Nutrition & dietary problems

Monday 30 April, 2012

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On this page: Eating after Whipple's surgery | Poor appetite and weight loss | Changes in taste or smell | Diarrhoea Nausea and vomiting | Diabetes | Enzyme supplements | Food-type nutrition supplements


Nutrition can be a major focus for people diagnosed with pancreatic cancer. Treatments such as surgery, radiotherapy and chemotherapy can affect your ability to eat, digest and absorb food.

This can lead to dietary problems, including:

  • poor digestion of fats and proteins (malabsorption) caused by a lack of digestive enzymes, which help break down food
  • poor appetite
  • weight loss
  • diarrhoea
  • nausea and/or vomiting
  • diabetes.

This page provides general suggestions on how to manage these issues. You'll probably find it helpful to talk to a dietitian, as your needs may vary to those of other people with pancreatic cancer. Dietitians are experts in nutrition who can give you specialist advice on how to cope with nutrition and eating problems.

Dietitians are available in all public hospitals and some private hospitals. You can also see a dietitian in private practice. Ideally, you should see a dietitian connected to your cancer centre. Ask your oncologist how to get in touch with one. The Dietitians Association of Australia can also help you locate an accredited practising dietitian in your area, or one who has experience with a particular issue.

Call Cancer Council on 13 11 20 to request free information about nutrition.

Eating after Whipple's procedure

People with pancreatic cancer who have a Whipple's procedure may have many questions and concerns about their diet after the operation. The following suggestions may be helpful when you start to eat after Whipple's surgery.

Tips

  • Avoid eating too many fatty, greasy or fried foods, or increase your pancreatic enzyme supplements when you have such foods.
  • Avoid eating too much of the foods that produce wind (gas), e.g. legumes (dried beans, peas or lentils); vegetables such as broccoli, brussels sprouts, cabbage, cauliflower or asparagus; and carbonated (gassy) drinks.
  • Have small meals every 2 to 3 hours rather than three large meals.
  • If you're not digesting and absorbing food properly (malabsorption), you'll need a multivitamin supplement including extra calcium, folic acid, iron, vitamin B12 and the fat-soluble vitamins A, D, E and K. If you drink while eating, take small sips to avoid filling up too quickly.
  • Take the right amount of digestive enzyme supplements.
  • Talk to a dietitian or your doctor for more information about vitamin and enzyme supplements.

Poor appetite and weight loss

Many people with pancreatic cancer lose weight. Pancreatic cancer can prevent your body from absorbing food, and it can also produce hormones that cause your body to break down your muscle and fat.

Cancer treatment may also affect your appetite or sense of taste, and you may not absorb food efficiently. If you can't manage to eat much or you're trying to gain or maintain your weight, there are ways to take in more energy (kilojoules/calories) without having to eat more ood.

Tips

  • Eat small snacks frequently (e.g. every two hours).
  • Have your biggest meal of the day when you're hungriest.
  • View food as a form of therapy. Keep track of your meals and snacks.
  • Add extras to your basic foods at mealtimes. For example, add milk powder to cereals, sauces, desserts, mashed vegetables, soup, drinks and egg dishes; add cheese to sauces, soup, vegetables, baked beans, casseroles, salads and egg dishes; and add sugar, golden syrup, honey or glucose powder to cereal, fruit and drinks.
  • Use food-type nutrition supplements.
  • Relax low-cholesterol and other dietary restrictions. Gaining weight or maintaining your weight is more important than avoiding extra amounts of fat and sugar.
  • Eat in a comfortable, relaxed place and make meals as enjoyable as possible.
  • Weigh yourself once or twice a week to see if your weight is stable.

Changes in taste or smell

Sometimes your sense of taste may change because of the effects of treatment. To compensate for the loss of taste, some people add sauces, spices and other condiments to make meals more appetising. Others find it more helpful to avoid strong flavours and eat bland, unseasoned food, such as rice, pasta, steamed vegetables and fruit. Try different ideas to see what suits you best.

Tips

  • Add flavour with salt, garlic, cheese, bacon, herbs, marinades, chutneys, pickles, sauces, spices, sugar or chocolate.
  • If food is too sweet, add salt, lemon juice or coffee powder – start with a few sprinkles, then adjust to your taste.
  • If food tastes metallic or salty, add sugar or honey or try sucking on tart-flavoured boiled lollies.
  • Marinate vegetables, meat or tofu to add extra flavour.
  • Choose cold food or food without a strong smell. Sometimes the smell of food can put you off eating.
  • Reheat meals in the microwave so the food smells don't put you off.
  • Use a drinking straw to bypass your tastebuds.
  • If possible, stay out of the kitchen when food is being prepared if cooking odours affect you.
  • Eat with plastic utensils to help reduce any bitter or metallic tastes. Don't drink out of aluminium cans, pewter beer mugs or metallic containers.
  • Don't force yourself to eat foods that you don't enjoy.

