Nutritional Interventions for Reducing
the Negative
Side Effects of Chemotherapy
by Bill Misner, Ph.D.
Cancer patients typically experience "Break-Through" nausea, Neutropenia, and anemia as a result of the active pharmacology imposed by Intravenous Chemotherapy. Specific practical nutritional interventions, ones that do not interfere with chemotherapy's anti-cancer metabolic endpoints present a balanced nutritional protocol for replacing required substrates for normal cellular functions which result in significant reduction of negative systemic reactions. The purpose of this paper is to acquaint the chemotherapy patient with each intervention that has been observed to reduce symptoms in some cancer patients during intravenous chemotherapy. Not all interventions will result in decreasing symptoms or increasing blood lab values for every subject, leaving each intervention-trial test subject to determine its individual merit.
NAUSEA
Nausea inhibits nutrient adequacy for homeostatic repletion. If nausea is
prolonged, white and red blood cell will be numerically depressed from nutrient
deficiency, resulting in weight loss. Doctors prescribe drugs called antiemetics to control nausea and vomiting. Regulation of
natural whole foods and/or concentrated supplemental substrates may reduce
"Outbreak Nausea" from testing 3 interventions:
[1]-DO'S--->HELPFUL NAUSEA-REDUCING INTERVENTIONS;
[2]-DO NOT'S: HARMFUL NAUSEA-INDUCING DIETARY INTERVENTIONS TO AVOID
[3]-METHODS: DIETARY APPLICATIONS REDUCE NAUSEA
1. DO'S--->HELPFUL NAUSEA-REDUCING INTERVENTIONS-
[RANKED MOST TO LEAST EFFECTIVE]
- Try foods with minimal odor (scent of food may cause nausea)
- Eat dry cereal, toast, or crackers in the AM [low blood sugar in AM triggers
nausea]
- Snack before bedtime, or even in the middle of the night [avoid an empty
stomach]
- Hydrate frequently in small doses [sipping]; dehydration may cause nausea,
clear liquids, Tea and Ginger Ale may decrease nausea, flat soda pop
- Eat a high protein diet. Try things like shrimp, eggs, tuna, milk, or peanut
butter.
- If high protein doesn't work, try a high carbohydrate diet like pasta, rice,
potatoes, bananas, toast, and dry cereal.
- Fruits & Vegetables: carrots, jello-peaches,
cherries, and apricots
- Find foods you tolerate; add one food per day for variety
- Get plenty of rest
- Use a cold washcloth over your eyes when you feel nauseous
- Dill Pickles may alter the metallic taste sensation from chemotherapy drugs
- Yogurt
- Sherbet
- Pretzels [low fat or no-fat are preferred]
- Angel food cake
- Skinned chicken (baked or broiled, not fried)
- Ice chips
- Oatmeal
- Wrist wrap acupressure points "SEABANDS" for motion sickness
[acupressure points on the wrist counteract nausea for some subjects]
- Drinking peppermint or raspberry-leaf warm or cool tea, or
peppermint-flavored candy
- Take vitamin B6 (20-50mg per day)
- Ginger Root* or Ginger Capsules*
2. DO NOT'S: HARMFUL NAUSEA-INDUCING DIETARY INTERVENTIONS
TO AVOID
- Fatty, greasy or fried foods
- Very sweet, such as candy, cookies or cake
- Spicy or hot
- With strong odors
- Avoid Iron supplements or try going without Vitamin multiples, except B-6
- Avoid NSAIDs, unless prescribed and/or enteric
coated
- Avoid coffee or high acid hot drinks
- Avoid icy drinks, highly carbonated drinks, or very hot drinks
3. METHODS: DIETARY APPLICATIONS REDUCE NAUSEA
Eat small amounts often and slowly. Drink fewer liquids with meals. Drinking
liquids can cause a full, bloated feeling. Drink or sip liquids throughout the
day, except at mealtimes for adequate hydration. Dehydration induces nausea. Overhydration induces nausea. Using a straw may help. Eat
foods at room temperature or cooler; hot foods may add to nausea. Don’t force
yourself to eat favorite foods when nauseated as this may cause a permanent
dislike of those foods. Avoid constipation; if bowels "back-up",
nausea may result of worsen.
