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Clinical Nutrition 1 > Nutritional Assessment and Intervention in Cancer > Flashcards

Nutritional Assessment and Intervention in Cancer Flashcards

1
Q

How does cancer impact nutritional status?

A
  • Presence of tumor
  • Host response
  • Anti-cancer treatment
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2
Q

What are the impacts of low nutritional status in cancer?

A

-Reduced intake
-Altered metabolism
Leading to malnutrition and weight-loss

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3
Q

Disadvantages to malnutrition and weight loss?

A

-Decrease quality of life, response to treatment and survival

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4
Q

In addition to decrease response to treatment, how else will malnutrition and weight loses affect treatment?

A
  • May have increased wait time to receive treatment in the first place
  • Malnutrition will also increase toxicity to treatments
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5
Q

Benefits of assessing nutrition?

A
  • Early ID of pts at risk
  • Help design nutritional support
  • Improves patients wellbeing, survival and improved eligibility and response to treatment
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6
Q

% weight loss?

A

IBW - CBW /IBW x 100

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7
Q

Most powerful independent variable that predict mortality in CA?

A

unintentional weight loss

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8
Q

What is the primary clinical manifestation of cachexia?

A

Unintentional weight loss

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9
Q

Important to consider about % weight loss in the presence of pleural effusion, ascites or edema?

A

Weight should be corrected but difficult to be precise

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10
Q

1 week 1-2% weight loss?

A

Significant

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11
Q

1 week >2% weight loss?

A

Severe

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12
Q

1 month 5% weight loss?

A

Significant

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13
Q

1 month >5% weight loss?

A

Severe

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14
Q

3 months 7.5% weight loss?

A

Significant

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15
Q

3 months >7.5% weight-loss?

A

Severe

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16
Q

6 months 10% weight loss?

A

Significant

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17
Q

6 months >10% weight-loss?

A

Severe

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18
Q

What is MAMA?

A

Mid-upper arm muscle area

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19
Q

What does MAMA calculate?

A

Calculated from mid-arm circumference and triceps skinfold

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20
Q

Low MAMA?

A

Less than 15th percentile for age and sex

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21
Q

What can 3-methyhistidine and urinary creatinine excretion measure?

A

Loss of muscle mass -

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22
Q

Urinary creatinine?

A

Metabolite of creatine phosphate, mainly found in skeletal muscle and index of muscle mass (creatinine/height ratio)

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23
Q

3-methylhistidine?

A

Released from actin and myosin degradation and marker of myofibrillar protein degradation

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24
Q

Relationship between 3-MH and Creatine?

A

3-MH/Creatinine ratio

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25
Q

Limitations of UC and 3-MH?

A
  • Wide day-to-day variation

- Both techniques require 24-hour urine collections and 3day meat free diet prior

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26
Q

What is muscle strength indicative of?

A
  • Muscle mass

- Functional status and survival

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27
Q

What is the BEST predictive marker of morbidity and mortality?

A

Gait speed

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28
Q

Having a walking speed of of less than ___ in the 4-m walking test is indicative of low gait speed, and low functional capacity

A

0.8 m/s

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29
Q

What are examples of functional tests?

A
  • Gait speed
  • Chair rise
  • 6-min walking test
  • Balance test
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30
Q

What does the chair rise test assess?

A
  • Time to rise 5 times from chair w/o arms

- Test leg strength and power

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31
Q

What is the 6-min walking test?

A

Endurance test, distance walked during 6 mins (<400m)

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32
Q

What is the balance test?

A

Time standing on one food, or one foot in front of the other

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33
Q

High albumin?

A

Dehydaration

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34
Q

Low albumin?

A
  • Inflammation
  • Protein deficiency
  • Sepsis
  • Hyper-hydration
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35
Q

Albumin is useful as a morbidity tool but NOT a useful marker of ___

A

Nutritional support

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36
Q

High B12?

A
  • Leukemia

- Liver mets

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37
Q

Low B12?

