Consensus recommendations from the US summit on immune-enhancing enteral therapy. Formulate a protocol to initiate an MCT oil diet. He serves as the Medical Director for Functional Formularies, manufacturer of the World's only organic, whole-food, enteral formulas for critically ill patients. Measured versus calculated resting energy expenditure in critically ill adult patients. They confer with other health care professionals to review patients' medical charts and develop individual plans to meet nutritional requirements. Early enteral nutrition and outcomes of critically ill patients treated with vasopressors and mechanical ventilation.
B. Nutritional assessment
In addition, combining drug therapy with nutrition support and increased physical activity may have even greater efficacy. CAS is a complex, multifactorial complication of cancer and its therapy, resulting in weight loss and decreased lean body mass. As understanding of the mechanisms of CAS improves and new agents that selectively target these proposed pathways become available, more efficacious treatments are also expected to become available.
Trials of new agents must be able to compare similar groups of patients. In addition, treating preventatively in high-risk patients, as opposed to treating patients already suffering from CAS, may be associated with better outcomes.
Further clinical trials are essential to determine the best possible therapies. Patients with advanced disease often develop new, or worsening, nutrition-related side effects associated with disease progression, treatment, or both.
In a large systematic review of symptom prevalence in patients with incurable cancer, the most common nutrition impact symptoms were anorexia, xerostomia, constipation, and nausea.
Other symptoms among advanced-cancer patients receiving care in inpatient palliative care units,[ 2 , 3 ] cancer cachexia specialty clinics,[ 4 ] hospice, or non-hospice settings [ 3 ] included bloating, constipation, dysphagia, chewing difficulties, early satiety, mucositis, taste changes, and vomiting.
Clinically refractory cachexia develops as a result of very advanced cancer or rapidly progressive disease that is unresponsive to antineoplastic therapy. It is associated with active catabolism and weight loss that is unresponsive to nutrition therapy. At the end of life, patients often have severely restricted oral intake of food and fluids as part of the normal dying process. The primary objective of nutrition intervention in patients with advanced cancer is to conserve or restore the best possible quality of life and control any nutrition-related symptoms that cause distress.
Nutrition goals for a patient with advanced cancer may depend on the overall plan of care. These patients may be receiving anticancer therapy with or without concurrent palliative care , may be receiving palliative care alone, or may be enrolled in hospice.
Regardless of the care setting, patients are screened to determine the need for nutrition intervention. As the focus of care shifts from cancer-modifying therapy to hospice or end-of-life care, nutrition goals may become less aggressive, with a shift in emphasis toward comfort.
Continued assessment and adjustment of nutrition goals and interventions is required throughout this continuum to meet the changing needs of the patient receiving palliative or hospice care services. Ethical issues may arise when patients, families, or caregivers request artificial nutrition and hydration when there is no prospect of recovering from the underlying illness or accruing appreciable benefit from the intervention.
When there is uncertainty about whether a patient will benefit from artificial nutrition, hydration, or both, a time-limited trial may be useful. Clear, measurable endpoints are outlined at the beginning of a time-limited trial. The caregiving team will explain that, as with other medical therapies, artificial nutrition and hydration can be stopped if the desired nutrition effects are not produced. Randomized controlled trials of enteral or parenteral nutrition in cancer patients receiving formal palliative care are lacking.
Patients with a life expectancy shorter than 40 days may be palliated with home intravenous IV fluid therapy, although this practice is controversial. Patients and caregivers often consider the provision of food and fluids to be basic care. However, the use of artificial nutrition and hydration at the end of life is a complex and controversial intervention that is influenced by clinical, cultural, religious, ethical, and legal factors.
Patients and families often believe the use of these interventions will improve quality and length of life, but evidence of clear benefit is lacking. In addition, agitated or confused patients receiving artificial nutrition and hydration may need to be physically restrained to prevent them from removing a gastrostomy tube, nasogastric tube, or central IV line. Patients at the end of life who have increased difficulty with swallowing have less risk of aspiration with thick liquids than with thin liquids.
