Case-31-32 Nutrition and Breast Cancer – Medical Nutrition Therapy: A Case-Study Approach : Book Guide

This Document Contains Cases 31 to 32 Case 31 – Nutrition and Breast Cancer I. Understanding the Disease and Pathophysiology 1. Describe the incidence and prevalence of breast cancer in the United States. How has this changed over the previous decade? • In 2012, breast cancer was diagnosed in 1.67 million women and 6.3 million women have been living with the diagnosis over the past 5 years. • ~1/8 U.S. women will develop invasive breast cancer during their life • Incidence rates have been declining in the U.S. since 2000 (dropped 7% during the year from 2002 to 2003) 2. What are the risk factors for developing breast cancer? Explain potential genetic and environmental risk factors. Does Mrs. Smith have any of these in her history? • Risk factors for breast cancer: ○ Female ○ Age (increases with age) ○ Adult height (increased risk in taller individuals) ○ Larger birth weight ○ Family history of cancer ○ Late menopause ○ Early menarche ○ Exposure of radiation to chest (for younger females) ○ Hormone replacement therapy (progestin > 5 yrs) ○ BRCA1 or BRCA2 gene ○ Central adiposity in postmenopausal women • Yes, Mrs. Smith has some risk factors: family history of breast cancer (mom and sister), female, and older age (61 yrs). 3. Explain Mrs. Smith's diagnosis: Stage IIB Invasive Ductal Carcinoma T2N1miM0. Specifically discuss the type of breast cancer and the staging of her diagnosis. • This means that her breast cancer originated in the mammary ducts and is spreading. • Stage IIB means that the cancer is either T2, N1, M0 or T3, N0, M0 • The T2 indicates that the primary tumor site is 2-5 cm • The N1mi indicates that the cancer has spread to 1-3 axillary lymph nodes and are micro metastases (< 2mm) • M0 indicates that no distant metastasis has been found (via imaging or physical exam) 4. She was treated with Docetaxel, Doxorubicin and Cyclophosphamide chemotherapy regimen. What are these medications and how do they work? • Docetaxel is a chemotherapeutic that is used for breast, ovarian, and non-small cell lung cancer. It inhibits replicating cells during mitosis by stabilizing microtubules and preventing their de-polymerization. • Doxorubicin is an antibiotic and antineoplastic agent that damages DNA through strand breakage and intercalation between DNA base pairs. • Cyclophosphamide is antineoplastic drug through DNA alkylation/cross-linking of guanine bases. This inhibits the cell's ability to replicate and divide. 5. Mrs. Smith was also treated with radiation therapy. What is the basic mechanism of using radiation therapy as a component of treatment for breast cancer? • Radiation therapy (RT) uses ionizing radiation to damage DNA and cause cell death. Due to the rapid proliferation of cancerous tissue and RT's use of oxygen to augment the damage due to radiation, RT affects these cells to a greater degree. • RT is typically used in breast cancer to accompany the surgical resection of cancerous tissue to kill any remaining cancer cells that were not removed. 6. What are the major side effects of her chemotherapy and radiation therapy? • Chemotherapy side effects: ○ Neutropenia ○ Thrombocytopenia ○ Anemia ○ Diarrhea ○ Nausea/vomiting ○ Dysgeusia ○ Xerostomia ○ Mucositis ○ Alopecia ○ Some are cardiotoxic, neurotoxic, and/or nephrotoxic • Radiation therapy side effects: ○ Side effects depend on the area of the body being irradiated ○ Nutritional effects are not expected unless the esophagus is affected, which may include: • Mucositis, xerostomia, odynophagia ○ Late effects may include pneumonitis, lymphedema, other malignancies, and brachial plexopathy ○ Fatigue ○ Anorexia 7. Mrs. Smith recently underwent reconstructive surgery. She had the deep inferior epigastric perforator (DIEP) flap reconstructive procedure. Describe this procedure. • This procedure uses the excess skin and fat tissue from the lower abdomen (no muscle) to recreate the breast. The surgeon will do everything possible to recreate a symmetric and natural-looking breast(s). Recovery from the surgery is about 4-6 weeks before normal activities can be performed. II. Understanding the Nutrition Therapy 8. What are the general principles of nutrition therapy for a patient undergoing treatment for a malignancy? • Provide interventions to maintain adequate protein and energy intake to prevent malnutrition/cancer cachexia • Provide interventions to treat the common side effects of cancer treatment: ○ Nausea/vomiting • Small, low fat meals; avoid favorite foods when nauseous; avoid odorous foods; take antiemetic medication