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Prevalence The National Cancer Institute (NCI 2000) estimates that about 8.9 million Americans alive today (3.75 million males and 5.15 million females) have a history of CA. About 1,268,000 new cancer cases (excluding carcinoma in situ of any site except urinary bladder) will be diagnosed annually and more than one million skin cancers will be recognized (ACS 2001).

About 553,400 people are expected to die from cancer in 2001, more than 1,500 per day. In the US, one in four deaths are attributable to CA. This makes cancer the second leading cause of death in the US, exceeded only by the cardiovascular diseases. Lung cancer accounts for the most cancer deaths in the US for both men and women (ACS 2001). The death rates for other forms of CA have declined by approximately 16% over the last 50 years. Today 60% (six in 10) of patients who develop CA will be alive five years post diagnosis (ACS 2001). Subgroups at Risk Cancer is in large measure a disease of the elderly. Fifty-eight percent of cancers in the US are diagnosed in people 65 years of age or older (Yancik 1994). Older people have a 10 times greater risk of developing cancer than those under 65 years of age. A list of most common types of cancers (Yancik 1994) that occur in the US, and estimates of the percentages of these cancers that occur in people over age 60 are: Cancer Type Men Women Lung/bronchus 63% 61% Colon 73% 78% Rectum 65% 71% Urinary/bladder 70% 74% Stomach 68% 75% Pancreas 68% 77% Prostate 84% -- Breast (female) -- 50% Ovary -- 49% Compared with the rest of the US population, older people suffer disproportionately from the morbidity, adversity, and hardship caused by CA. Eighty-one percent of all CA mortality occurs in people 60 years of age and older (ACS 2001). Mortality rates for the cancers mentioned above in men over age 65 range from a low of 63% for lung CA to a high of 90% for prostate CA. In women, mortality rates range from a low of 54% for breast CA to a high of 87% for urinary/bladder CA. In the US, the lifetime risk of developing cancer (probability that during the course of one's lifetime, an individual will develop CA) is 1 in 2 for men and 1 in 3 for women (ACS 2001). Smokers are 10 times more likely to develop lung cancer than non-smokers. Women with a mother, sister, or daughter who have breast CA are twice as likely to develop breast CA as women without this family history (ACS 2001). A number of external factors (diet, smoking, alcohol, sun exposure, viruses) and internal factors (hormones, immunocompetence, genetic mutations) contribute to CA causation. Cancers caused by cigarettes and excessive alcohol could be completely prevented (195,000 deaths annually). Many cancers related to dietary factors (187,000 deaths annually) could also be prevented. For the majority of Americans who don't smoke or drink alcohol to excess, dietary choices and physical activity are the most important modifiable determinants of CA risk (ACS 2001 Web site). It is currently estimated that about 32% of cancers may be avoidable by changes in diet (Willett 1995), with 20-42% of cancer deaths avoidable by dietary change. For all types of CA combined, cancer incidence rates (per 100,000) by gender, race and ethnicity (ACS 2000) are listed in descending order of occurrence. African-American males are at the highest risk for cancer occurrence.

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Males (per 100,000) Females (per 100,000) African American (598) White (352) White (476) African American (337) Asian/Pacific Islander (323) Asian/Pacific Islander (247) Hispanic (323) Hispanic (241) American Indian (176) American Indian (137) Impact of Nutritional Status on Disease Incidence, Progression, Prognosis and Health Outcomes Depending on the cancer site, 60-90% of patients will experience progressive weight loss during their cancer course. Weight loss of greater than 10% has been noted in 45% of hospitalized adult cancer patients. In some cancers, weight loss is the most frequent presenting complaint—more than 20% of cancer deaths are estimated to be due to cancer or treatment induced malnutrition and wasting (see Fig. 1) (Langer, Hoffman, Ottery 2001). Nutrition habits/food choices that impact the risk of developing CA (ACS 2001, NSI 1997) may include: • Type of food eaten (plant sources versus animal sources) • Food preparation method (low fat, limit smoked or pickled foods) • Serving size (moderate) • Variety (maximize vitamin/mineral intake from food sources) • Total caloric intake (maintain a reasonable weight, BMI of 22-27) • Alcoholic beverage intake (moderate consumption, if at all)

