addition to preventive constipation management medication protocols, which should be initiated prior to onset of constipation, nutrition intervention can be beneficial. While some literature suggests that constipation is not strongly related to dietary factors (Muller-Lissner, Kamm, Scarpignato, & Wald, 2005), numerous studies and reports indicate that nutrition can and should be an important part of constipation management (Geriatrics, 2005; Khaja, Thakur, Bharathan et al., 2005; Wilson, 2005; Wisten & Messner, 2005). It is important for the APN to encourage ongoing communication between the patient and family and their health care team about medication options that are useful for constipation management. Nutrition approaches work best in combination with medication. Suggested nutrition interventions for constipation include the following (American Cancer Society, 2006a; Dobbin & Hartmuller, 2000):
▪ Eat at regular times each day.
▪ Drink 8 to 10 cups of noncaffeinated fluid each day. If additional calories are needed to meet nutritional needs, focus on calorie-containing beverages including 100% fruit juices, milk, soy milk, rice milk, and any other tolerated beverages.
▪ Include water, prune juice (2 to 4 ounces to assess tolerance), warm juices, and teas as a portion of fluid intake. Drink two cups of warm liquid (can include coffee) with breakfast every day.
▪ Include foods high in insoluble fiber, only if tolerated. This includes whole-grain breads containing a minimum of 4 g of fiber per slice; cereals containing a minimum of 6 to 8 g of fiber per serving; whole-grain pastas; raw and cooked vegetables including skins and peels, such as apples, carrots, and green leafy vegetables; popcorn; and beans, such as navy beans, kidney beans, black beans, and lentils. If gas, bloating, and/or abdominal distention is present, do not increase insoluble fiber in the diet. Do not increase insoluble fiber if a low-residue diet has been prescribed.
▪ Eat a good breakfast that includes a hot drink and high-fiber foods, such as bran cereals, oatmeal, or Cream of Wheat (Kraft Foods).
▪ If additional calories are needed to meet nutritional needs, try a fiber-containing, high-calorie, high-protein, liquid supplement (e.g., Ensure Plus with Fiber [Ross/Abbott Laboratories]).
▪ Try adding in a fiber supplement such as Benefiber (Novartis Consumer Health) or Metamucil (Procter & Gamble). Benefiber may be better tolerated. Be sure patient consumes adequate fluids with fiber supplements.
▪ Try dried fruit such as apricots, figs, or raisins. If gas, bloating, and/or abdominal distention is present, do not increase insoluble fiber in the diet. Do not increase insoluble fiber if a low-residue diet has been prescribed.
Bloating*
The APN should encourage ongoing communication between the patient and family and their health care team about medication options for decreasing gas production. Nutrition approaches work best in combination with medication.
▪ Limit foods and drinks that cause gas, including carbonated beverages, broccoli, cabbage, cauliflower, cucumbers, peppers, beans, peas, onions, and garlic. A food and symptom diary can help identify other, individual triggers of gas and bloating from particular ingested foods.
▪ Lessen the amount of air swallowed by eating slowly and avoiding excessive talking while chewing and swallowing.
▪ Do not use straws to drink liquids.
▪ Avoid chewing gum.
Diarrhea†
†American Cancer Society, 2006b; Can, Besirbellioglu, Avci, et al., 2006; Chermesh & Eliakim, 2006; Coeffier, Hecketsweiler, Hecketsweiler et al., 2005; Cox & McCallum, 2000; Dobbin & Hartmuller, 2000; Heiser et al., 2004; Novak & Katz, 2006; Rushdi, Pichard, & Khater, 2004; Savarese, Savy, Vahdat et al., 2003; and Savarese, Al-Zoubi, & Boucher, 2000.
▪ Encourage ongoing communication between the patient and family and their health care team about medication options for managing diarrhea. Nutrition approaches work best in combination with medication.
▪ Increase intake of foods high in soluble fiber, including oatmeal, white rice, bananas, white toast, applesauce, and canned fruits without the skins, such as peaches and pears.
▪ Drink 6 to 8 cups of fluids each day to replace losses. Include nonwater beverages, such as Gatorade (Stokely-Van Camp, Inc.) or Pedialyte (Abbott Laboratories), to help replace lost electrolytes. Do not rehydrate solely with water; this can contribute to electrolyte abnormalities.
▪ Drink fluids at room temperature. Avoid very hot and very cold drinks.
▪ With each loose bowel movement, drink 1 additional cup of electrolyte-containing fluid, such as Gatorade or Pedialyte.
▪ Try nonacidic juices, such as apple juice, apricot nectar, peach nectar, or pear nectar.
▪ Sip broth and sports drinks to replace electrolyte losses.
