Special dietary needs of cancer patients

Definition

Good nutrition is important at any age, but even more so for older adults. As men and women age their dietary needs change. Older adults may face many challenges in maintaining good nutrition. These challenges may become even more difficult during cancer treatment

Good nutrition during cancer treatment may help cancer patients keep up their energy levels, prevent infection, cope with side effects of treatment, and help the body heal. In addition to eating a balanced diet and consuming enough nutrients, the dietary needs of cancer patients also include addressing challenges to eating such as difficulty chewing and swallowing, nausea and vomiting, diarrhea or constipation , and changes in smell and taste. Diet that provides adequate nutrition may also help cancer patients to recover more quickly after treatment is complete.

Description

Good nutrition can help cancer patients stay healthy and strong during treatment. Eating a healthy balanced diet is important. Good nutrition during cancer treatment helps build and maintain the body's store of necessary nutrients, decreases the risk of infection, and provides the strength to combat treatment side effects such as nausea, vomiting, dehydration, dry mouth , constipation, and diarrhea.

A balanced diet includes eating a variety of healthy foods that provide the full amount of nutrients necessary to stay healthy and to fight the cancer. Such a diet includes foods from all the major food groups, including protein, carbohydrates , and fat.

Protein helps the body to repair itself and to fight infection. While eating enough protein is generally not a problem for people living in the United States, it may be difficult for older patients fighting cancer. Consuming too little protein can lead to a decrease in the body's ability to fight infection, weakening of the heart and lungs, and, though rare, can be fatal.

Examples of foods that contain protein are lean meats, fish, dairy foods (such as cheese and low fat milk), nuts, beans, and soy products. Carbohydrates provide energy the body needs for the organs to function properly and for the body to move. Carbohydrates are made up of sugars, starches, and fiber. Both sugar and starch are digested by the body and provide energy. Fiber is not digested, but it is important to help the bowel function properly. Fiber can help remove excess fat and can lower the impact of excess sugar in the diet. For people with diabetes, carbohydrate intake may be carefully monitored. While carbohydrates, especially those from refined sugar, may be harmful, carbohydrates from whole grains and high in fiber are helpful. Carbohydrates are found in foods such as bread and baked goods, pasta, cereals, dried beans, rice, and vegetables such as corn, potatoes, and peas.

Fat is essential to the diet. While too much fat may be harmful, fats and oils provide energy for the body and are important in transporting certain vitamins throughout the body. Fat also makes many foods taste better and have a creamy or tender texture. Examples of foods containing fat include oils, butter, margarine, meat, poultry, and dairy products.

In addition to these foods groups, a healthy diet includes enough liquids. The American Dietetic Association (ADA) recommends drinking at least eight glasses of water each day. Proper hydration may help prevent constipation and allow nutrients to be digested and absorbed from the foods eaten. To ensure that adequate amounts of vitamins and minerals are consumed, those living with cancer may need to take supplements. Cancer patients should consult a doctor before taking any vitamins, minerals, or other supplements.

Demographics

Rates for all cancers increase as the population ages. Factors such as smoking , sun exposure, delayed child bearing, and exposure to carcinogens all increase the risk of developing cancer. According to the National Cancer Institute (NCI), 70 percent of all new cancer diagnoses were anticipated to be made in people age 65 and older and 70 percent of all cancer deaths occur in this age group.

According to the National Institutes of Health (NIH), women over the age of 60 have the highest risk of developing breast cancer . While white women are at a greater risk of developing breast cancer, African American women are at a greater risk of dying from the disease.

The NIH also reports that more than 65 percent of all prostate cancers occur in men over the age of 65. Men of African American decent are at the greatest risk of developing prostate cancer , and Asian men and Native American men have the lowest rate.

In addition to an increased risk for breast and prostate cancer, people over the age of 50 are at a greater risk of developing colorectal cancer.

