Nutrition _ NETs.ppt

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					Nutrition & NETs
Kylie Scarfe
Clinical Dietitian, Upper Gastrointestinal
Royal North Shore Hospital
What are NETs?
NET = Neuroendocrine tumours
• Slow growing tumours of the ‘diffuse’ endocrine system
• Many different types of NETs -
  digestive & respiratory systems, ovaries, testes and pancreas
• ‘Functioning’ (hormone secreting) or ‘Non-functioning’ (non-
  hormone secreting)
• Non-functioning tumours - symptoms relate to size, pressure
  on surrounding tissue
Why is nutrition important?
• High incidence of gastrointestinal involvement - small bowel,
  large bowel, rectum, stomach
• General symptoms & treatments may affect nutritional
  health – diarrhoea, weight loss, lethargy, gas & bloating, nausea
• ‘Carcinoid syndrome’ – increased intake of protein rich foods,
  role for limiting foods high in amines
• Asymptomatic tumours – general healthy eating principles to
  maintain health
• Prevention of reoccurrence of disease - general healthy eating
  principles for cancer prevention
Is there are ‘diet’ for people with NETs?

Short answer – NO
There are:
• General healthy eating principles – Australian Guide to
  Healthy Eating (AGHE), Cancer Council of Australia
• Specific nutritional strategies to cope with symptoms, effects
  of treatment.
  Nutritional adequacy must be individualised to be effective.
  No one diet fits all
• Some specific nutritional recommendations – carcinoid
  syndrome, increased intake of niacin
Australian Guide to Healthy Eating
                  Include a variety of different
                        Breads & cereals: 4-12
                        serves/day (½ wholegrain
                        Vegetables: 5 serves/day
                        Fruit:   2 serves/day
                        Meat: 3-4 serves/week
                        Fish:    2 serves/week
                        Dairy: 3 serves/day
                        ‘Extras’ – limit to maintain
                        a healthy weight
What is a serve?
Breads & cereals
• 2 slices of bread or 1 medium bread roll
• 1 cup cooked rice, pasta, noodles
• 1 1/3 cup of breakfast cereal
• ½ cup toasted muesli or 1 cup cooked porridge

• ½ cup cooked vegetables
• ½ cup cooked dried beans, lentils
• 1 cup salad
• 1 small potato
What is a serve?
• 1 medium piece of fruit (150g) e.g. apple, pear, banana
• 2 small pieces (150g) of fruit e.g. kiwi, manadarin
• 1 cup diced fruit, fruit salad
• 1 ½ tablespoons dried fruit
• ½ cup fruit juice
Meat, meat alternatives:
• ½ mince, 2 eggs
• 2 slices roast meat, ½ chicken breast
• 2 eggs
• 1/3 cup lentils, chickpeas, split peas, kidney beans
What is a serve?
• 150gm oily fish e.g. salmon, tuna, trout, mackerel
• Canola oils, margarine, walnuts, walnut oil
• Soy based foods e.g. edamame, tofu, soy & linseed bread
• Green leafy vegetables
• 250ml ‘lite’ or skim milk
• 200gm low fat yoghurt, custard
• 2 scoops low fat ice cream
• 2 slices (40gm) low fat cheese
Nutritional strategies for NETs
Survey of NET patients in 1999, repeated 2005 showed similar
Carcinoid Nutrition Survey (Carcinoid Foundation 1999, 2005)
n=97 62% female 38% male aged 26-81 years of age
Signs and Symptoms with possible nutrition implications
• Fatigue & weakness       60%
• Diarrhoea                51%
• Gas & bloating           51%
• Flushing                 45%
• Abdominal pain           33%
• Weight loss              21%
           "Nutritional Concerns for the Carcinoid Patient"
           Presented by Monica E. Warner, M.S., R.D., C.D.N.
Research Coordinator, Carcinoid Cancer Foundation, Inc., New York, New York
                      Year 2000 with Year 2008 update
Nutritional strategies for NETs
• Important to seek medical advice to find out underlying cause
  of symptoms in the first instance
• Doctor may refer to a dietitian to help manage symptoms
  through individualised dietary advice
• Nutritional health, wellbeing is always the priority for
  nutrition therapy. Avoid unnecessary food restrictions

