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Nutrition Issues
Bernadette Festa, RD, MS; Pat Kearney, RD; Isadora R. Rosenbaum, MA; and Ernest H Rosenbaum, MD

Loss of Appetite

Nausea and Vomiting

When Foods Taste or Smell Funny
Chewing or Swallowing Difficulties

Weight Gain

Herbs and Supplements

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Good nutrition is needed for general good health and is particularly important when you are ill. During this time, it is important to give your body the proteins, fats, carbohydrates, vitamins and minerals it needs for energy, repair of normal tissue, and to keep your immune system strong to fight disease. Food is not only something to delight the taste but is an essential ingredient in the fight against disease. It is as important as your medicine or medical therapy (e.g., surgery, radiotherapy, or chemotherapy). Because of your illness or treatments, you may not be able to eat in the same way as before. You might find that your pleasurable experiences around eating are affected.

During illness, you will be more attuned to the smell, taste and texture of foods. As your senses will be acute, it is important to savor and enjoy foods now more than ever. However, you may find that your tastes have changed and you are turned off by foods that you once enjoyed (food aversions). Allow your memory of the enjoyment to encourage you to seek these foods as well as to develop a taste for new foods.

Think of yourself as an explorer. Sample small portions of foods previously eaten, try new tastes and note the reaction your body and spirit have to them. Even an explorer needs a map to chart unknown territory. With the help of a registered dietitian you can learn to explore alternative tastes and foods. Classes and counseling sessions have been set up at Stanford and we are in the process of setting these up at the Mt. Zion campus of UCSF. Dietitians Bernadette Festa, MS, RD, and Patricia Kearny, RD can address your personalized needs. The goal of our class and counseling is to provide current information which will help you maintain or improve your nutritional status and help you better fight your illness.

You may have no, one, or more symptoms from therapy. Everyone is different and there is no set pattern. The bright side is that most cancer survivors do not have these problems for very long after therapy has been completed, and some may not have any eating problems at all.

Loss of Appetite - A Common Problem
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You may not be able to rely on your hunger mechanism as a signal to eat. Many problems as pain, nausea, vomiting and diarrhea or a sore or dry mouth may make eating difficult and cause you to loss interest in eating. Depression, stress and anxiety also cause a loss of appetite. As appetite may no longer motivate you, now you need a planned approach.

Eat by the clock rather than hunger mechanism.
- Eat because it is 9:00am, noon, 3:00pm or 6:00pm or whatever your studied daily pattern becomes. Snack between meals - choose high calorie puddings, shakes, high calorie and protein drink supplements, sandwiches, avocados, nuts

- If you miss or delay a meal for a test or therapy bring a snack of nuts, dried fruit, or cheese and crackers. Check with your dietitian if these foods fit into your medical diet.

Remember, you probably will not be hungry!

Choose high calorie foods at this time. Use cream soups, cooked cereals and vegetables with added butter or margarine, add nut butters to bread, use extra olive oil in salads.

Remember, you need the calories.
- If you're concerned about a higher fat diet because of high cholesterol or heart disease, talk with your dietitian and choose better fats such as avocados, oils and nuts.

- Plan your daily menu in advance
plan the time that you will eat.

- Have the food available, you may want to portion out snacks and keep in the refrigerator in ziplock bags so that it is really easy for you.
Make a list of your favorite foods and beverages and prepare a shopping list.

- Having the food in the house and a menu makes it so much easier!

- Enjoy help in preparing your meals A friend or relative is often happy to help out by preparing food for you. Home aid in preparing meals or delivered meals are available in many communities. Some grocery stores have shopping services that may be accessed through your computer. You are very important - ask for help when you need it, and ideally before you anticipate that you will need it.

- When you are feeling better, Fix several portions of your favorite foods and freeze them. Then you won't have to think about what to fix! It lessens the problem about thinking about what to eat when your appetite may be poor or you do not feel like cooking.

- Make food visually appealing- eye appeal is often the first step in eating. Attractive colors, garnishes as parsley, lemon wedges, olives, cherry tomatoes, Help to enliven the appetite and ready one for eating.

- Appeal to your sense of smell Tap into your sense of well-being that smells can stimulate. Haven't you smelled bread baking and suddenly become hungry in the past. Remember the cravings that the smell of chocolate have brought on in the past.