prior to meals ○ Early satiety • Small frequent meals; consume nutrient-providing beverages between meals; avoid high-fiber foods ○ Mucositis • Soft, non-fibrous, non-acidic foods; avoid hot foods; non-acidic juices/beverages to prevent dehydration; calorically-dense and protein-dense nutritional supplemental liquids may help meet intake requirements ○ Diarrhea • Drink small amounts of fluids throughout the day to prevent dehydration; avoid excessive intake of fructose containing beverages (e.g. fruit juices); consume good sources of soluble fiber and choose low fat foods. ○ Dysgeusia • Incorporate alternative high-protein foods (e.g. peanut butter, cheese, soy meat substitutes) due to problems associated with meats; encourage use of spices and marinades to flavor foods ○ Xerostomia • Sugar-free gum or sour candy to stimulate saliva production; avoid alcohol based mouthwashes; use lozenges and mouth-moisturizing gels. Drink frequently – use moist foods. ○ Anorexia • Small, frequent meals; maximize consumption when appetite is highest; don't consume empty calorie liquids during meals that prevent consumption of adequate calories and protein; mild exercise to stimulate hunger; use of energy- and protein-dense nutritional supplements • Abstain from alcohol or limit to less than one drink per day. 9. Now that Mrs. Smith has completed treatment for her breast cancer, what general nutrition recommendations can be made for prevention of cancer and specifically for breast cancer? • General: ○ Avoid sugary drinks ○ Limit consumption of processed foods high in sugar and fat ○ Eat more fruits, vegetables, whole grains, and legumes ○ Limit red meat and processed-meat consumption ○ Limit alcohol to no more than 1 or 2 drinks per day for women and men, respectively. ○ Limit salt consumption • Breast Cancer: ○ Vitamin D intake to meet normal serum vitamin D levels (not < 20 ng/mL) ○ Avoid/limit red meat consumption ○ Consumption of fish containing ω-3 fatty acids ○ Minimize alcohol intake ○ Increase fruits, vegetables, fiber, and polyphenol/phyto-estrogen-rich foods may help prevent breast cancer 10. Are there specific vitamin, mineral or herbal supplements that are recommended for prevention of breast cancer? • Vitamin D supplementation may be recommended to meet normal serum levels 11. What are the general nutrition therapy recommendations for Type 2 diabetes? To promote and support healthful eating patterns, emphasizing a variety of nutrient dense foods in appropriate portion sizes, in order to improve overall health and specifically to: Attain individualized glycemic, blood pressure, and lipid goals. General recommended goals from the American Diabetes Association for these markers are as follows:* A1C ,<7%. Blood pressure , 2 servings) of white wine per 24-hr recall. • Excessive fat intake related to food- and nutrition-knowledge deficit and consumption of high-fat meals as evidenced by 45% energy intake from fat and reported intake of 8 oz of filet mignon and fat-dense additives to foods (e.g. egg, mayonnaise, butter, ranch dressing). • Undesirable food choices related to food- and nutrition-related knowledge deficit as evidenced by consumption of 8 oz of filet mignon. 18. Write two PES statements for each nutrition diagnosis you have identified. V. Nutrition Intervention 19. Identify three major changes in Mrs. Smith's dietary intake that would be consistent with cancer prevention and survivorship guidelines, allow for continued weight loss and support the care of her Type 2 Diabetes. • Limit alcohol consumption to 2 servings) of white wine per 24-hr recall. Goal: Limit alcohol consumption to less than 1 drink (5 oz glass of wine) per day. Intervention: Patient education on importance of limiting alcohol consume and advise to consume only one 5-oz glass for dinner or her evening snack. • Excessive fat intake related to food- and nutrition-knowledge deficit and consumption of high-fat meals as evidenced by 45% energy intake from fat and reported intake of 8 oz of filet mignon and fat-dense additives to foods (e.g. egg, mayonnaise, butter, ranch dressing). Goal: Meet dietary recommendations to obtain 20%-35% of energy from fat. Intervention: Patient education on reducing added fat to foods and flavoring options (such as spices) to use instead. • Undesirable food choices related to food- and nutrition-related knowledge deficit as evidenced by consumption of 8 oz of filet mignon. Goal: Limit consumption of red/processed meats to less than 18 oz per week. Intervention: Patient education and counseling on the importance of avoiding/limiting red meat and proper portion sizes (e.g. palm of