How to Manage Therapy: Before, During and After

  • Before: I prepare myself in the best possible way

 

  • During: I can manage the side effects

 

  • After: I maintain a proper lifestyle

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Salvatore Artale - Oncology Director

Before the therapy – I prepare myself in the best possible way

WEIGHT LOSS

In many cases, during the therapy, or after a surgery, you may face weight loss and caloric-protein malnutrition.
In both cases it is strongly recommended to try to make changes in the diet right away, so as to prevent those side effects.

To assess whether our weight falls within an acceptable range, it is useful to calculate the body mass index (BMI = body mass in kg divided by the square of the body height in meters: for example, a person whose weight is 65 kg and who is 1.70 m tall has a BMI = 65 / (1.7 x 1.7) = 22.5). The body mass index allows us to assess whether we are underweight (BMI < 18.5), normal-weight (BMI between 18.5 and 24.9), or possibly overweight/obese (BMI > 25).

Weight loss can be due to several factors. A factor predisposing to weight loss may be due to illness and therapy one or more changes in metabolism leading our body to burn more calories than we eat, thus increasing the caloric requirement. In other cases, weight loss is due to the side effects caused by the drug: loss of appetite, difficulty in swallowing caused by inflammation of the oral cavity, nausea, vomiting, diarrhea, nutrients malabsorption.

It is therefore important to periodically check one’s body weight to ensure maintaining a proper weight.

In order to regain the lost weight, or at least to try to avoid caloric-protein malnutrition, it is useful to follow a high-calorie regimen, that is to take in more calories. In many cases, people are recommended to take high-calorie but also nutritionally unbalanced! foods (e.g. processed sauces such as mayonnaise, hamburgers, fatty cheeses, snacks). What we aim to do is to provide advice on how to increase the calorie intake deviating as little as possible from the concept of “healthy eating”. If you have a good appetite, increasing calories and protein will not be so difficult; you will just need to follow some simple directions:

  • Don’t skip meals: have at least 5 meals a day (never forget breakfast)
  • The main meals should always include a source of complex carbohydrates, fats and proteins possibly broken down in the following proportions 60%, 25-30%, and 10-15%.
  • Eat very caloric nuts (walnuts, hazelnuts, almonds, etc.) whose calories are due to the fat content mainly “good fats” and dehydrated fruits (dates, figs, plums, etc.) rich in sugars. They can be eaten as snacks or added to salads or smoothies
  • Eat fatty fish (e.g. salmon, mackerel, herring) at least once a week
  • In seasoning, prefer raw extra virgin olive oil (30-50g per day)
  • Consume at least two servings of fruit, also choosing from among the most caloric ones (avocado, banana, tangerine, grapes); one idea might be to make fruit smoothies with low-fat yogurt, Greek yogurt or partially skimmed milk
  • Use Parmesan cheese as a seasoning or snack
  • Always try to include a protein source (preferably of plant origin, but also animal) in the main meals: legumes, tofu, tempeh, white meats, egg whites, low-fat cheeses

The problem arises when, as often happens, we lack appetite. If that is our case, it may be useful to resort to oral nutritional supplements in liquid form or of other kinds. It is important to consult your doctor who will be able to direct you to the most appropriate solution for you.

Oral nutritional supplements in liquid form can be purchased at pharmacies. There are specific products for cancer patients that can promote the maintenance of weight and muscle mass. It is  preferable to drink them slowly, in small sips, in order to avoid the sensation of gastric and abdominal swelling.

Supplements are a good solution if the patient has special nutritional deficiencies. Their function is to increase the caloric intake or providing the proteins and/or vitamins that the patient fails to assimilate by means of food. It is possible to find non-flavored powder nutritional supplements on the market, which can provide either only calories or only proteins. Being totally tasteless, they lend themselves well to be added to drinks, soups, sauces and more.

The indications provided are general, then it is good to rely on a specialist who will be able to recommend a specific nutritional path according to the needs of each patient.

During the therapy – I can manage the side effects

Some side effects may occur during the therapy. Below are the most common. For each side effect we will provide some advice on how to best deal with them, especially as regards food and eating.
It is important to note that the following recommendations are not meant to replace the pharmacological therapies prescribed by your oncologist, but are to be considered as an integration of the medical supportive therapy you could have been prescribed.

NAUSEA and VOMITING

Nausea and vomiting are the most common symptoms in those undergoing chemotherapy treatments. If not properly managed, they can cause weight loss, dehydration, metabolic problems and electrolyte imbalance.
We can distinguish three types of nausea: the acute nausea (which arises during the first 24 hours after the therapy), the delayed nausea (which arises after the 24 hours following the administration of the therapy), and the anticipatory (which arises before the administration of the therapy and is typical of those who have already undergone these treatments).

