Cancer
Manual of Clinical Nutrition Management III- 14 Copyright © 2013 Compass Group, Inc.
Table III- 5 : Suggested Nutrition Interventions (1,2)
Problem (Signs and Symptoms) Nutrition Intervention
Weight loss (secondary to increased basal
metabolic rate, catabolism, decreased food
intake, decreased absorption)
Anorexia-cachexia syndrome (9)
Provide high-energy, nutrient-dense foods.
Use above strategies to promote food intake.
Consider use of pharmacotherapy (eg, progestational agents,
cannabinoids, anabolic agents, prokinetic agents,
antiserotonergic agents, branched-chain amino acids,
melatonin) with anorexia-cachexia syndrome (2).
Note: Energy expenditure may be increased or decreased;
diseases of long duration are associated with
hypermetabolism.
Constipation Increase fiber and fluid intake; limit gas-forming foods.
Light exercise is advised, if tolerated.
Evaluate medications as underlying cause (eg, narcotics).
Heartburn See Gastroesophageal Reflux Disease later in this section.
Bowel obstruction: Patients who have had radiation or surgery to the pelvic area are at risk for bowel
obstruction. Symptoms of bowel obstruction include cramping abdominal pain, diarrhea, and constipation.
Patients who have a partial bowel obstruction may have thin, pencil-like stools or sloughing of necrotic tissue,
which may be mistaken for diarrhea. Patients should not take over-the-counter medications without their
physicians’ approval (2). Patients should consume a low-fiber diet and reduce their intake of bowel-
stimulating foods, such as caffeine and sorbitol (2). Symptoms of complete bowel obstruction include
cramping that is often accompanied by nausea and vomiting. Diarrhea may precede the complete cessation of
bowel movements. The physician should be contacted immediately.
Hematopoietic Cell Transplant: Patients with hematologic malignancies undergoing allogeneic
Hematopoietic Cell Transplant (HCT) have shown to have higher energy and protein needs depending on the
phase of the HCT and if complications arise such as graft-versus-host disease (GVHD). Limited evidence
indicates that the estimated energy requirements are 30 to 35 kcal per kg per day during the first month
post-transplant and may be higher during acute GVHD and/or for patients receiving > 75% of their total daily
energy intake by parenteral nutrition (Grade II) (1). Protein needs are also higher than the RDA for these
patients. Limited evidence suggests that more than 2.2 g protein per kg may be needed to maintain nitrogen
balance (Grade II) (1). Further research is needed to define protein requirements in this population.
In the past, patients undergoing HCT or chemotherapy were often prescribed a neutropenic diet which was
based on the premise of limiting foods with high bacteria content (2). Neutropenia, a potentially serious side
effect of both HCT and chemotherapy, and major risk for infections can be life threatening in oncology
patients. It has been suggested that low bacterial foods and beverages can prevent the occurrence of
infections and infection-related deaths in cancer patients receiving chemotherapy or HCT. The evidence
supporting this practice is lacking and the actual efficacy of the neutropenic diet remains unknown (2, 10). In
one study it was shown that a higher rate of infections was observed in the HCT group of patients who
received the neutropenic diet compared to HCT patients receiving a regular diet (10). In addition, there is a
wide variability in defining the foods allowed on the diet and inconsistency in applying the diet among
institutions (2,10,11). Considering the evidence, the neutropenic diet has been removed from the Morrison
Manual of Clinical Nutrition. The evidence now suggests dietitians should advocate and educate patients
undergoing HCT or chemotherapy on standard food safety guidelines to reduce risk and exposure to foods,
beverages, and food preparation methods that could place them at increased risk for infection and food-borne
illness. The dietitian should advocate the selection of low-microbial foods and beverages while encouraging
proper washing and handling of fresh fruits and vegetables (2). High-microbial foods such as those
unpasteurized or raw (uncooked or undercooked foods) should be avoided until immunity is restored or
treatment is complete (12). If graft-versus-host disease (GVHD) symptoms are present it is prudent to avoid
lactose, high amounts of fat (fried foods, rich sauces, and rich desserts), and high amounts of fiber (including
legumes, nuts, and whole grain cereals with > 3 grams fiber/serving) (12).
*The Academy of Nutrition and Dietetics has assigned grades, ranging from Grade I (good/strong) to Grade V (insufficient evidence), to
evidence and conclusion statements. The grading system is described in Section III: Clinical Nutrition Management A Reference Guide,
page III-1.