Assistant Professor, Khalsa College of Nursing, Amritsar, Punjab, India.
INTRODUCTION: In industrialized countries every fourth death is caused by cancer. Scarcely any family or circle of acquaintance is spared the sad fate of watching while a loved one slowly succumbs to this illness. Those who have faced the knowledge that their body is carrying a tumor which is threatening to spread may well ask: what can I expect from the future? Must I give in without a fight or are there practical and promising methods for tackling the situation? Not all health problems are avoidable, but you have more control over your health than you may think. Research shows that a large percentage of cancer-related deaths are directly linked to lifestyle choices such as smoking, drinking, a lack of exercise, and an unhealthy diet. Therefore nutrition counseling is required to maintain health of the client which includes; diet, exercise & activity, behavior modification and managing acute side effects.
DEFINITION: Nutrition counseling is an ongoing process in which a health professional, usually a registered dietitian, works with an individual to assess his or her usual dietary intake and identify areas where change is needed.
FACTORS RELATED TO NUTRITIONAL DISTURBANCES
- External and internal factors
- Cancer related factors
- Treatment related factors
- External and internal factors: External factors include the environmental and social contexts within which an individual exists. These contexts encompass the overall health of the country’s economy, which has an impact on transportation, access to food shopping, availability of different nutrients, adequacy of housing and food preparation facilities, and availability of programs that offer food assistance. Environmental factors influence the individual, who possesses cultural beliefs and attitudes about nutrition and eating behaviors. Internal factors that influence a person’s tendency to develop nutritional deficiencies include age, body image, past history of food fads or eating disorders, social support, educational level, alcohol or tobacco intake, and presence of co morbid diseases. Much more research in this area is needed before individuals at risk can be reliably identified.
- Cancer-related factors: The type of cancer affects the probability of malnutrition. Individuals with breast cancer or leukemia are at low risk, whereas 31% to 48% of patients with non-Hodgkin’s lymphoma have significant weight loss. Moreover, unfavorable histologies are correlated with higher weight loss. Individuals with cancers of the aerodigestive (upper respiratory and digestive) and gastrointestinal (GI) tracts are at special risk for under nutrition from mechanical obstruction and physiological dysfunction due to local tumor compression. Host responses to the cancer and the cancer itself cause changes in metabolism and energy needs and may explain why those individuals with advanced disease are more likely to have nutritional problems.
- Treatment related factors: All cancer therapies have the potential to cause nutritional deficiency. The magnitude of the treatment-related risk depends on the area of treatment, type of treatment, number of therapeutic modalities used, dosages of therapy used, and length of treatment. Surgery itself alters function. Major aero digestive resections may produce taste alterations, dysgeusia, or impaired swallowing, resulting in reduced intake. Radiation therapy can alter nutritional status by exerting both systemic and local effects. The extent of the alteration varies with the area of the body being treated, the size of the area being treated, and the duration of treatment. Radiation alters function in the treatment area and poses particular problems for patients with aero digestive or GI cancers. Acute effects are transient and include anorexia, diarrhea, bleeding, nausea, vomiting, weight loss, mucositis, esophagitis, gastritis, xerostomia, and changes in taste. Local desquamation reactions can temporarily increase energy needs. Some of these changes—especially xerostomia, taste changes, and diarrhea—can become chronic. Chemotherapy has a number of direct and indirect effects on nutrition. Direct effects include alteration of the absorptive surface of the GI tract, excitation of the chemoreceptor trigger zone and true vomiting center, and interference with specific metabolic and enzymatic reactions. The majority of chemotherapeutic agents, because of the damage they cause to frequently reproducing cells, alter the length and surface area of intestinal villi. The reduced ability of the gut to absorb nutrients and water production that results can induce diarrhea and malabsorption.
CANCER-INDUCED ALTERATIONS IN NUTRIENT INTAKE
- Appetite loss
- Dry mouth
- Sore throat and trouble swallowing
Appetite Loss refers to when you do not want to eat or do not feel like eating very much. One may have appetite loss for just 1 or 2 days, or throughout your course of treatment. Reasons may include: the cancer itself, fatigue, pain, feelings such as stress, fear, depression & anxiety, Cancer treatment side effects such as nausea, vomiting, or changes in how foods taste or smell.
Suggested intervention to improve appetite are: after food choice, increase oral hygiene; avoid sight, smell of food; eat sour foods; eat cold foods; use straw; increase seasoning; use plastic utensils; small amount of alcohol.
Constipation: Constipation occurs when bowel movements become less frequent and stools become hard, dry, and difficult to pass. Client may have painful bowel movements, feel bloated, or have nausea. Chemotherapy, the location of the cancer, pain medication, and other medicines can cause constipation. Increase liquid intake; eat more fiber; eat more fruit; exercise; take laxative; drink hot beverages; add bran to foods.
