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1. Welcome to Seminar on Optimal Nutrition Support to Cancer Patients Meera Kaur, PhD, RD. [email protected]. KILDONAN MEDICAL CENTRE. 2. Outline of the Session. Motivation for this Study Objectives The concept The food development Clinical outcome Materials and methods - PowerPoint PPT PresentationTRANSCRIPT
Welcome to Seminar on
Optimal Nutrition Support to Cancer Patients
Meera Kaur, PhD, RD.
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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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KILDONAN MEDICAL CENTRE
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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 ….
KILDONAN MEDICAL CENTRE
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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KILDONAN MEDICAL CENTRE
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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KILDONAN MEDICAL CENTRE
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
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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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Meera Kaur, PhD, RDKILDONAN MEDICAL CENTRE
Materials and Methods
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Meera Kaur, PhD, RD
KILDONAN MEDICAL CENTRE
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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Meera Kaur, PhD, RDKILDONAN MEDICAL CENTRE
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
KILDONAN MEDICAL CENTRE
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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
KILDONAN MEDICAL CENTRE
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
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Results
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Meera Kaur, PhD, RDKILDONAN MEDICAL CENTRE
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
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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
(%)
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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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Meera Kaur, PhD, RDKILDONAN MEDICAL CENTRE
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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Meera Kaur, PhD, RDKILDONAN MEDICAL CENTRE
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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Meera Kaur, PhD, RDKILDONAN MEDICAL CENTRE
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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Meera Kaur, PhD, RDKILDONAN MEDICAL CENTRE
Discussion
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Meera Kaur, PhD, RDKILDONAN MEDICAL CENTRE
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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Meera Kaur, PhD, RDKILDONAN MEDICAL CENTRE
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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Meera Kaur, PhD, RDKILDONAN MEDICAL CENTRE
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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Meera Kaur, PhD, RDKILDONAN MEDICAL CENTRE
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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Meera Kaur, PhD, RDKILDONAN MEDICAL CENTRE
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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Meera Kaur, PhD, RDKILDONAN MEDICAL CENTRE
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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Meera Kaur, PhD, RDKILDONAN MEDICAL CENTRE
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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Meera Kaur, PhD, RDKILDONAN MEDICAL CENTRE
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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Meera Kaur, PhD, RDKILDONAN MEDICAL CENTRE
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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Meera Kaur, PhD, RDKILDONAN MEDICAL CENTRE
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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Meera Kaur, PhD, RDKILDONAN MEDICAL CENTRE
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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Meera Kaur, PhD, RDKILDONAN MEDICAL CENTRE
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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Meera Kaur, PhD, RDKILDONAN MEDICAL CENTRE
Thank you for gracing the session!
Any question?
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Meera Kaur, PhD, RDKILDONAN MEDICAL CENTRE
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
Meera Kaur, PhD, RDKILDONAN MEDICAL CENTRE