hand). Suggest to consume no more than 2.5 oz/day or 3 oz/day for 6 days of the week. 22. Mrs. Smith is interested in specific supplements that may help in cancer prevention. What would you tell her based upon the evidence? Provide suggestions for resources for Mrs. Smith that would support her decision making in regards to complementary and alternative medicine. • The American Institute for Cancer Research does not recommend using supplements to prevent cancer. • If you do choose to use supplements, speak with your physician about them due to their potential interactions with other medications/disease states. • Some resources include: ○ http://www.cam-cancer.org/ ○ breastcancer.org ○ cancer.org ○ aicr.org • www.aicr.org/reduce-your-cancer-risk/recommendations-for-cancer-prevention/recommendations_08_supplements.html • www.aicr.org/foods-that-fight-cancer/ 23. Mrs. Smith has asked about recommendations for physical activity. Provide credible resources and recommendations for her about physical activity. Determine at least three recommendations for increasing her physical activity. • Mrs. Smith should be physically active at least 30 minutes every day. • To get started, she should: ○ Add 30 min. physical activity to each day (e.g. hike, golf, run, aerobics, weight train) ○ Reduce time spent watching TV ○ Substitute moderate-level activities for more vigorous ones, twice weekly VI. Nutrition Monitoring and Evaluation 24. Write a note for your initial outpatient nutrition assessment and nutrition recommendations. Jennifer Smith, 7/8/2015 61 yo, F, referral from oncology clinic Onset of disease: Stage IIB invasive ductal carcinoma T2N1miM0 PMH: T2DM PSH: s/p hysterectomy, s/p R mastectomy, s/p deep inferior epigastric perforator flap reconstructive surgery 6 weeks ago Meds: metformin Labs: Glucose 137; CRP 1.1; Chol 210; TG 155; HbA1C 6.8; Hgb 11.9; Hct 36; transferrin 385; Diet Hx: lost weight 20 lbs d/t chemotherapy and RT; appetite is returning to normal "unfortunately"; wants to continue to lose weight; interested in changing diet to prevent cancer reoccurrence Diet: 24-hr recall: 1 c coffee; 1 c Cheerios w/ 1/2 cup strawberries, 1 c almond milk; 2 c coffee, granola bar; 3/4 c tuna salad (with egg and mayo) in tomato, 20 wheat thins, 1 can diet cola; 8 oz grilled filet mignon, 1 lg baked potato (w/butter, salt, pepper), salad (lettuce, spinach, croutons, sliced cucumber) w/ 3 tbsp ranch dressing, 12 oz Riesling wine;3 oz cheese w/10 wheat thins (~2926 kcal, 117 g pro, 18 g fiber, 45% fat) PA: walks dogs for 1/2 mile BID Alcohol: 1-2/week (wine) Ht: 5’5” Wt: 175# UBW: 195# %UBW: 89.7% IBW: 125# %IBW: 140% BMI: 29.2 kg/m2 EER: 1700-2000 kcal/d; EPR: 57-68 g/d; EER (for weight loss): 1300-1500 kcal/day D: Excessive energy intake related to large portion sizes as evidenced by an estimated energy intake of ~2900 kcal/day per 24-hr recall (900 kcal more than estimated needs). Undesirable food choices related to food- and nutrition-related knowledge deficit as evidenced by regular consumption of red meat and lower amounts of fruits and vegetables. I: Nutrition counseling and education on portion control, increasing fruits and vegetables, reducing dietary fat intake and red/processed meat consumption. Goals: Consume 1300-1500 kcal/day Consume less than 18 oz red/processed meat per week (~2.5 oz/day). M/E: Follow-up in 3-6 months Monitor weight status, adherence to nutrition therapy Monitor labs for glycemic control (BG, HbA1C - if available) and CVD risk (TG, Chol, LDL, HDL) Reassess motivation level/acceptance to lifestyle changes (consider additional diabetes counseling if necessary) Case 32 – Tongue Cancer Treated with Surgery, Radiation, and Chemotherapy I. Understanding the Disease and Pathophysiology 1. Mr. Seyer has been diagnosed with cancer of the tongue, which is a type of head and neck cancer. Head and neck cancers are categorized by the area where they begin. Describe these areas. • Oral cavity: this area includes the lips; gums; lining of the cheeks, lips, and under the tongue; the hard palate, the anterior 2/3 of the tongue, and an area of gums behind the wisdom teeth • Pharynx: the throat which leads to the esophagus and is divided into the nasopharynx (upper part by the nose), oropharynx (middle part in the back of the mouth), and hypopharynx (lower-most part) • Larynx: the organ that contains the vocal cords and epiglottis just below the pharynx • Paranasal sinuses and nasal cavity: nasal cavity and the small spaces in the bones surrounding the nose • Salivary glands: includes the glands beneath the tongue (mouth floor) and near the jawbone. 