1. Nutrition for an Immune
Compromised Patient
Jyothi Prasad
Manipal Hospital

2. 1. Evidence based nutrition
guidelines for oncology
2. The benefit of Neutropenic diet -
fact or fiction?

3. Why shouldn’t nutrition be a forgotten
ingredient in oncology care?
• 20-40% cancer patient deaths are related to cancer induced or
treatment related malnutrition
• Malnutrition causes:
Diminished tolerance to therapy
Lower survival rates
Diminished quality of life
Longer hospitalization
• Effects of symptoms on dietary intake is profound –
60% of head and neck and GI patients lose weight upon
beginning treatment

4. Impact of malnutrition
• Head and neck ca treated – the strongest predictor of survival was
pre treatment weight loss
• Postoperative morbidity and quality of life significantly influenced
by preoperative nutrition
• Immuno competence goes down
• Inability to tolerate anti neoplastic treatments
• Postoperative complications
• Surgical insult on post operative patients is well tolerated by
nourished individuals

5. Nutritional issues in Oncology
• Systemic effects of cancer on nutrition
• Localized tumor effects
• Nutritional problems of therapy
• Nutrition intervention and tumor growth
• Efficacy of nutrition support
• Guidelines for nutrition support
• Unproven diet and nutrition claims

6. Cancer Cachexia
Starvation amidst plenty
• The failure of nutritional repletion despite adequate caloric intake in
patients with malignancy. This is mediated by pro inflammatory cytokines
• The prominent feature of clinical feature of cachexia is weight loss in adults
and growth failure in children. There is competition between the tumour and
the host for nutrients resulting in an accelerated starvation state
• Anorexia, inflammation, insulin resistance, and increased muscle protein
breakdown are frequently associated with cachexia
• Cachexia is different from Anorexia. Anorexia is EFFECT rather than
CAUSE OF cachexia.
• Cachexia is distinct from starvation, age related loss of muscle mass,
primary malabsorption and hyperthyroidism and is associated with
increased morbidity and mortality

7. Pathogenesis of Cancer induced Cachexia
Cancer induced cachexia is invariably associated with the
presence and growth of tumor
CANCER
Nausea/Vomitting Anorexia
Metabolic changes:
Energy, protein, lipid
and cho
WEIGHT LOSS
NEOPLASTIC CACHEXIA SYNDROME

8. The Cachexia Journey
Pre Cachexia Cachexia Severe
syndrome Cachexia
Death
Weight loss Weight loss Severe muscle
Reduced food intake wasting
Systemic Fat loss
inflammation Immuno
compromised
>6-9 months 3-9 months <3 months
Survival

9. Changes that occur in metabolism
Carbohydrate Protein
• Insulin resistance • Increased protein
• Increased glucose catabolism
synthesis • Decreased protein
synthesis
• Gluconeogenesis
• Increased Cori cycle
Fat
activity
• Increased lipid
• Decreased glucose metabolism
tolerance • Decreased lipogenesis
• Decreased activity of
lipoprotein lipase (LPL

10. Therapy related issues
Radiation related problems Surgery related problems
Oropharyngeal Area Radical Resection of Oropharyngeal
Loss of taste Area
Xerostomia & odynophagia
Teeth loss Chewing & swallowing difficulties
Lower Neck & Mediastinum Esophagectomy
Esophagitis with dysphagia Gastric stasis & hypochorhydria
Fibrosis with esophageal secondary to vagotomy
stricture Steatorrhea secondary to vagotomy
Diarrhea secondary to vagotomy
Premature satiety
Abdomen & Pelvis Regurgitation
Bowel-damage syndromes
(acute or chronic) with Gastrectomy (high subtotal or total)
diarrhea, malabsorption, Dumping syndrome
stenosis & obstruction, Malabsorption
fistulization Achlorhydria & lack of intrinsic
factor and R protein
Hypoglycemia
Premature satiety

11. ……. Contd
Drug-related Problems
Intestinal Resection - Jejunum & Noncytotoxic
Ileum
• Decreased absorption efficiency Corticosteriods
including fat
• Fluid & electrolyte problems
• Vitamin deficiency with fat-soluble
vitamin malabsorption • Nitrogen & calcium losses
• Bile salt losses with diarrhea or • Hyperglycemia
steatorrhea
• Hyperoxaluria & renal stones Sex hormone analogues
• Calcium & magnesium depletion • Fluid retention
Massive Bowel Resection • Nausea
• Life-threatening malabsorption • Megesterol acetate - glucocorticoid
• Malnutrition effects
• Metabolic acidosis Chemotherapy
• Dehydration w/wo salt & water
balance problems • Nausea
• Vomitting
Blind Loop Syndrome • Loss of appetite
• Vitamin B12 Malabsorption
• Diarrhea
Pancreatectomy • Anorexia
• Malabsorption • Mouth ulcers
• Diabetes • Diarrhea/Constipation

