The format is wrong on the papers from New Orleans, shall redo ASAP. Susan, May 10, 2005

MRS. LEIGH ANNE BURNS, Instructor of Clinical Medicine, Section of Nutrition:

The Role of Diet and Nutrition in Carcinoid Patients


      I want to thank you-all so much for having me speak today.  This is


exciting to speak to so many people.  I have really enjoyed taking care of the


patients that I have seeing of Dr. Anthony's over the last two years with


carcinoid cancer.                          


      Today we're going to concentrate on involuntary weight loss that is a big


complication of the patients that I see in our practice and in many of the folks


who are here in the room.  When we get to those questions if we have questions


on general nutrition, I'll be glad to take those then.


      Using a multidisciplinary approach to reducing involuntary weight loss has


become a true asset of practice for us at LSU.  We have banded together as a


team of nurses, physicians and dieticians to stop involuntary weight loss as


quickly as we can in patients that we work with and maintain the quality of life


of those patients while they're going through treatment. 


      Involuntary weight loss is any unintentional weight loss that you might


have from disease.  Carcinoid may affect many of the organs that we need to be


able to metabolize and absorb calories and proteins.  When these are injured,


involuntary weight loss occurs.  So what we do when we go through our decision-


making process is first decide who's at risk for involuntary weight loss.  What


are our meaningful in-points? 


      Where are we trying to get?  When should we intervene?  Why do we need a


three-phased approach that we've taken in the past?  Because as many of you may


know weight loss in oncology has been seen in the past and is not unusual nor


do many people approach trying to stop it to the degree that is needed.


      How important is it to stop it?  Can we reverse it?  Is it important to


add functional weight in the muscle mass so that we can adequately increase


the strength and your performance status near the time of your treatment, in


treatment, and after it? 

      Studies done in weight loss date back to the 1930s show that surgical


outcomes in particular have involved weight loss among patients in the hospital


setting and post-op.  This was picked up again in the 1970s by Dr. George


Blackburn who spent many years of work in the nutrition support area with


physicians, nurses, and dieticians such as myself to stop hospital patients'


weight loss. 


      What are the implications of the weight loss?  Is it just the physical


appearance?  Not really.  What weight loss does is increase the risk and


complications of death and their treatment response, hospital length,      


rehospitalization, and also the part of the maze that we're working on these


days is the quality of life factors and helping patients with self-appearance,


quality of life, and satisfaction with care.


      The first thing the healthcare team needs to do in carcinoid is identify


weight loss seriousness.  So I'm going to go through some research in a few


minutes about general oncology patients and weight loss.  But carcinoid's a


little bit different and many of you might know this much better than I. 


      Carcinoid cancer is associated with a slow decline in weight and not an


acute weight loss.  There are studies that have been done with 3,047


chemotherapy patients with advanced cancer.  They found poor performance status


or ECOG performance statuses.  Patients with low performance status have less


ability to function and that most have a weight loss greater than 5 percent in


six months.


      Consequences of this weight loss are the shorter survival, decrease


response rates, toxicity increased and decreased of quality of life in patients.


      Carcinoid cancers by their nature affect your endocrine system directly or


indirectly.  One way is by interfering with nutrient intake and absorbtion. 


This results from increased metabolism, increased stress or decreased




      Contributing factors include lack of appetite, an impairment that prevents


you from taking food in, or things like an actual bowel obstruction or small


bowel resection which limits your absorption of nutrients. 


      Chronic malabsorbtion and diarrhea are the most common problems I see


among my patients, causing reduced performance status.  In times past, people


just say diarrhea, but we don't get the idea of what was causing it or that we


can help you with it and stop some of the side effects associated with it.  But


some of the problems are natural decrease or inactivity of the pancreatic


enzymes.  Pancreatic enzymes break down not only fats but also protein and


carbohydrates in your body.  It's important that you have enough pancreatic


enzymes to be able to help with your digestion in the small intestines.


Octreotide can cause this.


      Many times we have malabsorbtion or just not enough pancreatic enzymes


present as a result of the damage of the disease, requiring us to supplement the


pancreatic enzymes.  It is important that these enzymes are taken with food. 


