Managing dietary problems

Monday 1 February, 2016

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On this page: Eating after a Whipple procedure | Vomiting | Diabetes | Pancreatic enzyme replacement supplements | Nutritional supplements | Key points


Pancreatic cancer, and treatments such as surgery, chemotherapy and radiotherapy, can affect your ability to eat, digest and absorb food. This can have a significant impact on nutrition, which can become a major focus for many people.

Common problems include:

  • weight loss
  • poor appetite and feeling full quickly
  • nausea and/or vomiting
  • changes in taste and smell
  • changes in bowel habits
  • poor digestion (maldigestion) and absorption (malabsorption) of fats and proteins caused by a lack of pancreatic enzymes
  • diabetes caused by inadequate insulin production.

This page provides general suggestions about how to manage these problems. What you can eat and drink may vary from person to person. You may find it helpful to talk to a dietitian for individual advice.

Dietitians are experts in nutrition who can give you specialist advice on how to cope with nutrition-related problems and eating difficulties. See information on finding a dietitian.

Call Cancer Council 13 11 20 for a free copy of Nutrition and Cancer or to speak to a Cancer Connect volunteer who has had a similar cancer experience.

Eating after a Whipple procedure

People who have a Whipple procedure may have many questions and concerns about their diet following the surgery.

The suggestions below may be helpful when you start to eat after surgery.

Managing food after a Whipple procedure
  • Eat small meals every 2–3 hours rather than three large meals each day.
  • Ensure that meals and snacks are nourishing and include protein, e.g. meat, chicken, fish, dairy products, eggs, tofu and nuts. This will help recovery and improve your nutrition.
  • Sip only small amounts of liquids during meals to avoid filling up too quickly.
  • Limit 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.
  • Talk to a dietitian or your doctor about vitamin and enzyme supplements if you can’t digest and absorb food properly. You may need a multivitamin supplement to provide calcium, folic acid, iron, vitamin B12 and the fat-soluble vitamins A, D, E and K.
  • Ensure you take the right amount of digestive enzyme supplements, if prescribed.
  • Limit or avoid eating fatty, greasy or fried foods if these cause discomfort, even when taking adequate pancreatic enzymes.
  • Nutritional supplements drinks, such as Sustagen® Hospital Formula, Ensure® and Resource®, are high in energy and protein and have important vitamins and minerals. These may be prescribed after surgery.
Jan’s story

"I was diagnosed with pancreatic cancer when my third child was six weeks old.

"I went to the doctor because I was itchy and had constant diarrhoea. My GP initially thought it was gallstones and sent me for routine tests. After the CT scan I went into hospital for a laparoscopy and then had a biopsy, which confirmed I had cancer.

"A month later I had Whipple’s surgery. After the procedure, eating was hard and it was a real balancing act getting it right.

"I found that I would fill up quickly, but it helped to eat smaller meals. I also can’t drink a lot of liquids. A lunchtime meal of a cup of tea and a soup is out of the question.

"My taste buds had changed and chocolate was no longer appealing but ice-cream was okay. Fatty foods didn’t settle well at all. The more natural the foods, the easier it was to handle. I found packaged foods were harder to deal with.

"My tolerances have increased over the years, and trial and error has helped."

Coping with dietary issues

Poor appetite
  • Eat small meals frequently, e.g. every 2–3 hours.
  • Have your biggest meal of the day when you are hungriest.
  • Add extras to your basic foods at mealtimes.
  • 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.
  • Add golden syrup or honey to cereal, fruit and drinks.
  • Use food-type nutrition supplements.
  • Relax normal low-cholesterol and other dietary restrictions. Gaining weight or maintaining your weight is more important than avoiding extra fat and sugar.
Change in taste or smell
  • If food tastes bland, use seasoning, i.e. herbs, lemon, lime, ginger, garlic, soy sauce, honey, chilli, pepper, Worcestershire sauce or pickles.
  • Some drinks may taste different or be off-putting because of the smell or texture. Choose non-alcoholic alternatives or try a milkshake, fresh juice or hot chocolate.
  • Choose cold food or food at room temperature without a strong smell.
  • If cooking odours affect you, ask family or friends to cook.
  • If you have a bitter or metallic taste in your mouth, eat moist fruits such as berries or suck boiled lollies.
  • Try plain breakfast cereals with less added sugar such as porridge or bran flakes, instead of cereals with added dried fruit, honey or other sweeteners.
  • If meat is less appetising, try other protein sources, e.g. cheese, eggs, nuts, dairy foods or legumes.
Diarrhoea
  • Talk to your doctor if your stools are pale in colour, have bad odour, or float and are difficult to flush. This may be a sign that you do not have enough pancreatic enzymes. You may need to start enzyme replacement therapy or adjust your dose.
  • Talk to your doctor about anti- diarrhoea medication.
  • Drink plenty of liquids (e.g. water, fruit juice or weak cordial) to replace lost fluids.
  • Avoid fried or greasy foods.
  • Avoid alcohol and limit caffeine and spicy foods as these can make diarrhoea worse.
  • Try soy milk or lactose-reduced milk if you develop a temporary intolerance to the sugar in milk (lactose). This can sometimes occur when you have diarrhoea. Cheese and yoghurt in small amounts are usually okay.
Nausea
  • Talk to your doctor about trying anti- nausea medication.
  • Try snacks such as dry crackers or toast.
  • Try to eat a little bit at regular intervals – not eating can make nausea worse.
  • 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 peppermint or lemon-flavoured boiled lollies.
  • Try drinking ginger beer, ginger ale or ginger tea, or sucking on candied ginger.
  • See below for tips on dealing with vomiting.

Vomiting

Vomiting can occur as a result of the cancer or its treatment. For some people, just the thought of treatment or eating or the smell of food can make them feel unwell.

See your doctor if vomiting lasts for more than a day or if you can’t keep any fluids down, as you may become dehydrated. If you have persistent vomiting, the part of your body that connects your stomach to your small bowel may be blocked. This may be relieved with surgery.

How to cope with vomiting
Stage 1 – Small sips

Don’t try to force food down. Sip small amounts of liquid as often as possible. Try dry ginger ale, cold flat lemonade, weak cordial, cold apple or orange juice. Ensure fizzy drinks are flat before you drink them.

Stage 2 – Introduce drinks slowly

If the vomiting has stopped but you still feel nauseated, sip on drinks slowly in small frequent amounts. Start with cold or iced drinks. Prepare milk or fruit drinks with some water so they are not too strong. You can also try diluted fluids such as clear broth or weak tea.

Stage 3 – Introduce solid foods

Next, eat small amounts of solid foods, such as plain dry biscuits, toast or bread with honey or jam. Stewed fruits and yoghurt are also good. Aim to eat small regular food portions.

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 fatty 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.

Diabetes

Some people develop diabetes before pancreatic cancer is diagnosed or soon after surgery. Diabetes, or high blood sugar levels, can occur if your pancreas is not making enough insulin (a hormone responsible for regulating blood sugar levels).

The way diabetes is managed varies from person to person but usually includes a combination of dietary changes and medication. If needed, your doctor will advise you on medications and a dietitian will help you manage and change your diet.

Coping with diabetes
  • Eat small meals and snacks regularly to help control blood sugar levels.
  • If you are taking diabetes medication, you need to include high-fibre carbohydrate foods at everymeal to avoid low blood sugar levels. These include wholegrain breads and cereals, vegetables and fruit.
  • For more information about diabetes see diabetesaustralia.com.au

Pancreatic enzyme replacement supplements

The pancreas produces digestive enzymes to help break down the food you eat into basic nutrients that your body can use.

When you have pancreatic cancer, or have had pancreatic surgery, your body may not be able to make enough of these digestive enzymes. This affects the body’s ability to digest food, particularly fat and protein, and absorb vital nutrients. This is often referred to as pancreatic exocrine insufficiency (PEI). Signs of PEI include:

  • abdominal pain
  • bloating and excessive wind
  • diarrhoea or fatty bowel movements (stools) that are pale in colour, frothy, loose and difficult to flush
  • weight loss.
Taking enzyme supplements
  • Take supplements at the same time as food and drink to ensure adequate mixing.
  • Always take supplements with food and drink that contains fat or protein.
  • Slightly higher doses of enzymes may be needed if eating a high-fat meal, e.g. fried foods and pizza.
  • You don’t need to take enzymes for simple carbohydrates that digest easily, e.g. fruit, fruit juice, black tea and coffee.
  • Always take the dose as prescribed. Do not change the dose without talking to your doctor first.

Your doctor may prescribe pancreatic enzymes to help prevent these symptoms. Pancreatic enzymes are available in varying strengths. The dose will be based on, and adjusted to your individual symptoms and dietary intake. It may take time to get this balance right.

Often people who take pancreatic enzymes will also be prescribed acid-suppressing medicine. This medicine helps the pancreatic enzymes work properly.

Nutritional supplements

If you are not able to eat a balanced diet, or are experiencing unintentional weight loss, your doctor or dietitian may suggest that you take nourishing fluids and/or nutritional supplements.

Nutritional supplements such as Sustagen® Hospital Formula, Ensure® and Resource® contain energy, protein and other nutrients in a concentrated source. Nutritional supplements should be taken in addition to eating your usual meals, i.e. as snacks between meals. They are available as ready-made drinks or in powdered form to be mixed with milk or water.

Glucose powder supplements can also provide energy, but shouldn’t be used as a meal replacement as they don’t provide protein, vitamins or minerals. Glucose supplements may not be recommended if you have been diagnosed with diabetes.

Ask a dietitian where to buy the most appropriate supplement for you, and to advise you on the type and quantity.

Seeing a dietitian

Dietitians work in all public hospitals and most private hospitals. There may be a dietitian connected to your cancer treatment centre.

The Dietitians Association of Australia (DAA) can also help you locate an Accredited Practising Dietitian in your area, who specialises in cancer or has experience with particular clinical conditions.

Visit daa.asn.au or call them on 1800 812 942. Dietitians in private practice may also be listed in the Yellow Pages®.

If your doctor refers you to a dietitian you may be eligible for a Medicare rebate. Most private health insurers provide a rebate depending on your type and level of cover.

The DAA has information on the typical fee for private dietitian consultations.

Key points

  • Pancreatic cancer and its treatment can have a significant impact on eating and nutrition.
  • The impact of surgery and other treatments on what you can eat and drink will vary from person to person.
  • Some people will develop diabetes before pancreatic cancer is diagnosed or soon after surgery. Management usually requires a combination of dietary changes and medication.
  • If you develop pancreatic exocrine insufficiency (PEI), pancreatic enzymes will be needed to help you digest and absorb fats and proteins. Talk to a dietitian experienced in managing
  • Common nutrition related problems include poor appetite, feeling full quickly, nausea and vomiting, changes in taste, altered bowel patterns and poor PEI. digestion and absorption of food. These factors can contribute to significant unintentional weight loss.
  • It is important to eat a nourishing diet with regular meals and snacks. Often a diet high in energy and protein is required to prevent or minimise weight loss.
  • Dietitians are experts in nutrition who can give you advice on eating problems. They are found in most public and private hospitals.

Reviewed by: A/Prof Vincent Lam, Associate Professor of Surgery, Sydney Medical School & Hepatobiliary, Pancreatic and Transplant Surgeon Westmead Hospital, NSW; Dr Phillip Tran, Radiation Oncologist, Site Director, Sunshine Hospital Radiation Therapy Centre, VIC; Dr Victoria Atkinson, Senior Medical Oncologist, Division of Cancer Services, Princess Alexandra Hospital, QLD; Alison Keay, Upper GI Cancer Nurse Coordinator, WA Cancer & Palliative Care Network, WA; Belinda Steer, Clinical Lead Dietitian, Nutrition and Speech Pathology Department, Peter MacCallum Cancer Centre, VIC.
Updated: 01 Feb, 2016