Oncology Nutrition Overview - Dixon_supp.pdf - Oncology Nutrition

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					                                                                                                Reference Section

                                                                                                     Oncology Nutrition Over view

          a report by
          Suzanne W Dixon, MPH, MS, RD

          Director, Cancer Nutrition Info, LLC

Introduction                                                                      condition, illness, or injury that puts them at
                                                                                  nutritional risk. This includes review and analyses of
In the US, the lifetime probability of cancer is one in                           medical and dietary history, laboratory values, and
two for men and one in three for women.An estimated                               anthropometric measurements. Based on the
1,368,030 new cases of invasive cancer are expected to                            assessment, those nutritional modalities most
occur in 2004 and approximately 563,700 people will                               appropriate to managing the condition or treating the
die of cancer during this year as well.1 The important                            illness or injury are chosen. These include diet
role of nutrition, both as a causative factor and in the                          modifications and counseling leading to the
treatment and management of cancer, cannot be                                     development of a personal dietary plan to achieve           Suzanne Dixon, MPH, MS, RD, a
overstated. It is widely accepted that up to 40% of all                           nutritional goals and desired health outcomes, as well      cancer nutrition epidemiologist and
cancers occurring in the US today are due to poor                                 as specialized nutrition therapies including                registered dietitian, is Director of
                                                                                                                                              Cancer Nutrition Info, LLC (CNI), in
nutrition habits.2,3 Some health experts believe this                             supplementation with foods specifically modified to         Atlanta, Georgia. CNI is a Web-based
number could be much higher.                                                      meet the needs of patients unable to obtain adequate        information resource for oncology
                                                                                  nutrition through usual food intake alone.12 The            clinicians and their clients. She
                                                                                                                                              currently serves as adjunct faculty
Nutrition status becomes even more critical after a                               registered dietitian (RD) is the member of the              to the Program in Dietetics and
cancer diagnosis. It is estimated that 20% of cancer                              healthcare team who most commonly provides MNT.             Human Nutrition at Eastern Michigan
patient deaths are related to cancer-induced or                                   The RD is responsible for the nutrition care of the         University. Ms Dixon is an
                                                                                                                                              internationally recognized expert in
treatment-related malnutrition. Some studies indicate                             oncology patient before, during, and after treatment        cancer nutrition and epidemiology,
this number may be as high as 40% in certain oncology                             for cancer. Specific types of cancer may place an           has numerous scholarly and popular
patient populations.4–9 This is an unacceptably high rate                         individual at substantial nutrition risk. These cases       literature publications, and has
                                                                                                                                              lectured over 100 times to
of mortality due to a factor to which inadequate                                  require close and detailed nutrition care and, in these     professional and lay audiences.
attention has been paid in the oncology population.                               instances, the RD becomes an indispensable part of          While in her previous post as
Recent data indicates that even among individuals                                 the healthcare team. Ideally, the RD should see the         Director of Outpatient Oncology
                                                                                                                                              Nutrition Services at the University
being treated palliatively, nutrition is a limiting factor                        patient at the initial and all follow-up visits, along      of Michigan Comprehensive Cancer
influencing survival, and supportive nutrition care can                           with the physician and nursing staff, and other             Center in Ann Arbor, she helped
protect and preserve metabolic function in patients                               essential care providers such as social workers, mental     develop and teach a pilot program
                                                                                                                                              designed to integrate nutrition
with cachexia secondary to malignant disease.10                                   health therapists, and spiritual/religious counselors.      science into the University of
                                                                                                                                              Michigan Medical School curricula. She
In addition to mortality, the issue of quality of life must                       Goals of Conventional Nutrition                             has also taught and lectured at the
                                                                                                                                              University of Michigan Schools of
be addressed. A 1989 Eastern Co-operative Oncology                                Inter vention                                               Nursing and Public Health. Ms
Group (ECOG) study in a mixed cancer patient                                                                                                  Dixon has published chapters in
population demonstrated high prevalence of nutrition-                             The primary goals of conventional nutrition                 nursing and dietetics texts and is
                                                                                                                                              currently working on a cancer
related symptoms. Sixty-one per cent of patients                                  intervention for oncology cases are presented in Table 1.   nutrition book for the general
experienced abdominal fullness, 46% experienced taste                             These goals are the number one priority of the RD           public. She is the recipient of the
changes, 41% complained of constipation, 40%                                      when managing the nutrition status of oncology              2004 Distinguished Practice Award
                                                                                                                                              from the American Dietetic
experienced dry mouth, 39% complained of nausea,                                  patients. Given the limited time with each case, and the    Association’s Oncology Dietetic
and 27% experienced vomiting.11 These figures                                     heavy caseloads carried by most oncology dietitians,        Practice Group and is a member of
illustrate the need for close involvement of a qualified                          secondary goals, including evaluation of the risks and      The American Society of Preventive
                                                                                                                                              Oncology and the American Dietetic
nutrition practitioner in the management of cancer                                benefits of nutrition-related complementary and             Association.
cases, in particular for those deemed to be at high risk                          alternative medicine (CAM), promotion of nutrition
of malnutrition.                                                                  habits to improve long-term health, education on
                                                                                  nutrition to minimize risk of cancer recurrence, and
P rov i s i o n o f M e d i c a l N u t r i t i o n T h e r a py                  education on nutrition to minimize risk of other
                                                                                  chronic diseases should be addressed after weight
Medical nutrition therapy (MNT) involves the                                      stabilization and restoration of adequate nutritional
assessment of the nutritional status of patients with a                           status is achieved.                                                                            1