The timing of these things will make a big difference.  Another reason for


diarrhea is the location and length of the bowel resection, which may lead to a


deficiency or inactivation of the bile salts.  Short bowel syndrome which is


probably one of the biggest causes of the weight loss among patients that have


had multiple short bowel resections. 


      Hypoalbuminia.  It's your albumin that is the protein marker in your body. 


Many times diarrhea results from a low protein status and not necessarily from 


fat malabsorbtion.    


      Medication induced diarrhea may result from a high osmolality -- a example


is a highly concentrated cough medicine going into the small intestine can cause


diarrhea.  Also some of the medications that we know help with many of the


symptoms associated with carcinoid such as Sandostatin causes  malabsorption of


fat and diarrhea (steatorrhea).


      We're going to talk more about special screenings that we're using in the


clinical areas now.  But critical weight loss is one of the biggest categories


that put you in touch with the dietician because these things are directly


related to the outcome.


      Proteins.  Proteins carry medications to different areas of the body. 


Some problems are related to just getting the medicines where they need to be in


the body.  This is a very important nutritional screening marker. 


      Cholesterol levels.  We talk about cholesterol levels as being too high. 


We usually hear high and everybody wants to worry about where the level is


and keeping it from going too high.  But in malnutrition, we look for low


cholesterol level.


      Less than 160 is usually a sign of malnutrition and becomes important


marker for us in the area.


      It is important to monitor weight change time.  This is very, very


important.  It doesn't matter if you weigh 250 pounds and you're 5 foot 10,


which would put you overweight.  If you lose -- If you've lost 30 pounds in 6


months, it's significant.  It no longer matters that you were overweight. 


You're very much at risk for malnutrition, and it's very important that you get


taken care of as a patient for malnutrition and that you're not seen just as an


obese patient. 


      We do a complete height and weight and nutritional assessment.  If someone


has lost greater than 2 percent of their body weight in a week, then something's


usually going on.  If it's greater than 10 percent in 6 months, then someone


needs to intervene.  


      Some of the patients in my practice have been overweight and they were


fine for the first 30 or 40 pounds that they lost.  They now looked better and


feel the weight loss really isn't a big problem, until their proteins decrease


and their albumin is also dropping.  They may not even have approached seeing a


dietician because actually that's malabsorbtion wasn't causing them actually


self-appearance problems it actually was promoting some of the things they may

have been trying to do all their life in weight loss.  So they actually liked


the weight loss. 


      But in carcinoid cancer, as in any of the oncology areas, we do not advise


that you try to lose weight during treatment.  We try to stop this.


      One of the biggest problems we've had with weight loss is also every time


you're going to lose weight, you're going to lose lean body mass.  So what


we try to do is find simple ways that we can identify problems and stop them


when patients come to the office.  The best screening tool is to make sure that


someone weighs the patient every time they go to a physician.  Sometimes if


patients go to the doctor weekly or monthly they may just walk back to a chair


and see a nurse and not necessarily go through the full physical. The patient


may not get weighed.  So it's very important that we weigh you every chance we


get when you're coming into the clinical setting.


      When we talk about losing lean body mass, it means that you're going to


lose muscle mass.  This muscle mass is a very important part of your body


system and it's something that we really try hard to maintain.  This loss of


lean body mass is very much associated with compromised outcome.


      What do we talk about when we talk about lean tissues?  These are skeletal


tissues, the muscle that you build in your arm, and also smooth muscles that you


may not see.  These are your organs.  It's very important that you know that


some of these lean tissues that you're losing even if you like the weight loss


it’s not good.  Because you're also going to lose the normal function of many


of your organs. 


      Visceral protein is very important because it transports proteins to other


parts of your body.  These proteins also make your diaphragm and involve your




      What enzymes?  Enzymes break down food for digestion.  One of the first


things that get damaged is normal cell function of these enzymes when someone


starts losing lean body mass.

      Also our antibodies fight infection and are also reduced as well as the


growth factor. 


      Your extremities and your trunk.  Lean body mass.  If you lose it, you


have increased fatigue, decreased activity, increased bed rest, increased risk


of deep vein thrombosis and pulmonary embolism and risk of decubiatus.


      Decrease in visceral proteins affects your diaphragm and respiratory


muscles causing increased work breathing, inability to cough, the ability to


clear secretions are all decreased when you've had a decrease in lean body mass. 