In individuals who have CA, those at risk are those with cancers that by their nature interfere directly or indirectly with food and nutrient intake. These include cancers affecting: • Oropharynx and GI tract (↓ intake/absorption) • Locomotion, i.e. soft tissue sarcoma (↓ access to food) • Cognition, i.e. CNS tumors (↓ appetite, food intake) • Endocrine system, i.e. carcinoid tumors (↓ absorption, ↑ metabolism) • Paraneoplastic syndromes (effects of CA that occur at a site remote from the primary tumor and its

metastases - multiple effects) The presence of CA and the various antineoplastic regimens used in its treatment (surgery, radiation therapy, chemotherapy) can have a profound impact on nutritional status, just as nutritional status impacts the nature and extent to which various therapeutic modalities can be implemented and the degree to which they will succeed. Nutritional co-morbidities commonly seen in patients with CA (Shils 1994) include: • Anorexia/cachexia with progressive weight loss and undernutrition (to be discussed later in more

detail) • Sensory changes (taste, smell) that alter food intake • Tumor induced alterations in nutrient metabolism

- protein, fat and/or carbohydrate - hypercalcemia - hypophosphatemia/osteomalacia - hypo-/hyperglycemia

• Increased energy expenditure irrespective of body weight and activity level • Impaired food intake and malnutrition secondary to

- bowel obstruction - tumor induced intestinal dysmotility

• Malabsorption secondary to - deficiency/inactivation of pancreatic enzymes - deficiency/inactivation of bile salts - small bowel fistula - infiltration of small bowel, lymphatic system or mesentery by malignant cells - blind loop syndrome (bacterial overgrowth) - small bowel hypoplasia induced by malnutrition

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• Protein-losing enteropathy • Anemia secondary to

- chronic blood loss - bone marrow suppression

• Fluid and electrolyte disturbances secondary to - persistent vomiting (obstruction, intracranial tumors) - diarrhea, fistula - intestinal secretory abnormalities with hormone-secreting tumors - inappropriate antidiuretic hormone secretion (e.g. lung CA) - hyperadrenalism (tumors producing corticosteroids/corticotrophin)

• Miscellaneous organ dysfunction with nutritional implications - gastrinomas (gastric ulcers) - brain tumor (coma)

Fig. 1

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Cancer Anorexia Anorexia, absence of appetite, is common in cancer patients. For patients, family and healthcare professionals, anorexia often represents a major hurdle in the road to recovery or resumption of an acceptable quality of life. While a variety of etiologic factors are involved in the development of anorexia, a commonly held theory implicates the cytokine interleukin-1 (IL-1). IL-1 is believed to have a central and peripheral effect. Centrally it increases serotonin release and neuronal firing rate of the hypothalamus. Peripherally, it stimulates a high rate of serotonin synthesis by supplying the hypothalamus with the serotonin precursor aminoacid, tryptophan (Fig.2). (See Fig. 4 for more information about nutritional interventions in cancer anorexia and treatment choices based on the condition of the patient.)

Fig. 2

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Cancer Cachexia Cachexia is derived from two Greek words: “Kakos” meaning “bad” and “hexis” meaning a “state of habit of being”. It has been defined by Moldawer as “a syndrome characterized by the progressive loss of lean tissue (primarily somatic) and body fat, and losses are often in excess to that explained by the associated anorexia. There are often additional metabolic derangements, including anemia, acute phase induction and alterations in the plasma lipid profile. A detailed discussion of the pathogenesis and proposed mechanism for the development of cancer cachexia is offered by Moldawer and Ottery (Moldawer, 1997, Langer, Hoffman and Ottery 2001). Characteristics of cancer cachexia, “the wasting illness,” include: • Anorexia • Weight loss • Diminished lean body mass • Abnormal metabolism • Negative energy balance The etiology of cancer cachexia is primarily related to insufficient nutrient intake relative to energy and protein requirements. Cancer cachexia is related to tumor site (proximity to host immune cells may be important), but not to histiologic differentiation, disease duration, size or stage, though it behaves as a paraneoplastic syndrome. Abnormalities in anabolic regulatory (neuroendocrine) hormones have been implicated in the development of cancer cachexia, with decreased insulin:glucagon ratios noted. Combined administration of insulin, growth hormone and somatostatin can reverse some of the host changes seen in cachexia. Other mediators involved in cancer cachexia include proinflammatory cytokines, other neurotransmitters, including neuropeptide Y, ARP, MCH (orexin), and tumor derived or associated proteins, like proteolysis inducing factor (PIF).

Fig. 3

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Assessment and Management of Cancer Cachexia The early identification of patients at risk for or with cancer cachexia is of paramount importance in successful outcomes. A variety of tools and tests are available. One particular assessment tool which has been validated and continues to gain acceptance is the patient-generated subjective global assessment (PG-SGA) developed by The Society for Nutritional Oncology Adjuvant Therapy (NOAT) and adopted by The American Dietetic Association’s Oncology Dietetic Practice Group. Developed in 1993 from the original SGA of Detsky et. al., in 1987, this simple-to-administer tool is able to classify the risks of malnutrition and cachexia from information available directly from the patient or a surrogate. The PG-SGA has been available in Spanish since 1998. The pharmaconutrition management of cancer cachexia has four components: • Appetite stimulants (orexigenic). Agents include progestational agents (e.g., megesterolacetate), THC

related agents (e.g., dronabinol, marijuana), cortiosteroids (e.g., prednisolone acetate, dexamethasone), cyproheptadine, periactin and ethanol. While these agents can increase appetite and weight they do not prevent the decline in somatic and visceral protein which is so devastating to the cancer patient.

