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Nutrition


High Energy and Protein Dietary Advice for People with Cancer
By Liz Bradley & Joanna Grey

Liz and Jo are both dieticians working at Addenbrookes Hospital in Cambridge, UK.  Both have had specialised experience working with people suffering from cancer. Liz and Jo are Rama Foundation volunteers.

Liz and Jo give nutritional advice at GPH clinic


Many people with cancer find there are times when they cannot eat as much as usual and they may lose weight.

People that lose weight when they are unwell tend to lose muscle rather than fat and this can make you feel weaker, be more prone to infections and can make it more difficult to cope with any cancer treatments.

Eating a high energy and protein diet will help you to avoid losing weight, helps your body to re-build damaged tissues, fight infection, and cope with the side effects of illness. If you are not eating as well as you would normally, the following tips may help you to eat more. Although you may have previously been restricting the fat or sugar in your diet to manage other medical conditions such as diabetes or high blood pressure, this is less relevant now that you have cancer.

Eat “little and often”

Try to include snacks between meals and before bed. Keeping snacks at easy reach may help you to eat more often. Here are some snack ideas:

  • Biscuits, cakes , gurkipatti (peanut with jagerry) and tilpatti (sesame snap)
  • Bread dunked in sugary milk / tea
  • Fruit (fresh and dried) withkulfi,ice cream or custard
  • Cheese on toast
  • Bhajis, pakoras, spring rolls, samosas, Bombay mix
  • Desserts such as sugary yoghurt,barfi, rasgulla and gulabhjamun, rasmalai , halwa
  • Chips, nuts, peanuts, savoury biscuits, aalootikki

Useful tips:
Try not to get out of the habit of eating. You actually need to eat to stimulate your appetite.
Make the most of the times you feel like eating.
Don’t worry if it isn’t “normal‟ foods at “normal‟ times.
Experiment with different foods. You may find that you like things you don’t usually eat.
Accept offers from friends and relatives to help with cooking and shopping.
Sometimes the smell of food will be appetising while at other times it may put you off. If this happens, try to keep away from the kitchen while food is being prepared, or eat cold foods, which often have less smell.
Avoid drinking with meals as this may fill you up and spoil your appetite.

Fortify your food:
If you are only eating small portions the following tips may help you to get more calories without necessarily having to eat more food. Start by buying full fat foods.

Fortified Milk: Add 2tablespoons of milk powder to 1 cup of full cream milk. This can be used in the usual way in drinks, on cornflakes/dalia, in making mithai.

To savoury foods add oil, ghee, butter, milk powder, coconut milk/cream, nuts and seeds.
To sweet foods add fortified milk, sugar, honey, syrup, ice cream, evaporated milk, nuts and seeds.

For example:
Add coconut cream, butter, extra ghee to curries
Spread ghee or drizzle oil on breads
Add 2 tablespoons of milk powder to a portion of porridge, rice pudding, milk puddings and custard

Ideas for nourishing drinks:

Hot drinks such as:
Hot chocolate
Milky Chai
Milo, Horlicks, Ovaltine other malted milk drinks
Milky coffee
Soups can be made with fortified milk

Cold drinks:
Milkshakes with added ice cream and flavourings
Fruit smoothie - blend fruit with milk, ice cream/yoghurt and honey/malt.
Ice cream soda can be made by adding ice cream to a fizzy drink
Fruit juice and fizzy drinks (avoid low calorie ones)

Nourishing powdered drinks such as Complan,are available. They will provide you with more energy if you make them with full fat milk.

These powders can also be added to foods to increase their nutrient content.


Malnutrition in Cancer
By Mrs Artika Datta
Rama Foundation- Trustee and Treasurer

Artika Datta who has a B.Sc. Honours in Nutrition and an M.Sc. in Dietetics from King’s College, London works at Addenbrookes hospital at Cambridge. Artika specialises in Motor Neuron Disease and has a particular interest in palliative care in which she is actively involved.