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                             Table 1: Primary Nutrition Goals                                        hemoglobin, retinol-binding protein (RBP), glucose,
                                                                                                     c-reactive protein (CRP), and serum creatinine;
                             Primary Nutrition Goals                                               • information on medications and planned treatment;
                             Prevent or correct nutritional deficiencies                           • psychosocial status; and
                             Improve tolerance to treatment                                        • financial resources and limitations.
                             Minimize short-term and long-term treatment side effects
                             Achieve and maintain optimal body weight                              For the more detailed assessment, many RDs find that
                             Enhance quality of life during treatment                              development of their own forms to address the unique
                             Educate family members about special nutrition needs of               needs of the clinical settings in which they practice is
                             client                                                                the best approach. Regardless of the tools used,
                                                                                                   information from screening and assessment must be
Table 2: Indications and Contraindications For Enteral Feeding                                     made part of the permanent medical record.

Indications                                        Contraindications                               E n t e r a l Ve r s u s O r a l F e e d i n g
Inability to meet 50% or greater of required       Uncorrectable severe malabsorption
nutrient needs orally for seven or more days                                                       Screening and assessment will identify which
Expected inability to meet 50% or greater          Intestinal obstruction distal to feeding        individuals require more intensive nutrition
of required nutrient needs site orally for seven                                                   intervention and from this information an
or more days                                                                                       individualized nutrition care plan can be formulated.
Presence of a functioning GI tract (to some        High output enterocutaneous fistula             While a large majority of oncology patients in the out-
degree)                                                                                            patient clinical setting can meet nutrition needs orally,
Patient willing to accept enteral feeding method   Gastric/Esophageal aspiration                   some will require enteral feeding. In particular,
                                                   Severe acute pancreatitis                       individuals with tumors of the upper aero-digestive
                                                                                                   tract (head and neck cancers) are ideal candidates for
                             Nutrition Screening and Assessment                                    enteral feeding.

