Practical Management of Eating Difficulties

Anorexia

Anorexia (loss of appetite) is often associated with other eating difficulties, such as nausea, taste changes, and constipation, and addressing these problems may improve the patient's appetite. Pain may also contribute to anorexia, and regular analgesia for pain may in turn help improve appetite, as may dietary alterations (Table 2). For patients who have severe anorexia, an appetite stimulant should be considered, such as dexamethasone, medroxyproes-terone acetate, or megestrol acetate.

Taste Changes

Cancer patients may suffer from lack of taste or 'taste blindness,' they may find that foods taste metallic or excessively salty or sweet, or they may find that foods taste abnormal. Depending on the taste change experienced, it is often worth excluding certain foods from the diet or using certain flavorings to try to stimulate the taste buds (Table 3).

Table 2 Dietary management of anorexia

Give small, frequent meals and snacks in preference to three meals daily.

Serve food on a small plate.

Ensure food looks appetizing.

Encourage any food the person prefers, even if it is all of one type (e.g., puddings).

Distract from eating (e.g., by conversation, watching television, or listening to music).

Give an alcoholic drink to be sipped before meals or with food.

Table 3 Suggestions for overcoming taste changes

Taste change

Suggestions

Excessively

Reduce sugar content of food and drink.

sweet

Add a pinch of salt to drinks and puddings.

Excessively

Avoid packet soups, gravy, and sauces.

salty

Avoid salted snacks (e.g., crisps and nuts) or

try unsalted varieties.

Avoid bacon and other cured or tinned meat.

Add a pinch of sugar to sauces or soups.

Metallic taste

Soak red meat in acidic marinate (e.g., vinegar

and wine).

Eat white meat, fish, eggs, and cheese in

preference to red meat.

Avoid tea, coffee, and chocolate.

Taste

Use extra flavorings: salt, pepper, pickles,

blindness

mustard, herbs, and spices.

Eat highly flavored food (e.g., curry).

Nausea and Vomiting

Nausea and vomiting must be controlled with antie-metic drugs. Some dietary suggestions may help patients with food choice when they are feeling nauseous (Table 4).

Dysphagia

Dysphagia (difficulty swallowing) may occur with solid food, semisolid foods such as porridge, or liquids. For the person who cannot manage solid food but is able to eat semisolids, altering the consistency of the food may be the only dietary change needed, encouraging food with extra sauce, soft puddings, and nourishing drinks.

For the patient who is only able to swallow fluids, close attention must be paid to their intake and dietary supplements are likely to be necessary. Some people who can only manage liquids choose to liquidize their food; this dilutes the nutrients, so meals should be fortified with butter, cream, glucose, cheese, etc. to add protein and energy.

If there is complete dysphagia to both solids and liquids, feeding by an enteral tube should be considered.

Table 4 Suggestions for food and fluids when person has nausea

Have cold food and drink in preference to hot because these have less odor. Sip fizzy drinks. Drink through a straw.

Try ginger flavors (e.g., ginger ale and ginger biscuits). Eat small, frequent snacks to avoid the stomach from becoming completely empty.

In some instances, people can swallow solid food but aspirate liquids. Patients should undergo a complete assessment from a speech and language therapist to ascertain which textures are safe to swallow. It may be that thickened liquids such as milk shakes or those thickened with a commercial thickener are suitable, whereas thin liquids, such as tea and water, are aspirated. If thick fluids are also aspirated, it is usually safer to give nothing by mouth and to maintain hydration and nutrition through an enteral tube.

Mucositis and Stomatitis

If the mouth or throat is sore, eating can become very difficult. An analgesic taken before meals can help ease the pain and enable the person to eat a little more. Modifying the diet is also helpful (Table 5).

Xerostomia

Xerostomia (dry mouth) may be a long-term side effect of cancer treatment, and patients may need to use extra sauce with their foods or have soft food, and they usually need to sip a drink while eating. Chewing gum, preferably sugar-free, can stimulate saliva, although it should be avoided by those with no saliva because it will stick to their teeth. Pineapple can also stimulate saliva and eating it between meals may make the mouth more comfortable.

Good dental hygiene is particularly important because saliva protects the mouth against infection. If people with xerostomia also get mouth infections, the resulting mucositis makes it increasingly difficult for them to eat.