- If you find that you are overwhelmed by smells at this time, stay away from the kitchen, and have someone else prepare the cooking.

- Make your mealtimes pleasant your mealtime atmosphere is important to make you feel like eating. Set the table, add candles or wine, if permitted. Whenever possible eat with family, friends. Or if you are alone, turn on the radio, Television or music for company.

- Study friends who are overweight - notice that they eat when preoccupied with TV or reading or music. They also may have snacks in sight and put into desk drawers. Do the same. Realize that you need the calories at this time.

Nausea and Vomiting
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Nausea is a frequent side effect of cancer treatment or the cancer itself.
- Pay close attention to when it happens, and if possible try to modify your mealtimes

- Pay close attention to any psychological causes. Mr. So and so gets nauseous whenever he passes a restaurant a block away from where he was receiving his treatment and actually vomited once when he passed it.

- A visualization program helped him- ask your doctor or program coordinator. Try it -don't hesitate. You could be feeling better sooner.

- If nausea is extreme or severe speak with your doctor or nurse about it, medication can help.
Here are some practical tips for lessening Nausea:

- Keep crackers, dry bread at your bedside for early morning nausea

- Eat small amounts of food often- take clear, cool foods and chilled drinks at first, especially apple and cranberry juices, fruit drinks as Gatorade, ginger ale and 7-Up, room temperature chamomile or peppermint tea.

- Eat and drink slowly- use a straw for beverages to reduce the smell.

- Try bland, soft foods as peaches, mashed potatoes.

- Popsicles, salty foods (salads, olives,) soda crackers and toast are often well tolerated.

- Consider avoiding your favorite foods right now as you may start to associate these foods with treatment, nausea and vomiting and develop a strong aversion to them.

What to do for Vomiting:
- try only tiny sips of liquids as juices, ginger ale or 7-Up, lukewarm miso broth, or herbal teas

- start out with clear liquids then proceed to heartier more nutrient packed ones.

- Try softer, more bland foods until you feel better as pureed soups, smoothies, fruit nectars, yogurts, well-cooked cereals thinned with milk or soy, mashed cooked potatoes and vegetables, pasta with egg and grating cheese

- Drink and eat potassium-rich foods

- Drink lots of room temperature liquids to help prevent dehydration.

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Diarrhea may be due to many causes. You may get it because of chemotherapy, radiation therapy to the lower abdomen, malabsorption or sometimes antibiotics can cause diarrhea. It can also develop because of an intolerance to milk or difficulty in absorbing fats. Whatever the cause, diarrhea can be uncomfortable and embarrassing and causes you to lose vitamins, minerals and water.
- Try to find a pattern for the diarrhea.

- Speak with your health professional to try and determine the cause and get the proper treatment.

- Drink lots of room-temperature liquids to help prevent dehydration as fruit drinks, Gatorade, ginger ale, peach or apricot nectar, water, weak teas. Limit caffeinated beverages.

- Allow carbonated beverages to lose their fizz or stir them before you drink them.

- Have more potassium foods as orange juice, tomato juice, bananas, potatoes

- Try the BRAT diet - bananas, rice, applesauce, tea and toast, try a well-baked apple without the skin

- Try frequent, small meals

- Avoid fiber foods for now

- Try breads made from refined flour without seeds or nuts, limit raw

- Vegetables and salads right now as well as most fruits. - Do return to your higher fiber foods, fruits and vegetables once the diarrhea subsides (check with your dietitian and doctor first!)

- Have spicy or highly seasoned foods only as tolerated.

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Constipation may be caused by some chemotherapy medications as Vincristine, Vinblastine. Other drugs as morphine and codeine may contribute.

What you can do
- add more fiber and bulk to your diet

- try beans as kidney and chick peas, lentils, fresh fruit and vegetables, dried fruit, IF your not used to eating a lot of fiber slowly increase your intake as you may Initially have increased flatulence, gas. Soaking beans first in water and discarding the water may help to reduce flatulence from this group.

- eat bran cereals or shredded wheat, foods made with whole grains as bulgur, wheat berries

- plan your diet and when you will get your fiber intake in.

- Add unprocessed wheat bran to hot cereals and yogurt.

- REMEMBER to drink plenty of liquids. You need more fluid when you have more fiber for fiber to work effectively.