                             Two steps are required to ensure appropriate nutrition                The majority of head and neck cancer cases will
                             care and follow-up. These two steps are screening and                 receive radiation therapy at a minimum, and many
                             assessment. The purpose of nutrition screening is to                  undergo concurrent radiation and chemotherapy
                             detect the possibility of nutrition risk. Screening is not            protocols.18 Early effects of radiation include
                             intended to allow formulation of a detailed nutrition                 xerostomia, superficial ulceration in the field of
                             care plan, it simply provides information to determine                radiation, bleeding, pain, and               mucositis.19
                             if nutrition follow-up is required. Typical components                Chemotherapy may lead to symptoms that affect oral
                             of a nutrition screen include age and gender, weight                  intake including nausea, vomiting, weakness, and
                             history and per cent weight change, food intake,                      fatigue.19 Of additional concern is that while the rate of
                             symptoms, functional status, disease and stage, metabolic             mucositis during chemotherapy alone is approximately
                             demand, and quick visual examination by medical care                  40%, it is nearly 100% in patients receiving
                             staff.An ideal tool for screening is the patient-generated            chemoradiation.19 It is important to note that when
                             subjective global assessment (PG-SGA).13-17                           undergoing concurrent chemoradiation, patients must
                                                                                                   cope with both the local side effects of radiation and
                             Assessment is more intensive and thorough than                        the systemic side effects of chemotherapy.The effect of
                             screening. It includes intervention and follow-up, along              these symptoms on dietary intake is profound. One
                             with additional intervention and additional follow-up,                study indicated that approximately 57% of head and
                             as needed, to correct malnutrition.Typical components                 neck cancer patients lost weight upon commence-
                             of nutrition assessment include:                                      ment of treatment, with an average loss of 6.5kg,
                                                                                                   representing 10% of body weight.20 For all of these
                             • age and gender;                                                     reasons, early initiation of enteral feeding is typically
                             • weight history and per cent weight change;                          the most appropriate nutrition care plan.21,22
                             • ideal body weight;
                             • appearance, behavior and mental health status;                      The best route for enteral feeding is placement of a
                             • functional status (e.g. Karnofsky Score or ECOG                     tube via percutaneous endoscopic gastrostomy
                               Score);                                                             (PEG)21–23 or via radiologic percutaneous gastrostomy
                             • detailed information on cancer type and location;                   (RPG), for enteral access.24 Data indicate that PEG and
                             • detailed intake assessed by 24-hour recall and diet                 RPG tubes have significant advantages over nasogastric
                               history;                                                            (NG) tubes,25,26 and that pre-treatment placement of a
                             • examination of biochemical parameters such as                       feeding tube results in better outcomes in this
2                              albumin, prealbumin, transferrin, hematocrit,                       population of oncology patients.22,27,28

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    Placement of a PEG tube pre-treatment may be ideal;                    dietary intake, which may decrease treatment tolerance
    however, this may not be what occurs in practice. If                   and increase treatment complications.29,30 A
    clients are not offered this option, or decline early                  combination of pharmacologic and nutrition
    placement of a feeding tube, specific criteria are used to             approaches is important for optimal symptom control.
    determine when tube placement can no longer be                         Patients must be told that nutrition management is not
    delayed. Table 2 details these criteria, the indications and           to take the place of medical management, but rather to
    contraindications for placement of a feeding tube.                     complement it and allow for optimum symptom
    Appendix 1 provides guidelines for assessing nutrition                 control and improved quality of life during and after
    needs for an enteral feeding protocol.                                 treatment. Suggested nutrition interventions for some
                                                                           of the more commonly experienced nutrition impact
    Nutrition Symptom Management –                                         symptoms are presented in Tables 3–8.
    Meeting Needs Orally
    Regardless of whether an oncology patient is meeting
    nutrition needs orally or through enteral feeding,                     Cachexia is a set of metabolic aberrations that can affect
    symptoms that can affect nutrition status must be                      individuals with cancer and other inflammatory
    addressed. If enteral feeding is not in place and oral                 conditions including, but not limited to, HIV/AIDS,
    intake is expected to be the major route of providing                  sepsis, other chronic infections, and other inflammatory
    nutrition, it becomes even more vital that aggressive                  conditions.74 This unique metabolic milieu must be
    symptom management is initiated.The presence of any                    addressed if positive outcomes are to be achieved in
    nutrition impact symptoms can result in sub-optimal                    weight-losing cancer patients. It is important to note