2. What are the major risk factors for development of head and neck cancer? Does Mr. Seyer’s medical record indicate that he has any of these risk factors? • Risk factors: ○ Tobacco use ○ Alcohol abuse (especially smoking and alcohol abuse in combination) ○ Diet low in fruits and vegetables ○ African American ○ Environmental exposures (wood/nickel dust inhalation, sun, asbestos) ○ Radiation to the head and neck ○ Human papillomavirus ○ GERD (chronic) • Mr. Seyer’s risk factors: ○ Smoker ○ HPV positive ○ Reports daily consumption of alcohol ○ Family history of cancer (Mother - liver cancer) ○ Possible occupational hazards - contractor (wood dust inhalation, asbestos) 3. Mr. Seyer’s biopsy results indicated an HPV postive tumor. What is HPV? Does this imply a better or worse outcome? • HPV stands for human papillomavirus and is the most common sexually transmitted infection. The different strains of HPV is related to various health problems including cancer and genital warts. • An HPV positive tumor implies a better prognosis 4. Mr. Seyer's cancer was described as Stage IV T2 N2b. Explain this terminology, which is used to describe staging for malignancies. • The stage number I-V refers to how extensive the disease is. ○ Higher numbers indicate more extensive disease, greater tumor size, and/or spread of the cancer to nearby lymph nodes and/or organs. ○ In stage IV, the cancer has spread to distant tissues and organs. • The Tumor Node Metastases (TNM) Staging System uses T, N, and M to further categorize the tumor. ○ The T category describes the original tumor: • TX means the tumor can’t be measured or found. • T0 means there is no evidence of a primary tumor. • Tis means the tumor has not started growing into surrounding tissues. • The numbers T1-T4 describe size and/or level of invasion into nearby structures. ○ The N category describes whether or not the cancer has reached nearby lymph nodes: • NX means nearby lymph nodes can’t be measured or found. • N0 means nearby lymph nodes do not contain cancer. • N1-N3 describe size, location, and/or the number of lymph nodes involved. ○ The M category tells whether there are distant metastases: • MX means metastasis can’t be measured or found. • M0 means there are no known distant metastases. • M1 means distant metastases are present. ○ In stage T2 N2b, it means that cancerous cells have invaded into nearby tissues and are found in 7 or more nearby lymph nodes. 5. Cancer is generally treated with a combination of therapies. These can include surgical resection, radiation therapy, chemotherapy, and immunotherapy. The type of malignancy and staging of the disease will, in part, determine the types of therapies that are prescribed. Define and describe each of these therapies. Briefly describe the mechanism for each. In general, how do they act to treat a malignancy? Surgical resection: Removal of part of an organ or a structure in an attempt to remove the malignancy from the body. Radiation therapy: • Therapeutic radiation is the use of electromagnetic energy, which can destroy rapidly proliferating cells. • It alters DNA enough to “brake” the cell cycle. • It reduces tumor size and is often used in conjunction with other therapies. Chemotherapy: • Interrupts cell DNA, RNA, or protein synthesis of the cell cycle. • Different types of drugs interrupt cell proliferation at different stages. • It is common therapy to use a combination of drugs, which will enhance the effectiveness of treatment and minimize overall toxicity. Immunotherapy: • Also called biological therapy and biotherapy • Medications that will stimulate your immune system and medications that contain components of the immune system such as interleukin or interferon 6. Mr. Seyer had a partial glossectomy and right neck dissection on 9/7. Describe these surgical procedures. How may these procedures affect him nutritionally? • Partial glossectomy: ○ This is the removal of part of the tongue and then sewing the remaining portion back together or using a small skin graft to cover the resected area (which is then sewn into place). During this procedure, a tracheotomy is used to facilitate breathing during the procedure. • Right neck dissection: ○ This involves an incision into the neck to remove the lymph nodes containing cancer cells. Special care must be taken in order to avoid important blood vessels and nerves. • Nutritional concerns: ○ Mr. Seyer will not be able to swallow until cleared by the SLP and will need nutritional support ○ May incur issues with pain, altered tastes, difficulty chewing and swallowing, dyspnea, and nausea/vomiting which all may lead to lower oral intake and diminished