- Reduce your caffeine intake as caffeine may promote constipation by causing you to loose fluids.

When Foods Taste or Smell Funny
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You may notice a metallic or bitter taste in your mouth or that foods just don't taste as good. This can occur during certain cancer treatments, especially during or after chemotherapy or if you have received radiation therapy to the neck and mouth area.

When foods taste too bitter
- add sweet fruits to meals

- add honey or sweetener to foods and drinks

- eat meat cold or at room temperature

- try meat substitutes or blandly prepared chicken and fish; mild cheeses, eggs, dairy products, soy drinks or tofu or bean dishes.

- Marinate foods in wine, italian dressing, lemon juice, or low sodium soy sauce.

When foods taste off
- drinking water, tea, ginger ale or fruit juices mixed with club soda may remove some of the strange tastes from your mouth.

- try cold or room temperature foods which may taste better

- try chilled soups, starches as potatoes, rice and plain pasta, cold sandwiches.

- Do not add butter, margarine or other fatty substances to these foods.

- choose bland foods as eggs, mild cheeses, cereals, puddings and custards, rice, jicama, peanut butter instead of foods with more distinctive flavors.

- Eating in relaxed and pleasant surroundings may help reduce problems with Taste blindness. -Flavorings such as herbs, spices or food seasonings may help. Acidic foods such as grapefruit may stimulate taste buds (but avoid them if they irritate your mouth).

Chewing or Swallowing Difficulties
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Soreness and tenderness in the mouth and throat are not uncommon. If your swallowing difficulties are minor the following suggestions may help. You May need to work with a swallowing therapist or consider alternative methods of feeding if you have severe problems.
- Eat frequent small meals and snacks to ensure that you are getting enough calories.

- Choose soft foods or foods that can be cooked until tender, choose higher calorie foods that we have already discussed.

- Cut foods into -sized pieces or grind them so that less chewing is required.

- Many people find liquid supplements helpful or shakes that can be made in your blender.

- Some people will need to use a blender to puree the foods your family is eating. Remember to add high calorie liquids to blenderize this as gravy, milk, cream, broth may be used instead of water.

- Try very soft or thick liquid foods puree or blenderize potatoes, carrots, and other vegetables and soups, as well as meats.

- Dunk bread or other baked goods in your beverage

- Drink generous amounts of nutritious liquids with meals.

- Be adventurous - try new sauces, gravies, different oils on foods to make swallowing easier.

- Have some baby food on hand for something quick and tasty.

Weight Gain
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Gaining weight may be due to chemotherapy, prescribed steroids as prednisone, or fluid retention. Steroids may change your metabolism or the way your body uses calories and may also increase your appetite.

While you are being treated for cancer this is not the time to go on a strict weight loss program as your body requires nourishment.
- You may switch to a lower fat diet (less butter, margarine, oil, lean meats only)

- A low sodium diet may be needed if you are retaining water. Its not enough just to avoid adding salt to your diet.

- Avoid canned goods and prepared food items as flavored rices and grains, and frozen dinners.

- Look at food labels and note the amount of sodium on the label.

- Discuss this with your dietitian.

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- The times when you are weak and do not feel like eating are the times when you need the energy, protein and protective factors from foods most.

- Plan your meals

- Prepare a shopping list

- Prepare foods and meals when you are feeling better

- Have a positive attitude

- Remember, that during this time, you may be eating differently. If while under treatment the need for energy temporarily overrides other needs that this is OK. Remember that after treatment you have time to adjust your diet.

- Realize that this symptom may only be temporary and a few days, weeks or months from now you will be focusing on only the joy you are receiving from life.

- Lastly, Bon appetit!

Herbs and Supplements
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We are always asked questions regarding the use of herbs and supplements. Keep in mind that herbs are not regulated in the US. There are no standards so formulations vary in potency and recommended dosages. Always seek a diagnosis from a physician before taking herbs, especially for serious conditions and inform your medical team of herbs you are taking so a crosscheck can be made for contraindications of use with other prescription medications.

Some of the most common questions for supplements are on selenium, garlic, carotenoids and isoflavones.