    Table 3: Nutrition Options for Sore Mouth and Mucositis 31–37

    Be fastidious with mouth care/cleanliness to prevent secondary bacterial infection of mouth lesions
    Eat soft, bland foods such as creamed soups, cooked cereals, yogurt; pudding, mashed potatoes, eggs, custards, casseroles,
    smoothies and shakes
    Drink liquids and semi-soft solids through a straw to bypass mouth areas with sores and lesions
    Blend or moisten foods with yogurt, tofu, pudding, soft cereals such as oatmeal, cream of wheat, and malt-o-meal; warm
    water, juice, milk, soy milk, rice milk, etc.
    Try non-acidic juices such as apple, apricot, peach or pear nectar, grape juice (do not use grape juice if diarrhea is present)
    Avoid tart, acidic, or salty beverages and foods such as citrus, avoid pickled items, avoid tomato-based foods, avoid alcohol,
    caffeine, and tobacco
    Try powdered glutamine dissolved in liquid at 10g three times daily (tid), swish and swallow, may be contraindicated if renal
    and/or hepatic function is severely impaired
    Try anti-inflammatory approach such as capsaicin taffy recipe (see Appendix 2 for recipe)
    Encourage inclusion of soft, probiotic containing foods such as yogurt and kefir (fermented milk), may be contraindicated if
    severe immunosuppression is present

    Table 4: Nutrition Options for Dry Mouth and Thick Saliva 37–45

    Drink eight to 12 cups (8oz cups) of non-caffeinated liquids each day. Use WHO fluid replacers if possible (see Appendix
    2 for recipe)
    Sip 100% pure, papaya juice to stimulate saliva and break up secretions
    Use lemons and lemon juice to help increase production of saliva, contraindicated if mouth sores and mucositis are present
    Use fluids other than water, such as non-acidic juices, to aid with hydration and increase calorie intake
    Try stews and casseroles that contain plenty of liquid, such as those made with soups as the base ingredient
    Try soft cooked chicken and fish, tofu, thinned cereals, such as oatmeal made with plenty of water or milk, popsicles, shakes,
    smoothies, and slushies, warm soups and stews, canned fruit in its liquid
    Blend or moisten foods with yogurt, tofu, pudding, soft cereals such as oatmeal, cream of wheat, malt-o-meal, warm water,
    juice, milk, soy milk, rice milk, etc.
    Add broth, sauces, gravy, or soup to soften and moisten foods
    Use yogurt, juice, or jelly to make foods ‘slide’ down a dry throat easier
    Avoid or limit caffeinated foods and beverages such as coffee, caffeinated tea, colas, and chocolate
    Avoid alcoholic beverages including beer, wine, and mixed drinks – alcohol will dry the mouth further
    Avoid dry foods including tough meats, raw vegetables, breads, pretzels, rice, chips, muffins, and cakes
3   Avoid commercial mouthwashes – these contain alcohol which will dry the mouth further

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Table 5: Nutrition Options for Constipation 37,46-53

Drink eight to 10 cups of non-caffeinated liquid each day, try water, prune juice, other warm juices, and non-caffeinated teas
Try drinking a warm liquid, such as soup or tea half an hour before normal time for a bowel movement
Add other sources of liquid to the diet such as soup and popsicles
Add two tablespoons ground flaxseed to daily diet
Slowly add high-fiber foods to the diet, try high-fiber foods such as whole-grain breads and cereals, raw and cooked fruits
and vegetables with the skins and peels, and beans and peas
Snack on dried fruit such as apricots, raisins, prunes, and dates
Increase physical activity, even if by a small amount; try taking a short walk about one hour before your normal time for a
bowel movement
Eat a good breakfast; include a hot drink and high-fiber foods
Mix three parts wheat bran cereal, two parts applesauce, and one part prune juice; eat this three times per day or more as
needed, to promote a bowel movement, works well on toast.
If gas is a problem, avoid carbonated drinks, broccoli, cabbage, cauliflower dried beans and peas, onions, Brussels sprouts,
Swiss chard, radishes, turnips, and watercress, limit talking at meals to avoid swallowing air, do not use a straw, avoid
chewing gum