• Anti-metabolic and anti-catabolic agents. These are employed with the hopes of down-regulating the

proinflammatory cascade that leads to anorexia and/or cachexia. These include pentoxyfylline, hydrazine sulfate, thalidomide, melatonin and others including steroids and non-steroidal auto inflammatory agents such as ibuprofen. In addition, alteration in the composition of dietary fats to increase levels of the less inflammatory prostaglandins precursors EPA (Eicosapentaenoic acid) and fish oils have also been proposed. The majority of studies using these modalites have not demonstrated consistent benefits. However, recent reports by Barber et. al. (1999 a & b) using combinations (i.e., ibuprofen, fish oil, megestrol acetate) appear promising.

• Anabolic agents. Though often fraught with undesirable side effects, anabolic agents have been

shown to improve the protein status in selected patients. These agents include testosterone, nandrolone, oxandrolone, growth hormone and others.

• Appropriate nutrition. In addition to utilizing the three previous modalities, appropriate nutrition, preferably through the oral route, is recommended. In general, 25-30 cal/kg. day and 1.5 g-2.0 g of protein/kg per day is recommended, if tolerated, for the moderately/severe stressed cachectic cancer patient.

These four modalities provide appetite stimulation, reduce inflammatory response, increase anabolic signals and provide the necessary macro and micronutrients. When these methods are combined with attempts to reduce or eliminate inflammatory nidus through tumor excision or debulking, they offer the optimal approach to reduce cancer cachexia. Impact of CA on Health Services Utilization and Costs The estimated annual national economic burden of CA (in billions) is as follows (Brown 1990): Cost Category All Neoplasms Malignant Neoplasms Direct $ 35.2 $ 29.3 Morbidity $ 11.9 $ 9.9 Mortality $ 56.8 $ 55.1 Total $ 103.9 $ 94.3

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Screening exams, conducted at regular intervals, can detect cancers of the breast, tongue, mouth, colon, rectum, cervix, prostate, testis, and skin (ACS 1997). The relative survival rate for these cancers is about 80%. If all Americans participated in regular CA screening this rate could increase to more than 95%. Estimated annual national costs for various CA screening tests (Brown 1990) are: Screen No. performed Cost/Screen Total Cost (millions) (billions) Mammography 16.0 $120.00 $1.92 Pap Test 4.8 $ 10.00 $0.49 Fecal-occult blood 19.0 $ 5.00 $0.09 Sigmoidoscopy 14.2 $100.00 $1.42 Total Screening Costs $3.92 These are conservative estimates for numbers of people screened and cost/procedure. The completion of the human genome project coupled with other advances in genetic research will result in the introduction of tumor markers and genetic profiling for cancer and may lead to increased costs. Alternative/Complementary Integrative Medicine Therapies An additional category of costs not included in the above data is the cost of alternative and complementary cancer therapies. An estimated 42% of Americans used one or more of sixteen alternative therapies in 1997 spending an estimated $34.4 billion on out-of-pocket therapies and visits (Eisenberg 1998). Americans made more visits to alternative practitioners in 1997 (629 million) than to primary care physicians (386 million). These figures are higher than those obtained from a similar survey in 1990 (Eisenberg 1993) indicating an increased utilization of these therapies and practitioners. Each year over $34 billion (ACS 2000) are spent on complementary and alternative treatments, often marketed to cancer patients. Although more than half of cancer patients participate in alternative and complementary therapies, this information is often poorly communicated by patients to their oncologist for several reasons, including lack of inquiry by physicians and patient sense that the information is not important. With some reported positive outcomes using complementary methods, several medical schools have incorporated the study of complementary and alternative medicine into their curriculums. Major insurance carriers are beginning to cover some alternative and complementary cancer treatments, such as acupuncture and chiropractic treatments. While alternative and complementary treatments represent cost savings to insurance carriers, studies to support the financial benefits are lacking. Since insurance carriers are also more likely to cover services that are prescribed by a physician, patients may bear the entire brunt of complementary and alternative therapies. The American Cancer Society’s Guide To Complementary and Alternative Care Methods lists the following categories: • Mind, Body, and Spirit Methods - focuses on the connections between the mind, body, and spirit, and

their power for healing. These methods include: aromatherapy, art therapy, biofeedback, folk healing, faith healing, hypnosis, holistic medicine, imagery, prayer, yoga, tai chi and feng shui.