According to the National Cancer Institutes Cancer Trends Progress Report 2007 update, all cancer deaths continue to decline. Whites and African Americans continue to be the racial groups most likely to develop cancer, and African Americans are more likely to die from cancer than any other racial or ethnic group.

Purpose

In addition to helping to promote good health and healing during cancer treatment, dietary changes and good nutrition may help cancer patients cope with side effects of treatment. Most cancer patients undergo one or more treatment options, including chemotherapy , radiation therapy, surgery, and medication. These treatments can cause side effects such as nausea and vomiting, constipation and diarrhea, and dry mouth and difficulty swallowing. These side effects can make getting adequate nutrition difficult. The American Cancer Society advocates the use of nutrition and dietary changes to help cancer patients cope with the side effects of cancer treatment.

Diet and Chemotherapy and Radiation Therapy

The following suggestions may help cancer patients undergoing chemotherapy and radiation therapy:

• avoid fried or greasy foods
• eat small frequent meals
• eat larger, balanced meals when feeling well
• eat throughout the day, smaller regular meals and snacks
• drink plenty of fluids, eight to ten 8-oz glasses per day, sip liquids throughout the day
• eat bland and easy-to-digest foods on days when receiving therapy
• rinse the mouth with baking soda and salt mouthwash before and after meals

Diet and Surgery

Cancer patients may need to follow a specific diet prior to and following surgery. In general, patients are not allowed to eat or drink for several hours prior to surgery. Following surgery, many people are asked to follow a standard diet progression.

A Progression Diet is a three-stage diet:

• Stage one: Consume clear liquids such as clear carbonated beverages; plain gelatin; sports drinks; weak tea; clear, carbonated drinks; juices; popsicles; bouillon; broth; and water.
• Stage two: Eat easy-to-digest foods such as plain crackers, pancakes, cake, fruit juices, lean meat, broths and cream soups, milk, custard or pudding, and frozen yogurt or ice milk.
• Stage three: Eat a regular diet, careful to avoid high fat, fried, greasy foods and foods that produce gas such as beans, melons, cruciferous vegetables (broccoli and cauliflower), and milk products.

Diet and Side Effects of Cancer Treatment

Dietary changes may be very helpful in coping with the side effects of cancer treatment. There are many simple suggestions cancer patients may follow to help ensure they are consuming adequate amounts of food and liquids, and to help relieve side effects. The American Cancer Society offers helpful suggestions to help those coping with the side effects of cancer treatment.

DIARRHEA Cancer treatment, including radiation therapy, chemotherapy, and many medications, may affect the bowels. Some treatment may cause the bowels to work more slowly causing constipation. Other treatment may cause the bowels to move more often causing diarrhea. There are many dietary options cancer patients have to help control the discomfort and inconvenience of constipation and diarrhea.

To help reduce the occurrence of diarrhea, those living with cancer may do the following:

• eat small meals and snacks frequently during the day
• drink plenty of fluids avoiding carbonated beverages and extremely hot or cold liquids and being sure to drink at least one cup of liquid after each loose bowel movement
• consume foods high in potassium and high sodium foods such as fruit juices, sports drinks, broths and soups, peeled potatoes, bananas, pretzels, and crackers
• add soluble fiber to the diet by eating foods such as oatmeal, white rice, applesauce, and canned pears or peaches
• avoid fried, greasy, extremely spicy foods, or very sweet foods.
• avoid foods with sugar alcohols such as sorbitol, mannitol or xylitol, which can cause diarrhea

The following diet may help reduce the number of loose bowel movements:

• Protein: Boiled or baked meat such as beef, pork, fish, poultry, or veal; eggs, dairy products such as cheese, milk, and yogurt. Avoid dried beans, nuts, seeds, peanut butter and greasy or fatty meats.
• Breads: Products made with white flour such as rolls, bread, and pasta; hot cereals such as cream of wheat, cream of rice, and oatmeal; other breads such as waffles, pancakes, muffins, and crackers. Avoid high fiber foods such as bran, whole wheat, shredded wheat, wild rice, popcorn, and granola.
• Fruits and Vegetables: Peeled canned or frozen fruit; baked, boiled, or mashed potatoes without the skins; and soups made from potatoes, vegetables that are peeled and cooked such as asparagus, beets, carrots, mushrooms, celery, and tomato sauces, and pastes. Avoid fresh fruit with the skins on, melons, and most vegetables.
• Beverages: Decaffeinated beverages, sports drinks, and water. Avoid colas, drinks with caffeine, and hot or extremely cold drinks.
• Deserts: Sherbet, gelatin, cookies, angel-food cake, sponge cake, and fruit pies made with canned, skinless fruits. Avoid very sweet deserts, nuts, coconut, dried fruit, chocolate, and licorice.
• Seasonings and condiments: Butter and margarine, mayonnaise, salad dressing, some gravy, salt, cinnamon, and other spices as tolerated. Avoid taco seasoning, hot spices and seasonings, and pickles and relish.

CONSTIPATION To help reduce the occurrence of constipation, those living with cancer may:

• Attempt to have a bowel movement at the same time each day.
• Eat meals at consistent times each day.
• Drink eight to ten glasses of liquid every day.
• Eat high fiber foods and drink hot liquids at breakfast.
• Develop a plan with a doctor and registered dietician that may include a gradual increase of consumption of high fiber foods, taking over-the counter stool softeners, and drinking liquid supplements containing high quality protein, fiber, and calories.
• Increase daily activity levels if possible.
• Discuss laxative use with a doctor, and contact the doctor if it has been over three days without a bowel movement.

The following diet may help increase the frequency of bowel movements:

• Protein: boiled or baked lean meat such as fish and poultry, eggs, milk, and yogurt.
• Breads: Products made with whole grains such as whole wheat breads and rolls, high fiber foods such as bran, whole wheat, shredded wheat, and wild rice, whole grain cereals such as bran flakes, raw wheat bran, and granola, and popcorn.
• Fruits and Vegetables: Fresh fruits with the skins such as apples and pears, other fruits such as bananas, oranges, and berries; dried fruits such as prunes and raisins; vegetables such as potatoes with the skins on, carrots, brussels sprouts, and corn, legumes or beans such as kidney beans, navy beans, and nuts.
• Beverages: Decaffeinated beverages, sports drinks, and water, fruit juices such as prune juice and fresh pressed or squeezed juices, hot drinks such as coffee and tea.
• Desserts: Sherbet, gelatin, whole grain cookies, cakes and cookies with nuts, and fruit pies made with fresh and fruits with the skins on. Seasonings and condiments: Butter and margarine, mayonnaise, salad dressing, some gravies, salt, cinnamon, and other spices as tolerated.

NAUSEA AND VOMITING Nausea and vomiting may be especially troubling for cancer patients undergoing radiation therapy and chemotherapy. These side effects may be quite severe and may severely limit the patient's ability to consume adequate nutrition.

The American Cancer Society suggests the following to help cancer patients suffering from nausea and vomiting:

• eat frequent smaller meals rather than two or three large ones
• drink liquids before or after eating rather than with meals
• try eating foods at room temperature or cold to avoid smells
• drink cool liquids
• suck on ice cubes, mints, or tart candy

Patients may find it helpful to follow this eating plan on days they are receiving radiation or chemotherapy:

• protein: boiled or baked meats, fish or poultry, cold meats, eggs, yogurt, cream soups
• breads: crackers, toast, dry cereal, English muffins, bagels, noodles without sauce, rice
• fruits and vegetables: baked, boiled, or mashed potatoes; canned or fresh fruit; vegetables if tolerated
• beverages: cold fruit drinks, sports drinks, iced tea, decaffeinated colas
• desserts: sherbet, gelatin, angel-food cake, sponge cake, pudding, popsicles, and juice bars
• seasonings: salt, cinnamon, and other spices as tolerated

