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Jennifer Wolfshohl RD, CSO, LDRegional Patient & Family Conference

7 September 2013Boston, MA

Nutrition &

Bone Marrow Failure

Objectives

� Optimize blood production & maintain health

� Identify the building blocks of a healthy diet

� Nutrition during treatment

� Supplements

� Reliable resources

Where to begin?

American Institute for Cancer Research

� Be as lean as possible without becoming underweight.

� Be physically active for at least 30 minutes every day.

� Avoid sugary drinks. Limit consumption of energy-dense foods.

� Eat more of a variety of vegetables, fruits, whole grains and legumes such as beans.

� Limit consumption of red meats (beef, pork and lamb) and avoid processed meats.

� If consumed at all, limit alcoholic drinks to 2 for men and 1 for women a day.

� Limit consumption of salty foods and foods processed with salt (sodium).

� Don't use supplements to protect against cancer.

� And always remember . . . Do not use tobacco in any form

Maintain a Healthy Weight

� Waist circumference� Men < 40 inches

� Women < 35 inches

� Smaller, more frequent meals and snacks

� Focus on fiber & protein� Mindful eating

� Increase satiety

� Stabilize blood sugar � 25-30 grams fiber per day

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Nutrient Dense Food First� Minimally processed plant based

� 8-10 servings of fruits and vegetables every day� Green leafy vegetables

� kale, chard, mustard/collard greens� blueberries , blackberries

� Make your grains “whole”� 100% whole wheat/grain, barley, amaranth, rye, quinoa

� Beans & Legumes

� Excellent source of iron, protein, fiber and folate� Hummus – try adding avocado, lima beans, or edamame

� Healthy Fats � Nuts, seeds, avocado, olives/olive oil, canola oil, flax seed, fish

� Calcium rich foods� Lean protein

Nutrition Through Treatment

Nutrients for Bone & Bone Marrow� Protein

� Building blocks of red & white blood cells� Maintains strength, rebuilds tissue� Key nutrient for maintaining immune function

� Vitamins and minerals� Iron, Vitamins C and B for making blood cells� Antioxidants to help maintain integrity of cells� Calcium + Vitamin D for bone health

� Calories� Provide energy for all bodily functions� Keeps body from breaking down protein� Increased need when body is stressed

� Fluids � Required for blood volume� Electrolyte balance

Proper Nutrition Proper Nutrition Proper Nutrition Proper Nutrition Poor Nutrition Poor Nutrition Poor Nutrition Poor Nutrition

� Help the body to maintain healthy cells and support repair

� Maintain a sense of well-being

� Reduce risk of illness

� Help to maximize the impact of treatment

� Does not cause bone marrow failure

� Can reduce quality of life and functional status

� Increase risk for other illness

� Reduce our body’s natural defenses

� Limit body’s ability to repair itself

Maintain Your Weight� Weight loss during treatment can increase fatigue

� Adequate nutrition are essential for:� Rebuilding and maintaining blood cells

� Immune function

� Preserving lean muscle mass

� Optimizing energy

� Hydration

Poor Appetite� 6-8 small meals instead of 3 large meals

� Eat when you feel the hungriest

� Use smaller plates

� Keep favorite foods in the home

� Set a timer to go off every 1 – 1 ½ hrs

� Create an eating routine

� Eat protein first

� Keep meal times relaxing

� Carry snacks with you� Fill zip lock bags with high calorie, high snack ideas.

� Prepare in bulk when you feel the best

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Nutrition Supplements� Ensure/Boost

� Ensure Clear

� Boost Very High Calorie

� Scandi Shake

� Carnation Instant Breakfast

� Orgain

� Mix1

� Benecalorie

� Unjury

Taste Change (Xerostomia)� ¾ tsp baking soda, 1 tsp salt and 1 quart water swish and spit� Biotene tooth paste or mouth wash� Cold or moist may be best� Liquids, gravies, marinades, sauces, condiments� Citrus vs cooling fruit� Zinc lozenges, gum, mints� Try plastic-ware� Have a caregiver prepare food in a