Table 6: Nutrition Options for Lack of Appetite, Nausea & Vomiting 31,37,54,55

Treat as indicated with anti-emetics and/or pro-motility drugs; educate patient to use exactly as prescribed (nausea/vomiting
prevention is easier than treatment)
Educate patient on communication with health care team; encourage follow-up when symptom resolution is not achieved
with current medication regimen
Ginger: chopped dried extracts as tea two to three times daily – 940mg powdered ginger root once daily for nausea
prevention; 250mg root four times daily for nausea mgmt (may be contraindicated if coagulations parameters are abnormal)
Try small frequent snacks of bland foods such as oatmeal, plain pasta, rice, potatoes, broths (avoid ‘empty stomach’ which
may worsen nausea)
Completely avoid food smells – avoid preparing food for oneself if possible, focus on foods with minimal odors and short
cooking times
Avoid eating in a warm, stuffy room – avoid large quantities of fluids with meals/snacks, rinse out mouth before and
immediately after meals
Sip warm, natural ginger ale (higher ginger content) – sip ginger tea, chamomile tea, or peppermint tea (avoid peppermint if
reflux present)
Sit up to eat – do not lay down after eating for at least one hour; engage in relaxation activities after eating
Avoid fatty, greasy, fried, rich foods such as fatty meats, french fries, desserts (high fat will delay gastric emptying)

Table 7: Nutrition Options for Diarrhea 31,37,55-64

Try powdered glutamine dissolved in liquid at dose 10g tid, may be contraindicated if renal and/or hepatic function is
severely impaired
Increase intake of foods high in soluble fiber such as oatmeal, white rice, bananas, white toast, applesauce, peeled, canned
fruits, four oat bran tablets per day may help
Drink six to eight cups of fluids each day to replace losses, drink fluids at room temperature, with each loose bowel
movement, drink one additional cup of fluid
Try non-acidic juices such as apple; apricot, peach, or pear nectar, try broth and sports drinks to replace
electrolyte losses
Eat small frequent meals, drink fluids between meals rather than with meals, lie down after eating (do not lie down after
eating if reflux or vomiting present)
Nibble on salty, dry foods such as crackers and pretzels to replace lost sodium, consume these more often, but in small
quantities to avoid triggering diarrhea
Decrease intake of foods high in insoluble fiber such as fresh fruit with peel, raw vegetables, whole grain breads and cereals,
beans, peas, popcorn, etc.
Limit fatty and greasy foods such as meats, desserts, highly processed snack foods, potato chips, dips, sauces, gravies, etc.,
Limit or eliminate dairy if helpful
Try rice congee: one cup long-cooking rice combined with six to seven cups of water and one teaspoon salt, cook according
to directions; eat and sip mixture slowly                                                                                                       4

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    Table 8: Nutrition Options for Altered Sense of Taste/Smell 37,65-73

    Be fastidious with mouth care – follow your health care team’s instructions for best mouth care
    Try a mild mouth rinse of one teaspoon baking soda dissolved in one quart of water swished in your mouth (do not
    swallow) before each meal/snack
    Avoid food smells – stay away from the kitchen when food is being prepared; ask friends and family to help you with this
    Do not prepare food for yourself if it can be avoided – if possible, ask friends and family to help you with this
    Use plastic utensils instead of metal; this may decrease metallic flavor when eating
    Try foods that have minimal odors and short cooking time, such as scrambled eggs, French toast, pancakes, oatmeal, and
    cream of wheat
    Season foods with tart flavors such as lemon, citrus, vinegar, and pickled items (do not do this if you have sore mouth or
    Flavor foods with basil, oregano, rosemary, tarragon, mustard, catsup, or mint; marinate and cook meats in sweet juices,
    fruits, dressings, or wine, try sweet and sour pork, chicken with honey glaze, or beef with Italian dressing
    Try eating cold foods that do not have as much odor. Try popsicles, yogurt, frozen yogurt, frozen fruit, cold hard boiled eggs,
    juices and fruit nectars, cottage cheese and smoothies and shakes.
    If sweet things don’t taste good, try making a sour, tart, or less sweet shake or smoothie, use frozen cranberries for tart
    If you use liquid supplements, try drinking them in a covered container such as a ‘to-go’ coffee container
    Try using unusual flavors such as vinegar and pickles, strong and sour flavors may be better tolerated than more ‘typical’
    Rinse your mouth with tea, ginger ale, salted water, or baking soda and water to clear taste buds before eating
    Treat food like medication, know that even if it doesn’t taste good, your body needs food in order to heal, food provides
    energy and energy is what your body needs to recover from treatment