So although you may have lost weight and that not bother you, actually you may


have some of these other symptoms from the decrease in just the lean body mass.


      Some of the other tissues are the stomach.  Decreasing gastric emptying,


increasing nausea.  Fats digest last from your stomach and can cause nausea.  So


many times it's these delays in emptying will actually contribute to many side




      Decreased intestinal motility, or short bowel synrome, decreases nutrient




      And then the biggest tissue that we have and we're worried about is


probably the heart and our blood vessels and that's the loss of cardiovascular


response and debility.  And heart damage is seen in involuntary weight loss. 


      Simple starvation versus catabolic weight loss.  In most areas of oncology


we see catabolic weight loss.  But in carcinoid, we see simple starvation and


catabolic starvation.  So we have quite a combination of the two going on. 


Simple starvation is when we have a metabolic adaptation.  This is what people


that may go through a desert and be left without food can live for a longer


period of time because your body will actually drop the amount of calories it


needs in a day.  As a way of conserving energy, it's not going to use it.  So


that your body adapts; it doesn't need as much anymore.  It actually will


conserve the lean body tissue so that you don't have the wasted look.    


      That's what's in a carcinoid patient or people that I see often in

conserving people's health.  They've been fine for many years, but then there's


an insult of some type, an infection, a surgery, something that's going on


that's injured something, and then now we have a catabolic weight loss.  That


means there is no adaptation; your body is just going to continue to need higher


and higher calorie amounts and you're going to break down that lean tissue.  It


continues despite the nutrition, the nutrients that we take in.  That's because


of this injury to our metabolism.


      And it's -- when we go to case studies, I think you'll see what's really


interesting because this albumin marker that I've talked about as being real


important as an indicator of malnutrition, in a simple starvation, it will show


normal; it'll stay normal.


      Good clinicians that are trained to use it will say: Well, that albumin's


okay.  They're okay.  Because it stays okay.  It's held its own even though


you're losing weight.  But as soon as you have injury, this can drop very


rapidly in a Carcinoid patient.  When it drops, many times that's when you're


going to see the side effects of edema, the swelling in your feet and your knees


and throughout the rest of the body.  Those are related to this albumin and this


protein factor. 


      We've talked a little bit -- I've told you a little bit about the colon,


the catabolic features, the different types of hormones, burns, long ago


practice, surgery.  We talked about extensive abdominal surgery that Dr. Frey


talked about and interventions.  These are going to increase your catabolic


weight loss.  Infection.  Any infection that affects the system, if you have


infection, it's going to increase and may put you into some type of catabolic


weight loss.  And then the multifactoid etiology such as cancer, COPD.


      Well, how do we work with this?  Well, we do it in our facility as an


integrated strategy, each of us just taking parts of the puzzle and working with


it.  So that we can take our nutrition therapy, do some exercise, and some


meditation so that we can provide an optimal body composition and for the

physiological function to come back. 


      One reason we have to do this is when we think about -- we need to rethink


our bodies.  We found out that nutrition alone doesn't necessarily work.  And


medications alone don't necessarily work.  And if you don't keep that body mass


up, then we're not able to get the responses we need.  And that comes from some


type of exercise or function that's within your day to promote those muscle


builders for the muscles to stay healthy. 


      So what we do first is we're going to put together a plan of action.  And


this is going to be our endpoint.  It's: what do we want for weight and body


composition?  Our strength.  Before, we said appetite and quality of life. 


These are the objectives and what we're trying to work with and how we're going


to get there is through nutrition, meditation, and exercise.


      Here are some of the interventions that we use.  We want to -- first we


take in the assessment, what your age may be.  Caloric needs are different


according to your age.  And primary diagnosis, any other kind of differences. 


Just like anything else, you may have complication of Carcinoid cancer, but you


may also be diabetic or you may have other kinds of medical problems that we'll


have to take into consideration to make sure we're giving you something that


actually is going to benefit you in the long run.


      Your weight loss history is very, very important because all before -- I


need to know what percentage you lose in a certain length of time, that that's


very relevant to how we're going to treat you and how we're going to rebuild. 


When fluid is lost and a tremendous amount of weight, you can't refeed them


real fast.  You have to do it in a slow process or we can possibly do more harm


than good.  We can even cause somebody to have a heart attack if we do this


wrong.  So knowing how long you've taken to lose this weight, no matter what


your weight is, is very important for us.