A

-Gastrectomy (partial removal of stomach, less intrinsic factor)

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38
Q

If B12 is high, should we restrict intake?

A

No

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39
Q

If low B12, should we supplement?

A

No - Intramuscular injections (especially if gastrectomy)

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40
Q

High calcium?

A
  • mets
  • Lymphoma
  • PTH tumor
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41
Q

High calcium guidelines?

A

do not restrict Ca intake, but stop vit. D supplements

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42
Q

Low folate?

A

May be due to methtrexate (accelerate metabolism of folate in the liver)

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43
Q

When are supplements of folate useful?

A

Only when dietary intake is insufficient

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44
Q

High glucose?

A
  • Corticosteroids

- Pancreatic CA

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45
Q

High glucose recommendation?

A

Avoid concentrated sugars

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46
Q

Low hmg?

A
  • Radio/chem blood losses

- Cancer

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47
Q

Hypochromic anemia?

A

Suggest iron supplementation

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48
Q

Megoblastic anemia?

A

Suggest folate or B12 supplementation

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49
Q

Norochromatic anemia?

A

Suggest blood transfusion

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50
Q

Low K+?

A

Assoicated with cisplatine

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51
Q

Low lymphocyte?

A
  • Radio/Chemo
  • Leukemia
  • Corticosteroids
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52
Q

Low lymphocyte recommendation

A

May respond to increased protein intake

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53
Q

High levels of which values are indicative of dehydration?

A
  • Blood electrolytes
  • BUN
  • Creatinine
  • CBC:hematocrit
  • Specific gravity
54
Q

Clinical signs of dehydration?

A

-Low BP, rapid heart rate, skin dryness/loss of elasticity, dry mouth/lips, confusion and thirst

55
Q

What is the Glasgow Prognostic Score based on?

A
  • Inflammation based on CRP and Albumin

- Indicative of poor outcomes that may follow

56
Q

Low CRP and normal albumin?

A

GPS= 0 - No cachexia

57
Q

Low CRP and albumin?

A

GPS = 0 - undernourished

58
Q

High CRP and normal albumin?

A

GPS = 1 - pre-cachexia

59
Q

High CRP and low albumin?

A

GPS = 2 - refractory cachexia

60
Q

When is CRP low? high?

A

<10 mg/L

>10 mg/L

61
Q

When is albumin low? High?

A

<35 mg/L

>/= 35 g/L

62
Q

How may performance status be evaluated?

A

ECOG, assessing on a scale of 0-5

63
Q

ECOG 0?

A

Fully active

64
Q

ECOG 1?

A

Restricted in physically strenuous activity, OK for other lighter activity

65
Q

ECOG 2?

A

Ambulatory and capable of self care, but no work activities. Up and about for 50% of waking hours

66
Q

ECOG 3?

A

Only self-care. Confined to bed/chair more than 50% of waking hours

67
Q

ECOG 4?

A

Completely disabled, confined to bed.chair and no self-care

68
Q

ECOG 5?

A

Death

69
Q

What does PG-SGA stand for?

A

Patient-generated Subjective Global Assessment

70
Q

PG-SGA may be used for both screening and ?

A

Assessment

71
Q

What does PG-SGA do?

A

Will have patients complete on side, and will then be evaluated by healthcare professional

72
Q

What are the 4-boxes on the patient side of the PG-SGA?

A

1) Weight
2) Food intake
3) Symptoms
4) Activities and Function (same as ECOG)

73
Q

What is included on the HCP side of PG-SGA?

A

1) Weight scoring
2) Disease
3) Metabolic demands
4) Physical exam (muscle, fat and fluid status)

74
Q

When is PG-SGA indicative of dietetic education? Dietetic intervention?

A

Education: 2-3
Intervention: 4-8 (more common)

75
Q

What is the baseline nutritional assessment for patients with cancer?

A
  • Dietary assessment
  • Weight-loss history
  • Body composition
  • PG-SGA
  • Biochemical data (GPS)
  • Muscle strength
  • Physical examination
76
Q

Possible nutrition diagnosis in cancer?