• Manual Healing and Physical Touch Methods - treatment methods involve touching, manipulation, or

movement of the body. These techniques are based on the idea that problems in one part of the body often affect the other parts of the body. Examples of these methods include: acupuncture, kinesiology, rolfing, shiatsu, salves, chiropractic, colon therapy, magnet therapy, hyperbaric therapy, osteopathy, psychic surgery, therapeutic touch, reflexology and reiki.

• Herb, Vitamin, and Mineral Methods - plant-derived preparations that are used for therapeutic

purposes, as well as everyday vitamins and minerals. These products include: beta-carotene, cat’s claw, copper, black cohosh, chamomile, folic acid, ginger, ginseng, kava, licorice, thistle, peppermint, psyllium, selenium, vitamins A, B, C, and E, yohimbe, zinc, St. John’s wort, ginko biloba and echinacea. Herbal products have no documented effects in treating or preventing cancer.

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• Diet and Nutrition Methods - dietary approaches and special nutritional programs related to

prevention and treatment. Included are a wide variety of mushrooms, teas, soups and grasses, as well as a wide range of food preparations.

• Pharmacological and Biological Treatment Methods - substances that are synthesized and produced

from chemicals or concentrated from plants and other living things. Examples in this category include: animal cell injections, apitherapy, animal cartilage, chelation, DiBella therapy, DMSO, enzyme therapy, homeopathy, hydrogen peroxide therapy, laetrile, liver flush, melatonin, oxygen therapy and uro-therapy.

Alternative therapies that promise a cure or to prolong survival of a person living with cancer should be treated cautiously and with skepticism, as should those that promise benefits without side-effects, claim to treat a wide variety of diseases or contain secret ingredients. Patients should be selective when choosing alternative/complementary methods. Conventional therapy with alternative options should be discussed with care between the patient, physician, dietitian and oncology treatment team. It is imperative to realize that individual treatment plans are necessary and that there are individual variations in the response of patients to these unconventional methods. It is also important to remember that alternative and complementary therapies have no scientific evidence to support any claim that they effectively prevent or treat cancer. In fact, some may have adverse effects on the patient and interfere with traditional medical treatment. However, some alternative and complementary therapies may promote healing, relaxation and increase the patient’s quality of life. Consuming fruit, vegetables, grains, and fiber and avoiding excess dietary fat are preventive nutritional strategies widely embraced by the medical and scientific community. These foods have been shown in numerous studies to reduce cancer risk and the risk for most of the chronic diet-related diseases (ACS 2001 Web site). However, many purveyors of alternative regimens go beyond the realm of proven efficacy often claiming that a particular diet, strategy, device, or supplement will cure CA. Although a smaller percentage of CA patients use alternative therapies than the general population, an estimated 6-14% of individuals with CA purchase these services annually (Cassileth 1996). They are at significant risk for poor nutritional status, poor health outcomes, and poor, or at least no better, health or quality of life. Goals of Nutrition Management for CA Food choices and physical activity are the most important modifiable determinants of CA risk in people who do not smoke or drink to excess (ACS 1997, 2001). Goals of nutrition screening and intervention to reduce CA risk are for the individual to: • Maintain a reasonable weight (BMI 22-27) • Choose the majority of foods from plant sources • Limit intake of high fat foods, especially those from animal sources • Increase dietary fiber intake to 20-30 g/day (upper limit 35 g/day) • Moderate consumption/eliminate alcoholic beverages • Minimize intake of salt-cured, salt-pickled, or smoked foods • Become physically active Maintenance of optimal nutritional status in people with CA is of critical importance in the management of this disease. The presence of malignancy negatively impacts nutritional status, leading to increased morbidity and mortality (Laviano 1996). The goals of nutrition screening and intervention in people with cancer are: • Maintenance of a reasonable weight (BMI 22-27) • Prevention/correction of nutritional and metabolic derangements