*-GINGER CONTRAINDICATIONS: Ginger is to be used only after consultation with a physician. Side Effects: Heartburn. Drug Interactions: European researchers concluded that ginger might enhance absorption of sulphaguanidine. Excessive consumption of ginger may interfere with cardiac, antidiabetic, or anticoagulant therapy. Patients with gallstones should not take ginger except on the advice of their physician.
Once nausea is effectively controlled resulting in active appetite substrate repletion, homeostatic normal reference ranges will be achieved. Once nausea is controlled for optimal nutrient repletion, specific dietary interventions may be further modified to include low white blood cell counts[Neutropenia].
NEUTROPENIC DIETARY PROTOCOL
Neutrophils are an important defense against
infection, especially bacterial infection. Treatment and disease progression
may compromise neutrophil counts. When neutrophil counts fall below 1000 (1.0 x 109/L), patients
are in jeopardy of infections from bacteria found in everyday foods. If neutrophil counts drop to near or below 1000, patients
should be on a neutropenic diet and should be in
close touch with their Oncologists or Hematologists. These dietary protocols
may be used when you are neutropenic. It is important
to follow a low bacteria diet until your immune system returns to normal. You
must prepare foods in such a way that you avoid risk of infection. As your neutrophils increase your doctor may liberalize your diet.
KEEP FOOD CLEAN
Check expiration dates on all products before you buy them. Be sure nothing you
buy is past its expiration date.
NEUTROPENIC DIETS
Give your immune system a boost by including lots of
yogurt that contains live active cultures of LACTOBACILLUS BULGARICUS &
STREPOCOCCUS THERMOPHILUS. Some other specific foods to include are GARLIC,
FOODS HIGH IN ZINC SUCH AS OYSTERS, POT ROAST, DARK MEAT TURKEY, PUMPKIN &
SQUASH SEEDS (or make sure the multi-vitamin contains zinc), and shitake
mushrooms. These mushrooms may not be appealing, so try pureeing them to add to
spaghetti sauce, or chop them fine and add to a meat loaf. Other immune
boosting foods are FRUITS & VEGETABLES. They may not increase white cell
count, but they will make the white cells grow stronger. The best choices are
the deep green and orange ones like spinach and carrots, melon and oranges. On
the other hand, fish oil is an immune system enhancing agent. Serve a cup of
yogurt with pureed strawberries for desert. Serve fresh salmon with some tender
cooked broccoli florettes or spinach that has been
steamed with fresh garlic and a little water; (garlic needs to cook longer than
the spinach so give that a head start). A NEUTROPENIC DIET includes all
well-cooked foods and eliminates foods that may contain potential
disease-causing microorganisms (Oncology Nutrition Patient Education Materials
by Walker and Masino, published by The American
Dietetic Association, 1998). The restrictions on this diet vary from cancer
center to cancer center.
GENERAL GUIDELINES
You could also take fresh or frozen fruits and
vegetables, first wash them thoroughly under running water, microwave or steam
them until well-done, cool covered in the refrigerator, and then use them in
the shake. Some fresh produce even has better availability of nutrients and phytochemicals with cooking although other nutrients are
also decreased with cooking. However, remember that this diet is only for short
term use and try not to worry too much about the lost nutrients. Use the
vacuum-packed (pasteurized) tofu to minimize bacterial counts. Change the
storage water daily. Never buy tofu from open bins or barrels during this time
of being immune-suppressed. [DO NOT USE the wheat germ, wheat bran, or
flaxseeds stored in open bins.]