▪ Eat very small, frequent meals. Encourage a “bite-at-a-time” approach to eating.
▪ Drink fluids between meals rather than with meals (e.g., separate liquids from solids).
▪ Lie down immediately after eating.
▪ Snack on salty, bland foods, such as crackers and pretzels, to replace lost sodium.
▪ Consider powdered glutamine (amino acid) supplement, mixed with liquid, at a dose of 10 g, three times daily (research-supported brands of glutamine include RESOURCE GlutaSolve [Novartis Medical Nutrition] and Sympt-X [Cambridge Nutraceuticals/Baxter Pharmaceuticals]). Glutamine may be contraindicated if renal and/or hepatic function is impaired.
▪ Try probiotic supplements that contain a broad spectrum of probiotic flora including Lactobacillus acidophilus, Lactobacillus casei, Lactobacillus reuteri, Lactobacillus rhamnosus, Bifidobacterium bifidum, Bifidobacterium longum, and/or Streptococcus thermophilus.
▪ Avoid foods high in insoluble fiber, such as fresh fruit with the peel (the flesh of the fruit is okay), raw vegetables (well-cooked vegetables are okay), whole-grain breads and cereals, beans, peas, and popcorn.
▪ Limit fatty and greasy foods.
▪ Limit or eliminate dairy products (except yogurt) if helpful. Include yogurt to replace normal and healthy gut flora.
▪ Consider utilizing a rice congee that is made of 1 cup long-cooking rice combined with 6 cups water and 1 tablespoon of salt; cook according to package directions (typically about 40 minutes). Eat and drink this soupy mixture.
Feelings of Fullness, Early Satiety, and Poor Appetite*
▪ Incorporate a minimum of 2.2 g of EPA into the diet to halt cachexia, which may be contributing to poor appetite. EPA can be incorporated into the diet through specialized oral/enteral formulas such as RESOURCE Support (Novartis Medical Support) and ProSure (Ross/Abbott Laboratories) or EPA-containing fish oil supplements. Fish oil supplements are available in gelatin capsule and deodorized liquid form. Patients and families must be educated to reach therapeutic dose (at least 2.2 g of EPA per day) to maximize possibility of benefit.
▪ Assess zinc status and supplement as indicated.
▪ Avoid intake of noncaloric beverages such as water and tea in large quantities.
▪ Eat very small, frequent meals. Encourage a “bite-at-a-time” approach to eating.
▪ Focus on eating one to two bites every 20 minutes throughout the day.
▪ Make eating more enjoyable by setting an attractive table, playing favorite music, or watching television.
▪ Eating is a social activity. If patient is unable to eat at the table, have family join patient where he or she is able to eat. Prevent patient from eating alone, if at all possible.
▪ Keep snacks handy to eat immediately (hunger may last only a few minutes), such as granola bars; nuts; pudding cups; chips; crackers; pretzels; single serving sizes of tuna, chicken, or fruit; dried fruit; and/or trail mix.
▪ Eat favorite foods at any time of the day; for example, if breakfast foods are appealing, eat them for dinner. No foods are off-limits.
▪ Eat every hour at a minimum—do not wait until hungry. Relying on appetite is not a good guide when introducing appropriate nutrition.
▪ Treat food like medicine—set times to eat, such as every 30 minutes to 1 hour and encourage at least one or two bites of any food during “medication” times (quantity and type of food are less important; frequency of eating is more important).
▪ Consider fortified juice-based supplements such as Enlive! (Ross/Abbott Laboratories) if taste fatigue of other “creamy” textured supplements is a problem.
▪ Encourage fluids between meals, rather than with meals (e.g., separate liquids from solids). Liquids can cause stomach distension and worsen feelings of fullness, making intake of calorie-rich solids problematic.
Altered Sense of Taste and Smell*
*American Cancer Society, 2006h; Cox & McCallum, 2000; Dobbin & Hartmuller, 2000; Heckmann et al., 2005; Polisena, 2000; Ripamonti et al., 1998; and Shay & Mangian, 2000.
▪ Encourage ongoing communication between the patient and family and their health care team about specific conditions that can create unpleasant mouth taste. For example, infections such as thrush and zinc deficiency can alter sense of taste and smell. These problems can be treated with medication and/or nutritional supplementation. Nutrition approaches work best when combined with medication.
▪ If indicated, use a zinc supplement of 220 mg of zinc sulfate two times per day. Use supplement for up to 3 months. Short-term zinc supplementation may help with altered sense of taste, but long-term zinc supplementation may contribute to impaired immune status, micronutrient malabsorption, and other health problems.
▪ Provide education on fastidious mouth care to prevent secondary bacterial infections.
▪ Avoid food smells.