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Fig. 4

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Benefits of Nutrition Management to Patients Implementation of nutritional screening and risk reduction strategies in older people can help to prevent or delay the development of cancer in otherwise healthy individuals. The benefits of such low cost, low tech interventions are obvious (ACS 1997, 2001). Oral, enteral or parenteral nutrition support methodologies may not always be effective in retarding tumor growth or in the prevention of cancer recurrence after definitive therapy (radiation, surgery, chemotherapy, immunotherapy, etc.). However, many patients report significant improvement in the quality of life indices of GI discomfort, nausea, vomiting, fatigue level, morale, and social interactions during the course of nutrition intervention (Clifford 1993, Grindel 1996). Nutrition interventions are also frequently provided during definitive cancer therapy in an attempt to improve outcome or ameliorate toxicity. They facilitate the optimum delivery of either curative or palliative therapy at lower risk (Langer, Hoffman, Ottery 2001). Recognition of the significant alterations in metabolism that occur in individuals with CA has led to the development of newer enteral/parenteral formulations that may be of benefit in counteracting derangements in host metabolism experienced by patients with cancer (e.g. various combinations of amino acids, carnitine supplementation, etc.) (Garlick 1994, Laviano 1996). These types of products show promise in the amelioration of malnutrition and perhaps reduction in tumor growth rates in people with this dreaded disease. However, they are of unproven efficacy at this time. Benefits of Nutrition Management to Health Services Providers The benefits of implementing low cost, low tech nutritional screening and intervention to reduce cancer risk are significant. It is currently estimated that about 32% of cancers may be avoidable by changes in diet (Willett 1995), with 20-42% of cancer deaths avoidable by dietary change. Some evidence has accumulated to suggest that differences in activity patterns may account for some of the risk reduction formerly attributed to nutritional factors. However, recent data suggest that in addition to reductions in meat and fat consumption, the protective effects of as yet unidentified substances in fruits and vegetables are primary factors that contribute to these estimates of risk reduction. Patients with cancer, particularly those receiving radiation or chemotherapy or those with advanced disease, often experience anorexia (Meguid 1997), decreased food intake, fatigue, weight loss, muscle wasting and a decline in functional status. The provision of appropriate nutritional support often affords these patients a better quality, if not longer, life (Tchekmedyian 1995, Grindel 1996). From a health care provision standpoint, an intervention may be indicated and considered cost effective when the combination of its effects on length and/or quality of life warrant its use and support the required expense. Criteria useful in making decisions to refer patients for nutrition intervention are shown in Figure 4. Conservative cost estimates (Tchekmedyian 1995) for nutrition interventions range from $52.00/month for home prepared supplements to $8,400/month for home parenteral nutrition support. The estimated yearly national cost for home enteral nutrition and home parenteral nutrition services are $357 million and $780 million, respectively. The majority of these services are generated in meeting the nutritional needs of patients with cancer. At times, the use of life sustaining measures may not be in the patient's best interest. See Fig. 5 to facilitate such decisions.

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Fig. 5 Nutrition Screening Guidelines for CA At a minimum, nutrition screening for individuals at risk of developing CA should include: • Measure body weight at each office visit, calculate BMI • Measure height (annually in those age 65 and older) • Evaluate food and nutrient intake • Evaluate physical activity level and functional status • Evaluate current medications use • Evaluate smoking habits • Evaluate alcoholic beverage use

In addition to the elements listed above, screening in individuals who have been diagnosed with CA should include: • Evaluate serum albumin level (> 3.5 mg/dl) • Evaluate serum cholesterol level (160-200 mg/dl, note precipitous drop) • Identify type of cancer treatment utilized (i.e. radiation, surgery, chemotherapy, immunotherapy, etc.) • Evaluate additional anthropometric indices of nutritional status if indicated (e.g. triceps skinfold, arm

muscle circumference, etc.) • Evaluate possible physical signs/symptoms of nutritional deficiency

Use of the Nutrition Screening Initiative's (NSI 1992) DETERMINE Your Nutritional Health Checklist and Level II Screen provide a structured approach in assessing the majority of the elements listed above. The Level II Screen is an invaluable initial resource in the identification and treatment of nutritional risk factors associated with CA development and in the initial assessment of patients with cancer.

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Nutrition Intervention Guidelines for CA

Nutrition intervention to reduce risk of CA development should include: • Maintain a reasonable weight (BMI 22-27) • Choose the majority of foods from plant sources

- >5 servings of fruit and vegetables daily - >6-11 servings from the cereals and grain group - increase consumption of dried beans and peas as protein sources, especially soy beans/soy

products • Limit intakes of high fat foods, especially those from animal sources. Choose:

- low fat foods - low fat dairy products - lean cuts of meat, poultry without skin - low fat cooking methods

• Increase dietary fiber intakes to 20-30 g/day (upper limit 35 g/day) • Moderate consumption/elimination of alcoholic beverages • Minimize intake of salt-cured, salt-pickled, or smoked foods • Stop smoking • Be physically active

Nutrition intervention for patients undergoing definitive therapy for cancer is highly individualized and should be based upon risks associated with the provision of nutritional support and expected benefits to be accrued. An excellent publication of the National Cancer Institute (NCI 1992), Eating Hints: Recipes & Tips for Better Nutrition During Cancer Treatment, offers practical suggestions regarding food intake for patients with cancer and their families. When patients are unable to meet their nutritional needs via the oral route, the services of a Registered Dietitian (RD) should be enlisted to assist the patient in maintaining optimal achievable nutritional status.

