Nutrition and Cancer

Jessica Kasnik RD. Cross Cancer Institute, Alberta Health Services

April 2018
Faculty/Presenter Disclosure

• Speaker: Jessica Kasnik RD

Nutrition in Cancer
• Relationships with commercial interests:
– Grants/Research Support: None
– Speakers Bureau/Honoraria: None
– Consulting Fees: None
– Other: N/A
Disclosure of Commercial Support

 This Program is funded through AHS Operational Funding.

 This Program has not received financial support.
 This Program has not received in-kind support.
 Jessica Kasnik is presenting at this Program on a voluntary
basis.
 Potential for conflict(s) of interest: None
Learning Objectives

 Effect of cancer on nutrition status

 Nutrition and cancer: Hot Topics
 Physical and biochemical assessment
 Diabetes and cancer
 Actual needs and recommendations
 Vitamin/supplementation
 Special considerations
Cancer and Malnutrition

 Cancer is associated with rapid and extensive weight loss (muscle loss
or sarcopenia seen in 15-50%).
(Nutr. In Clin. Practice. 2017 Feb; Vol.32, No.1, 30-39)

 Malnutrition is a frequent problem in cancer patients.

 up to 45% patients admitted to hospital are found to be malnourished.
 The prevalence among cancer patients has been estimated to range between 40% and 80%.
(Gomez Candela et. al.,J. Nutricion Hsopitalari. 2010, 25(3), 400-405)

 Est. 10-20% deaths in cancer attributed to malnutrition rather than

malignancy
 Malnutrition associated w/: sarcopenia, cachexia, ↓ immune
competence, ↑infections, stress, ↓ QOL, treatment toxicity and
greater mortality.
 Nausea/ Pain Decreased
Vomiting QOL

Diarrhea/
Neuropathy
Steatorrhea

Hyper/Hypo Weight
glycemia Malnutrition loss

Mouth Anorexia
Sores

Anxiety/
Depression Constipation
Fatigue
Tumour Mediated Malnutrition

Pancreatic Cancer Action Network: pancan.org, Walters et al, Lancet Gastroenterol Hospital, 2016, ESPEN Guideline, 2016
 Malnutrition/Sarcopenia

 Inadequate nutritional intake is confirmed if

pt can’t eat for a week or intake is <60% of
requirements. **

Sarcopenia:
 Now confirmed, can occur concurrently w/
obesity.
 Associated with ↑ incidence of chemo
toxicity, shorter time to tumour progression,
physical disability, poor surgical outcomes, ↓
survival
Clinical Nutrition 36 (2017) ESPEN Recommendations for Cancer, J Cachexia Sarcopenia Muscle. 2011 Mar; 2(1): 27–35.
Hot Topics

Quiz time: Who am I?

A. Acai
B. Goji
C. Blueberry
D. Spinach
E. Chia
 Marketing term with no set
criteria or scientific basis

 Most have few studies

associated with them and
inconclusive results

 Can be costly compared to

items with nutritional
equivalence
FOLATE VITAMIN B12 FLAVONOIDS
Beans Eggs Onions
Asparagus Milk Apples
Green leafy vegetables Meats Soy Beans

IRON ZINC CAROTENOIDS

Oatmeal Fish Squash
Tofu Pumpkin seeds Sweet potato
Beans Legumes Carrots
Meats

VITAMIN C
Citrus fruits
Peppers
Broccoli
The Alkaline Diet can prevent
or help treat cancer.

A. True
B. Myth
C. Unsure – more evidence needed
Alkaline Diet

 “Cancer cells thrive in an acidic environment. Eating an alkaline diet will

change the pH of your cells so cancer can’t survive”.

 The Truth: Our bodies are excellent at regulating pH within a very narrow
range, any change would be life threatening. The basis of the ash-acidic and
ash-alkaline is not representative of their non-incinerated pH. More research
needed to determine the consequences of a foods potential renal acid load
(PRAL) on cancer risk/treatment.

 “Alkaline Diet” excludes many high protein choices, not replaced, significant
concern for cancer patients.
 Drinking alkaline water cannot change the pH of the whole body of blood.