• Nutrition therapy is unlikely to resolve symptoms completely
  and is usually an adjunct to medical therapy e.g. diarrhoea,
  gas & bloating
Nutritional strategies for NETs
Fatigue and weakness/weight loss
Cause? low body weight, poor appetite/nausea resulting in poor food
intake, poor dietary quality

• Small frequent meals
• High calorie, high fat, high protein meals if tolerated
• High calorie, high protein liquids often tolerated better than solids
• High calorie, high protein nutritional supplements (doctor, nurse,
• No weight loss? Assess dietary quality against AGHE
Nutritional strategies for NETs
Cause? Increased secretion of serotonin from tumour, small
bowel resection, chemotherapy, response to some medications
Very individualised - everyone has eats different food, reacts
differently to food, severity of diarrhoea, cause of diarrhoea
•   Small frequent meals
•   Reduce foods very high in fibre
•   Reduce lactose intake (component of dairy foods)
•   Lower fat meals
•   Reduce intake of alcohol, spice, caffeinated drinks, other foods?
•   Nutmeg – 3 teaspoons a day??
Nutritional strategies for NETs
Gas and bloating/abdominal pain
• Very individualised
• Small frequent meals
• Reduction in gas forming foods e.g. cabbage, cauliflower,
  broccoli, bok choy (Chinese broccoli), onion, leaks other
• Reduce fibre, spice, alcohol, high fat meals, caffeine
• Carbonated drinks
Nutritional strategies for NETs
• Symptom of ‘carcinoid syndrome’, occurs in only 10% of
  people with NETs
• Increased requirement for Niacin
• Increased requirement for protein 1-1.5gm/kg
• May be a role for limiting foods high in amines - (precursors
  for catecholamines e.g. adrenaline)
• Reduce large meals, alcohol, spices, other foods?
Eating more protein
• Recommended increase of 50-100% of recommended intake
  of protein foods
• Most people with good appetites eat this amount anyway
• 100gm steak = 20-25gm, 2 eggs = 7gm, 1 glass milk – 10gm
• Include protein foods at all meals and snacks
• Eat more protein = increase niacin intake
• Only recommended for patients with one or more symptoms
  of ‘carcinoid syndrome’ – flushing, diarrhoea, weight loss,
  poor intake of food
• Supplements not needed if you are following a balanced and
  varied diet
• Recommended dose - multivitamin 2 x dose daily
• Increased serotonin production increases need for niacin –
  60% of tryptophan is used in serotonin production, usual is
• Symptoms – ‘pellagra’ skin lesions, scaly skin, dermatitis
  dementia, diarrhoea, depression, death

Criteria for Niacin supplementation: Elevated serotonin levels,
flushing, weight loss, poor appetite/poor intake of food

• Increase protein intake (1-1.5g/kg) - meat, poultry, fish,
  wholegrain cereals, eggs, dairy
• 25-50mg daily x 2 doses (more can worsen symptoms)
Niacin supplementation

Complex B vitamin        Multivitamin (18mg
(100mg niacin) – ½ - 1                            Complex B vitamin
                         niacin) 1 tablet twice   (50mg niacin) ½ - 1
tablet twice daily       daily = 36mg             tablet twice daily
Foods high in amines
• Aged, fermented and spoiled protein foods
• Product of protein breakdown
• Levels increase with ‘age’ or mature
• Reducing the ‘load’ of amines in the diet may help with
• Not necessary to avoid all foods that contain amines

Aged cheeses, smoked, salted or pickled fish or meat, prawns,
some nuts, vegemite, alcoholic beverages, miso soup,
soy sauce, chocolate (in large amounts), coffee (in large
amounts), banana, avocado
Foods high in serotonin
There is no need to avoid foods high in serotonin to control
symptoms of carcinoid syndrome

Foods high in serotonin DO NOT cause high levels of serotonin in
the blood
• Butternuts, black walnuts, English walnut, pecans,
• Pineapple, banana, kiwifruit, tomatoes, plums (also high in
• Avocado, olives, eggplant (also high in amines)
Thank you
More information:

Unicorn Foundation (Aus)
The Carcinoid Cancer Foundation (USA)
UK & Ireland Neuroendocrine Society (UK)

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