      Many people have symptoms: diarrhea, vomiting.  Some of the complications


are fullness, no appetite.  When we're looking for loss of muscle and loss of

fat, you may have maintained some fat stores, but for the patients that have


done this for a long time, you may be down to where you really have very little


fat stores left.  You may actually showing signs of lean body mass that are


almost to where there's no appearance of fat.  It happens very quickly


especially to someone who wasn't real active before, didn't have a lot of muscle


mass previous to the diagnosis of carcinoid or cancer. 


      And then we're going look at the lab abnormalities.  We look at glucose to


see if you're tolerating.  We're going to look at the liver function.  We’re


going to look at calorie and protein needs for your system.  So there's many


aspects in trying to decide what we need to use when we get started with this. 


      We like to tell you things that are going to limit the weight loss –


reverse or limit any stressors.  First we've got to stop what is causing the


fever.  You've got to get to the bottom of everything that's causing this weight


loss in order to do a better job of correcting the weight loss and so we get you


on the right track. 


      This is where I talk about what I do now.  Oncology as a nutritionist is a


specialty just like you have physicians and you've seen physicians that are


specialists in different areas.  Not all dieticians are trained to take care of


cancer patients.  Some of us specialize in diets that are diabetic controlled,


diabetes.  Some of us specialize in hypolipidemia or cardiovascular areas.  And


some of us specialize in nutrition support.  And that is critical care work. 


      So those of us that have these specialties work in accordance with


standards of care that are put out for us by these programs.  One of them is


ASPEN, the American Society of Parental and Clinical Nutrition.  These standards


help us do a better job of taking care of patients in a very systematic




      They assist in development of the nutritional plans and establish


maintenance goals and approaches to use and monitor the effectiveness of these




      These things are very important in knowing how to choose a dietician as


well as any other area of the field.  Some of the things that doctors' offices


have used in the past to do this are some screening tools.  And some of you


might not have been screened, and I hope that some of you have been screened. 


      But some of these in the past have been the common toxicity criteria. 


We'll just look at weight loss.  It didn't particularly look at the time factor,


just weight loss in general.  The PSSGA is a very good tool to help monitor


weight loss over time.  And it also takes in some other factors that will give


you a reading of "No nutritional needs," "Mild," "Moderate," or "Severe," "Life




      There's no reimbursement for a nutritionist in oncology yet.  There's not


a third-party payer for it yet.  So if you have a dietician in your office,


that's a real luxury. 


      Probably one of the best training forms for the elderly is Determine


screening tool.  Now, this one goes very extensively into weight loss, and also


goes into the social aspects such as, if you eat alone, how many meals do you


eat alone?  Do you eat three different meals?   They're not going to go just


through the questions of weight loss.  They deal with many aspects and they also


cover the lab and the albumin and those things that I talked about previously. 


Very effective tool.


      Nutritional therapy is a very important skill and it is an up and coming


skill.  What registered dieticians do is evaluate the individual's needs and


prepare their care plan so that we can identify the bowel absorbtions, deal with


the diarrhea, help determine if the diarrhea is caused because you don't


tolerate fats, if the diarrhea is caused because you have short bowel syndrome,


if the diarrhea is caused because you don't tolerate fiber, or is it because the


Sandostatins make you go fast.  So we're going to be looking at these aspects


and along with what causes you not to have an appetite.  We may have to give you


something that really could work.  


      Sometimes the patients come in to see me and it seems like the doctors and


everybody's telling them something different so they're a little bit confused or


just not too sure I'm doing anything different.  One way of doing this, one


example of this, is we put together meal plans for you and your family.  And I


have known you're malabsorbant, and you maybe lack several vitamins, and you may


have had diarrhea for a long time, and I may want you to get some things on


board.  But instead of saying: You need 15 milligrams of these a day.  I'm going


to say: Can you eat eggs? 


      I'm going to give you a source of that nutrient that I want you to build


back in, and I'm going to tell to have that food instead of giving you a lot of


numbers and saying things that may confuse you, or give you specific nutrients


because people tend to go to the pharmacy and start buying bottles of these


things instead of trying to eat the foods themselves.


