1. Eva Glass Macmillan Specialist Oncology Dietitian
Nutrition update
Eva Glass
Macmillan Specialist Oncology Dietitian

2. Aims Malnutrition in cancer patients
Dietetic interventions used in Velindre
Discuss re-feeding syndrome & it’s management
Discuss the link between nutrition & albumin

3. Dietetic Department Eva Glass Rhiannon Williams Frances McGuire
Macmillan Specialist Oncology Dietitian
Head and Neck patients
Rhiannon Williams
Upper GI patients
Frances McGuire
Dietetic Assistant
Patient reviews and admin support
Hours of work: Mon-Fri, 8.30am-4.30pm
+ overtime

4. Meet Betty 69 year old female Lives at home with husband
Recurrent clear cell carcinoma of endometrium
Surgery in 2012
2 out of 4 cycles of palliative chemotherapy (carboplatin & taxol)
Admitted feeling generally unwell, neutropenic, fatigue, not coping at home
You ask her how she is eating, she says “not very well”. What factors do you think might have lead to this?

5. Effect of cancer on nutrition
Tumour
Treatment
Increased resting energy expenditure
Anorexia
Increased metabolism of fat, protein, & carbohydrates
Learned aversions
Cytokine production
Mucositis
GI obstruction
Taste changes
Nausea and vomiting
Diarrhoea
Constipation
Fatigue
Dysphagia
Nutritional implications can arise from the tumour itself or from the type of treatment given
Increased resting energy expenditure
Increased metabolism of fat, protein and carbohydrate
Gastrointestinal tract obstruction and associated nutritional issues:
Dysphagia
Early satiety
NBM
Vomiting
Cytokine production from tumour and immune cells promoting cancer cachexia
Cytokines identified: TNF (tumour necrotising factor), PIF (proteolysis inducing factor), LMF (lipid mobilising factor)
Why is it important to consider malnutrition?
Malnutrition

6. Malnutrition
‘50% of cancer patients report abnormalities with eating at time of diagnosis’ (DeWys et al, 1994)
Consequences
Cancer Cachexia
Estimated that 20% of mortalities is a result of cachexia not tumour burden (van Eys, 1985)
Decreased tolerance to treatment
Fatigue
Decreased quality of life
Increased mortality and morbidity
Increased length of hospital stay
e.g. Increased risk of infection, wound healing impaired
Increases workload of doctors and nurses
Greater cost to the NHS
What are the consequences of malnutrition in cancer patients?
Malnutrition in cancer patients is a huge problem be it as a result of the cancer or the treatment.
If pt does not tollerate treatment then it could mean a hospital admission, decreased tumour response if RT/ CT has to be cut down, poorer outcome

7. Betty
Started on a food chart that shows she is managing around ½ of her meals
Weight 56.5kg, she has lost 7kg in the past 3 months
BMI 21.3kg/m2
What would you do?
Height 1.63m
Normal weight 63.5kg (10 stone)
Weight loss 11%

8. Dietetic assessment
‘..early and intensive individualised dietary counselling by a dietitian produces clinically relevant effects in terms of decreasing weight loss and malnutrition..’ (van der Berg, 2010)
Decreased appetite
Feeling too tired to cook
A cooked dinner puts her off
11% weight loss
Estimated requirements:
kcal & 60-71g protein
Estimated intake- 950kcal & 48g protein
Detailed assessment including history of oral intake and weight, factors affecting intake, likes and dislikes, weight history and % weight loss if applicable, BMI, current oral intake & estimation of nutritional intake, and calculation of nutritional requirements taking into account stress factors and activity factors.
A care plan is decided upon.
Betty’s estimated requirements based on 0-20% stress & 25% activity & DIT, g N/kg
Also requires 1700ml fluid (30ml/kg)
Food fortification, small frequent meals tend to be first line advice used as we would like to keep people eating normally commencing on supplements. If they will meet nutritional requirements then supplements will not be needed
Texture modification is quite commonly needed in patients with UGI, H&N cancers and some cancers where RT/ CT affects mouth or oesophagus. If its related to dysphagia then we will liaise with SALT to assess and follow recommendations.
Specific diets e.g. if BM’s increase due to steroids
Alter fibre if someone is having diarrhoea/ constipation

9. Dietetic advice Food fortification Small frequent meals
Adding additional energy/ protein to foods without increasing quantity
Small frequent meals
Full fat products
High kcal options
Milky drinks
Supplement od

10. Oral nutritional supplements
Anyone hungry?!
We start Betty on Fresubin 2kcal od. She tolerates this and on review her weight has stabilised. When she is discharged Sarah follows Betty up in clinic.