Mrs Artika Datta
Mrs Artika Datta

The Statistics

  • Malnutrition affects 40-80% of cancer patients (Ollenschlager et al, 1991; Kern & Norton, 1998)
  • Prevalance of malnutrition depends on the tumour type, location, stage and treatment (Shike, 1996)
  • Risk of malnutrition increases with multi-modality treatments
  • Approx. 80% of patient's in advanced stages have cancer cachexia (or wasting syndrome which is loss of weight, muscle atrophy, fatigue, weakness, and significant loss of appetite) (Goo and Hill, 2003)
  • Up to 85% of patient with gastro-intestinal tumours are malnourished (Stratton et al., 2003)
  • In head and neck cancers the incidence of malnutrition can range from 40 to 58% (Connally, 2004; Grobbelaar et al., 2004)
  • Between 46 and 61% of patients with lung cancer and mesothelioma experience weight loss before diagnosis and treatment (Brown and Radke, 1998)
  • 75-80% of patients with head an neck cancers have significant weight loss (>10% of body weight) during treatment period (Hammerlid et al., 1998; Lopez
    et.al., 1994)
One of Main Factors of Malnutrition Is Poor Appetite
  • It is the most common cause of decreased food intake
  • 1 in 4 people diagnosed with cancer have loss of appetite
  • It can be caused by the cancer itself
  • And / or caused by the treatments. Many people find that during treatment for cancer there are times when they are unable to eat and drink as normal
  • Emotions such as fear or depression can also take away a person's appetite
Consequences of Malnutrition

Malnutrition affects both the quality of life and survival in patients with advanced disease
  • Muscle wasting, weakness and fatigue
  • Impaired immune function, increased infection rate
  • Apathy, depression, self neglect, reduced will to recover
  • Poor quality of life .Failure to complete chemotherapy
  • Reduced respiratory function
  • Delayed wound healing
  • Poorer outcomes
  • Readmission to hospital
  • Immobility and social isolation
  • Higher incidence of psychological and psychiatric disorders such as depression, causing a marked alteration of quality of life and a drastic reduction of performance status (Ottery 1995)
  • Some evidence that weight-losing patients have a reduced global QoL (Dahele & Fearon 2004)
Dietary modifications to overcome reduced appetite
  • Little & often eating pattern
  • High protein / energy meal options
  • Eating what the patient fancies
  • Food fortification
  • Food & fluids separately
  • Nutritional Supplements
  • Use of appetite stimulants which include
    1. Steroids - Can stimulate appetite, however side effects include fluid retention, muscle weakness, osteoporosis & skin fragility
    2. Megestrol Acetate - Shown to have beneficial effects on cancer related anorexia & weight loss
Ideas to Fortify Diet
  • Aiming to use 1 pint (568ml) of full cream milk / day and adding it to soups and porridge (sweet Dalia)
  • Using full cream milk to make dahi
  • Grated khoya or paneer can be added to vegetable curries, soups 
  • Add evaporated milk to dahi and daal
  • Add syrup to ice cream, or sugar and fruit puree to natural yogurt
  • Add ghee or butter to daal and sabji,
Nourishing snacks

3 rusks - 123 Kcal - 3.9 G protein
200ml Whole milk – 132 Kcal - 6.5 G protein
1 Samosa (filled with potato and peas)- 308 Kcal – 4.67 G protein

193g Kheer   -  282 Kcal –  8 G protein
2 Rasgullas – 304 Kcal – 8 G protein
Moong daal Dalia - 268 Kcal - 11 G protein

Oral Nutrition Supplements
  • A simple, non-invasive method of increasing nutrient intake
  • Most oral nutritional supplements are nutritionally complete
  • Majority contain 1-1.5 kcal/ml, but also available as ‘concentrated’ feed (2kcal/ml)
  • Protein content varies from 4 to 10g/100ml
Oral Nutritional Support
  • Oral nutritional supplements (ONS) considered when nutritional intake is insufficient despite nutritional counseling. 
  • ONS used
    -To supplement food intake if the patient is unable to eat enough 
    -To replace food 
  • Available in liquid form, soups, powders, and other consistencies such as puddings

Tips for Combating Common Dietary Problems in Cancer

Patients with advanced stage cancer often suffer from a number of problems which adversely affect their intake and digestion of food. Dietician Artika Datta has outlined some simple remedies to help deal with these distressing symptoms.

Nausea

  • Try dry or salty foods
  • Eat small, frequent meals
  • Sip cool, fizzy drinks
  • Try ginger flavoured food and drink
  • Try cold foods
  • Avoid highly spiced, rich or fatty foods
  • Anti-emetics

Sore Mouth

  • Avoid dry, rough or hard foods
  • Avoid highly spiced, salty or acidic foods
  • Have soft, mashed foods with sauce or gravy
  • Drink plenty of nourishing fluids
  • Cold foods and drinks can be soothing to a sore mouth
  • Try adding crushed ice to drinks and eating ice cream or soft milk jellies.
  • Ensure good oral hygiene
  • Treat any infections

Altered Taste

  • Eat foods that you like the taste of
  • Sharp tasting foods can help
  • Use pickles or chutneys
  • Use different seasonings, experiment with herbs and spices
  • Ensure good oral hygiene

