KILDONAN MEDICAL CENTRE

Welcome to Seminar on

Optimal Nutrition Support to Cancer Patients

Meera Kaur, PhD, RD.

[email protected]

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KILDONAN MEDICAL CENTRE

Outline of the Session• Motivation for this Study • Objectives• The concept• The food development• Clinical outcome

– Materials and methods– Results and discussion

• Implications for the healthcare professionals• Summary and conclusion• References• Acknowledgement

Meera Kaur, PhD, RD

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Meera Kaur, PhD, RD

Motivation for this research • Approximately 50 % of hospitalized cancer

patients are malnourished.

• Effective nutritional support to cancer patients is particularly challenging in developing countries due to the high cost of proprietary enteral formulae.

• Hence, the objectives of this study were ….


Objectives of the studyTo:• develop natural ingredient-based, low- cost

enteral food (LCEF) for cancer patients

• determine physicochemical and nutritional properties

• evaluate clinical outcome in cancer patients

Meera Kaur, PhD, RD

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The concept

• Improving the bioavailability of nutrients in natural ingredients by suitable processing

• Modifying the texture of natural ingredients to suit enteral tube or oral feeding

• Enhancing with synbiotics and conditionally essential nutrients

Meera Kaur, PhD, RD

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The process for LCEF (patented)6

Meera Kaur, PhD, RD

MaltedCereals

MaltedMung Bean

Toasted Soy

Mixing Cooking Homogenizing Spray drying Fortification

Vegetable/fish oil

Milk + LAB

PoppedAmaranth


LCEF

Nutritional information

Form Powder % of cal.Moisture (g%) 2.1Protein (g%) 22 19-20Fat (g%)-4 g fish oil 16 30-31Available Carbohydrate (g%) 56 49-50 Energy (Kcal/100g) 456Vitamins+minerals (g%) 2.5Total dietary fiber (g%) 5.0Soluble dietary fiber (g%) 2.3Insoluble dietary fiber 2.7Calcium (mg%) 300Phosphorous (mg%) 314LAB (cfu/g) 5.4×106

BCAA (g/100g of protein) 13.31(2.9g/100g food)L-Glutamine (g%) 4.0

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Meera Kaur, PhD, RDKILDONAN MEDICAL CENTRE

Clinical Outcome inCancer Patients

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Materials and Methods

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Meera Kaur, PhD, RD


Patients’ characteristics...Characteristics Experimental Control

(n=32) (n=31)

Gender ratio (M/F) 19/13 17/14

Age (years)* 51.8±7.4 53.7±7.7

BMI (kg/m2)* 17.6±3.4 17.4±4.6

Usual wt (kg)* 66.1±2.4 65.8±3.7

Wt. loss at admission(%)* 7.1±3.6 7.3±1.8

Performance Status (Zubrod) 2.1±0.6 2.1±0.7

*Values are mean±SD

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Patients’ characteristics• Type of Cancer:

• Treatment Received:

• Exclusion Criteria:

Inoperable Carcinoma Esophagus (Stage III or IV with no prior treatment)

Radiation and/or Chemotherapy

Pediatric patients, pregnant and nursing mothers

Meera Kaur, PhD, RD


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Nutritional Support• Feeding mode: BolusTube feeding

• Energy requirement: Herris-Benedict Equation

• Protein requirement: 1.5-2.0g /Kg/day

• Initiation of feeding: Within 24 of admission

• Feeding duration: Till Discharge (45-60 days)

• Additional nutrients L-glutamine, Fish oil,

in experimental diet: Lactic acid bacteria (LAB)

• Control diet: Isocaloric, Isonitrogenous

proprietary enteral formula

,

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Meera Kaur, PhD, RD


Outcome measures

• Tolerance

• Calorie intake

• Anthropometric indices

• Biochemical indices

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Meera Kaur, PhD, RD

• Liver function tests

• Infectious episodes

• Test for lactose intolerance

• Length of hospital stay


Results

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Energy Estimated and Intake

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Meera Kaur, PhD, RD

Energy Estimated and Intake

0

500

1000

1500

2000

2500

3000

1 2 3 4 5 6 7 8Week

Kc

al

E-EST E-INT C-EST C-INT


Changes in body weight

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Meera Kaur, PhD, RD

Changes in Body Weight

52

54

56

58

60

62

1 2 3 4 5 6 7 8Week

Wei

ght (

kg)

EXPT

CONT

Percent Loss of Body Wt.