For patients at the end of life, the goals of nutrition therapy are directed at alleviating symptoms rather than reversing nutrition deficits. The pleasure of tasting food and the social benefits of participating in meals with family and friends can be emphasized over increasing caloric intake. Other studies found no effect on terminal delirium, thirst, chronic nausea, or fluid overload.
The American Academy of Hospice and Palliative Medicine suggests that providers facilitate respectful and informed discussions about the effects of artificial nutrition and hydration near the end of life among physicians, other health care professionals, patients, and families.
Ideally, patients will make their own decisions on the basis of a careful assessment of potential benefits and burdens, consistent with legal and ethical norms that permit patients to accept or forgo specific medical interventions. Decisions about whether to provide artificial nutrition and hydration to patients in the late stages of life are complex and influenced by ethical, legal, cultural, and clinical considerations, and by patient and family preferences.
Guidelines on the ethical considerations about whether to forgo or discontinue hydration and nutrition support have been published by a number of organizations, including the American Medical Association,[ 25 ] the American Academy of Hospice and Palliative Medicine,[ 11 ] the Hospice and Palliative Nurses Association,[ 18 ] the American Society for Parenteral and Enteral Nutrition,[ 26 , 27 ] and the Academy of Nutrition and Dietetics.
Religion and religious traditions provide a set of core beliefs about life events and an ethical foundation for clinical decision-making. To provide an optimal and inclusive healing environment, all palliative team members need to be aware of their own spirituality and how it may differ from that of fellow team members and the spirituality of the patients and families they serve.
Religious beliefs are often closely related to cultural views. Individuals living in the midst of a particular tradition can continue to be influenced by it, even if they have stopped believing in or practicing it.
Patients may rely on religion and spirituality as important means to interpret and cope with illness. The wide range of practices related to neutropenic diets reflects the lack of evidence regarding the efficacy of dietary restrictions in preventing infectious complications in cancer patients.
Studies evaluating various approaches to diet restrictions have not shown clear benefit. A meta-analysis and a systematic review of articles evaluating the effect of a neutropenic diet on infection and mortality rates in cancer patients found no superiority or advantage in using a neutropenic diet over a regular diet in neutropenic cancer patients. Even after the observational study was omitted from the analysis, the results persisted. The review concluded that these individual studies provided no evidence showing that the use of a low-bacterial diet prevents infections.
Other studies have demonstrated potential adverse effects of neutropenic diets. One group of investigators [ 6 ] conducted a retrospective review of patients who had undergone hematopoietic cell transplantation HCT.
The patients who received the neutropenic diet experienced significantly more documented infections than did the patients receiving the general hospital diet that permitted black pepper and well-washed fruits and vegetables and excluded raw tomatoes, seeds, and nuts. The neutropenic diet group had a significantly higher rate of infections that could be attributed to a gastrointestinal source, as well as a trend toward a higher rate of vancomycin-resistant enterococci infections.
Without clinical evidence to define the dietary restrictions required to prevent foodborne infection in immunocompromised cancer patients, recommendations for food safety are based on general food safety guidelines and the avoidance of foods most likely to contain pathogenic organisms. The effectiveness of these guidelines is dependent on patient and caregiver knowledge about, and adherence to, safe food handling practices and avoidance of higher-risk foods. Leading cancer centers provide guidelines for HCT patients and information about food safety practices related to food purchase, storage, and preparation e.
Comprehensive food safety information designed by the U. Food and Drug Administration for people with cancer and for transplant recipients is also available online. Recommendations support the use of safe food handling procedures and avoiding consumption of foods that pose a high risk of infection, as noted in Table 7. Maintaining adequate nutrition while undergoing treatment for cancer is imperative because it can reduce treatment-related side effects, prevent delays in treatment, and help maintain quality of life.
Patients are likely to search the Internet and other lay sources of information for dietary approaches to manage cancer risk and to improve prognosis. Unfortunately, much of this information is not supported by a sufficient evidence base.