Too Tired to Cook or Eat

  • Be positive about what you do eat, every mouthful counts
  • Remember that cold meals can be as nutritious as cooked meals
  • Convenience foods are a useful standby and can be just as nourishing
  • If you have a freezer, try to prepare food in advance and store it for when you are not feeling so well
  • Accept offers of help with cooking and shopping from friends and family
  • Try to make food and drink as nourishing as possible
  • If you cannot face big meals, try to have smaller ‘ready to eat’ snacks and drinks on a regular basis

Dry Mouth

  • Have frequent sips of drinks
  • Sucking ice cubes or ice lollies may help to keep your mouth moist
  • Keep foods moist with lots of sauces and gravies
  • Some foods such as chocolate and pastry may stick to the roof of your mouth more
  • Boiled sweets may help to keep your mouth fresh
  • Artificial saliva solutions are available from your doctor if these are appropriate for you

Diarrhoea

  • Drink plenty of fluid
  • Eat small, frequent meals made from light foods – dairy produce, white bread, pasta or rice
  • Avoid highly spiced or fatty foods and eat your meals slowly
  • Anti diarrhoea medication

Constipation

  • Have plenty of fibre in your diet
  • Favourite natural remedies are syrup of figs, prunes and prune juice
  • Aim to drink at least 2 litres a day
  • Gentle exercise
  • If the constipation is due to medicines that you are taking (such as painkillers or anti-sickness drugs) you will need to take laxatives

Difficulty in Chewing or Swallowing

  • Soft or puree foods will be easier
  • Adding sauces and gravies to every day foods may be enough to help
  • If you need a puree consistency, blend every day foods using extra milk or creamy sauces to help make smoother consistency
  • Puree different foods separately so that they can be tasted e.g. keep vegetables all separate


Eating Well with a Feeding Tube
by Deep Shikha

Deep Shikha has worked as a dietitian with the Rajiv Gandhi Cancer Institute and Research Centre, Delhi, since 2012. She has a M.Sc in food and nutrition, and a P.G Diploma in Dietetics, food and nutrition.

Dietician Deep Shikha

Cancer patients often tend to have poor nutrition and low body weight. Dietitian Deep Shika discusses how patients can maintain a healthy diet, even with a naso-gastric feeding tube.

Nasogastric tube (NG) feeding, or "Ryles tube feeding", as it is generally known, is not uncommon in head and neck cancer patients. When a malignancy is such that it prevents swallowing of food through the mouth, a feeding tube becomes necessary to maintain nutritional levels in the body. Working as a dietitian in a cancer institute which sees thousands of patients from all over India is a challenge and often involves providing wholesome nutrition to patients who are on NG tube. These patients are facing emotional upheaval and physical discomfort at the same time. While in other hospitals, patients may come with a fever or a fractured bone and are optimistic of their return to good health, in a cancer hospital, when patients come to know of their diagnosis, they frequently break down emotionally and are overcome with the fear of death.

A Ryles tube is not a very convenient thing to have. The liquefied food needs to be given slowly through the tube over a number of hours as, if the feed is given quickly, it can flow into the gullet which is very unpleasant and makes the patient feel sick. Also, the patient's attendant's movement tends to become restricted during the feeding. For this reason, many attendants prefer to give the feed overnight so that they can move about in the day time.

Generally, a light vegetable broth of carrots, beetroot, beans, washed daal and broken wheat is nutritious. The ingredients are boiled and blended, and water and salt are added to taste. Often the mixture has some butter added at the end. A curd feed, thinned with water and a little sugar is also a good option. For diabetics, the same can be given with salt instead of sugar. For those who prefer khichri feed, rice and washed daal with some fresh cottage cheese and a little bit of butter provides a balanced meal with carbohydrates and proteins. Light vegetables, daal, or black chickpea soups are excellent for keeping the body's nutritional levels up.

Fresh vegetables are essential in proper nutrition
Sometimes convincing patients and their carers of good Ryles tube feeding practices and dispelling unfounded beliefs becomes part of the job. I have come across patients' family members who refused to let their patients have turmeric as they thought "yellow-coloured" foods had to be avoided during jaundice. Turmeric is, however, completely harmless and in fact acts as a natural anti-biotic.

As health care professionals, when we step inside the hospital for a day's work, we keep in mind that cancer patients have a very special need of empathy, good care, love and large doses of motivating words. A good, nutritious diet adds to the physical and mental strength of patients.