0

2

4

6

8

Expt. Cont

(%)


Anthropometrical indices of patients Parameters Control Experimental C Vs E

I T I T p <

TSF (mm) 8.311.4 7.861.0 10.51.1 10.32.01 0.05

MAC( cm) 20.01.2 19.81.3 20.31.9 19.91.3 NS

MAMC (cm) 19.761.9 19.362.0 21.11.21 21.11.09 0.05

I=At the initiation of study; T=At the termination of study; NS=not significantValues are mean ±SD

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Biochemical Indices of Patients Parameters Control Experimental C Vs E

I T I T P <

T. Protein (g%) 6.91.3 6.40.7 7.11.1 7.50.6 0.05

Albumin (g%) 4.1±0.3 3.1±0.6 3.80.4 4.70.5 0.05

Globulin (g%) 3.40.8 3.70.9 3.81.4 2.80.4 0.05

A/G 1.30.5 0.870.13 1.00.3 1.60.2 0.05

Alkaline 11.57.7 11.03.2 12.813.5 5.83.6 0.05

Phosphatase (Unit %)

SGPT (unit/ml) 208129.9 100.313.2 198.3135.7 44.711.1 0.05 I=At the initiation of study; T=At the termination of study; Values are mean ±SD

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Infectious episodesCommonly isolated organisms

Staphylococcus Coagulase negative Staphylococcus aureasStreptococcus pneumoniae Stenotrophomonas maltophilia

Number of infectious episodesControl: 5.3±2.3Experimental: 3.2±0.8C Vs E: p<0.05

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Other parameters• Tolerance of the feed: Well tolerated• Presence of lactose in stool: Nil • Length of hospital stay (days):

Experimental (E): 52.4±1.4

Control(C): 63.3±0.78

C Vs E: p<0.05• Cost of nutrition support/day:

Experimental (E): $3-5

Control(C): $10-15

C Vs E: p<0.05

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Discussion

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Discussion…Use of Glutamine in cancer patients:

Evidence of positive outcome

Oguz et al. (2007): colorectal cancer post operative complication & hospital stay

Ziegler (2001): cancer, BMT N2, infection, mucositis ,

hospital stay

Shewchuk et al. (1997): Morris Hepatoma 7777 tumor-directed natural killer cytotoxic activity or faster response to an immune

challenge.

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Discussion…Use of fish oil in cancer patients:

Evidence of significant positive outcome

Christopher & Wigmore (2005): cancer wt. Gain, prevent cachexia

Barber (2001): pancreatic cancer lean tissue, reverse

cachexia

Barber et al. (1999): pancreatic cancer acute-phase protein response (APPR)

and wasting

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Discussion…

Use of Branched-Chain Amino Acids (BCAA) in cancer patients: Evidence of significant positive outcome

Choudry et al. (2006): advanced cancer improves skeletal protein & quality of life

Okada (1988): gastric cancer (173 patients) improves metabolism and maintain good nitrogen retention

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Discussion…

Use of Lactic Acid Bacteria (LAB) in cancer patients: Evidence of significant positive outcome

Rafter (2002): cancer enhances the host's immune response, produces

antimutagenic compounds

Hirayama & Rafter (2004): cancer improves immune system

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DiscussionUse of synbiotics (LAB+plant fibre):

Evidence of significant positive outcomeBengmark (2006): Pancreatitis, trauma immunoparalysisBengmark (2005): Critically ill pathogens (c. diff)Bengmark (2005): Clinical Medicine reinforce immune

systemRayes et al. (2005): Liver transplant bacterial infection rateBengmark (2003) : Critically ill research limited, but great

hope for future; confirmed for LABOlah et al. (2002 ): Acute pancreatitis pancreatic sepsis,

no.of surgical interventions

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Implications for the Practitioners• Dietary intervention for the restoration of general

health and nutritional status• Dietary management of drug-related complications• Foods rich in natural stimulants and protectants

may be considered for the management of GI functions and over all health

• Whenever possible and applicable, foods rich in synbiotics may be included in the diet of patients to improve liver function and promote gut health

• Team approach and adjunctive therapy help provide optimal nutrition support

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Summary• Approximately 50% of hospitalized cancer patients are

malnourished. Nutrition support to cancer patients in developing countries is particularly challenging because of the high cost of proprietary formulae.

• Optimal nutritional support to cancer patients is important for effective medical treatment and overall clinical outcome.

• Research findings indicate that glutamine, fish oil, BCAA and LAB are anabolic and immunomodulatory nutrients in the nutritional support for cancer patients.

• In this study, a low-cost natural ingredient-based enteral food containing glutamine, fish oil, BCAA and LAB shows better clinical outcome in cancer patients than a proprietary defined-ingredient-based enteral food. Also, it is cost-effective.