To fight nausea and vomiting it may be helpful to follow some of these tips:

  • Eat small and frequent meals: split meals into 5-6 snacks so that the stomach never stays empty; slowly chew the food; prefer food at room temperature
  • It would be better if someone else prepared your meals, or, alternatively, you could prepare some meals in advance and freeze them, so that you just need to heat them on the days when you do not feel well
  • Nausea is often caused by the smells emanating from foods, so avoid foods with strong smell such as garlic, onions, peppers, horseradish, broccoli, savoy cabbage, etc.
  • Prefer salty and dry foods with a high content of carbohydrates, low in fat and fiber content, and easy to digest: pasta, bread, breadsticks, crackers or, even better, puffed rice cakes.
  • It may be useful to chew a brown rice cake, better if salted, or you can add to it a tip of teaspoon of miso (fermented seasoning rich in proteins and vital enzymes, consisting of yellow soybean, salt, rice or barley)
  • Another thing that can help you to prevent and combat nausea is ginger: you can sip a ginger herbal tea, eat candied ginger, or add a bit of fresh chopped root or some dried ginger to your food
  • To avoid dehydration, drink a lot during the day and not only during meals, taking small sips. It is  recommended to drink water, but also tea and herbal teas (mint tea could be a good aid against nausea) or fruit juices.

APPLE JUICE DRINK AND AGAR-AGAR

INGREDIENTS:
    • 1 cup unsweetened apple juice
    • 1 teaspoon agar-agar in flakes
PREPARATION:

Add the cup of apple juice to the agar agar flakes in a saucepan and boil for a couple of minutes, until the algae is completely dissolved. Turn off the heat and let it cool down.
Drink it light warm or warm, before it becomes a jelly.
If you have purchased the agar -agar powder instead of flakes, it I sufficient a small amount, the tip of a teaspoon.

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CONSTIPATION

Constipation is defined as a decrease in the normal frequency of stool evacuation or difficulty in passing stool. It can be caused by chemotherapeutics, painkillers, but also as a result of poor physical activity or poor nutrition (insufficient fiber and liquid content).

If this issue arises, we recommend that you follow these guidelines:

  • Drink a lot preferably on an empty stomach of water, but you can also drink tea (preferably green tea), juices (e.g. plum juice), or a drink that you can prepare with apple and agar agar (a thickening seaweed, see recipe)
  • Follow a diet rich in fiber (25-35 g of fiber per day), thus preferring whole foods (e.g. wholemeal sourdough bread or bread with linseeds, whole rice or other whole grains), fruits and vegetables (raw and cooked, with peel), legumes, dried fruits and oily seeds. All these foods, especially whole grains, must be chewed thoroughly to encourage digestion. However, it is very important to increase the fiber intake gradually to avoid the formation of swelling, cramps and intestinal gases. To combat constipation, it may be useful to have a drink made with carrot, daikon and tamari (see recipe)
  • Strive to have meals and snacks every day at the same time
  • Light daily physical activity is recommended (e.g. taking a walk, cycling or doing yoga)

In case of constipation it is better to avoid eating the following foods: high-fat dairy products, low-fiber foods, white rice, banana, cooked carrots, potatoes and chocolate.
What follows now is two recipes we propose in case of constipation:

DRINK OF CARROTS, DAIKON AND TAMARI

INGREDIENTS:
    • 1 Grated carrot spoon
    • 1 teaspoon tamari (fermented soy sauce)
    • 1 Grated daikon spoon (alternatively use turnip)
    • 1 Pinch of salt
PREPARATION:

Add the daikon and carrot grated in a saucepan, pour two cups of water, bring to a boil and simmer for 5 minutes together with a little salt and tamari.
You can add a pinch of grated ginger to taste. It is an excellent diuretic drink, able to help the intestines.

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DIARRHEA

Diarrhea is the presence of two or more discharges of very soft or liquid stools per day. It is a very frequent side effect of chemotherapy during the treatment of prostate, cervix, bowel, rectum and pancreas cancers.

Diarrhea makes the body unable to sufficiently absorb nutrients and water. Unless it is treated (through diet modification and drug therapy), diarrhea can lead to serious consequences: stomach cramps, weakness, weight loss, dehydration, poor appetite and electrolyte alterations.