      So if it sounds as simple as: Well, should I go in there?  And the only


thing she told me to do is I eat an egg every day.  We don't want to overload


you with information.  We don't want to confuse you, but we really look at


things that are going to make it easier for you.  And if you're going to stay in


with a diabetic diet counseling meal, you'll appreciate the fact that I don't


have you measuring everything and giving you the exact amount of everything. 


All I'm going to do is try to give you things that you can eat in a time that I


think you can do the best with after you do some things for me such as what I'm


going to talk about next: Use the tools that I have from the assessment, give me


a record of what you eat, when you eat, when you have a bowel movement, and so


that I can get a better picture, what you’re absorbing.


      I can't assume that any two people in this room are going to eat the same


food or the same amount of calories or get the same amount of protein in a day. 


The only way I can do that is follow the necessary nutrients themselves and


seeing.  But we're like calculators.  We look at milk  and we think of in terms

of calories.  And we look at milk and we think 8 grams of protein.  We're not


looking just at a white substance in a glass.  So we're trained to do a little


bit more than we actually let on that we do.


      Because the medical and surgical history is extremely important, we have


to go back and look at this.  We need to get as close as we can to finding out


what part of the bowel has been resected because it plays a big part in a


malabsorbtion and what nutrients that you need to have replaced daily, and some


things that may have to be injected such as B-12 because you know that you're


not going to get enough of this because of the surgery that you've had.


      When we start we're going to estimate how many calories you need daily. 


And it is a guesstimation and I'm going to go through how we get to that


guesstimation in just a minute.  If estimating calorie needs, we're going to say


how far out of surgery you are because if you've had surgery, how many calories


you need in a day goes up.  Your metabolism is going to increase.  If you have a


metastatic disease, if it's a disease of a specific organ, it's going to make a


difference in the types of carbohydrates that you tolerate and the amount I can


give you at one time, also the protein and catabolic needs in a day is going to


increase.  And then the type of tumor.  So all patients with different types of


cancers and tumors don't always lose a lot of weight.  So knowing the type of


cancer and the type of tumors that we are treating makes a big difference. 


      In a normal individual, your calorie needs are about 25 calories per


kilogram of body weight.  In carcinoid cancer and in as well many of the


cancers, this need increases to 35 calories, 35 to 45 calories per kilogram of


body weight.  It's very important to know how many calories you need in a day.


      Many people are used to eating the same way they did all their lives.  And


if you weighed 140 pounds and you ate about 2,000 calories a day, you probably


maintained your weight just fine all your life.  Then you have an injury such as


this and these tumors, and all of a sudden I know that you're going to gorge and


your body's going to need about 2800 calories a day.  If you're not used to


eating that much, that in itself is a complication.  It's a problem.  You're


just not used to these high loads of calories in a day.


      We just say medical weight loss.  I put this on here because I do think


it's important for people to know.  3500 calories is equal to 1 pound of weight. 


I'm probably going to calculate present intake and add 500 calories a day to it


because if I could add 500 calories a day to what you're able to absorb, not


necessarily take in, then in seven days you're going to get 3500 calories;


right?  And you're going to gain a pound. 


      That's one of the steps I use in trying to increase a patient’s weight,


trying to stop weight loss, is in increments of 500 calories a day.  If I put in


500 calories and I still haven't seen weight production, then I know I've got to


go up further.


      Protein requirements.  Protein requirements are normally recommended to an


individual that has not had any problems of limitation or disease.  It's around


.8 per kg/body weight.  But in this area of practice, it will go from 1 gram to


1.5 if your albumin is still holding normal, around 3.5 or a little less.  But


once it decreases to less than 2.7, these requirements are increased to 1.5 to


2.5 per kilograms of body weight.  And the other thing that's real important to


remember is that when you increase protein, it increases the risk of


dehydration.  So if you're taking protein supplements that someone's given you


from the health food store to try to help yourself and you're not getting enough


fluid on board or you're having trouble with dehydration in the first place,


you're only going to complicate this.  So we have to be very careful with


increasing protein levels in patients.


      I know you're familiar with a bowel resections and probably pancreatic


enzymes, but the “Blind Loop Syndrome” is where you've been on antibiotics for


a long time and it's wiped out the system.  And the bacteria make an overgrowth


of the lower part of the intestine and that in itself can cause diarrhea.  So a


long-term antibiotic and sometimes therapy can cause this.  We need to look at


those factors.  So there's things we can do about it and we need to know that


that's what's causing it.