11. Remember protected mealtimes

12. Meet Paul 63 year old male Lives with wife who is also unwell
Metastatic chest sarcoma
5 out of 6 cycles of palliative chemotherapy (Doxorubicin)
Admitted feeling with sepsis (presumed chest source)
Eating well
Albumin 18
Albumin 23 on admission, then decreased to 18, CRP 125

13. Dietetic assessment Weight 76.7kg, BMI 28.2kg/m2 No weight loss
No dietary issues
Eating well
Estimated requirements
kcal & 82-96g protein
Estimated intake
2100kcal & 115g protein
Diet hx: BF- cooked BF. L- steak meal, rice pudding/jelly & i/c. EM- could not remember what but had a main meal & pudding. Has also just had a cake. Drinks- tea, water.

14. It’s a myth!
If albumin & nutrition are linked why can you die from starvation with a normal albumin level?
Why do patients with anorexia nervosa often have a normal albumin level?
There has been studies linking albumin and malnutrition but these were published before the impact of inflammation on the level was fully appreciated.

15. Causes of low albumin Decreased synthesis - presence of inflammation
- acute trauma
Blood loss
Excess excretion by the kidneys
Excess loss in the bowel
Intravascular volume overload
Metabolic acidosis
Liver disease
Zinc depletion
Kidneys- nephrotic syndrome
Bowl- protein losing enteropathy

16. Cytokine response Increased vascular permeability
Hepatic protein synthesis re-prioritisation
Not influenced by nutritional support
Once cause been reversed albumin will return to normal
The body’s cytokine response has a major impact on albumin levels. Under normal circumstances, albumin leaks slowly from the intravascular space, across the capillary membrane and returns to the lymphatic system. This flux is reported to be 10 times the rate of albumin synthesis. The cytokine response to injury, infection, and inflammation increases this vascular permeability, accelerating the escape rate of albumin from the circulation causing serum levels to drop.
During sepsis, hepatic protein synthesis is re-prioritised away from the production of albumin (a negative acute phase protein) towards the production of positive acute phase proteins e.g. CRP.
The changes in albumin values are not influenced by the provision of nutritional support & low levels can indicate ongoing catabolism. Therefore before nutritional support can be of benefit this catabolism must be reversed by identifying and treating the cause. Hypoalbuminaemia in the acute phase of illness has no nutritional or metaboilic component and once the cause has been identified and resolved, the albumin concentration will return to normal. Nutritional studies may have shown some improvement in albumin levels with nutritional support but these are likely to be due to successful treatment of any underlying infection or inflammation.

17. Albumin
Low albumin increases mortality & morbidity risk, but this is due to the the cause rather than the low albumin itself
Increasing albumin using infusions does not improve outcome
Use of malnutrition screening tools to assess nutritional status
Infusions…therefore treatment needs to focus on the underlying condition causing hypoalbuminaemia.
The only instance where albumin has a nutritional diagnostic implication is in kwashiorkor although this association has also been questioned.
There is no convenient, measurable, specific and sensitive nutritional marker. Albumin is good at identifying a patient who may need nutritional support as reduced appetite often occurs during illness but patients can be extremely malnourished yet maintain a normal level. Malnutrition screening tools are validated to assess nutritional status and must be used.

18. Some examples from Velindre
Patient 1: alb 27, CRP 308
Patient 2: alb 20, CRP 193
Patient 3: alb 44, CRP normal
Patient 4: alb 47, CRP 3.3
Patients 2 and 3 are malnourished, the other 2 were well nourished
Patient 2- had lost 10% wt, BMI 25.7kg/m2, alb on 16/4/10 was 35, ? CRP
Patient 3- had lost 32% wt (oesophageal), BMI 16.4kg/m2, ? CRP but was not acutely unwell

19. Meet Mary 81 year old female Adenocarcinoma mid-lower rectum T3 N0 M1
Lives with husband, no children
1 cycle of capecitabine
Admitted with abdominal pains & diarrhoea- Cape toxic

20. Dietetic assessment Weight 83.4kg, BMI 29kg/m2 2% weight loss
Not absorbing nutrition via GIT for 10 days
Only slight improvement in diarrhoea with meds
NBM
Needs to start PN
At risk of refeeding syndrome
BO type 7 x 6

21. What is re-feeding syndrome?
Severe fluid & electrolyte shifts & related metabolic complications in malnourished patients undergoing refeeding
Solomon S.M. & Kirby D.F.
It can occur in patients fed orally, enterally, or parenterally. It is less likely to occur in those fed orally (although it is possible) since starvation is usually accompanied by a reduction in appetite. However, care should be taken when prescribing oral nutritional supplements.