appetite. II. Understanding the Nutrition Therapy 7. Many cancer patients experience changes in nutritional status. Briefly describe the potential effect of cancer on nutritional status. • Presence of a malignancy may cause systemic effects such as: ○ Increased metabolism ○ Altered metabolism ○ Anorexia ○ Dysgeusia • Alterations in metabolism may include: ○ Insulin resistance ○ Increased glucose synthesis ○ Gluconeogenesis ○ Increased Cori cycle activity ○ Increased protein catabolism ○ Decreased protein synthesis ○ Increased lipid metabolism ○ Decreased lipogenesis ○ Decreased activity of lipoprotein lipase. • Fatigue and emotional trauma may also impact nutritional status. • Cancer treatment additionally add to these complications and may further reduce nutritional intake. 8. Surgery, radiation, and chemotherapy affect nutritional status. Describe potential nutritional and metabolic effects of these treatments. • Surgery can affect nutritional status in a variety of ways depending on where it is performed. • In the case of gastric cancer, a partial or total gastrectomy increases a patient’s risk for vitamin B12 deficiency. ○ Calcium and iron absorption will also be reduced. ○ Dumping syndrome, delayed gastric emptying, early satiety, nausea, and vomiting may also occur as a result. • Surgery to treat intestinal cancer may cause malabsorption of nutrients and steatorrhea. • In general, patients undergoing surgery may require additional calories and protein for wound healing. • Radiation therapy to the head and neck area can cause the following, all which can all make consuming an adequate diet difficult: ○ Mucositis ○ Dysgeusia ○ Xerostomia ○ Dysphagia ○ Odynophagia ○ Severe esophagitis • Because radiation therapy damages the epithelial cells the body’s ability to digest and absorb nutrients may be impaired. • Radiation to the abdominal and pelvic area can cause diarrhea, nausea, and vomiting. • Chemotherapy greatly affects cells with a high turnover rate and thus have effects on the cells of bone marrow, the epithelial lining of the GI tract, and the hair follicles. The most common side effects include: ○ Neutropenia, thrombocytopenia, anemia ○ Diarrhea ○ Mucositis ○ Alopecia III. Nutrition Assessment 9. Calculate and evaluate Mr. Seyer’s %UBW and BMI. % UBW: 198/228 = 0.87  100 = 87% UBW – 13% weight loss in last 5-6 months BMI: 198/752  703 = 24.7 (within normal limits) 10. Summarize your findings regarding his weight status. Classify the severity of his weight loss. What factors may have contributed to his weight loss? Explain. • His weight loss is considered severe, which puts him at nutritional risk. (Anything >10% unplanned weight loss over six months is considered to be severe.) Additionally, the physical assessment indicating some muscle wasting suggests malnutrition, too. • Factors that may have contributed to his weight loss include: ○ Odynophagia ○ Decreased appetite ○ Early satiety ○ Anorexia ○ Dysgeusia • Mr. Seyer notes that he has not been able to eat because of the pain, feeling full early, and a diminished appetite. He also stated that liquids are easier to consume due to the pain, toast is too dry and bacon isn't appealing. • These factors in combination with increased needs due to the malignancy have resulted in significant weight loss over a short time period. 11. What does research tell us about the relationship between significant weight loss and prognosis in cancer patients? • Significant weight loss greatly increases risk of mortality in cancer patients. • Malnutrition can: ○ Reduce responsiveness to chemotherapy and radiation therapy ○ Increase perioperative morbidity ○ Reduce immune responses ○ Worsen the quality of life ○ Diminish likelihood of survival 12. Estimate Mr. Seyer’s energy and protein requirements based on his current weight. Energy Requirements (30-35 kcal/day for weight gain): 30-35 kcal/kg x 90 kg = 2700-3150 kcal/day Because there is evidence of some muscle wasting, protein needs will be greater: 1.2-1.5 g protein / kg body weight = 1.2-1.5  90 kg = 108-135 g 13. Estimate Mr. Seyer’s fluid requirements based on his current weight. 30 mL/kg: 30  90 = 2700 mL (range 2700-2800 mL) 14. What factors noted in Mr. Seyer’s history and physical may indicate problems with eating prior to admission? • Odynophagia • Sore throat/dry mucous membranes • 30 lb weight loss/some muscle wasting (low oral intake) • Early satiety • Anorexia • Dysgeusia 15. Mr. Seyer is currently receiving enteral nutrition, specifically Isosource HN at 75 mL/hr per PEG tube. a. Calculate the amount of energy and protein that will be provided at this rate. Isosource HN provides 1.2 kcal/mL and 0.0536 g protein/mL. At 75 cc/hr fed for 24 hours continuously, the feeding would provide 2160 kcal and 96.5 g of protein. 