Evaluation Criteria to Document Improved Health Outcomes

Evaluation criteria useful in documenting the impact of nutrition screening and intervention on health status are consistent with the goals of nutrition screening and intervention to reduce CA risk, and include: • Maintenance of a reasonable weight (BMI 22-27 for those age 65 years and older, or a weight within

the desirable range on standard weight-for-height tables) • Consumption of minimum number of recommended servings from vegetable, fruit and grain groups • Consumption of dried beans and peas as protein sources, especially soy beans/soy products • Limited intake of high fat foods, especially those from animal sources • Increased dietary fiber intakes to 20-30 g/day (upper limit 35 g/day) • Moderate consumption/eliminate alcoholic beverages • Limited intake of salt-cured, salt-pickled, or smoked foods • Stop smoking • Increased physical activity consistent with age and ability In individuals with established cancer, evaluation criteria useful in documenting the impact of nutrition screening and intervention on health status include, in addition to maintenance of a reasonable weight, when possible, factors related to quality of life such as: • Reduced GI discomfort • Improved ability to swallow • Improved food taste • Reduced mouth dryness • Increased food/nutrient intake • Decreased nausea and/or vomiting • Enhanced energy level • Improved functional status • Improved emotional and/or cognitive status • Improved morale • Increased social interaction

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Evaluation Criteria to Document the Impact of Nutrition Management on the Health Care System In addition to the evaluation criteria listed above, the following may be used to assess the impact of nutrition screening and intervention for CA on the delivery of health care. Reductions or improvements in these indicators could be used to document a positive impact of nutrition screening and intervention in individuals at increased risk of developing CA or those with established cancer to whom routine and appropriate nutritional care is made available. • Incidence of diet-related cancers in the population served • Tolerance for cancer treatment prescribed • Incidence/improvement in nutritional co-morbidities commonly seen in patients with cancer • Type, quantity or number of doses of medication needed to manage the nutrition-related side effects

of cancer therapy • Number of visits to the health care provider needed to successfully manage nutritional co-morbidities

associated with cancer and/or its treatment • Rates of admission, readmission or length of stay in acute or long-term care settings for the

management of CA and/or its nutrition-related consequences

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Patient Education Resources Nutrition Screening Initiative 1010 Wisconsin Avenue, NW, Suite 800 Washington, DC 20007 (202) 625-1662 NSI@gmmb.com American Academy of Family Physicians 11140 Tomahawk Creek Parkway Leawood, KS 66211-2672 800-274-2237 http://www.aafp.org American Cancer Society 1599 Clifton Road, NE Atlanta, GA 30329 800-227-2345 http://www.cancer.org American Dietetic Association 216 West Jackson Blvd. Chicago, IL 60606-6995 800-366-1655 http://www.eatright.org American Lung Association 1740 Broadway New York, NY 10019 800-LUNG-USA (800-586-4872) http://www.lungusa.org Ottery and Associates Oncology Care Consultants Pier 5 Suite 139 Philadelphia, PA 19106-1424 (215) 351-4050 e-mail: noatpres@pol.net http://cancereducation.uams.edu/Modules/Nutrition/Resources.html Partnership for Caring Inc. America’s Voice for the Dying 1620 Eye Street NW, Suite 202 Washington, DC 20007 800-989-9455 http://www.partnershipforcaring.org The Society for Nutritional Oncology Adjuvant Therapy 3455 Salt Creek Lane Arlington Heights, IL 60005 800-704-NOAT http://www.noat.org NIH/National Cancer Institute (NCI) 9000 Rockville Pike Bethesda, MD 20892 800-4-CANCER (800-422-6237) http://www.nci.nih.gov