If diarrhea is present, it is useful to make changes in the diet by following these directions:

  • Drink a lot in order to replenish the lost liquids (the same indications apply in case of constipation)
  • Have little snacks during the day instead of hearty meals, so that your body can digest food
  • Avoid eating foods that are too hot or too cold
  • Limit fiber consumption (reduce fruits and vegetables and avoid whole grains and legumes)
  • Eat simple, boiled or steamed, low-fat foods: plain, boiled rice and pasta, semolina soup, rice cream, crackers, breadsticks, white bread, white low-fat meat, low-fat fish
  • Given their astringent properties, prefer the following foods: banana, peeled apple, boiled potato, boiled carrot, white rice and lemon.

In case of diarrhea, you should avoid: dairy products, fried, fatty and spicy foods, sweets and foods with a high content of sugar, raw fruits and vegetables, legumes, all kinds of seeds, coffee and alcohol.

ORAL CAVITY INFLAMMATION

Some chemotherapeutics can cause inflammation of the mouth mucosae, with the formation of aphthae, ulcers, bacterial and fungal infections.

To resolve these inflammations your doctor will advise you some appropriate medications, yet it is important to maintain proper oral hygiene and to take some precautions in the choice of foods.

As for oral hygiene, it is recommended to use soft bristle brushes and to rinse your mouth with water and baking soda (avoid the use of alcoholic mouthwashes).

Another possibility is to rinse your mouth with sunflower oil on an empty stomach: this practice consists of taking a tablespoon of sunflower oil and making rinses, as usual. The oil must be passed between one tooth and another and between the tongue and teeth. If the cleaning is performed correctly, eventually the sunflower oil will turn whiteish. At that point you can expel the oil, and if necessary rinse your mouth one last time with water. This process expels toxins, microbes and bacteria present in the oral cavity.

As regards food, here are some useful tips:

  • Prefer soft, very moist and low-salted foods since they are easier to chew or swallow and cause less irritation. If severe mucositis arises, it is recommended to consume whole grains in the form of a cream
  • Be careful about the temperature of foods: avoid hot foods since they can irritate the mouth or throat; it is better to eat cold, room-temperature or warm foods
  • Prepare (peeled) fruit smoothies and mix them with yogurt or vegetable milks.
  • Avoid very sour, acidic or salty foods and drinks because they cause irritation (citrus fruits, fruits with small seeds, pickled foods)
  • Avoid spices and irritating seasonings (pepper, chili, horseradish, curry, mustard, etc.).
  • Avoid dry foods (crackers, chips, bread) since they can scratch your mouth
  • Avoid drinking alcohol

DRY MOUTH

Dryness in the mouth, also called “xerostomia”, is due to scarce saliva production. It is a problem not to be underestimated because it causes several problems (difficulty in chewing, swallowing, in the perception of taste).
To address this problem, it may be useful to follow some simple dietary tips:

  • Eat mainly soft foods (cream cereals, yogurt, ice cream, vegetables and fruit smoothies) and fresh fruits in small chunks (especially those rich in water, for example watermelon, grapes, oranges)
  • Drink a lot throughout the day, even just small sips, in order to keep your mouth moist. It is recommended to drink mainly water, but you can also drink fruit juices with no added sugars
  • Chew sugar-free gums or citrus candies to stimulate salivation
  • Avoid eating dry foods (such as bread, crackers, breadsticks, etc.), salty foods, spicy foods, raw and sweet vegetables.

After the therapy – I maintain a proper lifestyle

Once cancer medical care is done, it is essential to maintain a proper lifestyle.

By “correct lifestyle” we mean following a healthy diet and staying physically active. In the “famous 10  golden rules” a concept is remarked, namely that following the rules for prevention is important both for healthy people and for people who have already dealt with the disease. In fact, a healthy lifestyle reduces both the risk of cancer and that of possible recurrences.

Following a proper diet is the first step to start off the new path in the best possible way. Choosing the right foods will allow your body to regain the lost strength, help you during the healing process and make you feel better. This will result in a better quality of life and in an increased longevity.

To be able to follow the recommendations at one’s best and therefore to follow a correct diet one should pay special attention to the choice of foods and to how they are prepared. The ideal thing would be to start from raw materials and cook your meal by yourself in order to control the quality and quantity of nutrients you will eat.
For example, we can limit the amount of saturated-trans fatty acids (those in margarines and in foods fried in hydrogenated oils) and sugars we eat, or increase the intake of fiber, plant-origin proteins, minerals and vitamins.

Obviously, that is not always possible, so an alternative could be to freeze the prepared dishes, so that they are available when we are in the hour of need. If you do not really like cooking, you will have to rely on prepackaged foods and therefore it will be important to pay close attention to their composition (by reading the nutritional label).

It is important to remember that each patient has his own history and a personal life experience, which are different from those of anybody else. This means that these recommendations generally apply to everyone, but then each person helped by his doctor and a nutritionist will build a path “tailored” according to his needs.