75 cc  24 hrs = 1800  1.2 kcal/mL = 2160 kcal 1800  0.0536= 96.5 g protein b. Next, by assessing the information on the intake/output record, determine the actual amount of enteral nutrition he received on September 11. 1735 mL – His rate was decreased for one shift during this period. 1735 mL  1.2 kcal = 2082 kcal 1735  0.0536 = 93.0 g c. Compare this to his estimated nutrient requirements. • Mr. Seyer received 96% of his prescribed enteral feeding but is only receiving 77% of his estimated energy requirements. • He is receiving approximately 86% of his protein requirements. d. Compare fluids required to fluids received. Is he meeting his fluid requirements? How did you determine this? Why would you evaluate his output when assessing his fluid intake? • His input (IV and enteral feeding) documented in the I/O record was 4285 mL. • 1735 mL of the enteral formula provided 1419 mL of water (818 mL H2O/1 L of formula). Adding the 2400 mL he received via IV gives him a total of 3819 mL/day. Mr Seyer is meeting his fluid requirements of 2700 mL/day. • His output was 3700 mL in urine and an additional 300 mL in stool output. • He is in a positive fluid balance with an excess of 285 mL for 9/11. • It is important to evaluate his output to ensure renal function is adequate and he is properly hydrated. 16. What type of formula is Isosource HN? One of the residents taking care of Mr. Seyer asks about a formula with a higher concentration of omega-3-fatty acids, antioxidants, arginine, and glutamine that could promote healing after surgery. What does the evidence indicate regarding nutritional needs for cancer patients and, in particular, nutrients to promote postoperative wound healing? What formulas may meet this profile? List them and discuss why you chose them. • Isosource HN is a high-protein formula. • Both cancer patients and those undergoing wound healing have increased energy and protein needs. • Supplementation with arginine and glutamine may be important during times of metabolic stress when their synthesis rate cannot meet the increased needs. ○ Supplementation with arginine may assist with inhibiting the immunosuppression and improve nitrogen balance. ○ Supplementation with glutamine may decrease the infection rate and prevent translocation of bacteria from the GI tract. • EPA (omega-3-fatty acid) supplementation has been shown to support weight mainenance and preservation of lean body mass in cancer patients experiencing weight loss • Juven (modular to be added to tube feeding or other beverage) contains supplemental HMB, arginine and glutamine. • Impact Glutamine contains arginine and omega-3-fatty acids and is marketed as immunonutrition for surgical patients. • Impact Peptide 1.5 provides arginine, glutamine, nucleotides, and EPA and DHA for immunonutrition. • Pivot 1.5 Cal contains arginine, glutamine, and omega-3 fatty acids. 17. Are any clinical signs of malnutrition noted in the patient’s admission history and physical? • Sunken eyes • Evidence of some muscle wasting in extremities 18. Review the patient’s chemistries upon admission. Identify any that are abnormal and describe their clinical significance for this patient, including the likely reason for each abnormality and its nutritional implications. Albumin 9/5, 9/11: normal 3.5-5.5, Mr. Seyer 3.1, 3.0 • Reason for abnormality: ○ Inadequate nutritional intake ○ Increased nutritional needs ○ Malnourished ○ Inflammatory response - serum levels are reduced as a result of inflammatory process and a reduction in hepatic synthesis • Nutritional implications: ○ Decreased levels are associated with increased risk of morbidity and mortality. ○ Increase protein intake and provide adequate nutrition support. Total protein 9/5, 9/11: normal 6-7.8, Mr. Seyer 5.7 Prealbumin 9/5, 9/11: normal 18-35, Mr. Seyer 15, 12 • Reason for abnormality: ○ Inadequate nutritional intake ○ Increased nutritional needs ○ Malnourished ○ Inflammatory response - serum levels are reduced as a result of inflammatory process and a reduction in hepatic synthesis • Nutritional implications: Provide adequate nutrition support. RBC 9/5, 9/11: normal 4.5-6.2, Mr. Seyer 4.2, 4.3 • Reason for abnormality: ○ Possible anemia ○ May be associated with malignancy and subsequent bone marrow suppression • Nutritional implications: ○ No specific nutritional implications but supports overall need for nutrition therapy ○ Adequate kcal and protein HGB 9/5, 9/11: normal 14-17, Mr. Seyer 13.5, 13.9 • Reason for abnormality: ○ Possible anemia ○ May be associated with malignancy and subsequent bone marrow suppression ○ Protein-energy malnutrition • Nutritional implications: ○ No specific nutritional implications but supports overall need for nutrition therapy ○ Adequate kcal and protein HCT 9/5, 9/11: normal 41-51, Mr. Seyer 38 • Reason for abnormality: ○ Possible dehydration (9/5) ○ Possible anemia ○ May be associated with malignancy and subsequent bone marrow suppression • Nutritional implications: ○ No specific nutritional implications but supports overall need for nutrition therapy ○ Adequate kcal and protein MCH 9/5, 9/11: normal 26-32, Mr. Seyer 32.4, 32.3 MCHC 9/11: normal 32-36, Mr. Seyer 36.5 • Reason for abnormality: ○ Possible anemia ○ May be associated with malignancy and subsequent bone marrow suppression • Nutritional implications: ○ No specific nutritional implications but supports overall need for nutrition therapy ○ Adequate kcal and protein 19. Mr. Seyer has been diagnosed with a life-threatening illness. What is the definition of terminal illness? An illness that has no cure. 20. The literature describes how a patient and his family may experience varying levels of emotional response to a terminal illness. These may include anger, denial, depression, and acceptance. How may this affect the patient’s nutritional intake? How would you handle these components in your nutritional care? What questions might you have for Mr. Seyer or his family? List three. • The emotional trauma experienced in response to a terminal illness may cause a lack of interest in food and a decreased appetite. • It is important that the patient know the treatment team is doing everything necessary to improve quality of life and adequate nutrition is a major part of that. • Adequate nutrition will also increase success of the other treatments such as chemotherapy and radiation therapy. • A referral to a specialist such as a social worker, psychiatrist, and/or psychologist may help with emotional side effects. • Questions the RD may want to ask include: ○ Is there a caretaker in the home who can ensure Mr. Seyer is consuming an adequate diet? ○ Does Mr. Seyer have a history of depression? ○ Are there others outside the household who may be able to be part of a support group? IV. Nutrition Diagnosis 21. Select two high-priority nutrition problems after Mr. Seyer’s surgery and complete the PES statement for each. The following are possible PES statements. It may be helpful for students to initially write more than two nutrition diagnoses and then prioritize as to the ones that are most likely to have immediate nutrition interventions. • (Admit) Inadequate protein-energy intake related to nutrition prescription for Isosource HN at goal rate of 75 mL/hr, which provides 2160 kcal and 96 grams protein compared to estimated nutrient needs of 2700-3150 kcal and 108-135 grams protein • Inadequate enteral nutrition infusion related to nutrition prescription for Isosource HN at goal rate of 75 mL/hr, which provides 2160 kcal and 96 grams protein compared to estimated nutrient needs of 2700-3150 kcal and 108-135 grams protein • Unintended weight loss related to inadequate protein-energy intake and odynophagia as evidenced by a 30-pound weight loss within the past several months from 228# to present weight of 198#, some muscle wasting, and low oral intake. V. Nutrition Intervention 22. For each of the PES statements you have written, establish an ideal goal (based on the signs and symptoms) and an appropriate intervention (based on the etiology). • (Admit) Inadequate protein-energy intake related to nutrition prescription for Isosource HN at goal rate of 75 mL/hr, which provides 2160 kcal and 96 grams protein compared to estimated nutrient needs of 2700-3150 kcal and 108-135 grams protein ○ Ideal Goals: Enteral nutrition will meet nutrient needs ○ Intervention: Recommend change in formula to higher-protein/higher-calorie product (2 kcal/mL) or increase in rate with current feeding (95 mL/hr) • Inadequate enteral nutrition infusion related to nutrition prescription for Isosource HN at goal rate of 75 mL/hr, which provides 2160 kcal and 96 grams protein compared to estimated nutrient needs of 2700-3150 kcal and 108-135 grams protein ○ Ideal Goals: Enteral nutrition will meet nutrient and fluid needs ○ Intervention: Recommend increase in rate or change in formula to a higher-protein/higher-calorie product • Unintended weight loss related to inadequate protein-energy intake and odynophagia as evidenced by a 30-pound weight loss within the past several months from 228# to present weight of 198#, some muscle wasting, and low oral intake. ○ Ideal Goals: Patient does not lose any more weight ○ Intervention: Recommend change in formula to higher-protein/higher-calorie product (2 kcal/mL) 23. Does his current nutrition support meet his estimated nutritional needs? If not, determine the recommended changes. Discuss any areas of deficiency and ideas for implementing a new plan. • His current nutrition support does not meet his nutritional needs. • Increasing the rate to 95 mL/hr would meet his needs. • If this rate is too high, other formulas higher in caloric density (2 kcal/mL) may be preferable. • Examples of formulas better suited to the diagnosis include those with added arginine, glutamine, and omega-3-fatty acids. 