      The other thing I hear that I think is very important -- we talked a


little bit about medication -- but it's herbs in all kinds of therapy.  These


things can be very controversial in treatment and no research at this time has


shown that these things are of any benefit in this arena. 


      My biggest problem with them is there's no one that watches over it, no


FDA approval for any of the herbal remedies out there.  And we know that in


therapy we can have interaction and many of the problems we've had with bleeding


and interactions with medications, these are all related to herbal remedies.


And until we see that these things are really beneficial and there's been


research on them, I do not recommend the use of these.                                        


      But I need to know if someone's doing it because it really does relate to


diarrhea and because some of these things actually do induce it.  One of the


favorite things that people used to like to drink for diarrhea is aloe juice. 


And aloe juice is something that causes diarrhea so we have to be real careful


with its use.


      A nutrition invention.  Six to eight small meals a day.  I have patients


eat six small meals a day because this is very important.  Because in this


arena, you have to have enough enzymes to digest what you're taking in and it


cannot take in a lot at one time.  And there's also notes from previous works in


this field that large feedings are associated with the symptoms that you have


with a crisis. 


      Fat.  First of all, there's different types of fat.  Some fats are going


to cause you more complications than others: long-term fatty acids.  These are


the things like salad dressings and margarine.  They're broken down in the


system and absorbed through the liver.  And these things, many times, aren't


tolerated well.  But we do not recommend a low fat diet; we don't do that


anymore because we actually need fats for calories.  So we do allow fats.  We


want to encourage them but in moderate amounts.  But we can add pancreatic


enzymes to help with absorption.  There's another type of fat called medium


transcarglyceride.  And this product is in a lot of the supplements that we


give, because it does not have to be absorbed through the liver.  So this has an




      Fiber.  Some people tolerate fiber very well.  Well, actually, there are


two types of fiber.  Insoluble fiber is the type that does not digest and builds


the bulk of your stool and it's in the part of your vegetables that doesn't


digest, the skins on the beans, potato skins.  This is insoluble fiber.


      Sometimes these things are tolerated in patients.  And if you're not


having complications of weight loss, this is something that we want more


patients to use because it helps with some of the constipation problems that we


might have from medications.  So these fibers are used when we can.


      When you increase fiber, you also have to increase water.  So remember


that if you have a high fiber diet, you need a lot of fluid.  Again, contributes


to dehydration if you're not able to take this amount of fluid in the day.  Be


careful of high fiber.


      The other type of fiber is soluble fiber.  It absorbs in your body.  It


can actually help the reabsorbtion of water. 


      Carbohydrates.  There are different types of carbohydrates.  Complex


carbohydrates or starches give you the best energy source for a longer period of


time.  It doesn't use or contribute to the dumping syndrome that our patients


have experienced.  Soluble rice formula which is starch, a longer more complex


chain.  And it also increases the absorption of hydration better than any other


products do. 


      But simple carbohydrates are Coca Colas, sucrose, table sugar, or even


fruit sugar from a lot of juices, these things really can cause more diarrhea in


patients than actually do any good.  If you can tolerate it, fine.  Use it.  But


if you happen to be drinking apple juice every day and you have diarrhea every


day, at least use half strength of it; dilute it or try to take it out because


it really will make a difference.


      Proteins are very important.  Proteins in our regular diet, some of them


are absorbed better than others.  Red meats, some patients just don't do well


with this type. 


      Its good to use Enteral products that we give you.  Try it.  We want you


to give them a chance.  Now, I will say that the favorite thing that put people


on this super Ensure is that's very high in sucrose and, I might comment, is not


tolerated well by carcinoid patients.  It's necessarily a good product for them. 


      And if we find that you are not tolerating much at all and you have a lot


of diarrhea, I would usually use an elemental type product, means that


everything is broken down already.  You don't need the enzymes to break it down


and it absorbs directly into the intestines.  And these products have been very


useful in the patients that I have seen in my practice.