Diarrhea: Diarrhea occurs when there are frequent bowel movements that may be soft, loose, or watery. Foods and liquids pass through the bowel so quickly that body cannot absorb enough nutrition, vitamins, minerals, and water from them. Diarrhea can be caused by cancer treatments such as radiation therapy to the abdomen or pelvis, chemotherapy, or biological therapy.
Take medicine; increase fluids; drink rehydration fluids; low-residue diet; avoid spices and caffeine, avoid milk products; take soluble-fiber supplement; eat low-fat diet.
Dry Mouth: Dry mouth occurs when there is less saliva than it is used to. This can make it harder to talk, chew, and swallow food. Dry mouth can also change the way food tastes. Chemotherapy and radiation therapy to the head or neck area can damage the glands that make saliva. Biological therapy and some medicines can also cause dry mouth.
Take prescribed medicine; increase fluids; chew gum; suck on sugarless candy; blend foods; avoid acid, salty, or spicy foods; moisten food, humidify air; apply oil to oral cavity.
Nausea: Nausea occurs when the client feels queasy or sick to stomach. It may be followed by vomiting (throwing up), but not always. Nausea can keep from getting the food and nutrients the client needs. Not everyone gets nausea and those who do may get it right after a treatment or up to 3 days later. Nausea almost always goes away once treatment ends. Nausea can be a side effect of surgery, chemotherapy, biological therapy, and radiation therapy to the abdomen, small intestine, colon, or brain. It can also be caused by certain types of cancer or other illnesses.
Take medicine; alter diet, practice relaxation; listen to music; rest after meals; avoid sight, smell of food; eat cold foods; increase oral hygiene; eat small frequent meals; eat slowly; get fresh air; drink clear liquids; keep busy/distracted; chew food well; drink between meals; eat crackers; breathe through the mouth: eat sour foods; eat low-fat foods; avoid spicy foods; eat sweet foods.
Sore Throat and trouble swallowing: Chemotherapy and radiation therapy to the head and neck can make the lining of your throat inflamed and sore. It may feel as if one has a lump in throat or that chest or throat is burning. There may also be trouble in swallowing. These problems may make it hard to eat and cause weight loss. Some types of chemotherapy and radiation to the head and neck can harm fast-growing cells, such as those in the lining of your throat.
Take prescribed medicine; apply cold (ice) to oral cavity during chemotherapy administration; increase oral hygiene; drink liquids; use soft toothbrush; avoid spicy food; humidify air, avoid use of gravy; use baking soda mouthwash; apply mucosa-adhesive film, avoid alcohol and tobacco; use straws; use supplements; use glutamine.
Vomiting: Vomiting is another way to say “throwing up.”Vomiting may follow nausea and be caused by cancer treatment, food odors, motion, an upset stomach, or bowel gas. Some people vomit when they are in places (such as hospitals) that remind them of cancer. Vomiting, like nausea, can happen right after treatment or 1 or 2 days later. Biological therapy, some types of chemotherapy, and radiation therapy to the abdomen, small intestine, colon, or brain can cause nausea, vomiting, or both. Often, this happens because these treatments harm healthy cells in your digestive tract.
Take prescribed medicine; practice relaxation; rest after meals; drink clear liquids; avoid sight, smell of food; eat slowly; eat crackers; eat cold foods; get fresh air; chew mint candy; eat room-temperature foods; alter diet; increase oral hygiene; eat small frequent meals; eat low-fat diet; avoid spicy foods.
Physical inactivity can lead to muscle atrophy, contributing to loss of cardio respiratory fitness and fatigue. Weight loss that occurs secondary to catabolic activity or cytokine mediated changes in metabolism or corticosteroid use can also contribute significantly to decreased muscle mass. The structure and function of muscle and bone depend on physical activity combined with appropriate nutritional intake and a hormonal milieu that supports anabolism. An evolving body of knowledge supports the role of physical activity in enhancing a number of clinical outcomes. Improvements have been documented in functional capacity, fatigue, medication requirements, self-esteem, and mood, sense of control and well-being, and immunological parameters. Physical activities might include walking programs, stretching, and use of resistance bands, swimming, cycling, or dancing, as tolerated.
VERBAL COUNSELING AND EDUCATION
Verbal counseling can be extremely effective in assisting patients to choose calorie-dense foods and treat symptoms that interfere with oral intake. A number of self-care actions have been proposed for the treatment of cancer induced nutritional problems. Patient education material commonly includes interventions related to decreased appetite, nausea, vomiting, constipation, taste changes, and mucositis. Little research has explored the effectiveness of most of these actions. Of those studies that employed an experimental approach, the majority have included non pharmacological interventions. Much of what is suggested to patients regarding treatment of side effects is not based on scientific evidence or systematic review of patient experience. Moreover, some of the interventions are global in nature. For example, counseling and psycho educational approaches have benefited patients having nausea. However, the actual content of the counseling and psycho educational interventions has not been standardized, so research application is difficult. Much more research is needed before health personnel can accurately predict which intervention will prove effective for a specific patient in a given situation. Patients and their families may identify self-care activities that differ from those commonly suggested in the cancer patient education literature.