**A diet high in fruit and vegetables is beneficial for overall health.
Sugar Feeds Cancer!

 Belief that sugar preferentially “feeds” cancer cells or directly fuel their
growth.
 Belief that all sugar, sweets, pop and carbohydrates like pasta, rice, grains,
cereals contain sugar and should be avoided.
 Patients frequently call in or report that “sugar causes cancer, so what can I
eat”?
 The Facts

 All cells prefer glucose for energy

 Even without any carbohydrate in the diet, your body will make sugar
from other sources, including protein and fat
 Research shows sugar’s relationship to ↑ insulin levels and related growth
factors → influence cancer cell growth and ↑ risk of other chronic
diseases.
 Many types of cancer cells have ++ insulin receptors, making them
respond more than normal cells to insulin’s ability to promote growth
 Sugar and beverages add substantial calories, promote weight gain
(adverse outcomes/risk ie.breast/prostate).
 Sugar: What we recommend
 Avoid added sugars:
 Hidden in pasta sauce, salad dressing, canned vegetables, processed foods.
 Other disguised names: fructose, lactose, sucrose, glucose, maltose.
 Simple Carbohydrates vs complex. GI
 Approximate Recommended Maximum Intake of Added Sugar Age, in
teaspoons
 Children: 8
 Youth:10.5
 Teenagers:13
 Female adults:11.5
 Male adults: 15
 1 Can of regular cola has 19tsp
How does this impact our patients?
 Misinformation can produce anxiety, fear and unnecessary weight loss or gain
and fatigue.
 Eliminating all sugars (simple and complex) can impair overall health in the
form of energy for activity, healing and disease-fighting nutrients.
 Avoiding natural sugars such as fructose, lactose can take out many key food
groups from diet, leaving little choice, taste and satisfaction.
Ketogenic Diet in Cancer Care
 Pre-clinical and early clinical evidence that ketogenic diets can influence
cancer progression is promising.
 Ketogenic diets are safe and tolerable but require effort to implement and
maintain (medical & nutritional monitoring is highly recommended).
 Risk factors: Weight loss, micronutrient malnutrition, dehydration/electrolyte
imbalance.
 Pt’s need ++ education & training in order to safely implement, clinician and
dietitian’s need help to guide informed decision-making, assist patients and
educate the medical community.
 More clinical research is needed (and is underway).
 Development of a clinical protocol.
Ketogenic Diet
 Very high fat diet, low carbohydrate (CHO) and protein(PRO). Example (~75-
90%kcal/fat, 10-15%kcal/protein, 5-10%kcal/CHO) 20-30g CHO/d
 Body switches from burning glucose to burning fat for energy
 Carbohydrate restriction and fasting promote ketosis or the formation of
ketone bodies;
 beta-hydroxybutyrate (found in blood; most prevalent)
 acetoacetate (found in urine)
 acetone (found in the breath)
 Ketone bodies can be used as an alternative energy source for normal cells
but not cancer cells.
Hyperglycemia & Cancer

 Although the exact mechanisms are still not clear, research shows that
hyperglycemia may contribute to enhanced;
 cancer cell proliferation
 apoptosis inhibition
 metastasis
 perineural invasion
 chemotherapy resistance
 reduced treatment tolerance
 Inconsistencies in measuring and assessing hyperglycemia in cancer patients2.
 Lack of standardized guidelines in treating hyperglycemia.
“It’s ok, I can stand to lose some weight during
treatment!”

 Patients with increased body weight/obesity is becoming more common

 Patients often say “oh I have a few pounds to lose anyways”
 Patients are aware of the side effects of cancer treatment, and how it
impacts their ability to maintain their weight
 Just because this weight loss is ‘easy’ doesn’t mean its healthy or safe!
How does this impact our patients?