The sections below summarize the state of the science on some of the most popular diets and dietary supplements. A vegetarian diet is popular, is easy to implement and, if followed carefully, does not result in nutrition deficiencies. There is strong evidence that a vegetarian diet reduces the incidence of many types of cancer, especially cancers of the gastrointestinal GI tract. There are no published clinical trials, pilot studies, or case reports on the effectiveness of a vegetarian diet for the management of cancer therapy and symptoms.
There is no evidence suggesting a benefit of adopting a vegetarian or vegan diet upon diagnosis or while undergoing cancer therapy. On the other hand, there is no evidence that an individual who follows a vegetarian or vegan diet before cancer therapy should abandon it upon starting treatment. One pilot study has suggested that following a plant-based diet can prevent tumor progression in men with localized prostate cancer.
It is a high-carbohydrate, low-fat, plant-based diet stemming from philosophical principles promoting a healthy way of living. Although there are anecdotal reports on the effectiveness of a macrobiotic diet as an alternative cancer therapy, none have been published in peer-reviewed, scientific journals.
No clinical trials, observational studies, or pilot studies have examined the diet as a complementary or alternative therapy for cancer.
In fact, two reviews of the diet and its evidence for effectiveness in cancer treatment concluded that there is no scientific evidence for the use of a macrobiotic diet in cancer treatment. No current clinical trials are studying the role of the macrobiotic diet in cancer therapy. A ketogenic diet has been well established as an effective alternative treatment for some cases of epilepsy and has gained popularity for use in conjunction with standard treatments for glioblastoma.
The ketogenic diet can be difficult to follow and relies more on exact proportions of macronutrients typically a 4 to 1 ratio of fat to carbohydrates and protein than do other complementary and alternative medicine CAM diets. Because safety and feasibility have been proven, several trials are recruiting patients to study the effectiveness of the ketogenic diet on glioblastoma.
Therefore, if a patient diagnosed with glioblastoma wishes to start a ketogenic diet, it would be safe if implemented properly and under the guidance of a registered dietitian,[ 10 ] but effectiveness for symptom and disease management remains unknown.
The use of probiotics has become prevalent within and outside of cancer therapy. Strong research has shown that probiotic supplementation during radiation therapy, chemotherapy, or both is well tolerated and can help prevent radiation- and chemotherapy-induced diarrhea, especially in those receiving radiation to the abdomen. Melatonin is a hormone produced endogenously that has been used as a CAM supplement along with chemotherapy or radiation therapy for targeting tumor activity and for reducing treatment-related symptoms, primarily for solid tumors.
Several studies have shown tumor response to, or disease control with, chemotherapy alongside oral melatonin, as opposed to chemotherapy alone; one study has shown tumor response with melatonin in conjunction with radiation therapy. However, another study did not demonstrate increased survival with melatonin, but did demonstrate improved quality of life. Melatonin taken in conjunction with chemotherapy may help reduce or prevent some treatment-related side effects and toxicities that can delay treatment, reduce doses, and negatively affect quality of life.
Melatonin supplementation has been associated with significant reductions in neuropathy and neurotoxicity, myelosuppression, thrombocytopenia, cardiotoxicity, stomatitis, asthenia, and malaise. Overall, several small studies show some evidence supporting melatonin supplementation alongside chemotherapy, radiation therapy, or both for solid tumor treatment, for aiding tumor response and reducing toxicities, while negative side effects for melatonin supplementation have not been found.
Therefore, it may be appropriate to provide oral melatonin in conjunction with chemotherapy or radiation therapy to a patient with an advanced solid tumor. Glutamine is an amino acid that is especially important for GI mucosal cells and their replication. These cells are often damaged by chemotherapy and radiation therapy, causing mucositis and diarrhea, which can lead to treatment delays and dose reductions and severely affect quality of life.