SPECIFIC FOODS RECOMMENDED BY THE ONCOLOGY NUTRITION PATIENT EDUCATION
MATERIALS:
-Pasteurized yogurt
-Peeled thick-skinned, unblemished fresh fruit (banana, citrus, melon - be sure
to wash the outside peels prior to cutting through the fruit with your
knife)
-Peeled apples
-Cooked dried fruit
-Processed fruit juices - pasteurized milk (and soy milk)
SPECIFIC FOODS TO AVOID [ONCOLOGY NUTRITION PATIENT EDUCATION MATERIALS]
-Fresh-squeezed fruit juice
-Unpasteurized fruit juice
-Too much fat [polyunsaturated vegetables oils adversely effect immune system
strength]
Be sure your blender and its cover, cutting board and utensils are clean, preferably by washing them all in the dishwasher. If you need to wash these items by hand, use warm soapy water, rinse well, and then wash again with a solution of 1-Tablespoon bleach in 4 cups of warm water. Let the solution stay on for at least 2 minutes and then rinse clean with hot clean water. PROBABLY MOST IMPORTANT OF ALL, THOROUGHLY WASH YOUR HANDS WITH SOAP AND WATER BEFORE HANDLING THE FOODS AND PREPARING THE SHAKE. [1]
NUTRITION-SPECIFIC COMPARISONS: THE PERMITTED VS NOT
PERMITTED FOODS AND FLUIDS
PERMITTED: Distilled water, boiled well water, bottled spring water, and tap
water
NOT PERMITTED: Raw, unpasteurized milk, eggnog or
milk shakes made with raw eggs, fresh apple cider
PERMITTED: Shellfish well cooked, home prepared meat, and
fish salads, pre-packaged sandwich meats
NOT PERMITTED: Raw or rare meat, fish, eggs, poultry commercially prepared meat
and fish salads, sushi, and sandwich meats from the deli
PERMITTED: Pasteurized or Lactaid milk or yogurt
Pre-packaged ice cream or frozen yogurt, pre-packaged hard cheeses: cheddar,
Colby, Monterey jack, Swiss, mozzarella pre-packaged soft cheeses: cottage
cheese, cream cheese, ricotta
NOT PERMITTED: Soft serve ice cream or frozen yogurt hand-packed ice cream or
frozen yogurt, feta, brie, camembert, blue, gorganzola,
and quesco fresco cheeses any imported cheeses, and
any cheese sliced at a deli
PERMITTED: Breads, cereals, rice, potatoes, pasta, all
pre-packaged or homemade breads, muffins, cakes, rolls, donuts, cookies and
crackers all boxed hot or cold cereals, except those with dried fruit or nuts,
cooked potatoes, rice, noodles
NOT PERMITTED: Bakery breads, muffins, cakes, donuts, cream, or custard filled
cakes, commercially prepared potato, or macaroni salad, popcorn (due to dental
problems)
PERMITTED: All well washed and thoroughly cooked vegetables, all cooked or
canned fruits, raw, thick-skinned, well-washed fruits (unbruised):
oranges, grapefruits, melons, bananas, tangerines
NOT PERMITTED: Raw vegetables and salads, uncooked thin skinned fruits: apple,
peaches, grapes, plums, nectarines, kiwi, strawberries, dried fruits
PERMITTED: Processed peanut butter, packaged roasted nuts, cooked nuts (in
cookies, cakes, etc)
NOT PERMITTED: Raw nuts, uncooked nuts, unprocessed nuts
PERMITTED: All cooked fresh or canned spices (add at least 5 min. prior to end
of cooking) ketchup, mustard, mayonnaise, served in separate containers with
clean utensils, sugar, jelly, honey served from clean containers with clean
utensils
NOT PERMITTED: Uncooked spices, raw honey, anything from a family container
that isn't freshly washed
PERMITTED: Thoroughly cooked frozen dinners, thoroughly cooked frozen pizza,
canned entrees, do not eat at restaurants for at least two months or use take
out deli food even if it's behind the counter, avoid all salad bars for at
least one year, avoid all self-serve buffets for at least one year.
SPECIFIC FOODS THAT SHOULD BE RESTRICTED ON A NEUTROPENIC DIET
[2]:
-Raw nuts, vegetables, and salads
-Apples, peaches, grapes, plums, nectarines, kiwi, strawberries, and other
uncooked thin-skinned fruits
-Self-serve buffets, salad bars, and deli foods
-Cheeses such as feta, Brie, Camembert, blue, etc.
-Raw or rare meats, fish, and poultry
-Commercially prepared potato or macaroni salad
-Raw, un-pasteurized milk and eggnog or milk shakes made with raw eggs
-Bakery breads, muffins, cake donuts, and cream or custard filled cakes
In addition to the selection of appropriate foods, extra care is important in
food preparation. Food preparers must wash their hands frequently in warm soapy
water, especially if handling raw meat, chicken, eggs, and fish. Counter tops,
cutting boards, and cooking utensils should also be washed with hot soapy water
after they have come in contact with food.