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References American Cancer Society’s Guide to Complementary and Alternative Cancer Methods. Washington, DC: ACS;2000. (MONOGRAPH) Barber MD, Ross JA, Voss AC, Tisdale MJ, Fearon KCH. The effect of an oral nutritional supplement enriched with fish oil on weight-loss patients with pancreatic cancer. Br J Cancer. 1999a;81:80-86. Barber MD, Ross JA, Preston, T Shenkin A, Fearon KCH. Fish oil enriched nutritional supplement attenuates progression of the acute-phase response in weight-losing patients with advanced pancreatic cancer. J Nutr. 1999b;129:1120-1125. Barrocas A. Complementary and alternative medicine: Friend, foe, or OWA? J Am Diet Assoc. 1997;97:1373-1376. Brown ML. The national economic burden of cancer: An update. J Natl Cancer Inst. 1990;82:1811-1814. Cassileth BR, Chapman CC. Alternative and complimentary cancer therapies. Cancer. 1996;77:1026-1034. Clifford C, Kramer B. Diet as risk and therapy for cancer. Med Clin N Am. 1993;77:725-744. Eisenberg DM, Kessler RC, Foster C, et al. Unconventional medicine in the United States. N Engl J Med. 1993;328:246-52. Eisenberg DM, Davis RB, Ettner, SL, Appel S, Wilkey S, Rompay M, Kessler R. Trends in alternative medicine use in the United States. JAMA. 1998;280:1569-1575. Garlick PJ, McNurlan MA. Protein metabolism in the cancer patient. Biochimie. 1994;76:713-717. Goodwin JS, Brodwick M. Diet, aging, and cancer. Clin Geriatr Med. 1995;11:577-589. Greenlee R.T., Hill-Harmon MB, Murray T, Thun M. Cancer Statistics 2001. CA: Cancer J. Clin. 2001;51 (1):15-36. Grindel CG, Whitmer K, Barsevick A. Quality of life and nutritional support in patients with cancer. Cancer Pract. 1996;4(2):81-87. Inui A. Cancer Anorexia-Cachexia Syndrome: Current Issues in Research and Management. CA: Cancer J Clin. 2002;52:72-91. Langer CJ, Hoffman JP, Ottery FD. Clinical significance of weight loss in cancer patients: Rationale for the use of anabolic agents in the treatment of cancer related cachexia. Nutrition. 2001; Supple:17:1:F1-F20. Laviano A, Meguid MM. Nutritional issues in cancer management. Nutrition. 1996;12:358-371. Meguid MM, Laviano A, Yang Z-J, Blaha V. Cancer anorexia: A hypothesis. Contemp Surg. 1997;50: 219-222. Moldawer LL, Copeland EM. Proinflammatory cytokines, nutritional support and the cachexia syndrome. Cancer. 1997;9:1828-1152. NSI. A Physician’s Guide to Nutrition in Chronic Disease Care for Older Adults. NSI: Washington, DC; 2002. National Academy of Sciences. Diet, Nutrition, and Cancer. National Academy Press:Washington, DC; 1982. www.nap.edu/books.

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National Cancer Institute. Cancer Fact Book, 2000. (http://www.nci.nih.gov/admin/fmb/Factbook2000.PDF). National Cancer Institute. Eating hints: Recipes & tips for better nutrition during cancer treatment. USDHHS/PHS Office of Cancer Communications. NIH Publication No. 92-2079:1992. Shikany JM, White GL. Dietary guideline for chronic disease prevention. So Med J. 2000;93:1138-1152. Shils ME. Nutrition and diet in cancer management. In: Modern Nutrition in Health and Disease. Eighth edition. Shils ME, Olson JA, Shike M, editors. Philadelphia, PA:Lea & Febiger;1994:1317-1348. Tchekmedyian NS. Costs and benefits of nutrition support in cancer. Oncology. 1995;9(Suppl):79-84. US Department Health and Human Services. The Surgeon General's Report on Nutrition and Health. US Government Printing Office. Bethesda, MD:1988. Willett WC. Diet, nutrition, and avoidable cancer. Environ Health Perspect. 1995;103(Suppl 8):165-170. Yancik R, Ries LA. Cancer in older persons. Magnitude of the problem - how do we apply what we know? Cancer. 1994;74:(7 Suppl):1995-2003.

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PATIENT EDUCATION HANDOUT

SUGGESTIONS FOR INCREASING CALORIC INTAKE IN ADULTS

Provide a 3 meal/3 snack regimen (smaller, more calorie dense meals)

Encourage increased consumption of calorie/nutrient dense foods

Milk and Milk Products • Switch to whole milk • Use half and half or double strength milk (fluid

milk mixed with powdered milk) for cereal, in beverages, in cooking, etc.

• Add nonfat dried milk to mixed dishes, cereal, beverages, soups, to add calories and protein.

• Drink milkshakes, eggnog or other flavored milks 3-4 ounces at a time

• Add cheeses to sandwiches, casseroles, baked goods, meats, vegetable dishes, fruit, fruit pies, potatoes, rice, noodles and gelatin desserts

• Add cream or cheese sauces to pasta, rice, potatoes and vegetables

• Add ice cream to carbonated beverages, milk drinks, cereals, fruit, gelatin desserts and fruit pies