Some evidence suggests that oral glutamine can reduce both of those toxicities by aiding in faster healing of the mucosal cells and entire GI tract. For patients receiving chemotherapy who are at high risk of developing mucositis, either because of previous mucositis or having received known mucositis-causing chemotherapy, oral glutamine may reduce the severity and incidence of mucositis.
For patients receiving radiation therapy to the abdomen, oral glutamine may reduce the severity of diarrhea and can lead to fewer treatment delays. In addition to reducing GI toxicities, oral glutamine may also reduce peripheral neuropathy in patients receiving the chemotherapy agent paclitaxel.
Oral glutamine is a safe, simple, and relatively low-cost supplement that may reduce severe chemotherapy- and radiation-induced toxicities.
The PDQ cancer information summaries are reviewed regularly and updated as new information becomes available. This section describes the latest changes made to this summary as of the date above. Added Carneiro et al. Nutrition Screening and Assessment. Added Daniel et al.
Added text to state that the prevalence of obesity is higher in adult cancer survivors than in those without a cancer history; and that cancer survivors with the highest rates of increasing obesity are colorectal and breast cancer survivors and non-Hispanic blacks cited Greenlee et al.
Added text about the benefits of using immune-enhancing formulas for preoperative and postoperative nutrition support for individuals undergoing gastrointestinal surgery cited Song et al. Added Pharmaceutical management of cancer-associated cachexia and weight loss as a new subsection. This PDQ cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about nutrition before, during, and after cancer treatment.
It is intended as a resource to inform and assist clinicians who care for cancer patients. It does not provide formal guidelines or recommendations for making health care decisions. Board members review recently published articles each month to determine whether an article should:. Changes to the summaries are made through a consensus process in which Board members evaluate the strength of the evidence in the published articles and determine how the article should be included in the summary.
Any comments or questions about the summary content should be submitted to Cancer. Do not contact the individual Board Members with questions or comments about the summaries.
Board members will not respond to individual inquiries. Some of the reference citations in this summary are accompanied by a level-of-evidence designation. These designations are intended to help readers assess the strength of the evidence supporting the use of specific interventions or approaches.
PDQ is a registered trademark. Although the content of PDQ documents can be used freely as text, it cannot be identified as an NCI PDQ cancer information summary unless it is presented in its entirety and is regularly updated.
Permission to use images outside the context of PDQ information must be obtained from the owner s and cannot be granted by the National Cancer Institute.
Information about using the illustrations in this summary, along with many other cancer-related images, is available in Visuals Online , a collection of over 2, scientific images. The information in these summaries should not be used as a basis for insurance reimbursement determinations. More information on insurance coverage is available on Cancer.
More information about contacting us or receiving help with the Cancer. Questions can also be submitted to Cancer.
Menu Contact Dictionary Search. Questions to Ask about Your Diagnosis. Types of Cancer Treatment. A to Z List of Cancer Drugs. Questions to Ask about Your Treatment. Questions to Ask About Cancer. Talking about Your Advanced Cancer. Planning for Advanced Cancer. Advanced Cancer and Caregivers. Questions to Ask about Advanced Cancer. Finding Health Care Services. Adolescents and Young Adults with Cancer. Reports, Research, and Literature.
Late Effects of Childhood Cancer Treatment. Unusual Cancers of Childhood Treatment. Bioinformatics, Big Data, and Cancer. Frederick National Laboratory for Cancer Research. Research on Causes of Cancer. Annual Report to the Nation. Milestones in Cancer Research and Discovery.
Research Tools, Specimens, and Data. Statistical Tools and Data. Grants Policies and Process. Introduction to Grants Process. Peer Review and Funding Outcomes. Annual Reporting and Auditing. Transfer of a Grant. Cancer Training at NCI. Funding for Cancer Training. Building a Diverse Workforce. Resources for News Media. Multicultural Media Outreach Program. Contributing to Cancer Research. Advisory Boards and Review Groups. Steps to Find a Clinical Trial.
Help With Clinical Trials Search. What Are Clinical Trials? Where Trials Take Place. Types of Clinical Trials. Phases of Clinical Trials. Paying for Clinical Trials. Insurance Coverage and Clinical Trials. Deciding to Take Part in a Trial. Questions to Ask about Treatment Clinical Trials.