▪ Consider foods that have minimal odors and short cooking time, such as scrambled eggs, plain pasta, yogurt, pudding, oatmeal, and Cream of Wheat.
▪ Season foods with tart flavors such as lemon, citrus, vinegar, and pickled items (avoid if sore mouth or throat is present).
▪ Flavor foods with spices not normally used, such as basil, oregano, rosemary, tarragon, mustard, catsup, or mint.
▪ Marinate and cook meats in sweet juices, fruits, dressings, or wine, such as sweet and sour pork, chicken with honey glaze, or beef with Italian dressing.
▪ Rinse mouth with tea, ginger ale, saltwater, or baking soda and water to clear taste buds prior to eating.
▪ Suck on lemon drops or mints or chew gum ( avoid if sore mouth or throat is present; avoid sugarless gums and candies if diarrhea is present).
▪ Encourage patient to experiment often. Very unusual flavors, such as a pickle juice milk shake, may be acceptable to a patient with altered sense of taste and smell.
Dry Mouth and Thick Saliva†
†American Cancer Society, 2006c, 2006d; American Institute for Cancer Research, 2006; Cox & McCallum, 2000; Dobbin & Hartmuller, 2000; and Guggenheimer & Moore, 2003.
▪ Encourage ongoing communication between the patient and family and the health care team about what is creating a dry mouth and/or thick saliva. Medication options may be available to alleviate severe xerostomia. Nutrition approaches work well in combination with medications.
▪ Drink 8 to 12 cups of liquid a day and take a water bottle when leaving the house (adequate and even extra fluids can help loosen mucus). Use nonacidic juices and other high-calorie liquids to increase calorie intake if weight loss is a problem.
▪ Consider 100% papaya juices or eating papayas, which contain an enzyme (papain) that can help to break up thick saliva.
▪ Introduce 100% pineapple juice or pineapple, which can help to thin mucus (avoid if sore mouth or throat is present).
▪ Use a straw to drink liquids to bypass mouth sores (avoid if bloating and gas are present).
▪ Eat soft foods at room temperature or cold. Try blenderized fruits and vegetables, soft-cooked chicken and fish, well-thinned cereals, Popsicles, and shakes/smoothies made with juices and fruit; if dairy foods increase mucus production, try making a smoothie with a nondairy alternative such as soy or rice milk).
▪ Try limiting intake of dairy products, which may promote mucus secretions; use a nondairy alternative such as soy or rice milk.
▪ Suck on lemon drops (avoid if sore mouth or throat is present) or frozen grapes or ice chips ( do not chew ice, as this can damage teeth).
▪ Try mixing 1 cup of peach or papaya nectar with 1/2 cup of club soda and drink (avoid if sore mouth or throat is present).
▪ Avoid commercial mouthwashes; these contain alcohol, which is drying.
▪ Try alcohol-free mouthwashes and gums, such as Biotene (Laclede).
▪ Avoid alcoholic beverages, caffeinated beverages, chocolate, and tobacco products. These are drying to the mouth.
▪ Use a cool mist humidifier to moisten room air (keep clean to avoid spreading bacteria, fungi, or mold).
Sore Mouth and Throat*
*American Cancer Society, 2006f, 2006g; American Institute for Cancer Research, 2006; Anderson, Schroeder, & Skubitz, 1998; Anonymous, 2005; and Peterson, 2006.
▪ Encourage ongoing communication between the patient and family and their health care team about medication options for managing mouth and throat pain. Nutrition approaches work best in combination with medication.
▪ Encourage fastidious mouth care to prevent secondary bacterial infections.
▪ Eat soft, bland foods, such as creamed soups, cooked cereals, macaroni and cheese, yogurt, pudding, mashed potatoes, eggs, custards, casseroles, cheese cake, and milk shakes or smoothies.
▪ Drink through a straw to bypass mouth sores (avoid if bloating is present).
▪ Eat high-protein, high-calorie foods to promote healing.
▪ Consider a powdered glutamine (amino acid) supplement, dissolved into warm water, at a dose of 10 g, three times daily (research-supported brands of glutamine include RESOURCE GlutaSolve [Novartis Medical Nutrition] and Sympt-X [Cambridge Nutraceuticals/Baxter Pharmaceuticals]). Swish and swallow the glutamine mixture for best results. Glutamine may be contraindicated if renal and/or hepatic function is impaired.
▪ Soften foods such as bread by soaking in milk.
▪ Stick to nonacidic juices such as apple juice; peach, pear, or apricot nectars; and grape juice (do not use grape juice if diarrhea is present).
▪ Avoid tart, acidic, or salty beverages and foods such as citrus, pickled items, and tomato-based foods.
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