      So we haven't done tube feeding in this arena, but we do know by history


that there is quite a bit of benefit in small bowel syndrome if we put a tube in


the jejunum and just fed a little slow drip feeding of one of these products


around the middle, we get really good results and we really do make a difference


in weight gain.  But that hasn't been used in this arena quite as much as we


do in regular short bowel syndrome. 


      And then we can consider keeping in parental nutrition if your body


doesn't perform or quality of life warrants that.  And that is kind of a new


arena but it has been used very successfully. 


      I said it was a three-part thing, so I'm going to go through real quickly


what our meditation intervention can be and has been very helpful for us


especially in cases that had some anorexia and just had no appetite or they were


losing weight. 


      First of all, we started and was used previously more than it is now were


the corticosteroids.  They did increase especially in very extensive, but they


did increase muscle catabolism and we really did not see much weight gain with


their use. 


      Antiemetics have been used in practice especially with patients receiving


chemotherapy.  But again, we saw very little weight gain and it also has other


effects on the central nervous system that -- so it's not used very much in


practice -- as much in practice now.


      The progestitional agents, you have probably been exposed to some of


these.  They were used for an appetite stimulus and they're pretty effective. 


They can make you really, really hungry.  But what they haven't shown to do is


to make you increase in your lean body mass.  The weight gain is primarily fat


and it also has other problems in it and hormonal effects.  But it has increased


quality of life, so we have used it and continue to use it effectively in




      And the last one is the one that we're using more in our practice and I'm


real excited about it because we're actually seeing some success.  We're hoping


that this will be a practice that we can use and that is the anabolic agents. 


And it increases the lean body weight, increases nitrogen retention, increases


muscle synthesis, and increases quality of life for its statuses.  Now it does


have its side effects.  Some patients may not be able to use it because it is a


hepatic metabolism and it has some fluid retention associated with it.


      Activity.  Light activity or moderate activity is needed daily.  Some


light weight resistance -- a two-pound weight, something light, nothing too


strenuous but something that gives that muscle some work.   These are very


helpful in building back the muscle.  But also remember that overexertion can


lead to increased weight loss.  I don't want y'all running around and burning


1,000 calories when I'm trying to get 3,000 calories in you.  So sometimes I


have to tell patients you've got to sit down and rest.  Stay in the chair for 30


minutes after you eat. 


      Then the effects on the quality of life.  This probably is one of the


things that I'm most concerned with because many people use nutrition and


eating out as their social activity.  And many times when we make these changes


and you can't find the foods and you really are not able to do your social


functions and this is something that will affect your quality of life. 


      The numbers of other things that you're actually having to depend on other


people to do for you now that you didn't have to do this previously.  And that


can reduce your quality of life. 


      And then the overall performance status, the point where you don't feel


like getting up and doing those things anymore where you really have a reduced


quality of life.




      Please recommend what's the best, easiest for a lay person to understand


books or to go to get on keeping up weight for cancer patients?  What's the best


source for someone to go to?




      The NCI has put out a book “Eating Hints for Cancer Patients” and in the


back of this it has increasing weight, protein, and calories and convincing


products and it's very useful.  And also the Cancer Society has put out a very


good book that gives its information a little bit different.  But it's also


very useful.  And then a couple of office type of books, but I can find it if I


don't have it if you get in touch with me.




      People who have carcinoid can't do hard physical exercise.  How is there


anything you can do that will help get good results?







      Sometime the band therapy where they use  these little bands, resistance


bands.  These can be put -- at times I've had patients where we tied them to the


bed and they can just reach up and pull when they felt like it.  And they can do


the same thing with leg lifts.  Real light.  Those things will help.  They


really make a difference.




      The nausea that some carcinoid patients experience could it be caused by


the carcinoid itself but indirectly by the inability to digest fat? 




      Yes.  Many times it's the fat malabsorbtion or the presence of the fat too


long in the stomach that will cause some of this nausea.  Some of it's






      What causes swelling in the face, more in the morning when getting up or


when there's no leg edema and there is weight loss?




      That's probably your kidney.  (To Dr. Anthony) You may have to deal with


that one more than me.  In the face and legs, many times it's associated with


Albumin, but in the face, I'm not too sure that's the problem.




      Well, it's obviously positional because it's more in the morning. 