 There is a time and place for weight loss – during cancer treatment isn’t
that place
 Under stress the body preferentially breaks down muscle. Decreased
muscle mass = Sarcopenia: decreased function, decreased energy,
decreased ability to tolerate chemo and a longer road to recovery
 For the majority of patients: focus on weight stability
 Weight loss may be indicated under supervision of a dietitian and
physician (breast, prostate)
 Post treatment, focus on a healthy diet
 Why Nutrition Matters
Optimized nutritional status leads to…
• Increased life span
• Increased tolerance to treatment, prevent delays
• Decreased fatigue
• Wound healing
• Improved immunity/ fight infection
• Preserve lean body mass
• Maintain hydration status
• Maintain healthy bowel function
Assessing Patient’s Nutrition Status:
Canadian Nutrition Screening Tool (CNST)
2 Questions, help indicate if consult to dietitian now!
Ask the patient the following questions* Yes or No
1. Have you lost weight in the past 6 months WITHOUT TRYING to lose this weight?
*If the patient reports a weight loss but gained it back, consider it as NO weight loss.
2. Have you been eating less than usual FOR MORE THAN A WEEK?
 Two “YES” answers indicate nutrition risk†
 http://www.nutritioncareincanada.ca/sites/default/uploads/files/CNST.pdf
Physical Assessment and Biochemistry
 Weight measures with all visits, extremely helpful
 Fat/Muscle wasting assessment (SGA)
 CBC
 Iron status (Ferritin)
 HgbA1C
 Glucose
 Vit D ** Only in presence of malabsorption, special req
 Lytes/Mg
 Serum protein markers
 Micronutrient panel: Vit A, E, C, B12, Folate, Selenium, zinc, copper
 Lipid Profile +/-
Serum Protein Markers

 Lacking a reliable lab indictor to identify malnutrition

 Not specific, nor sensitive
 Many variables affect serum protein markers
 i.e. inflammation… cancer! Also infection, surgery, autoimmune processes, etc
 Commonly used:
 Albumin
 Prealbumin
 Albumin
 Very little of albumin pool is comprised of newly
synthesized albumin, therefore protein intake very
little effect on total albumin pool on a daily basis.
 Often affected by redistribution between
extravascular and intravascular space (common with
edema from certain cancers/chemo, problems with
heart/liver/kidney, IVF, inactivity)
 Affected by capillary permeability, drugs, impaired
liver function, inflammation, etc…
 May be falsely high in dehydration (decreased
plasma volume).
 Negative acute phase reactant (levels decrease with
acute phase response)
 Long half-life (14-20 days), therefore more a marker
for chronic malnutrition
 Primary function is a carrier protein, maintains
oncotic pressure (may be given via IV, although
practice is controversial)
Prealbumin
 Like albumin, is a visceral protein
 Affected by many of same factors as
albumin
 Negative acute phase reactant – assess
with c-reactive protein
 Advantage: Shorter half-life (2-3 days),
therefore changes more rapidly with
acute changes in nutrient intake
 Elevated in AKI
 Unaffected by hydration status
Other markers

 Transferrin (half-life: 8-10 days)

 Influenced by iron status (deficiency increases transferrin)
 Retinol Binding Protein (RBP) (half-life: 12 hours)
 Elevated in renal failure
 Dependent on normal Vit A and Zn
 Nitrogen balance
 Gold standard but also inconsistent, mainly for inpatients (with foley)
 Nitrogen intake minus nitrogen loss from the body
 Need 24 hour urine urea and total protein intake
 Affected by kidney dysfunction and diuretics
 Diabetes and Cancer

 Increased risk as other treatment can effect BBGM control; PET, anti-emetics
(dexamethasone), chemotherapy, weight loss, stress…

 DM occurs commonly in pancreatic cancer pts, ~50% are at diagnosis

 Recent onset of DM without family history or high body wt is a warning sign

 Type 3c DM, pancreatogenic diabetes, originates from pancreatic dx. lends to

more “brittle diabetes”

Gilliland, TM et. All: Feb 2017, Practical Gastroenterology: March 2016, Flory, J. et. all: June 2016
 Diabetes and Cancer

 Patients with active cancer, the focus of hyperglycemia management shifts from
preventing long-term complications toward avoiding acute and sub-acute
outcomes, such as dehydration from polyuria, infection, catabolic weight loss,
hyperosmolar non-ketotic states (HNK), and diabetic ketoacidosis

