Welcome to Seminar on Optimal Nutrition Support to Cancer Patients Meera Kaur, PhD, RD. [e-mail]

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Welcome to Seminar onOptimal Nutrition
Support to Cancer PatientsMeera Kaur, PhD,
RD.kaur_at_cc.umanitoba.ca
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KILDONAN MEDICAL CENTRE
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Outline of the Session
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• 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
KILDONAN MEDICAL CENTRE
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Motivation for this research
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• 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 .

Meera Kaur, PhD, RD
KILDONAN MEDICAL CENTRE
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Objectives of the study
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• To
• 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
KILDONAN MEDICAL CENTRE
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The concept
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• 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
KILDONAN MEDICAL CENTRE
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The process for LCEF (patented)
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Malted Cereals

Vegetable/fish oil
Malted Mung Bean
Mixing
Cooking
Homogenizing
Spray drying
Fortification
LCEF
Toasted Soy
Milk LAB
Popped Amaranth
Meera Kaur, PhD, RD
KILDONAN MEDICAL CENTRE
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Nutritional information
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• Form Powder of cal.
• Moisture (g) 2.1
• Protein (g) 22 19-20
• Fat (g)-4 g fish oil 16 30-31
• Available Carbohydrate (g) 56 49-50
• Energy (Kcal/100g) 456
• Vitaminsminerals (g) 2.5
• Total dietary fiber (g) 5.0
• Soluble dietary fiber (g) 2.3
• Insoluble dietary fiber 2.7
• Calcium (mg) 300
• Phosphorous (mg) 314
• LAB (cfu/g) 5.4106
• BCAA (g/100g of protein) 13.31(2.9g/100g food)
• L-Glutamine (g) 4.0

Meera Kaur, PhD, RD
KILDONAN MEDICAL CENTRE
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Clinical Outcome inCancer Patients
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Meera Kaur, PhD, RD
KILDONAN MEDICAL CENTRE
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Materials and Methods
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Meera Kaur, PhD, RD
KILDONAN MEDICAL CENTRE
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Patients characteristics...
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• Characteristics Experimental Control
• (n32) (n31)
• Gender ratio (M/F) 19/13 17/14
• Age (years) 51.87.4 53.77.7
• BMI (kg/m2) 17.63.4 17.44.6
• Usual wt (kg) 66.12.4 65.83.7
• Wt. loss at admission() 7.13.6 7.31.8
• Performance Status (Zubrod) 2.10.6 2.10.7
• Values are meanSD

Meera Kaur, PhD, RD
KILDONAN MEDICAL CENTRE
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Patients characteristics
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• Inoperable Carcinoma Esophagus (Stage III or IV
  with no prior treatment)
• Radiation and/or Chemotherapy
• Pediatric patients, pregnant and nursing mothers

• Type of Cancer
• Treatment Received
• Exclusion Criteria

Meera Kaur, PhD, RD
KILDONAN MEDICAL CENTRE
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Nutritional Support
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• 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
• ,

Meera Kaur, PhD, RD
KILDONAN MEDICAL CENTRE
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Outcome measures
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• Liver function tests
• Infectious episodes
• Test for lactose intolerance
• Length of hospital stay

• Tolerance
• Calorie intake
• Anthropometric indices
• Biochemical indices

Meera Kaur, PhD, RD
KILDONAN MEDICAL CENTRE
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Results
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Meera Kaur, PhD, RD
KILDONAN MEDICAL CENTRE
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Energy Estimated and Intake
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Meera Kaur, PhD, RD
KILDONAN MEDICAL CENTRE
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Changes in body weight
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Meera Kaur, PhD, RD
KILDONAN MEDICAL CENTRE
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Anthropometrical indices of patients
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• Parameters Control
  Experimental C Vs E
• I T I T p lt
• TSF (mm) 8.31?1.4 7.86?1.0 10.5?1.1
  10.3?2.01 0.05
• MAC( cm) 20.0?1.2 19.8?1.3 20.3?1.9
  19.9?1.3 NS
• MAMC (cm) 19.76?1.9 19.36?2.0
  21.1?1.21 21.1?1.09 0.05
• IAt the initiation of study TAt the
  termination of study NSnot significant
• Values are mean SD