Diarrhoea

With some cancer treatments, the bowel may become irritated and sensitive, causing temporary changes to your bowel habits. Diarrhoea means your bowel motions are urgent, watery and frequent. You may also get abdominal cramping.

Diarrhoea may have several causes, including chemotherapy, radiotherapy to the abdomen or pelvis, infection, food sensitivity, malabsorption and emotional upset.

Whatever the cause of diarrhoea, a change of diet often helps, particularly if you reduce your fibre intake temporarily.

Coping with diarrhoea

Foods to choose

  • soft, well-cooked,  peeled vegetables and fruit
  • white bread, white rice and pasta
  • corn- or rice-based cereals
  • lean meat, fish, chicken
  • eggs and dairy products

Foods to avoid

  • fruit and vegetable skins
  • wholegrain bread
  • bran and muesli-based cereals
  • nuts
  • legumes such as lentils, peas and baked beans

There are also medications available, especially if the diarrhoea is caused by not having enough pancreatic enzymes. If you develop diarrhoea that lasts more than a couple of days or keeps recurring, or if it causes you discomfort or distress, see your doctor or dietitian.

Tips

  • If the stools are pale in colour, float and are difficult to flush, it may be a sign that you don't have enough pancreatic enzymes (pancreatic enzyme insufficiency). Talk to your doctor about starting on enzyme replacement therapy or adjusting your dose.
  • Take anti-diarrhoea medication as prescribed by your doctor.
  • Drink plenty of liquids (e.g. water, fruit juices or weak cordials) to replace lost fluids.
  • Try to eat three small meals and three snacks every day.
  • Avoid fried or greasy foods.
  • Avoid alcohol and limit caffeine and spicy foods as these can worsen diarrhoea.
  • Some people develop a temporary intolerance to the sugar in milk (lactose) when they have diarrhoea. If this occurs, try soy milk or lactose-reduced milk. Cheese and yoghurt in small amounts are usually okay.

Nausea and vomiting

Feeling sick (nausea) and vomiting may be brought on by treatment, food odours, gas in the stomach or bowel, or motion sickness. For some people, just the thought of treatment makes them feel unwell.

Some cancers press on the duodenum and prevent food from leaving the stomach. This can cause persistent vomiting and rapid weight loss.

See your doctor if vomiting lasts for more than a day or if you can't keep any fluids down and risk becoming dehydrated.

How to cope with vomiting

  • Stage 1: Small sips
    For persistent vomiting, sip small amounts of liquid as often as you can. Try flat ginger beer/ale or lemonade, or suck on an ice-block.
  • Stage 2: Introduce drinks slowly
    If your vomiting has stopped but you still feel sick, have small, frequent meals to stop feelings of hunger, which can aggravate nausea. Start with cold drinks. A mixture of half milk (or skim milk) and half water (or soda water) may be surprisingly soothing. A spoonful of ice-cream in a glass of lemonade, diluted fruit drinks or jellies can also be satisfying. Later, try warm drinks such as weak tea, clear soups (broth) or Bonox®.
  • Stage 3: Introduce solid foods
    Next try small amounts of solid foods, such as plain biscuits or toast with honey or jam. Stewed fruits and yoghurt are also good.
  • Stage 4: Return to normal diet
    As soon as you can, increase your food intake until you are eating a normal, well-balanced diet. Limit rich foods, such as meats or full-cream dairy products. Your doctor or dietitian may advise you to take additional nourishment (such as supplements) on your good days to make up for the days when you can't eat properly.

If you have persistent vomiting, the part of your body that connects your stomach to your small bowel may be blocked. Your doctor may be able to bypass it by surgery or endoscopy.

How to cope with nausea

  • Eat small meals often – not eating can make nausea worse.
  • Try snacks such as dry crackers or toast.
  • Eat and drink slowly. Chew food well.
  • Choose cold foods instead of hot, fried, greasy or spicy foods.
  • Avoid strong odours and cooking smells.
  • Suck boiled lollies with peppermint or lemon.
  • Try drinking ginger beer, ginger ale or ginger tea, or sucking on candied ginger.
  • Talk to your doctor about trying anti-nausea medication.

Diabetes

Some people develop diabetes before the pancreatic cancer is diagnosed or soon after surgery. Diabetes, or poorly controlled blood sugar levels, occurs because your pancreas may not be making enough insulin or the cancer is stopping the glucose from working.

Symptoms of diabetes include blurry vision, excess thirst, frequent urination, hunger or weight loss.

The way diabetes is controlled varies from person to person but usually includes a combination of balancing your blood sugar levels and managing your diet. If needed, you'll have medication to control your blood sugar levels. Your doctor and a dietitian will tell you the best way to take care of yourself if you have diabetes.

Tips

  • Eat small meals and snacks regularly to help control blood sugar levels.
  • If you're taking diabetes medication, you need to include carbohydrate foods at every meal to avoid low blood sugar levels. These include breads, cereals, pasta, rice, fruit and some starchy vegetables, such as potato, sweet potato, pumpkin or corn.
  • For more information about diabetes see Diabetes Australia.

Enzyme supplements

The pancreas produces digestive enzymes, which help break down the food you eat into basic nutrients that the body can use. When you have pancreatic cancer, your body may not have enough of these digestive enzymes. This happens when the cancer blocks the pancreatic duct, and it makes it difficult to digest fats or proteins (malabsorption).

Malabsorption can cause:

  • cramping
  • wind
  • diarrhoea
  • fatty bowel movements (stools) that are difficult to flush
  • weight loss.

Your doctor may prescribe enzyme supplements to treat these symptoms. A dietitian can also advise you on dosage, which can change depending on the amount of fat you eat. Generally, a very low-fat meal or snack (such as fruit) may not need a capsule, while a meal with fried food would require a larger dose.

It may take time to get the right balance of enzyme supplements for the foods you're eating. Write down any digestive symptoms you have and discuss them with your doctor or dietitian so you can find the right balance faster. If the tablets cause side effects, or if symptoms of malabsorption persist, tell your doctor or dietitian.

Most enzyme supplements are in capsule form. If you find it hard to swallow them, open the capsules and mix the contents with food that can be swallowed easily without chewing.

Food-type nutrition supplements

Nutritional supplements such as Ensure®, Sustagen® and Resource® can be used to boost a small meal or snack or to replace solid food. Most supplements contain a good variety of nutrients, particularly energy (kilojoules/calories), protein, vitamins and minerals. They're available as ready-made drinks or in powdered form to be mixed with water or milk.

Nutrition supplements can be sprinkled onto cereal and fruit, or mixed into foods such as mashed potato, gravy, casseroles, scrambled eggs, custard, hot and cold drinks and soup.

Protein and glucose powder supplements can also be added to meals and snacks for extra energy. These shouldn't be used as meal replacements as they don't provide vitamins or minerals. Glucose supplements may not be recommended if you've been diagnosed with diabetes.

Talk to your dietitian for more information about food-type nutrition supplements. The dietitian will advise you on the type and quantity you should have.

Seeing a dietitian

Ask your surgeon, GP or gastroenterologist for information about seeing a dietitian, either in hospital or afterwards.

The Dietitians Association of Australia can also direct you to an accredited practising dietitian in your area or to one who has experience in particular problems. Call 1800 812 942. Some dietitians are also listed in the Yellow Pages.

If you want to see a dietitian after you leave hospital, you may be able to receive a Medicare rebate for some of your consultations. To be eligible, your GP needs to refer you to an accredited practising dietitian as part of your Enhanced Primary Care (EPC) plan. Many private health funds also provide a rebate to see a dietitian.

The Dietitians Association of Australia has information on the typical fee for a dietitian's consultation.


Reviewed by: Dr David Chang, Pancreatic and Upper Gastrointestinal Surgeon, Sydney South West Area Health Service and Research Fellow, Pancreatic Cancer Research Group, Garvan Institute of Medical Research, NSW; Professor Andrew Biankin, Head, Pancreatic Cancer Research Group, Garvan Institute of Medical Research, Consultant Hepato-Pancreato-Biliary, Upper GI Surgeon, Sydney South West Area Health Service, NSW, and Clinical Lead, Australian Pancreatic Cancer Genome Initiative; Annie Angle, Oncology Nurse, Cancer Council Victoria; Dr Lorraine Chantrill, Medical Oncologist, Macarthur Cancer Therapy Centre, Campbelltown Hospital, NSW; Leslye Dunn, Consumer; Helen Gooden, Manager, Multimedia Cancer Support Grants, Cancer Council NSW; Barbara Hunter, Consumer; A/Prof Lara Lipton, Medical Oncologist, Cabrini and Royal Melbourne Hospital, VIC; Barry Ranson, Consumer; Meg Rogers, Cancer Nurse Coordinator, Upper Gastrointestinal Service, Advance Practice Nurse, Peter MacCallum Cancer Centre, VIC; Karen Tokutake, Medical Oncology and Haemotology Dietitian, Prince of Wales Hospital, NSW; and Belinda Vangelov, Senior Oncology Dietitian and Clinical Educator, Prince of Wales Hospital, NSW.
Updated: 30 Apr, 2012