Nasogastric Tube Feed: Some Recipes

1. Milk Feed

Ingredients:

  • Milk
  • Sugar
  • Bread slices

Directions:

  1. Cut the edges off the bread and crumble the slices;
  2. Mix the crumbs well with sugar and milk;
  3. Sieve all ingredients so that they become a homogeneous whole.

2. Vegetable Broth

Ingredients:

  • Carrot
  • Beetroot
  • Beans
  • Bottle gourd (ghiya)
  • Washed daal
  • Broken wheat (daliya)
  • Butter
  • Salt to taste

Directions:

  1. Dice vegetables and boil them with the washed daal and broken wheat;
  2. Blend the boiled ingredients to a smooth paste consistency;
  3. Add salt to taste and a dash of butter (optional).

3. Curd Feed

Ingredients:

  • Curd
  • Water
  • Sugar to taste
  • Salt to taste instead of sugar for a diabetic patient

Directions:

  1. Add water and some sugar (replace with salt for diabetics) to curd;
  2. Blend all three ingredients.

4. Kedigree (khichdi)

Ingredients:

  • Rice
  • Washed daal
  • Cottage cheese (paneer)
  • Salt
  • Turmeric powder
  • Butter

Directions:

  1. Boil the rice, washed daal, cheese, with salt and turmeric powder;
  2. Blend the ingredients well and boil again;
  3. Add a dash of butter at the end.

5. Custard Feed

Ingredients:

  • Milk
  • Custard powder
  • Sugar

Directions:

  1. Heat the milk and add custard powder and some sugar to it;
  2. Stir till no lumps of custard powder are visible.

6. Mixed Vegetable Soup

Ingredients:

  • Bottle gourd
  • Carrot
  • Cabbage
  • Coriander
  • Salt to taste
  • Pepper to taste

Directions:

  1. Boil all vegetables along with the coriander;
  2. Blend the boiled ingredients by adding some water;
  3. Boil again, adding salt and pepper to taste;
  4. Add a dash of butter (optional)

 

Nutrition and Health
by Renu Gulati

 

(Renu Gulati is a Ganga Prem Hospice Ayurvedic Practitioner)

Renu Gulati

Ayurveda literally translates as ‘knowledge of life’. It originates from the ancient traditions of India and is over 5000 years old. It is an holistic system of health and well-being based on the inter- relationship of mind body and spirit.

Ayurveda provides a comprehensive understanding of nutrition and is of the view that good physical, psychological and emotional health is not possible in the absence of a diet suited to your constitution. In Ayurveda, there is no standard diet for all. To understand your individual nutritional requirements, it is advisable to consult with an Ayurvedic practitioner. However, all can follow the simple guidelines on healthy eating habits given below

Healthy Eating Habits
1. Always respect your food. Begin each meal by giving thanks to it.
2. Choose the foods according to your constitution.
3. Choose seasonal, local foods as much as possible.
4. Eat only when hungry so that you have the digestive capacity to process the food
5. Eat in a settled atmosphere as ambience is emotional diet
6. Avoid drinking with a meal as the digestive juices become diluted. If necessary you can sip on a little warm water. Never drink iced drinks with a meal as these dampen the digestive fire.
7. When eating, eat. That is, don’t read, watch TV or be distracted by too much conversation. Focus on food while eating it
8. Never eat when upset as food eaten at this time becomes toxic
9. Always sit down to eat to help put your attention on your food
10. Chew well, at least 32 times per mouthful. This enables the digestive enzymes in the mouth to do their work properly
11. Eat at a moderate pace to be aware of intake and limits
12. Eat freshly cooked meals to imbibe Prana (vital energy)
13. Reduce raw foods as they are harder to digest
14. Experience all six tastes at a meal (sweet, sour, salty, bitter, pungent and astringent).
15. Leave 1/3 to ¼ of your stomach empty to ease digestion.
16. Sit quietly for a few minutes after your meal to consciously transform food into your being

EAT TO LIVE, DON’T LIVE TO EAT.

Unhealthy Eating Habits
1. Overeating
2. Eating too soon after a full meal
3. Drinking too much water with a meal
4. Drinking very chilled water during a meal, or indeed at any time
5. Eating when constipated
6. Eating at the wrong time of the day, either too early or too late
7. Eating fruit or drinking fruit juice with a meal as this can lead to fermentation in stomach
8. Eating without real hunger
9. Emotional eating
10. Eating incompatible foods (e.g. fish with milk, salt with milk, fruit with meals, milk with bananas, yogurt with milk, melons with everything, eggs with milk)
11. Snacking between meals
12. Consuming honey when cooked or when added to a hot drink/substance. When honey is heated, the molecules become like glue that adheres to mucus membranes and produces toxins.

 

 
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