    that anorexia or simple lack of appetite marked by an                  dose that is sufficient to halt cachexia. For patients to
    involuntary decline in food intake is an effect of                     derive true benefits from this intervention, the
    cachexia, not the cause. Bearing this in mind, it                      metabolic benefits of EPA must be described. This
    becomes apparent that simple calorie feeding will not                  enables individuals to understand that the intervention
    address the metabolic changes inherent in the cachexia                 is not simply ‘food’ or ‘calories’, but rather a medication
    syndrome and typically will not result in weight                       that needs to be incorporated as diligently as other
    stabilization and/or weight regain.                                    medical interventions.

    One potentially useful approach for addressing cachexia                Conclusion
    is the use of omega-3 fats. There is evidence that the
    metabolic alterations that contribute to cancer cachexia               Cancer cases require close and consistent follow-up
    can be normalized by increased intake of                               by a qualified nutrition professional. In particular,
    eicosapentanoic acid (EPA).75–86 Research has indicated                cancers     involving     the    aero-digestive    and
    that amounts up to 18g per day of EPA are well                         gastrointestinal tracts require special attention. The
    tolerated.85 The most common dose-limiting symptom                     oncology RD, in conjunction with the full, multi-
    is diarrhea.85 However, a dose of 2.2g of EPA per day is               disciplinary team approach, is the ideal individual
    believed to be effective and this lower dose is associated             to provide the specialized nutrition care required in
    with minimal risk of side effects.75,76 EPA can be                     this patient population. By working closely with
    incorporated into the diet either through the use of                   the medical care team, collaborating to provide
    specialized oral/enteral formulas such as Novartis                     comprehensive nutrition care, and reinforcing
    Resource Support® and Ross ProSure® (two                               the importance of medication management for
    containers of supplement daily supply 2.2g) or EPA                     optimal symptom control, the RD can improve
    containing fish oil supplements. Generally, it has been                both quality of life and outcome in the oncology
    recognized that food sources of EPA do not provide a                   patient population. ■


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    Appendix 1 Nutrition Needs Guidelines


    The Harris-Benedict Equation (HBE)1 can be used to determine calorie requirements to meet basal
    metabolic rate (BMR):

    • Males: BEE = 66.5+(13.7xW{kg})+(5.0xH{cm})-(6.8xA{yrs})
    • Females: BEE = 655+(9.6xW{kg})+(1.9xH{cm})-(4.7xA{yrs})

    For individuals with head and neck cancer who enter treatment malnourished and experience hyper-
    metabolism, BMR will need to be multiplied by 1.4 to 1.6 to meet total calorie needs.

    The HBE is appropriate for evaluating short-term energy needs of critically ill patients,2 however, it may
    underestimate needs in some patient populations.3

    For quick,‘rule of thumb’ estimates of calorie needs in hypermetabolic patients, 35–50kcal/kg may be used
    as well.


    •   1.3 to 1.5g/kg body weight (ideal body weight (IBW) or adjusted IBW)
    •   Adjusted IBW = (actual BW – IBW) x (0.25 to 0.4) + IBW
    •   IBW for Males = 106lbs + 6lbs/inch + 10%;
    •   IBW for Females = 100lbs + 5lbs/inch + 10%

    Fluid Needs

    1,500mL for first 20kg of body weight + 20mL per kg for each kg over 20kg


    1. Lin P H, Proschan M A, Bray G A, Fernandez C P Hoben K, Most-Windhauser M, Karanja N and Obarzanek E,
       “DASH Collaborative Research Group. Estimation of energy requirements in a controlled feeding trial”, Am. J. Clin. Nutr.
       (2003), 77: pp. 639–645.
    2. MacDonald A and Hildebrandt L, “Comparison of formulaic equations to determine energy expenditure in the critically ill
       patient”, Nutrition (2003), 19: pp. 233–239.
    3. Compher C, Cato R, Bader J and Kinosian B, “Harris-Benedict equations do not adequately predict energy requirements
       in elderly hospitalized African Americans”, J. Natl. Med. Assoc. (2004), 96: pp. 209–214.