separate room

� +fat, salt, sour, sweet

Nausea/Vomiting� Simple carbohydrates

� breads, rice, pasta, pretzels, crackers, cooked sushi

� Try eggs� Complete protein= contain all essential amino acids which are

the building blocks for protein

� Moist and bland, easy to tolerate

� Try adding to casseroles, pasta, or making a breakfast wrap or omelet

� Hard boiled or deviled egg

� Ginger ale, ginger tea, ginger candies/chews/gums

Constipation� Do not exceed 72 hrs with out a bowel movement

� Increase insoluble fiber� Bran, prunes, plum juice, potato with skin, popcorn

� Fluids� Eat a high fiber breakfast with a hot drink

� Bran muffin made with prune juice in place of water

� Regular activity

� If gas is a problem� Omit carbonated drinks, gums, straws, cruciferous vegetables,

cucumbers, dried beans, peas, and onions

� Bowel regimen� Senokot, Colace, Milk of Magnesia, Miralax

Diarrhea� Limit fat, sugar, artificial sweeteners, caffeine

� > 4 loose BM/day� Drink 8 oz of clear liquid, isotonic solution following each BM

� Jell-o, G2, Popsicles, watermelon

� Soluble fiber to add bulk to stool� Banana, potato, rice, apple sauce, smooth peanut butter� Benefiber, Metamucil

� Greek yogurt� Double protein, contains probiotics� Cool/easy to swallow

� Base for fruit smoothies or topping for a whole grain waffle� Dip a banana in yogurt, roll in nuts, freeze to make a Popsicle

� Glutamine?

Hydration

� Drink 8 -12 cups caffeine-free non alcoholic liquids/day

� Take a water bottle when leaving home.

� Drink even if not thirsty

� Stagger liquids with meals to increase overall consumption of both liquids and solids

� If urine is darker than a pale straw color or has a strong odor, you likely need to drink more water

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Fight Fatigue� Exercise each day� Prepare meals ahead of time and freeze them� Use convenience foods that are ready to eat� Let friends and relatives help � Fluids– dehydration can worsen fatigue� Protein� Increase rest

� Getting more sleep at night� Naps � Minimize caffeine

� Avoid skipping meals. � Try to eat even when you are tired. � Food is fuel --- eat or drink something every 2-3 hours.� Make eating a priority!

Food Safety� Goal = Use the common sense approach to lower risk of

infection, and encourage diet flexibility to eat as well as possible.

� Wash hands

� Autologous- 3 months

� Allogenic- follow diet until off all immunosuppressive therapy � (cyclosporine, prednisone, FK-506 (Tacrolimus) or MMF

(CellCept)

Food Safety� Keep hot foods hot, & cold foods cold

� Danger zone 40 – 140 degrees F

� Avoid raw meat and fish� Avoid aged cheese� Avoid raw or unpasteurized drinks, honey, unroasted raw

nuts� Avoid homemade fermented drinks, homemade wine, cider,

root beer, miso, and vinegar� Avoid buffets, salad bars, and crowded restaurants� Wash fruits and vegetables well� Recalls and Alerts

Supplements

Reasons for Caution� Not FDA regulated� Blood thinning or thickening properties

� Vitamin K (K2)

� Altered metabolism� Grapefruit, Green tea & Velcade

� Antioxidants and chemo/radiation� Hormonal properties

� Soy Isoflavone & Estrogen

� High dose of herb/vitamin toxicity� Fact check:

� Memorial Sloan Kettering Herbal Database� Quack Watch

Color Phytochemical Fruit/Vegetables

Red Lycopene Tomatoes and tomato products, pink grapefruit, watermelon

Red/purple Anthocyanins, polyphenols

Berries, grapes, red wine, prunes

Orange α-, β-carotene Carrots, mangoes, pumpkin

Orange/yellow β-cryptoxanthin, flavonoids

Cantaloupe, peaches, oranges, papaya, nectarines

Yellow/green Lutein, zeaxanthin Spinach, avocado, honeydew, collard and turnip greens

Green Sulforaphanes, indoles Cabbage, broccoli, Brussels sprouts, cauliflower

White/green Allyl sulphides Leeks, onion, garlic, chives

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www.eatright.org

Resources� American Institute for Cancer Research

� www.aicr.org

� Academy of Nutrition and Dietetics� www.eatright.org

� www.foodsafety.gov

� Memorial Sloan Kettering Herbal Database� www.mskcc.org/mskcc/html/11570.cfm

� Quack Watch� www.quackwatch.com

Questions?