What should I eat during chemotherapy?

By Michael McCulloch, LAc, MPH, PhD
Article Current as of December 20, 2020

Essential issues to address, and a critique of available books

“In many ways, reforming American agriculture depends on rebuilding a culture of routine home cooking. I’ve come to think that cooking is a ¹political act, with large consequences not only for ourselves but for the environment and agriculture as well... Cooking is probably the most important thing you can do to improve your diet. What matters most is not any particular nutrient, or even any particular food: it’s the act of cooking itself. People who cook eat a healthier diet without giving it a thought.”[1]

-Michael Pollan, author of The Omnivore's Dilemma and In Defense of Food

The goal of this article is to present tools you can use – and the evidence supporting them – to protect body weight and strength during cancer chemotherapy. The intentions with this goal are improving long-term treatment outcomes, reducing toxicity, helping complete the planned course of treatment, and improving overall quality of life.

Immune health, and the starts in the gut. The quality and composition of meals shape the balance and function of the biome, the microbes in your gut. This in turn affects the innate and adaptive immune functions of the immune system,[2] and the integrity of the body’s muscle mass.[3] Although cancer chemotherapy can substantially impact nutritional quality of life, taking action with appealing and healthful foods early in the course of treatment is an important way to minimize that impact. And, by combining foods with exercise – addressed in another upcoming article – you can protect and maintain your body weight and functional strength,[4] which will improve long-term treatment success.[5]

In this article, we address questions frequently seen in clinical practice, and include evidence from recent research:

• How can chemotherapy affect nutritional health?
• How to know if you’re developing – or at risk for – malnutrition during cancer chemotherapy? And, what tools can you use in tracking the results of your action plan?
• What evidence-based cancer nutrition guidelines are available to you and your oncologists?
• What questions are important to ask of your oncology team?
• What observations of your health are important to report to your oncology team?
• What books are available to help learn what to eat during chemotherapy, and how to assess them for taste appeal and evidence-based nutrition standards?

Questions like these are essential, and are not always adequately addressed during the very busy workflow of cancer treatment, and the distress of having a new diagnosis. This can lead to cancer malnutrition being overlooked in its early – and more treatable – stages.[6]

How does chemotherapy affect nutritional health?
When food intake is reduced due to nausea, vomiting, stomach pain, diarrhea and/or constipation,[7] weight loss can quickly develop, leading to loss of muscle strength.[8] Early intervention to prevent weight loss during cancer chemotherapy is essential, as a drop in weight by over 5% total body weight can adversely affect survival.[8] This occurs more often in men than women, and is also more likely if protein intake is reduced, and if there are significant medical problems in addition to the cancer.[9] Depending on the type of cancer diagnosed, weight loss can be seen in anywhere between 40% and 92% of cases. But, using nutrition and exercise to prevent or reverse muscle loss leads to improved survival[5] and improved overall quality of life.[10]

How to know if you’re developing – or at risk for – malnutrition during cancer chemotherapy? And, what tools can you use in tracking the results of your action plan?
Given the crucial importance of protecting body weight during cancer chemotherapy, accurate ways to measure and track weight are essential. Muscle loss can be already present, even if a patient’s nutritional status is stable, or they are overweight.[11] And, many chemotherapy drugs have higher toxicity when malnutrition and muscle loss have occurred: 5FU, Irinotecan, oxaliplatin, FOLFOX, cisplatin, capecitabine, epirubicin, taxol, sorafenib, safeni, vandetanib, pemetrexed, gemcitabine, vinorelbine, ribuximab, cyclophosphamide, doxorubicin, vincristine, and R-CHOP.[11]

Tools you can measure yourself (listed in order from lowest to highest accuracy):

• Body Mass Index (BMI): This long-used measure is reasonably good for general health, but has only a 29% sensitivity (ability to detect) malnutrition during cancer care, when compared with PG-SGA, described below.