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    Appendix 2 Recipes

    C a p s a i c i n Ta f f y 1

    Ing redients:

    •   1 cup sugar
    •   3/4 cup light corn syrup
    •   2/3 cup water
    •   1 tablespoon cornstarch
    •   2 tablespoons butter or margarine
    •   1 teaspoon salt
    •   2 teaspoons vanilla
    •   1 1/2 teaspoons cayenne pepper


    Combine all ingredients except vanilla and cayenne pepper and cook over medium heat stirring constantly,
    to 256°F (use candy thermometer). Remove from heat, stir in vanilla and cayenne pepper. When cool
    enough to handle, pull taffy.When stiff, cut into strips, then pieces and wrap.

    Wo rl d H e a l t h O r g a n i z a t i o n ( W H O ) O ra l Re hy d ra t i o n S o l u t i o n s

    A goal of 2L of fluid daily will ensure adequate hydration status. Approximately 1L of fluids may be with an
    oral rehydration solution, rather than plain water. This will result in rehydration and aid in maintenance of
    normal electrolyte balance. Plain water, if consumed in excess, can result in hyponatremia and additional
    electrolyte abnormalities. Examples of ideal fluid replacers are the World Health Organization Oral
    Rehydration Solutions listed below. If patient acceptance of these fluid replacers is low, a low-carbohydrate
    commercial fluid replacer such as Gatorade® can be substituted. Avoid carbohydrate loading drinks such as
    Carboplex®.The extra carbohydrate is not necessary and can result in diarrhea in sensitive patients.

    Oral Rehydration Solution #1

    1/2 teaspoon salt
    1/4 teaspoon potassium chloride
    8 teaspoons sugar
    1/2 teaspoon baking soda
    1 liter water

    Oral Rehydration Solution #2

    1 cup orange juice (substitute non-citrus juice if mouth sores are present)
    8 teaspoons sugar
    3/4 teaspoon baking soda
    1/2 teaspoon salt
    1 liter water


                                                    ,         ,
    1. Berger A, Henderson M, Nadoolman W Duffy V Cooper D, Saberski L and Bartoshuk L, “Oral capsaicin provides
       temporary relief for oral mucositis pain secondary to chemotherapy/radiation therapy”, J. Pain Symptom Manage. (1995),
       10 (3): pp. 243–248.


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1. Statistics for 2004, American Cancer Society, Available at: Accessed August 25,
2. Doll R and Peto R,“The causes of cancer: quantitative estimates of avoidable risks of cancer in the United States today”, J. Natl.
    Cancer Inst. (1981), 66: pp. 1,191–1,308.
3. Willett W C, “Diet, nutrition, and avoidable cancer”, Environ. Health Perspect (1995), 103: pp. 165S–70S.
4. Ottery F D, “Pharmacologic management of anorexia/cachexia”, Semin. Oncol. (1998), 25: p. 35S–44S.
5. Ottery F D, “Supportive nutritional management of the patient with pancreatic cancer”, Oncology (1996), 10: p. 26S–32S.
6. Ottery F D, “Definition of standardized nutritional assessment and interventional pathways in oncology”, Nutrition (1996),
    12: pp. S15–S19.
7. Ottery F D,“Supportive nutrition to prevent cachexia and improve quality of life”, Semin. Oncol. (1995), 22: pp. 98S–111S.
8. Ottery F D,“Rethinking nutritional support of the cancer patient: the new field of nutritional oncology”, Semin. Oncol. (1994),
    21: pp. 770–778.
9. Ottery F D, “Cancer cachexia: prevention, early diagnosis, and management”, Cancer Pract. (1994), 2: pp. 123–131.
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