12. Intermediary Secondary infections,
Endocrine malignant lesions
metabolites abnormalities
Nutritional Medications
abnormalities
Neurological Appetite Cytokines
influences
Psychiatric,
psychological
influences
Learned aversions Social, cultural &
Food intake
to therapy economic factors
Physical
factors

13. Nutritional support – how to go about?
• Assess: Patient history, look for signs, weigh regularly and
know the lab values
• Plan: Nutritional requirements - set short term and long term goals
and individualize needs
• Intervene: Symptom management - strategies for patients, enteral
and parenteral nutrition
• Evaluate: Effectiveness of intervention, achievement of long and
short term goals

14. Evaluation : Before beginning intervention
• Cardinal principle:
Individualize to needs of patient
• Short-term goal:
Improve nutritional status
• Long-term goal:
Normalize Nutrient Intake
Alleviate disease symptoms
• Outcomes???
Better Quality of life / Vigor
Fewer Crisis / Improved Treatment Response

15. Screening Vs Assessment
Screening Assessment
• Done to detect the possibility of • More intensive and thorough
nutrition risk • Needs intervention, follow up
• All patients in all settings regularly
require it • Assessment must have weight
• Required to be stored in the history, appearance, functional
medical file status, diet history, biochemical
• Patient generated SGA is often parameters, medication and
used and is useful and easy to planned treatment
score • Assessment can include financial
• Score generated guides nutrition and psychosocial aspects is
intervention possible
• If screen indicates risk, full • Has to be done by a dietician or
assessment must be done doctor only

16. Nutritional assessment criteria
1. Anthropometry: Weigh regularly
BMI
Severe weight loss
Mid – arm circumference
5. Laboratory data: Not always the most accurate when
viewed alone
Serum albumin : Level falls only after significant depletion has occurred
Serum pre albumin: Can be used for assessment
Serum transferrin: More sensitive marker for marginal protein depletion
Total iron binding capacity
Delayed hypersensitivity skin testing to a recall antigen
Total lymphocyte count
12. Diet history
24 hour recall, Food frequency etc

17. Who is severely malnourished?
• Weight loss more than 10%
• Poor intake for 2 weeks or more
• BMI less than 18.5
• Mid arm circumference: Male <17.6cms Female <17.1 cms
• Subjective global assessment score – “C”
• Mini nutritional assessment score - <25
• Albumin on entry <3gm %
• Total lymphocyte count <1500

18. Nutrition requirement guidelines
Calories (Harris-Benedict formula)
• Obese patients: 21-25 kcal/kg
• Non-ambulatory/sedentary adults: 25-30 kcal/kg
• Sepsis: 25-35 kcal/kg
• Slightly hypermetabolic or those in need of weight gain or those with stem
cell transplant: 30-35 kcal/kg
• Hypermetabolic or severely stressed: ≥35 kcal/kg
Protein needs
• Normal or Maintenance: 0.8-1.0 g/kg
• Non-stressed cancer patient: 1.0-1.5 g/kg
• Bone marrow transplant or HSCT patients: 1.5 g/kg
• Increased protein needs: 1.5-2.5 g/kg
• Hepatic or renal compromised or elevated ammonia: 0.5-0.8 g/kg
• Vitamins Minerals
Folate Magnesium
Vit C Zinc
Retinol Copper
Iron

19. Fluid requirements
• 16-30 years, active: 40 mL/kg
• 31-55 years: 35 mL/kg
• 56-75 years: 30 mL/kg
• 76 years or older: 25 mL/kg
1 mL/kcal of estimated energy needs

20. Managing symptoms
• Nutrition can help manage symptoms. The key is to start early
• Specific diet modifications will help minimize nutrition related
side effects
• Each side effect has numerous approaches for management
• Strategies for patients include teaching and trial and error
pragmatism
• Screening and assessment will identify those who require
aggressive intervention
• For others enteral and sometimes parenteral support is a must