Drugs Approved for Different Types of Cancer. Drugs Approved for Conditions Related to Cancer. Access to Experimental Drugs. Chronic disease—related malnutrition e. Acute disease—related or injury-related malnutrition e. Loss of muscle mass.
Loss of subcutaneous fat. Localized or generalized fluid accumulation that may sometimes mask weight loss. Diminished functional status as measured by hand grip strength. Screening Early recognition of nutrition-related issues is necessary for appropriate nutrition management of cancer patients.
Education by registered dietitian or other clinician. Intervention by registered dietitian. Critical need for improved symptom management. Food- and nutrition-related history. Biochemical data, medical tests, and procedures. Localized or generalized fluid accumulation. Diminished functional status e. Subcutaneous fat loss Orbit. Thoracic and lumbar regions. Subcutaneous muscle loss Temple. Tumor location current or anticipated mechanical function impairment.
Anticipated duration of symptoms. Eat foods that are high in protein and calories. Eat high-protein foods first in your meal while your appetite is strongest—foods such as beans, chicken, fish, meat, yogurt, and eggs. Add extra protein and calories to food.
Cook with protein-fortified milk. Drink milkshakes, smoothies, juices, or soups if you do not feel like eating solid foods. Prepare and store small portions of favorite foods. Seek foods that appeal to the sense of smell. Experiment with different foods. Eat larger meals when you feel well and are rested. Sip only small amounts of liquids during meals. Eat your largest meal when you feel hungriest, whether at breakfast, lunch, or dinner.
Be as active as possible to help develop a bigger appetite. Consider asking your health practitioner about blenderized drinks with a high nutrient density. Tell your doctor if you are having eating problems such as nausea, vomiting, or changes in how foods taste and smell. Perform frequent mouth care to relieve symptoms and decrease aftertastes. Consider tube feedings if you are unable to sustain a certain amount of caloric intake to maintain strength. Drink plenty of fluids each day, including water, warm juices, and prune juice.
Be active each day; take walks regularly. Eat more fiber-containing foods. Drink hot liquids to help relieve constipation, including coffee, tea, and warm milk. Talk with your doctor before taking laxatives, stool softeners, or any medicine to relieve constipation. Limit certain foods if you develop gas, including broccoli, cabbage, cauliflower, beans, and cucumbers.
Eat a large breakfast, including a hot drink and high-fiber foods. Consider a fiber supplement. Drink plenty of fluids to replace those lost from diarrhea, including water, ginger ale, and sports drinks.
Let carbonated drinks lose their fizz before you drink them. Eat foods and liquids that are high in sodium and potassium. Very hot or cold drinks. Greasy, fatty, and fried foods. Foods that can cause gas, such as carbonated beverages, cruciferous vegetables, legumes and lentils, and chewing gum.
Nutrition support in palliative and hospice care. Summary version of the standards, options and recommendations for palliative or terminal nutrition in adults with progressive cancer Quality of life and length of survival in advanced cancer patients on home parenteral nutrition.
Winkler M, Wetle T. A pilot study of a qualitative interview guide designated to describe quality of life in home parenteral nutrition dependent patients. Fostering coping skills and resilience in home enteral nutrition HEN consumers. Increasing incidences of withholding and withdrawal of life support from the critically ill. A national survey of end-of-life care for critically ill patients. End-of-life practices in European intensive care units: Making decisions about the forgoing of life-sustaining therapy.
Ethical considerations at the end of life in the intensive care unit. Family perspectives on end-of-life care at the last place of care. Where does hospice fit in the continuum of care? J Am Geriatr Soc. Discomfort in nursing home patients with severe dementia in whom artificial nutrition and hydration is forgone.
Medical nutrition therapy in palliative care. The Clinical Guide to Oncology Nutrition , 2nd ed. American Dietetic Association; Texas Conference of Catholic Bishops. On withdrawing artificial nutrition and hydration.