Meera Kaur, PhD, RD
KILDONAN MEDICAL CENTRE
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Biochemical Indices of Patients
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• Parameters Control
  Experimental C Vs E
• I T I T P lt
• T. Protein (g) 6.9?1.3 6.4?0.7 7.1?1.1
  7.5?0.6 0.05
• Albumin (g) 4.10.3 3.10.6 3.8?0.4
  4.7?0.5 0.05
• Globulin (g) 3.4?0.8 3.7?0.9 3.8?1.4
  2.8?0.4 0.05
• A/G 1.3?0.5 0.87?0.13 1.0?0.3 1.6?0.2
  0.05
• Alkaline 11.5?7.7 11.0?3.2 12.8?13.5
  5.8?3.6 0.05
• Phosphatase (Unit )
• SGPT (unit/ml) 208?129.9 100.3?13.2
  198.3?135.7 44.7?11.1 0.05
• IAt the initiation of study TAt the
  termination of study Values are mean SD

Meera Kaur, PhD, RD
KILDONAN MEDICAL CENTRE
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Infectious episodes
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• Commonly isolated organisms
• Staphylococcus Coagulase negative
• Staphylococcus aureas
• Streptococcus pneumoniae
• Stenotrophomonas maltophilia
• Number of infectious episodes
• Control 5.32.3
• Experimental 3.20.8
• C Vs E plt0.05

Meera Kaur, PhD, RD
KILDONAN MEDICAL CENTRE
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Other parameters
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• Tolerance of the feed Well tolerated
• Presence of lactose in stool Nil
• Length of hospital stay (days)
• Experimental (E) 52.41.4
• Control(C) 63.30.78
• C Vs E plt0.05
• Cost of nutrition support/day
• Experimental (E) 3-5
• Control(C) 10-15
• C Vs E plt0.05

Meera Kaur, PhD, RD
KILDONAN MEDICAL CENTRE
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Discussion
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Meera Kaur, PhD, RD
KILDONAN MEDICAL CENTRE
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Discussion
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• 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.

Meera Kaur, PhD, RD
KILDONAN MEDICAL CENTRE
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Discussion
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• 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

Meera Kaur, PhD, RD
KILDONAN MEDICAL CENTRE
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Discussion
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• 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

Meera Kaur, PhD, RD
KILDONAN MEDICAL CENTRE
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Discussion
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• 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

Meera Kaur, PhD, RD
KILDONAN MEDICAL CENTRE
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Discussion
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• Use of synbiotics (LABplant fibre)
• Evidence of significant positive outcome
• Bengmark (2006) Pancreatitis, trauma? ?
  immunoparalysis
• Bengmark (2005) Critically ill? ? pathogens (c.
  diff)
• Bengmark (2005) Clinical Medicine? reinforce
  immune system
• Rayes et al. (2005) Liver transplant? ?
  bacterial infection rate
• Bengmark (2003) Critically ill? research
  limited, but great hope for
  future confirmed for LAB
• Olah et al. (2002 ) Acute pancreatitis? ?
  pancreatic sepsis, ? no.of surgical
  interventions

Meera Kaur, PhD, RD
KILDONAN MEDICAL CENTRE
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Implications for the Practitioners
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• 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

Meera Kaur, PhD, RD
KILDONAN MEDICAL CENTRE
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Summary
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• 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.

Meera Kaur, PhD, RD
KILDONAN MEDICAL CENTRE
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Conclusion
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• 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.

Meera Kaur, PhD, RD
KILDONAN MEDICAL CENTRE
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References
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• Oguz 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.

Meera Kaur, PhD, RD
KILDONAN MEDICAL CENTRE
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References
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• Rayes 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

Meera Kaur, PhD, RD
KILDONAN MEDICAL CENTRE
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References
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• Ziegler, 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 oilenriched
  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.

Meera Kaur, PhD, RD
KILDONAN MEDICAL CENTRE
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Acknowledgement
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• I 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.

Meera Kaur, PhD, RD
KILDONAN MEDICAL CENTRE
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Thank you for gracing the session!Any
question?
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Meera Kaur, PhD, RD
KILDONAN MEDICAL CENTRE
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Natural Vs Defined ingredient-based formula

• Natural 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, RD
KILDONAN MEDICAL CENTRE