OTHER NUTRITIONAL CONSIDERATIONS
It is very important to maintain your weight during
cancer treatments. If you have a scale weigh yourself
weekly. If you notice a loss of five pounds or greater, contact your doctor.
You may not wish to eat large amounts of food, so you are advised to maximize
the calories you do eat.
EAT SMALL, FREQUENT MEALS OR SNACKS
Add margarine, butter, gravy, cheese, and non-fat milk powder to appropriate
items. (If you're having dry mouth as a result of treatment you'll
really appreciate these suggestions.)
Consume nutritional supplements like ice cream frappes made with enriched milk.
To make enriched milk mix 1 quart of milk with 1 cup of dry milk powder. Stir
well and keep refrigerated. This increases the protein, calorie and vitamin
content of the milk.
Drink Instant breakfast, Ensure, Sustacal, or other
commercially prepared supplements.
Some people may have trouble digesting milk products. Watch for symptoms of
bloating, gas, cramps, or diarrhea after consuming milk products. You may want
to switch to Lactaid Milk, or chew lactaid tablets
when eating dairy products. Discuss this with your dietitian, nurse, or doctor.
DIETARY INTERVENTIONS FOR ANEMIA
COMMON CAUSES
The most common cause is iron-deficiency anemia in red blood cells which are
smaller than usual and pale in color due to improper amounts of hemoglobin (the
molecule in red blood cells that binds to oxygen and carries it in the blood).
This lack of iron for the production of hemoglobin is due to:
-Loss of iron from the body due to blood loss
-Poor absorption of iron from one's diet
-Lack of dietary iron
-Radiotherapy or Chemotherapy
-Anti-cancer drugs
-Certain types of viral infections
-Genetic reasons
-A result of malaria
-AIDS
-A deficiency of vitamin B-12.
-A deficiency of folic acid.
-An imbalance between the ratio of B-12 & Folate
SYMPTOMS OF ANEMIA
[Note: There may be no symptoms if anemia is mild.]
1. Tiredness and weakness
2. Lethargy
3. Dizziness, shortness of breath, and palpitations (rapid heart rate)
4. Headaches
5. Pale complexion
6. Brittle nails (due to lack of iron)
7. Irritability
8. Sore tongue
9. Unusual food cravings (called pica)
10. Decreased appetite
11. Headache - frontal
12. Blue tinge to sclerae (whites of eyes)
MECHANISMS OF ANEMIA
Red blood cells that carry iron-rich hemoglobin live only 120 days or four
months. Unless there is a continual supply of iron, vitamin B12, vitamin C and folacin from either food or
supplements, anemia will result in poorly formed red blood cells that are
ineffective carriers of oxygen. Iron deficiency anemia is the most common form
of anemia. Approximately 20% of women, 50% of pregnant women, and 3% of men are
iron deficient. Iron is an essential component of hemoglobin, the oxygen
carrying pigment in the blood. Iron is normally obtained through the food in
the diet and by the recycling of iron from old red blood cells. The causes of
iron deficiency are too little iron in the diet, poor absorption of iron by the
body, and loss of blood (including heavy menstrual bleeding). It may also be
related to lead poisoning or chemotherapy. Anemia develops slowly after the
normal stores of iron have been depleted in the body and in the bone marrow.
Women, in general, have smaller stores of iron than men and have increased loss
through menstruation, placing them at higher risk for anemia than men. In men
and postmenopausal women, anemia is usually due to gastrointestinal blood loss
associated with ulcers, the use of aspirin or nonsteroidal
anti-inflammatory medications (NSAIDS), or colon cancer. High-risk groups
include: women of child-bearing age who have blood loss through menstruation;
pregnant or lactating women who have an increased requirement for iron;
infants, children, and adolescents in rapid growth phases; and people with a
poor dietary intake of iron through a diet of little or no meat or eggs for
several years. Risk factors related to blood loss are peptic ulcer disease,
long term aspirin use, colon cancer, or cancer-related chemotherapy treatment.