22. What are the potential consequences?
Hypophosphataemia
Hypokalaemia
Hypomagnesaemia
Altered glucose metabolism
Fluid balance abnormalities
Vitamin deficiency
These lead to cardiac, respiratory, neuromuscular, renal, metabolic, hematologic, hepatic, & gastrointestinal problems

23. How does this happen? Starvation Refeeding
Partial switch to protein as an energy source
↓ insulin & ↑ glucagon
↓vitamins & trace elements
↓ K, Mg, PO4
↑ intracellular & whole body Na & water
Impaired cardiac, intestinal, & renal reserve ⇨ ↓ ability to excrete excess Na & water
Abnormal liver function
Glucose as energy source
Insulin release ⇨
↑ uptake of K, Mg, PO4 ⇨
extracellular ↓
↑ protein synthesis
↑ cellular glucose uptake
↑ requirements for micronutrients
Shifts of Na & fluid out of the cells
During starvation the body adapts to reduce cellular activity & organ function in order to save energy. The changes include down-regulation of metaboilc pumping & synthetic activities with consequences that include…
Decreased insulin and increased glucagon secretion, with a switch from glucose towards ketone bodies as a source of energy
Deficiency of vitamins & trace elements
Whole body depletion of K, Mg, PO4
During refeeding…
Insulin release stimulates the ATPase pump (which requires Mg as a cofactor) and leads to an increased uptake of glucose, PO4, K into cells, for cellular pump activity
Reactivation of the Na/K membrane pump drives the K into the cells and Na and fluid move out. CHO load and insulin release stimulate PO4 shifts into the cells and PO4 depletion is associated with increased urinary Mg excretion. These processes lead to a low extracellular PO4, Mg, and K, leading to the symptoms of re-feeding syndrome.
Stimulation of protein synthesis leads to increased anabolic tissue growth which in turn leads to increased cellular demand for PO4, K, glucose, and water.
Increased cellular thiamine utilisation due to its role as a co-factor for CHO metabolism.
There is also a reduced Na and water excretion.

24. NICE- At some risk V. little intake for >5 days
Max 50% or req. for 1st 2 days
e.g. patient admitted with wt 73.7kg but Ur of 11.3, when rehydrated his wt was 79kg & it was calculated he had lost 6.7% wt; his BMI was 23kg/m2. V. little oral intake for 5 days.

25. NICE- At very high risk
1 or more of: BMI <16 kg/m2, >15% wt ↓, v. little intake for >5 days, low K, PO4, Mg
OR 2 or more of: BMI <18.5kg/m2, >10% wt ↓, v. little intake for >5 days, h/o alcohol abuse, or some drugs inc. chemo.
Start feed at max. of 10kcal/day, increasing slowly to meet req. By 4 to 7 days
Wt los in past 3-6 months.
V. little or negligible intake.
Some drugs including insulin, chemo, antacids or diuretics.

26. NICE- At extremely high risk
BMI <14kg/m2 or negligible intake for >15 days
Start feed at 5kcal/kg/day increasing slowly to meet req. by 10 days