 Studies found correlation between hyperglycemia and increase toxicities with

systemic cancer treatments

Gilliland, TM et. All: Feb 2017, Practical Gastroenterology: March 2016, Flory, J. et. all: June 2016
Nutritional Requirements:
What We (dietitians) Recommend!
 Assess REE/caloric needs. Start 25-30kcal/kg/d
 Decreased in >65y, Non-metastatic Breast/Prostate, brain as not high needs (21-
25kcal/kg/d)
 Increased with large tumour burden, esophageal, head and neck, lung, pancreatic,
metastatic malignancies. (35-45kcal/kg/d)
 Pt are placed on high protein diet: 1.2-2g protein/kg of body weight/day.
Normal person 0.8-1g/kg/d.
 We do no restrict fat, we encourage healthy fat consumption. Fat is calorie
dense, helpful with poor appetite. 9kcal/g fat vs 4kcal/g CHO. Also does not
raise blood sugars
 We absolutely recommend management of diabetes pre,during and post-
treatment, balanced CHO intake, low glycemic index if possible
 We often suggest: Multivitamin, Vit D3, Fish oil, Iron or B12 (correction of
anemia)
Nutrients to Highlight
 Multivitamin, If pt malnourished, poor intake, suggested, age appropriate 1/d
 Vit D3: Plays role in immune system, evidence showing increased apoptosis, decrease
ability of tumour to form blood vessels, preserved & increased lean body mass, improved
sarcopenia
 RCT 2017 showing high dose of vitamin D supplementation significantly improved
progression-free survival (PFS) by about 2 months compared to a low dose. (Colorectal CA)
 31% reduced relative risk for disease progression in the high-dose group (unadjusted hazard ratio,
0.69; P = .04)
 The disease control rate in the high-dose group was 96% vs 84% in the low-dose group (P = .05)
 The high dose did not increase toxicity. There was also significantly less serious (grade 3 and 4)
diarrhea in the high-dose group (12% vs 1%; P = .02).

https://www.cancer.gov/about-cancer/causes-prevention/risk/diet/vitamin-d-fact-sheet, https://www.medscape.com/viewarticle/881250#vp_2
 Nutrients to Highlight
Omega 3 Fatty Acid: DHA/EPA
 Source long-chain Omega 3 fatty acid suggestive to improve appetite, oral intake, lean body
mass, body weight in pt with advanced cancer
 Promising evidence improved tumour response when taken during treatment
 Trend towards improved one-year survival
 2g Fish oil/d

J.Arends et al./Clinical Nutrition 36(2017) 1187-1196

Special Considerations:

 Pancreatic cancer → Pancreatic Enzymes Insufficiency (PEI) requiring

Pancreatic Enzyme Therapy (PET), Pt will malabsorb all macronutrients and
fat soluble vitamins. Signs: bloating, foul gas, steatorrhea, diarrhea, pain
w/ingestion, unexplained weight loss, hypoglycemia…
 PET: Use enterically coated orally: Contain pancrealipase – amylase, lipase and
protease (Cotazyme ECS, Creon). Start low and titrate.
 Have been found to be useful post gastrectomy. Improve steatorrhea secondary to
fast transit time.
 Discourage extreme supplementation or dietary changes.
 High dose Vit C found to be detrimental for cancer pts, causing cancer cell to be
protected as well as healthy cells
 Evidence does not support removing meat and becoming vegan/vegetarian.
Dietary restriction in choices could prove more dangerous
 Consult Dietitian and rely on their expertise to navigate dietary changes
Resources for Patients

 Canadian Cancer Society: https://www.cancer.ca/

http://www.cancer.ca/en/support-and-services/resources/publications/?region=on
 National Cancer Institute: https://www.cancer.gov/
 American Cancer Society: https://www.cancer.org/
 Gastric Cancer: https://www.nostomachforcancer.org/
 Pancreatic Cancer: https://www.pancan.org/
 American Institute for Cancer Research: http://www.aicr.org/
 Breast Cancer: http://www.breastcancer.org/
 Lymphoma: https://www.lymphoma.ca/
 Prostate Cancer: http://www.prostatecancer.ca/
 Questions
Jessica.Kasnik@ahs.ca, (780)577-8050