Trismus and Difficulty Chewing

Trismus (difficulty opening the mouth) and difficulty chewing may be overcome with soft food or, failing that, with nourishing drinks and dietary supplements. If the person loses weight and can manage very little orally, an enteral tube feed should be considered.

Table 5 Suggestions to relieve mucositis and stomatitis Avoid citrus fruits and drinks.

Avoid salty, spicy food, vinegar, pickles, and other strong flavors. Avoid carbonated drinks. Have tepid food and drinks.

Iced drinks may be soothing (or may increase the pain). Avoid dry foods that need extra chewing (e.g., toast). Eat soft food and use extra sauce.

Gastrointestinal Fistulas

A fistula may develop anywhere in the gastrointestinal tract. The site of the fistula will determine the dietary management (Table 6).

Constipation

The cause of constipation must be considered initially. If it is due to a tumor pressing on the bowel (e.g., cancer of the ovary or colon), a low-fiber diet may be helpful. Low-fiber food is less bulky and may pass through the bowel more easily, particularly if accompanied by appropriate laxatives (e.g., stool softener).

If constipation is due to lack of fiber in the diet, then an increased fiber and fluid intake may be helpful. If constipation is due to analgesia, then appropriate laxatives need to be used in conjunction with any changes in the diet. In addition to fiber, a good fluid intake must be maintained to avoid constipation; approximately 2 litres per day is recommended.

Diarrhea

Diarrhea may be due to overflow from constipation, in which case the advice for constipation should be followed. Diarrhea due to intestinal hurry caused by bowel disease or drugs may be controlled with drugs and by avoiding excessive intake of high-fiber foods, which naturally pass through the bowel quickly. When malabsorption is suspected, a low-fat, elemental enteral tube feed should be considered. When diarrhoea is severe, it is important to replace the fluid lost to prevent dehydration. Oral rehydration solution is useful to replace fluid loses. Diarrhea caused by radiotherapy needs to be controlled with drugs, and a low-fiber diet is not thought to be helpful in this instance.

Intestinal Failure

A long-term side effect of pelvic radiotherapy may be enteritis resulting in intestinal failure. Extensive gastrointestinal surgery leaving less than 100 cm of small bowel, or a fistula in the small bowel causing high stoma losses, may also cause intestinal failure. Previous chemotherapy that may affect the function of the bowel can contribute to this condition. Intestinal failure is more likely to occur when the patient does not have a functioning colon (e.g., in the case of ileostomists or when the ileo-caecal valve is absent).

Dietary manipulation can greatly alleviate the symptoms of intestinal failure, such as thirst, dehydration, and high stoma losses or large volumes of diarrhea (Table 7).

An oral rehydration solution consisting of 20 g glucose, 3.5 g sodium chloride, 2.5 g sodium bicarbonate, and 1000 ml water provides 90mmol of sodium per liter. It may be used chilled and to dilute weak fruit squashes. If the patient remains dehydrated despite following the advice detailed in Table 7, intravenous fluid replacement is necessary.

Drugs may be given to increase gut transit time or reduce fluid losses. If medication is in the form of capsules, these should be opened and the drugs given 60min before meals. Suitable drugs include codeine phosphate, loperamide, rantidine, and octreotide. In the longer term, the following should be monitored:

Plasma electrolytes, ferritin, and vitamin D levels Serum albumin, magnesium, zinc, calcium, phosphate, and alkaline phosphate Folate and vitamin B12 concentrations Prothrombin time Body weight

Urinary sodium concentration Bowel Obstruction

Bowel obstruction may be subacute or complete. In cases of complete bowel obstruction, the clinical condition of the patient must be considered. If it is

Table 6 Sites of fistulas and their management

Site Management

Neck, salivary 'Nil by mouth' and enteral tube feed until fistula healed

Chyle leak (e.g., Low-fat diet initially; if unsuccessful, a low-in neck) fat, medium-chain triglyceride enteral tube feed If unsuccessful, consider parenteral nutrition

Large bowel Low-residue diet or elemental enteral tube feed

Small bowel See Table 7

Table 7 Dietary management to reduce gut losses in intestinal failure

Restrict fluids to 500-1000 ml daily, increasing to 1500 ml.