24. How may these interventions (from #22) change as he progresses postoperatively? Discuss how Mr. Seyer may transition from enteral feeding to an oral diet. • The initial oral diet will be modified in texture (softened/pureed foods and thickened liquids) • The SLP will have to assess Mr. Seyer's swallowing capacity and a modified-textured diet will be prescribed. • As the oral diet increases in adequacy, enteral feeding can be reduced. ○ A general rule of thumb is that when oral intake meets 60% of estimated energy requirements, enteral feeding can be weaned. • An option for Mr. Seyer is that he receive his enteral feeding cycled at night and be able to consume solid food while awake. VI. Nutrition Monitoring and Evaluation 25. List the factors you should monitor for Mr. Seyer while he is receiving enteral nutrition therapy. • Monitor sufficiency of nutrient intake daily (weekly if nutritionally stable) • Monitor electrolytes, BUN, creatinine daily then 3  per week when nutritionally stable • Magnesium, phosphorus, calcium daily then 3  per week when nutritionally stable • Hydration status 3  per week • Bowel function as needed • Nitrogen balance as necessary 26. Mr. Seyer will receive radiation therapy and chemotherapy as an outpatient. In question #8, you identified potential nutritional complications with both. Choose one of these nutritional complications and describe the nutrition intervention that would be appropriate. Mucositis • Sip warm tea slowly. • Eat chilled foods and fluids. • Eat soft foods that are moist and easy to swallow. • Eat small, frequent meals of bland, non-spicy foods. Avoid raw vegetables and fruits, and other hard or crusty foods such as chips or pretzels. • Avoid acidic fruits and juices, such as tomato, orange, grapefruit, lime, or lemon. • Avoid carbonated drinks. • High-calorie, high-protein milkshakes or nutritional supplements may be beneficial (Ensure, Boost, Resource, etc.). Dysgeusia • Avoid metal utensils. • Use plastic utensils. • If meat is not tolerated, try peanut butter, cottage cheese, cheese, poultry, and soy meat substitutes. Xerostomia • Rinse mouth with water and baking soda (½-1 tsp in 8 oz water) every 2 hrs while awake. • Avoid mouthwashes that contain alcohol. • Brush with a very soft “baby” toothbrush. • Avoid tobacco, alcohol, coffee, and tea as these may exert a drying effect. • Increase fluid intake to assist chewing and swallowing. • Carry a water bottle and sip regularly throughout the day. • Limit foods that stick to teeth to cut back the risk of caries. • Use Chapstick® and moisturizing gels on lips. Dysphagia: Thickening agents may be necessary (readily available foods from the grocery store can be used as thickeners). Odynophagia • Avoid hot foods (temperature); allow them to cool to room temperature. • Avoid rough foods like nuts, crackers, dry cereal, and raw fruits and vegetables. • Avoid spicy foods or “acidic” foods likes tomatoes, oranges, grapefruits, lemons, or limes. • Ice chips or a cool drink may soothe the pain. • Soft or pureed food, like applesauce, puddings, custards, mashed potatoes, cooked cereals, high-protein milkshakes, ice cream, ice milk, or sherbet, may cause less pain. • Drink liquids through a straw. • Avoid alcohol and tobacco. • Take small bites and chew food thoroughly. Diarrhea • Drink small amounts of liquids frequently throughout the day (avoid excessive fruit juice) • Increase intake of foods high in soluble fiber (this may conflict with anorexia and meeting adequate amounts of oral intake) 27. Identify major assessment indices you would use to monitor his nutritional status once he begins therapy. • Weight – weekly • Nutritional intake – 24-hour recall, food diary, interviews • Nutrition-focused physical assessment (presence of subcutaneous fat and muscle wasting and hand-grip strength) Solution Manual for Medical Nutrition Therapy: A Case-Study Approach Marcia Nahikian Nelms 9781305628663, 9780534524104, 9781133593157