Nutrition for Patients with

Cancer or HIV/AIDS
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 CANCER

The relationship between nutrition and cancer is multifaceted:

• One-third of all cancer deaths are related to dietary factors.
such as eating substances that may promote cancer or failing
to eat foods that may protect against cancer.
An estimated 14% to 20% of all cancer-related mortality in the
United States is related to overweight and obesity.
A diet that provides a variety of fruits and vegetables, whole
grains, and fish or poultry or is lower in red and processed
meats is associated with a lower risk of developing certain
cancers or dying from cancer.

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• The local effects of tumors, particularly those of the gastrointestinal
(GI) tract, can impede eating. For instance, head and neck cancers
can interfere with swallowing.
• Tumor-induced changes in metabolism can alter nutrient absorption
or metabolism. Thus, it is possible for people with cancer to eat an
adequate calorie intake and still lose weight.
• Cancer and cancer treatments can cause anorexia from a variety of
factors, such as pain, depression/anxiety, early satiety, fatigue,
nausea, loss of taste, sore mouth, dry mouth, thick saliva, or
esophagitis. Anorexia can lead to weight loss, malnutrition, and poor
prognosis.
• Adequate nutrition during the course of cancer treatment may
improve tolerance to treatment, enhance immune function, aid in
recovery, and maximize quality of life.
• Diet and lifestyle interventions can improve long-term outcomes for
cancer survivors.

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Nutrition in Cancer Prevention and Promotion

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 The Impact of Cancer on Nutrition

• Cancer impacts nutrition through local effects caused by the

tumor and by altering metabolism.
• It has been shown that at the time of diagnosis, 80% of
patients with upper GI cancer and 60% of patients with lung
cancer have already experienced significant weight loss,
defined as a loss of at least 10% of body weight in 6 months.

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Local Tumor Effects:
• Local tumor effects occur when the tumor impinges on
surrounding tissue, impairing its ability to function.
• The effects vary with the site and size of the tumor and are
most likely to impact nutrition when the GI tract is involved
(Table 22.2).
• GI obstruction can cause anorexia, dysphagia, early satiety,
nausea, vomiting, pain, or diarrhea, leading to weight loss and
malnutrition.

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Metabolic Changes:
• A cascade of metabolic changes resulting from the effects of the tumor, the
body’s response, and the host–tumor interaction can lead to cancer cachexia
(a wasting syndrome associated with cancer characterized by progressive loss
of body weight, fat, and lean body mass.
• Tumor cells can produce proinflammatory and procachectic factors that
stimulate inflammation and the breakdown of body protein and fat. The body
responds with inflammatory and endocrine changes.
• The interplay between tumor and host leads to a systemic inflammatory
response.
• The catabolic state is characterized by insulin resistance, decreased muscle
protein synthesis, increased body protein turnover, and accelerated fat
breakdown. Weight loss and anorexia occur, and cachexia results.
• Other signs and symptoms include reduced muscle strength, fatigue, and
altered biochemistry, such as anemia and hypoalbuminemia.
• Cachexia is associated with decreased quality of life, poor physical function,
and poor prognosis.

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 The Impact of Cancer Treatments
• Cancer treatments include surgery, chemotherapy, radiation,
immunotherapy, hemopoietic and stem cell transplantation, or a
combination of therapies.
• Each treatment modality can contribute to progressive nutritional
deterioration related to localized or systemic side effects that
interfere with intake, increase nutrient losses, or alter
metabolism.
• Nutritional therapy, used as an adjuvant to effective cancer
therapy, helps to sustain the client through adverse side effects
and may reduce morbidity and mortality.
• Conversely, inadequate nutrition can contribute to the incidence
and severity of treatment side effects and increase the risk of
infection, thereby reducing the chance for survival.

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Surgery:
• Surgery is often the primary treatment for cancer.
• People who are malnourished prior to surgery are at higher
risk of morbidity and mortality. If time allows, nutritional
deficiencies are corrected before surgery.
• Postsurgical nutritional requirements increase for protein,
calories, vitamin C, B vitamins, and iron to replenish losses
and promote healing.

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Chemotherapy:
• The most commonly experienced nutrition-related side
effects are anorexia, taste alterations, early satiety, nausea,
vomiting, mucositis/esophagitis, diarrhea, and constipation.
• Side effects increase the risk of malnutrition and weight loss,
which may prolong recovery time between treatments.
Radiation:
• Patients most at risk for nutrition-related side effects are
those who have cancers of the head and neck, lungs,
esophagus, cervix, uterus, colon, rectum, and pancreas.

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Immunotherapy:
• Immunotherapy seeks to enhance the body’s immune system
to help control cancer.
• The most common side effects include fever, which increases
protein and calorie requirements, and nausea, vomiting,
diarrhea, and fatigue.
• Left untreated, symptoms can cause weight loss and
malnutrition, which impedes recovery.

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Hemopoietic and Peripheral Blood Stem Cell Transplantation:
• Hemopoietic and stem cell transplants are preceded by high-
dose chemotherapy and possibly total-body irradiation to
suppress immune function and destroy cancer cells.
• Nutritional side effects arise from high-dose chemotherapy,
total-body irradiation, and immunosuppressant medications,
which are given before and after the procedure.
• Anorexia, taste alterations, nausea, vomiting, dry mouth, thick
saliva, constipation, stomatitis, and esophagitis may occur.
• Intestinal damage may cause severe diarrhea and
malabsorption.

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• When an oral diet resumes, a liquid diet restricted in lactose,
fiber, and fat is given to minimize malabsorption and improve
tolerance. Solid foods are gradually reintroduced.
• Neutropenia leaves the patient susceptible to infection, so
precautionary measures must be taken to prevent foodborne
illness.

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• Initially, most fresh fruit and vegetables and ground meats
may be excluded to reduce the risk of foodborne illness.
• A high-protein, high-calorie, high-calcium diet is needed to
counter the negative nitrogen and calcium balances caused by
immunosuppressant medications.

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 Nutrition Therapy During Cancer Treatment

The goals of nutrition therapy for people being treated for

cancer are to:
• Manage weight.
• Maintain lean body mass.
• Prevent or reverse nutrient deficiencies.
• Maximize quality of life.

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Calories and Protein:
• Calorie needs may range from 25 to 30 kcal/kg for
nonambulatory or sedentary adults to 35 kcal/kg or more for
hypermetabolic or severely stressed patients.
• Protein needs range from 1.0 to 2.5 g/kg.

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 NUTRITION AND IMMUNODEFICIENCY

• Good nutrition is important for immune system functioning. For

instance, protein and various micronutrients are involved in the
synthesis of enzymes, complement, antibodies, and other proteins
important in immune system functioning. Malnutrition can impair
immune system function and the ability to fight infection.
• Infection can impair nutritional status by causing inflammatory,
hormonal, and immune responses that increase metabolic rate
and nutrient requirements, promote loss of lean body tissue, cause
anorexia, and alter nutrient storage and availability. Infections in
the intestines can lead to diarrhea, malabsorption of nutrients,
blood loss, and damage to the intestinal lining. Severe infection
increases the risk of malnutrition.

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• HIV-related wasting syndrome, an AIDS-defining medical
diagnosis, is defined by the CDC as unintentional weight loss
of more than 10% of baseline weight plus either diarrhea or
chronic weakness and fever for more than 30 days without a
known cause.
• Rapid or significant weight loss may be a risk even if BMI stays
within the normal range.
• Wasting causes a loss of both lean body mass and fat.
• Despite major advances in the treatment and survival of
people living with HIV and AIDS (PLHA), the incidence of
wasting syndrome appears to have held steady.

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• Observations suggest that weight loss or wasting occurs in
more than 30% of HIV-infected patients regardless of anti-HIV
treatment.
• Although ART (antiretroviral treatment) has significantly
improved morbidity and mortality related to HIV infection, it
has not eliminated the issue of weight loss.
• All people who are HIV positive, including those treated with
ART, are at risk for wasting.
• Like cancer cachexia, the etiology of HIV-associated wasting is
multifactorial and not completely understood.

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• Contributing factors may be decreased intake related to nausea,
anorexia, mouth infections, or fatigue.
• Diarrhea and malabsorption of nutrients decrease nutrient
availability.
• Opportunistic infections or malignancies may also contribute to
altered metabolism and weight loss, although they are not the
major cause of wasting in PLHA.
• Excessive production of cytokines has also been implicated in
HIV-associated weight loss.
• Although the majority of weight loss currently seen in PLHA
cannot be explained, impaired intake and altered metabolism
may be at least partially responsible.

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 Impaired Intake

Results from the Nutrition for Healthy Living Cohort study show that
impaired intake among PLHA may be related to diet itself, GI
symptoms, or malabsorption and GI dysfunction. For instance,
• Men in the lowest CD4 cell count percentile need the most calories
per kilogram of body weight to maintain a lower BMI, yet their total
daily calorie intake was not different than that of men of similar age
in the general population. This suggests that nutritional need is high
and intake falls short.
• Episodes of acute weight loss, defined as 5% of body weight, were
associated with oral symptoms and difficulty swallowing but not
anorexia. Even in the absence of an opportunistic infection, many
people may have GI symptoms related to HIV infection or HIV
medications that increase the risk of weight loss.

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• Eighty-eight percent of the cohort had at least one
abnormality in GI function, such as malabsorption. Because
malabsorption can occur in the absence of diarrhea,
malabsorption cannot be excluded on the basis of normal
bowel patterns alone. Uncorrected, malabsorption can lead to
malnutrition, wasting, and impaired quality of life.
• In many cases, socioeconomic factors, not clinical factors, may
be blamed for poor intake. Almost 8% of participants did not
have access to adequate food.

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 Changes in Metabolism

• Resting energy expenditure (REE), the amount of calories used to

fuel the involuntary activities of the body, increases in people
with HIV/AIDS who are asymptomatic and untreated.
• Viral load and ART have also been found to independently
increase REE.
• Significant decreases in caloric intake may be a more important
factor in weight loss than the increase in REE.
• HIV lipodystrophy is a metabolic alteration characterized by
changes in the distribution of body fat and metabolism.
• Most commonly, subcutaneous fat loss occurs in the face,
extremities, and buttocks; fat accumulation may be seen at the
back of the neck and trunk.

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• Lipodystrophy may also cause insulin resistance,
hypertriglyceridemia, and excess fat in the liver and skeletal
muscle and is associated with increased REE.
• ART is implicated in its development, although the exact cause
is not clear. Factors affecting risk include age, gender,
genetics, length of time the patient has been HIV positive, and
severity of the disease.

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 Nutrition Therapy

• Nutrition therapy for PLHA seeks to meet the client’s nutrient

needs, alleviate symptoms, and manage complications of the
disease or medication intolerance.
• Although scientific knowledge about the role of nutrition in
HIV is incomplete, it is apparent that the nutrient needs of
PLHA differ from those of noninfected people, even before
the onset of symptoms (e.g., weight loss).
• There are no unanimously agreed upon recommendations for
calories or nutrients despite the universal goals of maintaining
body weight and lean body mass.

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 Calories

• Calorie recommendations from HIV Research of the Nutrition

Infection Unit at Tufts
• University School of Medicine are as follows (the “normal”
healthy adult standard commonly used is 30 kcal/kg):
■ 37 to 45 kcal/kg if the client’s weight is stable and there are no
secondary infections
■ 45 kcal/kg if the client has an opportunistic infection
■ 55 kcal/kg if the client is losing weight

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 Protein

• Adding protein may be beneficial in maintaining or building

lean body mass.
• 1.2 to 2.0 g/kg/day of protein may be needed, an increase
above the normal Recommended Dietary Allowance (RDA) of
0.8 g/kg/day.

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 Fat
• Because PLHA may have lipid abnormalities, a low–saturated
fat diet, not a low–total fat diet, may be beneficial.
• A heart-healthy diet with monounsaturated fats and omega-3
fatty acids may help reduce the risk of cardiovascular disease.

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 Vitamins and Minerals

• Observational studies suggest that low blood levels and

inadequate intakes of some vitamins and minerals are
associated with faster HIV disease progression and mortality.
• Nutrient deficiencies may occur from poor intake,
malabsorption, infections, or diet–medication interactions. In
general, dietary intake of micronutrients at RDA amounts is a
reasonable recommendation for people with clinically stable
disease.

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• Clients with HIV/AIDS may experience problems with appetite
and intake similar to those of cancer clients.
• Nutrition therapy and exercise may help reverse some
changes in body shape and improve the metabolic
abnormalities of glucose intolerance, hypertriglyceridemia,
and hypercholesterolemia.
• Because PLHA have compromised immune systems, steps
should be taken to reduce the risk of foodborne illness.

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