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 foood may cause nausea)
- Eat dry cereal, toast, or crackers in thee AM [low blood sugar in
AM triggers nausea]
- Snack before bedtime, or even in the midddle of the night [avoid
an empty stomach]
- Hydrate frequently in small doses [sippinng]; 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 perr day for variety
- Get plenty of rest
- Use a cold washcloth over your eyes when you feel nauseous
- Dill Pickles may alter the metallic tastee sensation from chemotherapy
drugs
- Yogurt
- Sherbet
- Pretzels [low fat or no-fat are preferredd]
- Angel food cake
- Skinned chicken (baked or broiled, not frried)
- Ice chips
- Oatmeal
- Wrist wrap acupressure points "SEABAANDS" for motion sickness
[acupressure points on the wrist counteract nausea for some subjects]
- Drinking peppermint or raspberry-leaf warrm 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 cakke
- Spicy or hot
- With strong odors
- Avoid Iron supplements or try going withoout Vitamin multiples, except
B-6
- Avoid NSAIDs, uunless prescribed and/or enteric coated
- Avoid coffee or high acid hot drinks
- Avoid icy drinks, highly carbonated drinkks, 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. Wash with soap/citrus
cleanser and hot water before and after touching food: counter tops,
cutting boards (wash them in a dishwasher if you have one) all cooking
utensils, all silverware, and all pots and pans. Food preparer should
wash hands frequently with warm soapy water and dry with paper towels.
This is especially important after touching raw meat, chicken, eggs,
and fish. Wash dishes in hot soapy water or in dishwasher. Air-dries
dishes--DO NOT use cloth towel. Keep perishable food very hot or
very cold. DO NOT leave perishable items at room temperature for
more than 10 to 15 minutes. All perishable foods should be cooked
thoroughly. Yes, that means no rare meat. Thaw frozen foods in the
refrigerator overnight or quickly in the microwave. DO NOT thaw food
on the counter. Refrigerate leftovers promptly in airtight containers.
Use leftovers only if they have been stored properly and have been
around for no more than 24 hours.
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 frruit (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 frruit juice
-Too much fat [polyunsaturated vegetables ooils 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, p>lums, nectarines, kiwi, strawberries,
and other uncooked thin-skinned fruits
-Self-serve buffets, salad bars, and deli ffoods
-Cheeses such as feta, Brie, Camembert, blue, etc.
-Raw or rare meats, fish, and poultry
-Commercially prepared potato or macaroni ssalad
-Raw, un-pasteurized milk and eggnog or millk shakes made with raw
eggs
-Bakery breads, muffins, cake donuts, and ccream 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 enzzymes - Bromelain & Papain
- Selenium - 200 mcg daily
- Vitamin A - 15,000 IU daily or Beta Carottene - 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 orr Picolinate- 50-80 mg daily ---->(Do not take
zinc in amounts over 100 mg daily as it can impair the immune response.)
Reference:
[1]-Diana Dyer, MS, RD CNSD, [resource on World Wide Web]: Available
from URL: http://www.cancerrd.com/FAQs/FAQ1.htm -cited
2-13-2002.
[2]-Dana Farber Cancer Institute Dietitians-cited 2-13-2002.
[3]-Neupogen [Filgrastim] Pharmacology Information-cited 2-13-2002:
[resource on World Wide Web]: Available from URL: http://www.neupogen.com/patients/patientpi.html
[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 2-13-2002. @: http://www.procrit.com/profonly/nephrology/what_is_procrit/the_science_behind_procrit.html
[6]-Guyton AC, Hall JE. Textbook of medical physiology. 9th ed. Philadelphia,
PA: W. B. Saunders;1996.
[7]-Guyton AC, Hall JE. Human physiology and mechanisms of disease.
6th ed. Philadelphia, PA: W. B. Saunders;1997.
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,
Livermore California, 1998. Misner is also a published author in the
physician peer-reviewed Journal, CLINICAL PRACTICE OF ALTERNATIVE MEDICINE,
and, has contributed to numerous sportscience articles to the world-wide
web and magazines such as VOGUE, HEART & SOUL, RUNNERS WORLD, MOUNTAIN
BIKE ACTION, & MUSCLE MEDIA, respectively. Misner’s most
significant credential meriting consideration of this text is his wife,
Celia, a Breast Cancer Survivor, who during remarkable treatment from
the Rockwood Clinic in Spokane, Washington, defined the model “Heroine” providing
inspiration that requires this information be shared with others.
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.