Meat and Meat substitutes • Add hard cooked eggs to salads, vegetables or

served deviled eggs • Add cooked dried beans, peas, or bean curd to

soups, casseroles and pasta dishes • Add peanut butter to milkshakes, desserts,

cookie or cake recipes and sandwiches • Use ground nuts or seeds in place of bread

crumbs Fruit • Roll fruit in nuts or dip in chocolate • Add sugar to fruit juices or fruit drinks • Add dried fruits to salads, cereal and baked

goods • Blend ice cream with soft fruits for a sundae or

parfait • Add fruit to custards or puddings

Vegetables • Stuff or spread vegetables with cottage, cream,

pimento cheese or other cheeses • Spread peanut butter on celery, carrots or other

raw vegetables • Use full fat salad dressings • Melt cheese on our add sour cream to

vegetables Bread or Grain Products • Add cheese to breads, rice, noodles and pasta • Stuff biscuits, rolls, muffins or bread sticks with

cheese before baking • Blend nuts or seeds with parsley, spinach or

herbs, and cream cheese or sour cream for a pasta sauce

• Add nuts and dried fruit to cereals, quick breads, cookies, cake or other baked products

Fats and Sweets • Increase fat content of the diet as tolerated

through use of butter, margarine, mayonnaise, peanut butter, oils, etc.

• Use sweets for snacks • Add sugar to beverages • Use jams, jellies, honey syrup • Drink flavored milks, juices, and other high

calorie beverages in place of those that are low calorie or calorie free

Supplement meals and snacks with commercial medical nutritional products if you are unable to obtain adequate calories from food

19

PATIENT EDUCATION HANDOUT

GAINING WEIGHT: A HEALTHY PLAN FOR ADDING POUNDS

Winning at weight gain comes down to pairing a balanced eating pattern with regular physical activity – like any healthy lifestyle. While many overweight people find it difficult to shed extra pounds, those who are underweight face their own challenges trying to keep each pound and add more. The good news for those trying to gain weight is that adding pounds can be simplified by following these healthy and practical tips. Plan ahead for extra meals and snacks The key to gaining weight is shifting the body weight equations so that you take in more calories than you burn. To gain weight, you may need to eat more food. Instead of the traditional “three squares a day,” add two or three substantial snacks between three moderate-size meals. By spreading out your food choices during the day, you’ll be more likely to enjoy your meals and snacks without feeling overstuffed. Concentrate on calories Tip the scales toward weight gain by choosing foods that are “calorie-dense,” or high in calories. While rich desserts and fried foods quickly come to mind, the emphasis should be on foods that pack other nutrients, such as protein, vitamins, and minerals, in addition to calories. Where can you start? Begin by choosing calorie-rich foods from each group of the Food Guide Pyramid, plus fats, oils and sweets in moderation.

Aim for the higher end of the recommended number of servings from each group shown in the Pyramid. Here are some calorie-dense, nutritious foods: • Bread, cereal, rice, and

pasta: granola, bagels, biscuits, cornbread

• Fruits: canned fruit in syrup, dried fruits, fruit nectars

• Vegetables: avocado, olives, potatoes, peas, corn, squash

• Meat, poultry, fish, dry beans, eggs, and nuts: beef, pork, lamb, poultry, salmon, swordfish, omelets, nuts, peanut butter, kidney beans, chickpeas

• Milk, yogurt, and cheese: milk, fruited yogurts, hard cheeses, ice cream, puddings, custards, milkshakes

Use in moderation fats, oils, and sweets, such as butter, margarine, sour cream, cream cheese, gravy, salad dressings, jellies, jams, honey and candies. Maximize each mouthful Incorporating extra calories into everyday meals can make eating a creative and flavorful experience. Try adding these nutritious, calorie-packed combinations to your meals: • Use milk in place of water in

hot cereal, soups, and • sauces. Sprinkle powdered

milk into casseroles and meatloaf for added calories, protein and calcium.

• Add avocado, cheese, and salad dressings to sandwiches. Even fat-free dressings and cheeses will add calories without added fat.

• Mix cooked, chopped meat, wheat germ, nuts, beans, or cheese into casseroles, sidedishes and pasta.

• Choose calorie-dense beverages, appetizers, soups, salads, entrees and desserts when dining out. Take home leftovers for a snack.

Let snacks work in your favor Smart snacking plays an important role in gaining weight. Choose snacks that add calories, vitamins and minerals, such as powdered milk added to a yogurt or ice cream-based shake with fruit and fruit juice. Dip crackers, chips, and fresh vegetable relishes into high calorie dips made with cheese, sour cream (either regular or reduced-fat), mashed beans or fat-free salad dressings. Space out snacks during the day so you don’t spoil your appetite for later meals. For more information: The American Dietetic Association/National Center for Nutrition and Dietetics For food and nutrition information or for a referral to a registered dietician in your area, call the Consumer Nutrition Hot Line at 800/366-1655. Pass the Calories Please! By Gail Farmer, MS, RD. The American Dietetic Association, 1994. 1995 ADAF. Reprinted with permission from the American Dietetic Association.