Whenever anybody assumes a supine posture, it's going to shift wastes in the


legs and the lower body to the upper body.  So it's a fairly common problem to


have more upper body edema if you tend to swell.  It all depends on how


collective rest you try to do to see how it acts on that.   Things that we


think about with edema in general are what can happen in patients' renal and


cardiac functions are and then obviously do many things the oncotic factor of


Albumin which can be irrascible.  So it's really where nutrition and oncology


come together that determines that.




      Is there a difference in coordinating needs?  Protein needs, et cetera, in


a patient with carcinoid?  Those without Carcinoid syndrome versus a patient


with the syndrome assuming equal therapies?




      Yes.  There can be different calorie needs among individuals in regards to


the amount of benefit.  Everybody would be different and everybody is such an


individual that they get different benefit.




      What causes chronic foul smelling burps?




      Probably food being retained in the stomach too long is causing these


types of eruptions.




      How can I put weight on when I have diarrhea every time I eat?




      Probably what you're eating at each meal.  That's where we have to look at


what you're taking in at that meal, what type of fats.  It's a puzzle.  But it's


probably the things that you're eating that are causing that diarrhea. 


Sometimes it's just the presence of food alone.  That person I may have to see


individually to stop that, to answer that question for you.




      Since we never get to a point past treatment through recovery, does this


mean we never get to go on the entire weight loss regimen?




      I don't refer anybody to go off.  If someone is very, very stable in


treatment and isn't -- we're not seeing the weight loss for any other reason, we


might could do it very slowly and individually.  But it is not something that I


recommend at all.




      Where can I read about phytochemicals in someone with carcinoid?




      There is no big research done with those specifically in this area.  We


are seeing it in other areas of the cancer and they said some research would


be coming down the road.  Phytochemicals are very good for us in prevention. 


But as far as treatment, we're not too sure exactly where they play.




      Can TPN be administered at home?  If not, why not?




      It can’t be made at home.  It has to be made under a sterile hood in a


pharmacy under real aseptic conditions.  You can add something to the TP at home


and use it at home, but the initial mixing step has done be done at a pharmacy.




      Discuss good general nutrition for a patient.  What food items, et cetera,


are good?  What is not good?




      Again, it's generally, we want you to eat according to the food pyramid


that you see in your magazine where you get more complex carbohydrates in a


diet and less concentrated sweet and fats.  Do eat some vegetables and fiber,


fruits, and vegetables and those that can be tolerated are very important in the


prevention and treatment of cancer.  But again, it's to what you can tolerate is


the most important thing.




      Is Glucerna a tolerable drink for a carcinoid patient with diabetes?  Does


your body break it down and absorb it easily?





      This one is one that would depend on how much injury you've had to the


small bowel.  Glucerna has both types of vitamins that I talked about previously


but the patients that don't tolerate it – the insolubles, the fibers that stays


with you, this part can cause problems.  And in patients that do not tolerate


this intact protein which is a protein that hasn't been broken down has not


worked for them.




      For those of us with short bowel syndrome, what are your thoughts about


using Creon as a method to help control diarrhea and Creon being a pancreatic






      We use Creon and have used it successfully.




      Bowel resection.  Fourteen inches of terminal ileum.  When should B-12


shots be used?  Are there other deficiencies possible after bowel resection with


no apparent weight loss?




      B-12 injections probably starts the following month if you've been eating


healthy previously.  If not, I'm sure you probably can get an injection.  And


it's given monthly after that.  And then other deficiencies can be -- all your


fat soluble vitamins, A, B, E, and K, and zinc will be a problem because of


the diarrhea.




      What's a short easy exercise if you have no flushing? 




      Probably stepping in place in your living room so that you have some


control is probably the best one.





      What is your opinion on the muscle building supplements in health food


stores?  Is there one in particular that you would recommend?




      No.  I don't hate health food stores.  But I don't like patients going out


there and getting recommendations without a physician's recommendation.




      Any risks with drinking large amounts of green tea?




      There can be diarrhea associated with it.




      Would you recommend acidophilus?  Do you buy the stuff already made?




      I recommend that you use it daily and use it three times a day.  I do use


in my practice the capsule that is put out on the market, Culprel, and it's been


used very well.




      What are the top 5 foods/products that you recommend?




      If you're tolerating protein, probably fish.  For diarrhea, applesauce has


been good.  White rice and potatoes.

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