• Further research is necessary to establish the role of specific nutrients for optimal nutritional support in cancer patients.

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Conclusion• This study reveals the clinical efficacy of the LCEF

in cancer patients.

• LCEF is cost-effective and provides optimal nutritional support to the cancer patients.

• Development of the low-cost enteral foods contributes to patient care, particularly in developing countries where poverty is prevalent.

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ReferencesOguz M., Kerem M., Bedirli A., Mentes, B B., Sakrak O., Salman B., H.

Bostanci. (2007),” L-Alanin L-glutamine supplementation improves the outcome

after colorectal surgery for cancer”, Colorectal Disease. 9 (6): 515 - 520. Bengmark, S. (2006), “Aggressive management of surgical emergencies,” Ann Roy

Coll Sur of Engl 88(7): 624-629. Choudry, HA., Pan, M., Karinch, AM., Souba WW. (2006), “Branched-Chain Amino

Acid-enriched nutritional support in surgical and cancer patients”, J Nutr: 136: 314S-318S.

Bengmark, S.(2005), “Synbiotics and the mucosal barrier in critically ill patients”, Curr opi gastro 21(6): 712-716.

Bengmark, S. and Martindale R. (2005), “Prebiotics and synbiotics in clinical medicine”, Nutr Cli Prac 20(2): 244-261.

Christopher, D., Stephen, WJ. (2005), “Systemic inflammation, cachexia and prognosis in patients with cancer. Anabolic and catabolic signals”, Cur Opi Clin

Nutr & Met Care. 8(3): 265-269.

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ReferencesRayes N., Seehofer D. and Theruvath T. (2005), “Supply of pre- and probiotics

reduces bacterial infection rates after liver transplantation - A randomized, double-blind trial”, Am J Trans 5(1): 125-130.

Hirayama, K., Rafter, J. (2004), “The role of lactic acid bacteria in colon cancer prevention: mechanistic considerations”, Antonie van Leeuwenhoek (November): 391-394.

Olah A., Belagyi T., Issekutz A., Gamal M E. and Bengmark S. (2002), “Randomized clinical trial of specific lactobacillus and fibre supplement to early enteral nutrition in patients with acute pancreatitis”,The Brit J Sur 89(9): 1103-1107

Rafter, J. (2002), “Lactic acid bacteria and cancer: mechanistic perspective”, Brit J Nutr: 88 (Supplement, September): 89-94

Barber, MD. (2001), “Cancer cachexia and its treatment with fish-oil-enriched nutritional supplementation”, Nutr: (September): 751-755

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ReferencesZiegler, T R. (2001), “Glutamine supplementation in cancer patients

receiving bone marrow transplantation and high dose chemotherapy”, J Nutr: 131: 2578S-2584S.

Barber, MD., Ross, JA., Preston T., Shenkin A., Fearon KCH. (1999), “Fish oil–enriched nutritional supplement attenuates progression of the acute-phase response in weight-losing patients with advanced pancreatic cancer” J Nutr: 12(4): 1120-1125.

Shewchuk, LD ., Baracos, VE., Field, CJ. (1997), “Dietary l-glutamine supplementation reduces the growth of the morris hepatoma 7777 in exercise-

trained and sedentary rats”, J Nutr: 127(1): 158-166. Okada, A., Mori, S., Totsuka, M., Okamoto, K., Usui, S., Fujita, H., Itakura, T. and

Mizote. H. (1988), “Branched-chain amino acids metabolic support in surgical patients: a randomized, controlled trial in patients with subtotal or total gastrectomy in 16 Japanese institutions” JPEN 12(4): 332-337.

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AcknowledgementI gratefully acknowledge:

• The financial support provided by the Council of Scientific and Industrial Research (CSIR), Government of India, New Delhi, India.

• Dr. A. Anantha , MD, DMRE and S. Taramani, RD, Kidwai Memorial Institute of Oncology, Bangalore, India, for their support while conducting the clinical trial.

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Thank you for gracing the session!

Any question?

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Natural Vs Defined ingredient-based formulaNatural ingredient-based Defined- ingredient-based Carb: cereals and millets glucose,fructose,

maltodextrin,etc.

Protein: milk, legumes, etc. peptides, amino acids, etc.

Fat: edible oils fatty acids, MCT, triglycerides, etc.

Fibre: naturally present externally added

Flavor: need not to add must be added to mask off flavor of defined sources

Color: need not to add added to enhance acceptability

Osmolality: desirable range usually high

Efficacy: more physiological less physiological

Cost: less expensive more expensive


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