• The simple question: “Have you had unintentional weight loss in the last 3-6 months?” This question is often used in oncology centers, only has 56% sensitivity in detecting malnutrition, meaning that over half of the time it fails to detect malnutrition that has already begun.

• PG-SGA: The gold standard against which other tools to identify malnutrition are compared, PG-SGA, is accurate and only slightly more complex to use. There is also a newly available iOS app called Pt-Global.

• The Malnutrition Universal Screening Tool (MUST): this new test has perfect agreement with PG-SGA (Cohen’s Kappa=0.79), is more straightforward to use,[6] and has been validated for use both in oncology, and in most other health concerns.[12] Click here for an online version.

Tools your oncology team can provide:

• If you have had a CT-scan at the level of the third lumbar vertebrae: this targeted scan allows an accurate and specific way of examining muscle mass.[11]

What evidence-based cancer nutrition guidelines are available to you and your oncologists?
Medical practice guidelines for care are intended to harmonize clinical decision-making, thereby ideally helping improve outcomes. These typically come in two types: those that are evidence-based (developed using published research) vs. consensus-based (developed by experts based on their experience and approach to medical care).[13]

How well do patient exercise/nutritional guidelines work?
Some guidelines are tested to see if they make a difference, making them clearly evidence- based. One example is the American Cancer Society’s “Nutrition and Physical Activity Guidelines for Cancer Survivors”. In a large trial, 992 people diagnosed with Stage III Colon cancer were recruited after surgery, and provided with guidance on how to use exercise and diet to maintain weight during chemotherapy. They were also given questionnaires mid-way during chemotherapy, and 6 months after completion. This 6-point scale assigned 2 points each to body weight, exercise and diet.

• Body weight: to get a score of 2, maintain BMI between 18.5 to 25;

• Exercise: to get a score of 2, each week exercise at least 2 1⁄2 hours, and strength training twice weekly. For example, an hour of fast walking, 30 minutes of light strength training, and 1 hour of jogging; and,

• Diet: to get a score of 2, eat 5 or more fruit/veg servings/wk, and eat only whole grains[5]

Those patients who maintained a score of 5-6 on the ACS scale, were 1/3 less likely to have recurrence after 7 years, and more than twice as likely to still be alive after 7 years.

What questions are important to ask of your oncology team when preparing for – or already receiving – chemotherapy?
"Do you have a team-based nutritional intervention program?"

Team-based nutritional interventions can make a difference in helping maintain body weight and quality of life. Two recent studies make this point clearly:

• Detecting muscle and weight loss: A Cancer Nutrition Program set up at a French university cancer center screened 3078 people being treated for cancer, and discovered that 70% (that’s 2 of every 3) had cachexia, a problematic type of malnutrition and muscle weight loss frequently occurring in people with cancer.[14]

• Preventing weight loss with a team-based intervention: In a study of 110 colorectal cancer patients receiving chemotherapy were randomly divided into two groups of 55 each. In the control group, a normal diet was provided. In the intervention group, individualized recipes were designed by a team of nurses, doctors, dietician, family caregivers, and the patients themselves. After the intervention, although there was no difference in body weight between the two groups,[15] there were improved levels in the blood of albumin, a protein which can predict cancer survival.[16] This team-based approach, therefore, provided important immune system changes which can help improve a person’s longevity.

Books helpful for learn what to eat during chemotherapy:

Tools used in assessing nutritional health:

"Malnutrition Universal Screening Tool" from BAPEN (PDF)

References:

1. Cooking: FAQ & Useful Links: https://michaelpollan.com/resources/cooking/

2. Kau AL, Ahern PP, Griffin NW, Goodman AL, Gordon JI: Human nutrition, the gutmicrobiome and the immune system. Nature 2011, 474(7351):327-336.

3. Mareschal J, Achamrah N, Norman K, Genton L: Clinical Value of Muscle Mass Assessment in Clinical Conditions Associated with Malnutrition. J Clin Med 2019, 8(7).