A
  • Involuntary weight loss
  • Malnutrition
  • Dehydration
77
Q

What could be an etilogy of malnutrition?

A

Some patients may have unsupported beliefs and attitudes about food - especially in relation to cancer

78
Q

Goals of nutritional intervention?

A

1) Preventative
2) Adjuvant
3) Palliative

79
Q

Describe prevention nutritional intervention

A

In prevision of treatment that will affect nutritional status/pre-cachexia

80
Q

Describe adjuvant nutritional intervention

A

To improve nutritional status to initiate and support anti-cancer treatments (or in cachexia)

81
Q

Descrive palliative nutritional intervention

A

To improve or maintain the quality of life when anti-cancer treatments have stopped (refractory cachexia )

82
Q

Key points in nutritional counselling?

A
  • Individual
  • Provide adequate energy and protein
  • Consider multi-vitamin/mineral supplements
  • Adapt diet to therapy, appetite
  • Encourage PA
83
Q

Goals of nutritional approach?

A
  • Increase lean mass
  • Predispose to better response to treatment
  • Increase immunocompetence
  • Symptom management
  • Improve perception of well-being
84
Q

Why should we encourage PA in CA?

A

Beneficial for increasing mood and energy, improved quality of life and potentiate the nutritional support

85
Q

If we are dealing with a cachexia patient in active weight loss, should we focus on increasing lean mass or weight stabilization?

A

Weight stabilization as going from a catabolic to anabolic state is extremely difficult

86
Q

Why may energy prediction equations NOT be appropriate to use in cancer patients?

A

As REE either increases or decreases in patients (which we cannot determine) and REE may vary according to treatment

87
Q

What is used to predict E in CA?

A
  • Rule of thumb
  • 25-30 kcal/kg/day and depends on performance status (assumes more sedentary)
  • 35 if more active
88
Q

What is important when determining energy requirement?

A

Establish current intake (i.e. 24 hour recall) and then recommend increases to avoid severe weight-loss

89
Q

Obese patients may not need more energy, however may need what?

A

More protein

90
Q

If we feed the patient, do we feed the tumor?

A

NO evidence that this is the case, but is shown in animal models.

91
Q

Should we provide a certain ratio of CHO:Fat?

A

Not much evidence, but if there is insulin resistance we can increase ratio of fat:CHO and decrease simple CHO

92
Q

Protein in CA?

A

Above 1.0 to 1.5 g/kg/day

93
Q

Protein if inactivity an systemic inflammation?

A

1.2-2.0 g/kg/day

94
Q

Protein if kidney disease?

A

1.0-1.2 g/kg/day

95
Q

Why do protein needs increase in cancer?

A

Cancer therapy can increase cell turnover and cell death and we need protein to support

96
Q

(T/F) Micronutrient or mineral supplements should be recommended as dosages much greater than DRIs

A

False - but can be recommended in amount close to DRis

97
Q

Recommendations on micronutrient/mineral supplementation?

A
  • Consider prior and current diet and oral supplement use

- Avoid mega doses of single nutrient in absence of specific deficiencies

98
Q

What kind of intervention would allow for the increased oral intake of cancer patients who are able to eat, but are malnourished or at risk?

A

-Dietary advice, treatment of symptoms impairing food intake, offering ONS

99
Q

Diets that ____ should NOT be recommended to pts with or at risk of malnutrition

A

restrict energy

100
Q

Describe the appeal of keto diets in cancer

A

Animal studies showed some decrease in tumor growth but no clinical evidence in cancer patients
-Keto diets eliminate foods and may lead to weight loss

101
Q

Describe the appeal of fasting in cancer

A

Short-term fasting around the time of anti-cancer treatment suggested increased efficacy of treatment

102
Q

Are keto and fasting completely rejected as treatments?

A

NO, cannot be currently recommended, but enough evidence to pursue clinical trials

103
Q

If patients are able to eat what route is recommended?

A

ALWAYS oral

104
Q

How can we potentiate success in oral-feeding routes?