Selenium - Researchers currently advise against supplements until they can prove anti-cancer benefits as well as decide on the amount to optimize health without toxicity. It is believed that an amount of 200 micrograms a day is probably safe. Some food superstars are brazil nuts (4), 436 micrograms (mcg), 3.5 ounces of light tuna -50 mcg., 3.5 oz. Pork sirloin - 52 mcg., 1 cup cooked pasta - 30 mcg. IF you are taking supplemental selenium and are undergoing radiation, be sure to speak with your dietitian or medical team about possible interactions.

Garlic: growing research suggests garlic and its allium cousins are effective cancer fighters but the American Cancer Society for one is hesitant to endorse garlic, citing too little evidence as yet. Garlic supplements can lower blood sugar so this is not recommended for diabetics on medications. People with a clotting disorder or on blood thinners need to check with their physician before using supplements. Most nutritionists will recommend using both raw and cooked garlic in your diet instead of supplements.

Carotenoids: research results have been mixed and there are possible risks of single carotenoid supplementation. Consumption of foods rather than supplements, particularly vegetables and fruits that contain other protective substances is preferred, eating at least 5 to 9 servings per day. Lycopene, another powerful carotenoid antioxidant has been listed in recent ketchup ads as a cancer prevention food. Be aware that label comparisons are shown per ounce not per serving. One study found a daily consumption of 40 milligrams (mgs) did boost blood levels of carotenoids. Some rich food sources include - cup of tomato sauce - 23 mgs., 6 oz. Vegetable juice- 18 mgs., 8 oz. Tomato soup - 12 mgs., 2 tablespoons ketchup - 6 mgs and 1 medium tomato 4 mg.

Isoflavones: These phytoestrogens are found in soy foods. Benefits are thought to be increased by as little as one serving of soy food per day. Eating soy foods is still preferable to using supplements and as a protein source and can replace animal saturated fat. Some rich food sources are l cup soy milk - 70mgs,1 oz. soy nuts - 40 mgs, 1/2 cup of tofu - 40 mgs, 1/2 cup of cooked soybeans - 35 mgs. Recent research suggests that if you have estrogen positive or hormone positive breast cancer that you should avoid taking in large amounts of soy products.Generally a few servings per week are acceptable.

Most of the questions we receive on herbs are on the following four: ginger, bilberry, milk thistle and saw palmetto. Here is a brief pro and con review.

Ginger (Zingiber Oficinale)- May be useful for nausea and indigestion and may work by promoting secretion of saliva and digestive juices, neutralizing stomach acid and toxins, increasing tone and movement in intestines. There are capsules available or try 2 cups of tea using l teaspoon (tsp) fresh ginger or 1 1/2 tsp. powdered ginger. Excessive amounts may cause heartburn. Do not use for postoperative nausea as it may prolong bleeding or with combinations of other blood thinners.

Bilberry: (vaccinium Myrtillus) may be useful for simple diarrhea. There are capsules however it may be easier to make a tea using 1 tablespoon (tbl) of dried berries per cup. Do not use the leaves and fresh berries as they may have a laxative effect. Bilberry may prolong blood coagulation so caution is advised if taking other blood-thinning agents, like aspirin.

Milk thistle: (silybum Marianum) May be useful for chronic inflammatory diseases of the liver such as cirrhosis or hepatitis. Liver conditions require a physician's care. Milk thistle may work by acting on cell membranes to prevent toxins from entering the liver. Acts as an antioxidant. If you take: use seed extracts standardized to at least 70% silymarin at daily dose of 200 to 400 mgs. Teas are not effective because silymarin is not water soluble. It may have a mild laxative effect and is a possible allergen for those sensitive to ragweed.

Saw Palmetto (serenoa repens) may be useful for early non-cancerous prostate enlargement. May lessen symptoms but does not reduce prostate size. May work by counteracting androgenic hormones and fighting inflammation. If you take it: the usual dose is 320 mgs.dried fruit extract in 1 to 2 doses. Teas are of little value because few of the active ingredients are water soluble. Large amounts may cause diarrhea. Prostate enlargement requires physician care and there is some concern that the herb may cause inaccurate readings on prostate-specific antigen (PSA) tests.

For additional information refer to:
l.Tyler's Herbs of Choice or Tyler's Honest Herbal, Haworth herbal Press #l-800-Haworth
2. Consumer Reports on Health
3. Berkeley Wellness Letter
4. Dietary Supplements
5. Beyond Vitamins, the New Nutrition Revolution

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