Dietary sources of iron are red meat, liver, and egg yolks. Flour, bread, and
some cereals are fortified with iron. If the diet is deficient in iron, iron
should be taken orally monitored by a physician.
DIETARY INTERVENTIONS
Non-heme iron (ferric) is highly variable in its
availability for absorption. Foods high in non-heme
iron are grains, vegetables, fruits, eggs and some iron supplements. Absorption
of non-heme iron increases in the stomach's acidic
environment and the presence of vitamin C in foods. Also, the presence of red
meat may increase absorption of non-heme iron four
times. However, oxalates and phytates found in dark
green leafy vegetables and whole cereal grains decreases the absorption of iron
because they bind with iron in the gastrointestinal tract.
Heme iron (ferrous), found in red muscle meats of
animals, is far more effectively absorbed. The
absorption of heme iron is influenced by other foods
in the diet such as foods containing vitamin C and an acid environment like the
stomach. The Recommended Dietary Allowance (RDA) for iron is 10 milligrams for
adult males and postmenopausal females. Males (ages 11 to 18) need 12
milligrams of iron per day. Females (ages 11 to 50 years) need 15 milligrams.
The best food source of iron is liver and red meats. These foods contain heme iron, which is better absorbed than non-heme iron. Non-heme iron can be
found in dark green, leafy vegetables (spinach, chard and kale) and whole
cereal grains (bran and whole wheat bread). Include dark green, leafy
vegetables and whole cereal grains in your daily diet. Oxalates and phytates found in dark green leafy vegetables and whole
cereal grains decrease the absorption of iron because they bind with iron in
the gastrointestinal tract. You should also look at iron fortified cereals to
supplement iron in your diet. Also, if you are a menstruating woman, contact
your doctor about having an annual blood workup. You may not develop anemia on
a meat-free diet, but your iron stores may be low.
SUBSTRATE SUPPLEMENT CONSIDERATIONS [4]
- Acidophilus - 2-8 Billion Count, Good Bacteria
- Coenzyme Q10 - 100-150 mg daily
- Garlic capsules - 2 capsules 3 x daily
- Germanium - 200 mg daily
- Kelp - 100-225 micrograms/day
- Vitamin B6 - 50 mg 1-3 daily
- Vitamin B12 - 200-1,000 mcg
- Folic Acid - 800 mcg
- Proteolytic enzymes - Bromelain
& Papain
- Selenium - 200 mcg daily
- Vitamin A - 15,000 IU daily or Beta Carotene - 25,000 IU daily
- Vitamin B Complex - 50-100 mg/day
- Vitamin C plus Bioflavonoids - 3000 mg daily
divided doses
- Vitamin E - 400 IU daily
- Copper - 2 mg daily
- Zinc chelate or Picolinate-
50-80 mg daily ---->(Do not take zinc in amounts over 100 mg daily as it can
impair the immune response.)
Reference:
[1]-
[2]-Dana Farber Cancer Institute Dietitians-cited
[3]-Neupogen [Filgrastim]
Pharmacology Information-cited
[4]-As with any supplement, always confer with your physician or nutritionist as to the appropriate level or selection prior to use.
[5]-The "Science Behind" Procrit
[resource on World Wide Web]-cited
[6]-Guyton AC, Hall JE. Textbook of
medical physiology. 9th ed.
[7]-Guyton AC, Hall JE. Human physiology
and mechanisms of disease. 6th ed.
DISCLAIMER: This information is presented for educational purposes only. Please
discuss this information with your personal physician or dietitian. If a
medical or health concern is present, applications of this information are
subject to the approval of your personal physician or licensed health care
provider.
*Bill Misner Ph.D. is the director
of Research & Product Development for E-CAPS INC., a manufacturer of micro-
and macro- nutrients specifically formulated for endurance athletes. He is an
Associate Editor, Metabolic Responses to Exercise for the Journal of Exercise
Physiology-online, Editor of the Journal of Endurance, and author of
"NUTRITION FOR ENDURANCE: FINDING ANOTHER GEAR" Dolezal
& Associates Publishing,
Altering the intended context of this article requires the author's consent. You may contact Bill Misner Ph.D. drbill@omnicast.net or 1-800-336-1977.