4. Naito T, Okayama T, Aoyama T, Ohashi T, Masuda Y, Kimura M, Shiozaki H, Murakami H, Kenmotsu H, Taira T et al: Skeletal muscle depletion during chemotherapy has a large impact on physical function in elderly Japanese patients with advanced non-small-cell lung cancer. BMC cancer 2017,17(1):571.

5. Van Blarigan EL, Fuchs CS, Niedzwiecki D, Zhang S, Saltz LB, Mayer RJ, Mowat RB, Whittom R, Hantel A, Benson A et al: Association of Survival With Adherence to the American Cancer Society Nutrition and Physical Activity Guidelines for Cancer Survivors After Colon Cancer Diagnosis: The CALGB 89803/Alliance Trial. JAMA Oncol 2018, 4(6):783-790.

6. Hettiarachchi J, Madubhashini P, Miller M: Agreement between the Malnutrition Universal Screening Tool and the Patient-Generated Subjective Global Assessment for Cancer Outpatients Receiving Chemotherapy: A Cross-Sectional Study. Nutrition and cancer 2018, 70(8):1275-1282.

7. Caillet P, Liuu E, Raynaud Simon A, Bonnefoy M, Guerin O, Berrut G, Lesourd B, Jeandel C, Ferry M, Rolland Y et al: Association between cachexia, chemotherapy and outcomes in older cancer patients: A systematic review. Clin Nutr 2017, 36(6):1473-1482.

8. Buskermolen S, Langius JA, Kruizenga HM, Ligthart-Melis GC, Heymans MW, Verheul HM: Weight loss of 5% or more predicts loss of fat-free mass during palliative chemotherapy in patients with advanced cancer: a pilot study. Nutrition and cancer 2012, 64(6):826-832.

9. Stobaus N, Muller MJ, Kupferling S, Schulzke JD, Norman K: Low Recent Protein Intake Predicts Cancer-Related Fatigue and Increased Mortality in Patients with Advanced Tumor Disease Undergoing Chemotherapy. Nutrition and cancer 2015, 67(5):818-824.

10. Mijwel S, Backman M, Bolam KA, Olofsson E, Norrbom J, Bergh J, Sundberg CJ, Wengstrom Y, Rundqvist H: Highly favorable physiological responses to concurrent resistance and high-intensity interval training during chemotherapy: the OptiTrain breast cancer trial. Breast Cancer Res Treat 2018, 169(1):93-103.

11. Bozzetti F: Forcing the vicious circle: sarcopenia increases toxicity, decreases response to chemotherapy and worsens with chemotherapy. Ann Oncol 2017, 28(9):2107-2118.

12. Comparing Must and the NRI Tools in the Identification of Malnutrition in Heart Failure Patients DNP Projects. 36. [http://uknowledge.uky.edu/dnp_etds/36]

13. Djulbegovic B, Guyatt G: Evidence vs Consensus in Clinical Practice Guidelines. JAMA 2019.

14. Senesse P, Isambert A, Janiszewski C, Fiore S, Flori N, Poujol S, Arroyo E, Courraud J, Guillaumon V, Mathieu-Daude H et al: Management of Cancer Cachexia and Guidelines Implementation in a Comprehensive Cancer Center: A Physician- Led Cancer Nutrition Program Adapted to the Practices of a Country. J Pain Symptom Manage 2017, 54(3):387-393 e383.

15. Lin JX, Chen XW, Chen ZH, Huang XY, Yang JJ, Xing YF, Yin LH, Li X, Wu XY: A multidisciplinary team approach for nutritional interventions conducted by specialist nurses in patients with advanced colorectal cancer undergoing chemotherapy: A clinical trial. Medicine (Baltimore) 2017, 96(26):e7373.

16. Gupta D, Lis CG: Pretreatment serum albumin as a predictor of cancer survival: a systematic review of the epidemiological literature. Nutr J 2010, 9:69.