A
  • Enrich/modify texture
  • Eliminate food restriction (i.e. no low salt diets)
  • Take advantage of circadian patterns of appetite
  • Identify sensory changes (food odours, taste aversions)
105
Q

When should enteral nutrition be recommended?

A
  • Unable to ingest/digest foods
  • Surgery
  • Radio/chemo
  • Oral intake insufficient
  • May be provided alongside oral intake
106
Q

Advantages of enteral nutrition?

A

-Preserve GI architecture, barrier, immune function and gut permeability

107
Q

When may parenteral nutrition be administered?

A

When enteral route not accessible, severely malnourished patients and head/neck CA w/ multiple treatments

108
Q

When is parenteral nutrition NOT recommended?

A

In advanced cancer patients receiving chemotherapy

109
Q

How should parenteral nutrition be based on? When is it not appropriate?

A
  • Expected survival in order of months - not when close to death (<3 mo)
  • Refractory cachexia
  • Quality of life
110
Q

What are risks in parenteral nutrition?

A

Infection, and CA patients are immunosuppressed

111
Q

What is hematopoietic stem cell transplantation?

A

Treatment for hematological and lymphoid cancers, may be curative (previously known as bone marrow transplant)

112
Q

What are the 3 sources of stem cells used in HSCT?

A

1) Donor (allogenic)
2) Genetically identical twin
3) Autologous

113
Q

Which patients are at the highest risk of graft-versus host disease?

A

Thos undergoing allogenic HSCT

114
Q

Discuss to HSCT procedure (breif)

A

Stem cells harvested, then body undergoes conditioning (high dose chemo/total body irradiation) which eradicates malignant cells and decrease rejection (immunosuppression), then stem cells are infused back in an

115
Q

Complications with HSCT?

A
  • Infections associated with immunosuppression
  • Symptoms of toxicity of TBI
  • Graft-versus-host disease, long-term problems
116
Q

What are some symptom of toxicity from TBI?

A

Nausea, vomiting, mucositis, diarrhea, pancytopenia (deficiency of RBC, WBC and platelets)

117
Q

Nutrition approach for HSCT?

A
  • Avoid food at risk of infections, adopts safe food handling during neutropenia
  • Provide supplementalEN
118
Q

When is PN used in HSCT?

A

-Patients unable to ingest or absorb adequate nutrients for a prolonged period and those who develop severe GVHD

119
Q

What are 2 promising nutrition therapies for cachexia?

A

Omega-3

Amino Acids

120
Q

Omega-3 and cachexia?

A
  • Anti-inflammatory, reduce chemotoxicity

- May be recommended in most pts, since not harmful if <3 g/day

121
Q

When should omega-3s NOT be recommended?

A

In patients receiving anti-coagulation therapy

122
Q

(T/F) The anabolic response to sufficient protein/AA is maintained in CA patients

A

True

123
Q

Which AA have promise in CA?

A
  • Leucine

- Glutamine and arginine

124
Q

Leucine in CA?

A

Stimulates protein synthesis and insulin secretion, anabolic properties
-May be beneficial if consumed with omega-3,

125
Q

Glutamine and arginine in CA?

A

Increase immune competence, help would healing, could benefit pre and post OP

126
Q

10 days of bed rest in health, older subjects = ___ ofl eg muscle loss

A

1 kg

127
Q

How can the LBM and strength in the elderly and bed-ridden patients improve?

A

Resistance exercise and nutritional supplement

128
Q

Why does exercise improve nutrition?

A

Exercise is anabolic, and potentiate the effect of nutrition

-May increase appetite and well-being

129
Q

(T/F) Exercise cannot be done during chemo TX

A

False, no interference but adapt to lower intensity/duration

130
Q

When is exercise recommended?

A
  • During active treatment
  • During recovery
  • Long-term survivorship
131
Q

Key conclusion of CA?

A
  • We must combine dietary, physical, exercise and pharmacological
  • Individualized and early intervention

Clinical Nutrition 1 (30 decks)

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