DIFFICULTY SWALLOWING AND DRY MOUTH For patients who suffer from difficulty swallowing and dry mouth, it may be helpful to consult with a speech pathologist and registered dietician to develop a meal plan that helps maintain good nutrition and adapts for difficulty swallowing. A diet that consists of consuming plenty of fluids and semi-thickened liquids may help maintain good nutrition during treatment. Liquid nutritional supplements and pureeing food in a food processor or blender may be necessary. Other dietary suggestions for coping with difficulty swallowing include: using thickening agents such as gelatin, pureed fruit or vegetables, flour, cornstarch, tapioca, or baby cereal.

The American Cancer Society suggests the following guidelines may be helpful in relieving the discomfort of difficulty swallowing and dry mouth:

• Consume pureed thick liquids that contain an adequate amount of good quality protein such as dairy products, yogurt without fruit, sour cream, pureed meat, poultry and fish, scrambled eggs, and cream soups
• Make cereals, grains, and breads easier to swallow by adding slurry to them. (Slurry is made by combining flour and water to make a very thin paste. When this paste is added to hot liquids foods it thickens them slightly.) Slurry may be spread on top of cakes or breads to soften them as well.
• Eat semi-soft breads, grains, and cooked cereals such as oatmeal, Cream of Wheat or Rice, with slurry added.
• Eat pureed fruits and vegetables with the skins and seeds removed
• Consume other sources of nutrition that may be easier to swallow such as milkshakes, eggnog, ice cream, thickened juices, cream soups, thickened broths, pudding and custard, cake and cookies with slurry on top, honey, butter, or spices.

As treatment progresses, patients with difficulty swallowing or dry mouth may find it easier to swallow thick liquids. Once this occurs, it may be possible to consume soft but thicker foods.

Examples of slightly thicker but still soft foods include:

• Proteins include cheese, ground meats, casseroles, fish, and sandwiches made with spreads or ground meats.
• Breads and grains that are thicker but still soft include soft bread, crackers, pasta, cereals with milk, pancakes, and rice.
• Fruits and vegetables that may be eaten without pureeing include bananas, fruit cocktail, canned fruit, and boiled or steamed vegetables, and pureed fruits and vegetables.
• Other nutritional sources that may be easier to swallow include most beverages, ice cream, cream soups, thickened broths, pudding and custard, soft cakes, honey, butter, or spices.

Challenges

Because of diminished immunity, it is especially important to use good food handling practices and avoid exposure to bacteria and food contamination. Always wash hands well before handling food. The United States Department of Agriculture (USDA) advises anyone handling food, but especially those with weakened immune systems such as people battling cancer, to clean, separate, cook, and chill.

• Clean hands well before and after handling food, clean all work surfaces before and after food preparation, wash all fruits and vegetables prior to cooking and eating them, and clean can lids before opening canned goods.
• Separate all raw meat, poultry, fish, and eggs from other foods in the shopping cart, grocery bags, and especially in the kitchen while preparing foods. Use a separate cutting board or surface for raw meats and all other foods, and never use plates or containers that previously held raw meats to hold or serve cooked meats. Never use marinades that have been on raw meats to season cooked meat. Either discard the marinade or boil it prior to serving it with cooked meat.
• Cook foods to a proper temperature to ensure that all bacteria are killed and the food is safe. To be certain food is cooked thoroughly, use a food thermometer. It is impossible to tell if food is completely cooked by looking at it alone.
• Chill foods to prevent or slow the growth of bacteria. Refrigerate or freeze all perishable food within two hours or less of cooking or bringing home from the grocery. Thaw meat in the refrigerator, in cold water, or in the microwave oven, never at room temperature or on the kitchen counter.