21. When Is Initiation of Enteral Nutrition Indicated?
• Actual or anticipated inability
to meet 50% of needs for 7 or
more days Advantages
Food in liquid form
• Contributes to Quality/Length
of life in meaningful way
Keeps the stomach and
intestines working
• Can improve tolerance to normally
treatment and/or ultimate
outcome
Fewer complications than
parenteral nutrition
• A functioning gut (to some
degree) is present
Nutrients used more
easily by the body
• Is not contraindicated
• Obstruction? Can be administered at
• Gastroparesis? home
• NG tube or PEG depends on
the length of stay

22. Parenteral Nutrition
• Appropriate for patients who are severely malnourished or have contraindications
to enteral feeding – severe nausea or vommitting, fistulas in intestines, loss of
body weight with enteral nutrition, stomach and intestines removed etc
• Requires central venous line and daily laboratory evaluation and composition
adjustments
• Complication include Hypoglycemia, Hyperglycemia Hypokalemia,Blood
clots,Infection at site of insertion, Elevated liver enzymes
• In transplant patients TPN is not used as the patients are nourished prior to
transplant to withstand the procedure as the mortality & morbidity is high
• TPN is reserved for patients with unintentional weight loss prior to transplant
and possess non functioning GI tracts.
ORAL NUTRITION ENCOURAGED, ENTERAL NUTRITION
ATTEMPTED AND TPN DISCOURAGED!

23. Complementary Cancer Therapies
 Glutamine: Neutral, gluconeogenic, non essential aa. May
help decrease symptoms, but not consistently documented.
 Eicosapentanoic acid (Omega 3 fatty acid): Potential role
in inflammation, may help cachexia
 Probiotics: Healthy bacteria, may decrease opportunistic
infections, improve nutrient absorption etc
 Zinc, Co-enzyme 10 etc . . . . . . . . .

24. Neutropenia and neutropenic diet?
• Neutropenia is defined as the neutrophil count below 1.5 x 10 9/1
• Neutrophils are needed against defense and when the neutrophil
count falls below the risk of developing an infection greatly
increases
• In bone marrow transplant patients it falls below 0.5 and is
called profound neutropenia
• Many food contain food borne pathogen which may be harmful
for a person with very low immunity
• A diet that limits certain types of foods to limit the exposure of
certain types of bacteria and limit food borne infection in an
already immune compromised patient

25. Neutropenic diets - demystified
• Neutropenic diets restrict many foods especially fresh fruits, veg, juices,
curd etc.
• Patients, especially paed find it difficult as it excludes many foods,
importantly fresh fruits and veg
• Though foods contain harmful bacteria and bacterial translocation is
possible, recent studies have been unable to obtain significant
differences between placebo and intervention groups
• Unanswered questions in regard to the neutropenic diet include the
following: (a) which food should be included; (b) which food preparation
techniques improve patient compliance; (c) which patient populations
benefit most; and (d) when should such a diet be initiated
• Without scientific evidence, the best advice for neutropenic patients is to
follow food safety guidelines as indicated by government entities.

26. Food safety guidelines – A common sense approach
All patients need to follow 4 basic steps to food safety
Clean: Wash hands, surfaces, produce and clean lids for canned
produce
Separate: Don’t cross contaminate. Separate foods and cutting boards.
Especially true for flesh foods
Cook: Cook to proper temperatures. Use a food thermometer to check
internal temperature
Chill: Refrigerate promptly. Cold temp slows the growth of harmful
bacteria
• While shopping be careful and read all the labels for expiry date
• Be smart while eating out and transport food carefully and go by rules
• Be aware of food borne illnesses and know the symptoms!!

27. Future directions in oncology nutrition
• We have a knowledge base with cancer survivors
• We know about potential carcinogens thru food and water –
prevention is the key
Practice issues:
• Development of cancer rehab programmes. Evaluation of
intervention is needed
• Benefit of nutrition intervention to be documented – outcome
research
• Oncology nutrition to be a special field and a oncology
nutritionist to be a part of the multi disciplinary team

28. To conclude . . . . . .
• All patients undergoing HSCT with myeloablative conditioning regimens are
at nutrition risk and should undergo nutrition screening, assessment if
required and a proper nutrition plan
• Nutrition support therapy is appropriate in patients undergoing HSCT who
are malnourished . When PN is used, it should be discontinued as soon as
toxicities have resolved
• Enteral nutrition should be used in patients with a functioning GI tract in
whom oral intake is inadequate to meet nutrition requirements
• Pharmocological doses of Glutamine may benefit patients
• Patients should receive couselling regarding food safety guidelines as they
may pose a infectious risk
• Nutrition support therapy is appropriate for patients who develop moderate
to severe GVHD accompanied by poor oral intake

29. Thanks for your
attention!