27. NICE- at very & extremely high risk
Thiamine mg/d
Vitamin B Co norm/strong 1 or 2 tablets tds or full IV dose
A balanced multivitamin & trace element supplement od
Restore circulatory volume & monitor fluid balance & overall clinical status closely
Provide supplements of K, PO4, & Mg unless pre-feeding plasma levels are high
Monitor cardiac rhythm in extremely high risk
Vitamin B Co strong if oral, Vitamin B Co Norm if crushing for tube feeding.
TPN refeeding syndrome guidelines.
Providing oral, enteral, or intravenous supplements of K (likely requirement 2-4mmol/kg/day) (sando K or IV KCL), PO4 (likely requirement mmol/kg/day) (sando PO4 via PEG or Polyfuser via IV), & Mg (likely requirement 0.2mmol/kg/day intravenous, 0.4mmol/kg/day oral) (IV Mg sulphate) unless pre-feeding plasma levels are high.
Pre-feeding correction of low plasma levels is unnecessary-
As the vast majority of deficits are intra cellular, they cannot be corrected without commencing low level energy provision. Any reassurance gained from pre-feeding correction of plasma levels is therefore unlikely to reflect significant changes in whole body status or significant reduction in risks.
Patients with normal pre-feeding levels of K, Mg, & PO4 can still be at high risk. Many of those with high plasma levels will still have whole body depletion and may therefore need supplementation as re-feeding progresses and renal function improves.
Patients with normal prefeeding levels of K, Mg, PO4 can still be at risk of refeeding syndrome.
N.B. monitor cardiac rhythm continually in these patients and any others who already have or develop any cardiac arrhythmias.

28. Dietetic intervention
Estimated requirements
kcal & 14.2g N & 2500ml fluid + losses
Started on Nutriflex Lipid Peri 2500ml & 250ml vits & mins at 125ml/hr
- 1000ml at 45ml/hr day 1
- gradually increased over 5 days

29. Meet Harold 67 year old male
Lives alone. Previously heavy smoker but has now stopped, does not drink alcohol.
T1 N2b M0 SCC right lingual epiglottis
Right radical neck dissection
25/30# RT
Admitted struggling, dehydrated, for pain control & NGT feeding
Struggling ++. Pain is most sig issue. Says taking co-codamol QDS and oramoph QDS wih no effect.
O/E Oral thrush. No mucositis visible. Skin dry and cracked in paces - only using cream every couple of days. Bowels ok.
Bloods: mildly raised urea and Cr, otherwise ok.
Imp: Needs admission. Not complying wih skincare and ?meds. No beds avail here.
Discussed admission to R Glam but pt refusing.
Plan: Fluconazole. Admit as soon as bed avaiable. Increase fluids and oramorph.

30. Dietetic assessment Weight 57.4kg, BMI 19.4kg/m2 12.4% weight loss
Only managing water & milk orally
Not tolerating supplements orally
NGT placed
Pump feed commenced- increased over 3 days to 1L Twocal at 100ml/hr with 100ml flushes pre & post feed & additional 550ml fluid

31. N.B.
Need minimum 48hour notice of discharge for patients who have started enteral feeding during their admission
Diarrhoea, vomiting- it’s not necessarily the feed- consider other causes

32. Dietetic treatment Nutrition Support Texture modification
Oral
Enteral
Parenteral
Texture modification
Low/High fibre
Diabetes
Renal e.g. high K
Weight management
Advice on alternative diets
Neutropenia
Fatigue management
Catering
We add supplements onto the catering list and the catering assistants distribute these. This has occurred as there is better compliance with catering distributing them rather than n/s. Therefore if a patient is admitted with supplements on prescription they need to be referred to the dietitian to assess whether they need supplements and prescribe on catering list otherwise they will not be given.
Prior to enteral or parenteral feeding pts are screened for refeeding risk, if they are deemed to be a high risk e.g. BMI < 16, little or no intake for greater than 10 days, low K, PO4, Mg, Ca. If they are high risk then the dietitian will request multivitamin (od), thiamine ( mg od)/ pabrinex and vitamin b co strong if pabrinex not given 1-2 tablets tds. These should be prescribed for the first 10 days of feeding. Biochem should be monitored esp U&E’s LFT’s, Mg, PO4, Ca, K daily initially.
Enteral: All tube types are seen in velindre. Feed is adjusted as per patients requirements, clinical condition, cancer type and tollerance. If pts need to go home with an NG/ gastrostomy/ jej 4 working days notice is required to ensure safe discharge to arrange training etc.
Parenteral – indicated if the gut is not functioning e.g. obstruction, radiation enteritis, chemo toxicity. Dietitian devises regime according to nutritional requirements and access route – only certain bags can be given perpheraly all bags can be given centeraly.
Bloods need to be taken routinely. Intitially NICE recommend U&E’s LFT’s Bone profile, magnesium phospate, CRP, BM’s, FBC, iron, ferritin folate, b12. zinc, copper, selenium need to be taken as a baseline then they all differ as to when they need to be taken next some are daily e.g. U&E;s until stable . Details summarised in the ward nutrition file. People are rarely discharged with home PN.

33. Thank you!