SAFE FOOD TEMPERATURES: ACCORDING TO THE USDA

• Steaks and Roast: 145 degrees F
• Fish: 145 degrees F
• Park: 160 degrees F
• Ground Beef 160 degrees F
• Eggs: 160 degrees F
• Chicken Breasts: 165 degrees F
• Whole Poultry: 165 degrees F

Other challenges faced by those living with cancer include difficulty eating well when in pain , feeling tired or unwell, or when coping with side effects of treatment such as mouth sores, nausea, vomiting, constipation, diarrhea, and a limited ability to eat. It may be difficult to get to the grocery to purchase nutritious food. Asking friends and family to assist with grocery shopping and meal preparation may be extremely helpful in ensuring the patient has access to fresh, nutritious foods.

Many people fighting cancer must travel away from home to receive treatment. It may be difficult to maintain proper nutrition or deal with side effects that impact nutrition when one lives in an unfamiliar city. Individuals with access to a kitchen may find it helpful to store portioned food that is easy to prepare such as canned soup, frozen foods, and single serving snacks such as cereal, fruit, pudding, or gelatin. If there is no access to a kitchen, it may be helpful to bring snacks that do not require refrigeration or heating such as canned fruit, crackers, cereals, and peanut butter.

KEY TERMS

Carbohydrates —A component of food that provides energy for the body. Carbohydrates are broken down into sugar during digestion.

Carcinogens —Any substance that produces cancer in humans or animals.

Chemotherapy —The treatment of disease using chemicals that destroy cells.

Constipation —Inability to pass stool for three or more days. When stool is passed it may be hard, dry, and painful to pass.

Diarrhea —Loose, watery, or frequent bowel movements.

Laxative —Any food, beverage, or medication that stimulates bowel movements or softens stool.

Nutrients —Compounds that are necessary to survival and cannot be made by the body.

Protein —An essential nutrient that helps the body build necessary parts of the body such as muscle, tissue, and blood cells.

Radiation therapy —The treatment of disease using radiation to destroy cells.

Registered dietician —A healthcare professional who has completed an academic program and been accredited to provide advice about proper nutrition.

Speech pathologist —A healthcare profession who has been trained and certified to provide advice and therapy to individuals with disorders of speech, language, swallowing, or eating.

Stool softeners —Medication that causes stool to become softer and easier to pass.

Risks

Other medical conditions such as diabetes may require special attention to diet and may be impacted by dietary changes during cancer treatment. It is important to meet with a registered dietician or nurse to be sure dietary needs are met. Healthcare professionals may be able to prescribe medication to treat side effects such as nausea, vomiting, diarrhea, and constipation so that is it easier for patients to maintain a healthy diet during cancer treatment.

Results

Eating a healthy, well-balanced diet is always important, but even more so when undergoing treatment for cancer. Good nutrition can help cancer patients to maintain strength and energy, cope with treatment and side effects, and return to normal activities following treatment and during remission.

Side effects and symptoms such as dry mouth, decreased appetite, difficulty swallowing, and fatigue may persist for a period of time after treatment ends. Continuing to follow dietary guidelines that address these issues may help until these side effects subside.

Resources

BOOKS

Beliveau, Richard, and Denis Gingras. Foods that Fight Cancer: Preventing Cancer through Diet. Toronto, Ontario: McClelland and Stewart, 2006.

Keane, Maureen, and Daniella Chace. What to Eat if You Have Cancer. New York: McGraw-Hill, 2006.

ORGANIZATIONS

American Cancer Society, PO Box 22718, Oklahoma City, OK, 73123-1718, (800) ACS-2345, https://www.cancer.org/.

National Cancer Institute, 6116 Executive Blvd., Room 3036A, Bethesda, MD, 20892-8322, (800) 422-6237, http://www.cancer.gov/.

National Coalition for Cancer Survivorship, 1010 Wayne Avenue, 5th Floor, Suite 300, Silver Spring, MD, 20910, (888) 650-9127, http://www.canceradvocacy.org/.

Deborah L. Nurmi MS