Avoid drinks for 30min before and 45min after meals.

Avoid foods that are particularly high in fiber.

Sprinkle salt liberally on food.

Consider fat restriction if patient has a colon and there is evidence of steatorrhea.

Take salt and carbohydrate foods together to help sodium absorption.

If gut losses are 1000 ml or more, part or all of fluid intake should consist of an oral rehydration solution.

anticipated that the obstruction will resolve, or if aggressive treatment such as surgery is planned, par-enteral nutritional support should be considered. Total parenteral nutrition may be inappropriate and is unlikely to be useful in cases in which the prognosis is poor and no treatment is possible.

Depending on the degree of obstruction, in cases of subacute obstruction the following action may be taken under medical supervision:

First day: sips of clear fluid, approximately 10mlh-1 Second day: 30mlh-1 clear fluid Third day: 60mlh-1 clear fluid Fourth day: free clear fluids

Fifth day: free fluids, including milk, low-fiber soup, custard, and jelly Sixth day: low-fiber diet, avoiding all fruit and vegetables, nuts, pulses, and whole grain cereals, whole meal bread, etc.

A patient who starts to vomit should return to the diet prescribed for the preceding day. If symptoms of bowel obstruction, such as abdominal pain and indigestion, remain controlled, fruit and vegetables may be introduced as tolerated, starting with small amounts.

Weight loss

Weight loss is often the consequence of the dietary problems described previously. The measures in Table 8 should be considered to help prevent weight loss or encourage weight gain. It must be remembered that energy requirements may be elevated due to the physiological effects of malignancy. Much interest has focused on attempts to influence the metabolic alterations in cachexia via nutrients. Research has examined the possible role of eicosa-pentaenoic acid (EPA), an n-3 fatty acid, in reducing the inflammatory response in cachexia. A randomized trial in pancreatic cancer patients compared a high-energy drink fortified with EPA to a standard high-energy drink to examine whether this was more effective at promoting weight gain. The study failed

Table 8 Dietary advice to help prevent weight loss

Fortify food with cream, butter, cheese, oil, sugar, honey, glucose, jam, etc. Have small, frequent snacks. Use full-fat and full-sugar products. Avoid large amounts of lower energy foods (e.g., fruit and vegetables).

Try dietary supplements, such as milky drinks and glucose polymer power.

Consider an overnight enteral tube feed to supplement the diet if weight loss continues despite following the previous advice.

to show any additional benefit of EPA in terms of weight gain.

Palliative Care

In some people, cancer will not be cured. Palliative care focuses on the relief of symptoms rather than aggressive curative treatment. The majority of people receiving palliative care will suffer from at least one eating difficulty. Much of the advice detailed previously for overcoming dietary problems is relevant, but it is often upsetting for these patients to have to pay close attention to their dietary intake. If patients are unconcerned about their poor dietary intake, it may be appropriate not to offer any advice; conversely, for those who are very concerned, the problem should be addressed seriously.

Alternative and Complementary Diets

The alternative and complementary diets considered here are modifications of a normal diet that are claimed to cure or treat cancer. Such diets are often followed for their anticipated antitumor effect. Often, they have not been tested or demonstrated to be effective in scientifically acceptable clinical trials. Patients may use other complementary therapies, such as healing, relaxation, visualization, homeopathy, and herbalism, in addition to making dietary changes. Dietary regimens may share common features:

Mainly vegetarian or vegan—alternatively, diets may limit red meat and allow limited free-range chicken and deep-sea fish No manufactured or processed foods Low in salt Low in sugar Low in fat

High in fiber, including raw fruit and vegetables and whole grains (these may be organic) May include fruit and vegetable juices High-dose vitamins and minerals

Nutritional inadequacies may arise in the patient who has a poor appetite. The diets may cause weight loss and are restrictive and time-consuming to prepare. Some ingredients may be difficult to obtain and are often costly. Studies appear to show no difference in survival rates between patients following complementary therapies and patients receiving conventional treatment alone. Patients who use complementary therapies, however, do report psychological benefits, such as feelings of hope and optimism. Patients should have enough information about the possible advantages and disadvantages before embarking on strict complementary or alternative diets.

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