Should nutrition and hydration be considered medical therapy? Pope John Paul II. Position of the American Dietetic Association: Ethical and legal issues in nutrition, hydration, and feeding.
J Am Diet Assoc. Worldwide similarities and differences in the forgoing of life-sustaining treatments. Patient responses during rapid terminal weaning from mechanical ventilation: Parenteral nutrition in advanced cancer: Indications and clinical practice guidelines. Nutrition support and the troubling trichotomy: A call to action. Great Valley Publishing Company, Inc.
Publisher of Today's Dietitian. Advertise Media Kit Gift Shop. Uptake of vitamin E succinate by the skin, conversion to free vitamin E, and transport to internal organs.
Biochem Mol Biol Int. Clinical trial showing superiority of a coconut and anise spray over permethrin 0. Effect of mineral oil, sunflower oil, and coconut oil on prevention of hair damage. Secondary ion mass spectrometric investigation of penetration of coconut and mineral oils into human hair fibers: Relevance to hair damage J Cosmet. Basic Clin Pharmacol Toxicol. Effect of saturated fatty acid-rich dietary vegetable oils on lipid profile, antioxidant enzymes and glucose tolerance in diabetic rats.
Glycerol monolaurate inhibits Candida and Gardnerella vaginalis in vitro and in vivo but not Lactobacillus. Antibacterial study of the medium chain fatty acids and their 1-monoglycerides: Glycerol monolaurate prevents mucosal SIV transmission. Antimicrobial activity of potassium hydroxide and lauric acid against microorganisms associated with poultry processing. Glycerol monolaurate inhibits virulence factor production in Bacillus anthracis. Effect of fatty acids on arenavirus replication: Lauric acid inhibits the maturation of vesicular stomatitis virus.
Contrasting metabolic effects of medium- versus long-chain fatty acids in skeletal muscle. Anti-bacterial and anti-inflammatory properties of capric acid against Propionibacterium acnes: Inhibition of Candida mycelia growth by a medium chain fatty acids, capric acid in vitoro and its therapeutic efficacy in murine oral candidiasis Med Mycol J. Combined medium-chain triglyceride and chilli feeding increases diet-induced thermogenesis in normal-weight humans. Sophorolipid production by Candida bombicola on oils with a special fatty acid composition and their consequences on cell viability.
Enhancement of muscle mitochondrial oxidative capacity and alterations in insulin action are lipid species dependent: Medium-chain fatty acids improve cognitive function in intensively treated type 1 diabetic patients and support in vitro synaptic transmission during acute hypoglycemia.
Effect of ingestion of medium-chain triacylglycerols on moderate- and high-intensity exercise in recreational athletes. J Nutr Sci Vitaminol Tokyo. Partial replacement of dietary n-6 fatty acids with medium-chain triglycerides decreases the incidence of spontaneous colitis in interleukindeficient mice. Effects of beta-hydroxybutyrate on cognition in memory-impaired adults. Consumption of an oil composed of medium chain triacyglycerols, phytosterols, and N-3 fatty acids improves cardiovascular risk profile in overweight women.
An enteral therapy containing medium-chain triglycerides and hydrolyzed peptides reduces postprandial pain associated with chronic pancreatitis. Protective effects of medium-chain triglycerides on the liver and gut in rats administered endotoxin. Medium-chain triglycerides increase energy expenditure and decrease adiposity in overweight men. Larger diet-induced thermogenesis and less body fat accumulation in rats fed medium-chain triacylglycerols than in those fed long-chain triacylglycerols.
Comparison of diet-induced thermogenesis of foods containing medium- versus long-chain triacylglycerols. Eur J Gastroenterol Hepatol. The influence of a preserved colon on the absorption of medium chain fat in patients with small bowel resection. Effects of intravenous supplementation with alpha-tocopherol in patients receiving total parenteral nutrition containing medium- and long-chain triglycerides Eur J Clin Nutr Feb;56 2: