Dietetics A

Question	Answer
Definition of OC	Cancer of the oesophagus classified as: 1. squamous cell carcinoma (SCC) (cancer that begins in flat cells lining the esophagus) 2. adenocarcinoma (cancer that begins in cells that make and release mucus and other fluids).
Incidence rates of OC	8,332 new cases diagnosed each year in the UK 13th most common cancer 15% 5 year survival 2:1 male to female ratio Survival rate at 1 year is 42% and at 10 years is 12%.
Risk factors of OC	Adenocarcinomas risk factors: Smoking, ↑ BMI, ↓fresh fruit and vegetables, GORD SCC risk factors: ↑ Alcohol, ↓ fresh fruit and vegetables. ↓BMI
Symptoms of OC	Progressive dysphagia Pain - Retrosternal Weight loss Also, acid reflux, coughing up blood, hoarseness or chronic cough
Nutritional implication of OC	Malnourishment Risk: Due to- poor dietary habits Site of cancer Process & treatment of cancer Hammerlid et al. (1998) - 50-75% experience moderate-severe malnutrition
Treatment of OC	Dependent on type and location of cancer, stage of the disease (I, II, III, IV), fitness of patient, and patient choice Stage I & II - Single modality treatment (Surgery or radiotherapy) Stage III & IV - Multimodality therapy (Surgery, radiotherapy & chemo) Radical: 2 cycles of chemo then surgery (oesophagectomy, possibly with partial gastrectomy) or radiotherapy with further chemo (chemoradiotherapy seen as gold standard in advanced cancers. Chemo doses dependant on BMI - if malnourished, optimal dose not given! If small tumour with no nodal disease can go straight for surgery. Palliative: 4-6 cycles of chemo, scan at 4 cycles. Stents mainly used as a palliative measure although occasionally a biodegradable stent may be used whilst patient is having radical treatment.
Nutritional effects of Tx	Tx can have permanent effects on organs of head & neck eg. eating & drinking (NICE 2004) Surgery: oral nutrition (taste & smell changes, aspiration, fistulae) Patients report wt. loss prior to radiotherapy & additional 10% body wt. loss from radiotherapy
Dietetic management of OC	Dependant on whether they are for radical or palliative care. Whether they are having surgery (with neoadjuvant chemo) or chemoRT or palliative RT. And how big the tumour is i.e. how dysphagic the patient is. Dysphagia- modified texture diet, ensure adequate nutrition, may require ONS or EN, if total dysphagia would require EN (PN in mean time if unable to place quickly or get NGT down) or stent. Stent dietary advice. Nutritional support required due to dysphagia, or appetite loss, leading to reduced oral intake and weight loss. Decreased appetite- small frequent meals, avoid fluids pre/with meals, avoid fizzy drinks, make the most of best times of day and foods that do fancy, small amount of alcohol to increase appetite, steroids may be appropriate, advice for weight loss may need to be considered. Decreased weight- small frequent meals, food fortification, high kcal/protein foods and drinks, full fat products, ONS if not meeting nut. req. EN can be used but in common practice it is used more for dysphagic patients.
Risk factors of GC	Helicobacter pylori Genetic Diet - ↑salt, nitrates and ↓fruit and vegetables Tobacco Acid reflux NSAIDS Increased BMI (adenocarcinoma) Previous peptic ulcer surgery Environmental
Treatment of GC	Dependent on: Stage Size Location Patient condition Radical - Surgery (partial/total gastrectomy) + chemo (neoadjuvant & adjuvant) Palliative - chemo Some radiotherapy Recent - targeted therapy (Herceptin)
Nutritional Implications of Tx in GC	Wt. loss & malnutrition due to: Small stomach syndrome (Early satiety) Dumping syndrome vomiting bile Diarrhoea Steatorrhoea Malabsorption (esp. Pr & Fat(Fat soluble vits)) Iron Deficiency Anaemia (IDA) - Poor Fe intakes & absorption
Dietetic Management of GC	Small freq. Reg. meals meals/fluids separately nutrient dense non-bulky foods (milk, dairy, meat, eggs)
Incidence of PC	10th most common in UK 5th most common cause of cancer death UK 80% unresectable at diagnosis - 3% survival rate at 5yrs - disease usually diagnosed too late stage
Risk Factors of PC	++Alcohol ++BMI (central adiposity) Chronic pancreatitis Stomach ulcers Diabetes IBD & other cancer
Evidence of effective tx for Crohn's	Dignass et al. (2010) Not enough evidence for n-3 FA, probiotics, Enteral nutrition for tx Efficacy of medication well established
Aetiology of Crohn's	Autoimmune response to GI bacteria
Diagnosis considerations of Crohn's	more difficult in Crohn's disease than ulcerative colitis, since symptoms (such as pain or diarrhoea) may be due to causes other than active disease. Considerations for symptoms: enteric infection, abscess, bacterial overgrowth, bile salt malabsorption, dysmotility (IBS), gall stones IDA - symptoms of fatigue or lethargy
Incidence rates of Crohn's	1 in 1000 UK Prevalent in children & young adults
Micronutrient deficiencies in Crohn's	Fat malabsorption & fat Vit deficiencies Vit B12 Vit D & calcium - Steroids Iron, Mg, K, Phosphate
Risk factors associated to Crohn's	Cause remains unknown Genetic predisposition - 10 fold in 1st degree relitives Environmental triggers Smoking - 65% reduction relapse risk in cessation vs cont. smokers
assessment of Crohn's	HBI - Harvey Bradshaw Index <3 = remission >6 = active & relapse
Dietary management of IBD	Achieve & maintain good nutritional status during active disease & remission Alleviate clinical symptoms in combination with med/surgical tx Achieve remission when EN used as primary or combination tx
recommended Ca intakes in IBD	1000mg/day (Lewis & Scott, 2007)
Remission maintenance with diet	LOFFLEX diet Less time consuming than elimination diet symptomatic foods reported >5% Crohns pt. excluded Basic diet followed - 2-4wks gradually introduce foods while maintaining remission/symptoms
EN in UC	not used
Signs & symptoms of Coeliac disease	Abdo pain, cramping or distension chronic or intermittent diarrhoea faltering growth in children fatigue IDA nausea or vomiting wt. loss
Symptoms resulting from chronic malabsorption in Coeliac	Tiredness Irritability Depression Breathlessness Anaemia Oedema Abdo. discomfort GI upsets unexplained wt. loss mouth ulcers bone disorders infertility dental enamel defects neurological symptoms
Diagnosis of Coeliac	Serological testing - EMA & TTGAs (NICE, 2009) Normal diet including gluten in 1 meal/day for 6wks before testing. IgA deficiency can show false negative - IgG testing 1st for IgA deficient pt. Then tests for EMA & TTG. If EMA +ve referral for duodenal biopsy, if only TTG +ve = further investigation.
Stages of damage in Coeliac disease	Marsh Classification (1992) 0: Normal Mucosa 1: increased intraepithelial lymphocytes 2: increased lymphocytes & crypt depth 3: partial or complete villous atrophy (common) 4: villous atrophy without lymphocytes (rare)
Associated conditions with Coeliac disease	malignant small intestinal lymphoma - non Hodgkin's Lymphoma (risk reduced to general pop. after 5yrs GF diet adherence) increased risk of small bowel adenocarcinoma decreased risk of breast cancer (Van Heel & West, 2006) Osteoporosis (NICE, 2009)
Osteoporosis risk factors related with Coeliac disease	Late diagnosis chronic Ca malabsorption prior diagnosis reduced Ca intake post diagnosis - GF diet (bread & cereals contribute ~30% Ca intakes - Henderson et al, 2003) Lactose intolorance Low BMI lapse from GF diet Villous atrpohy
Ca recommendations in Coeliac	BSG (2007) - 1000-1500mg/day in adults non for children
Coeliac disease and T1DM	common genetic predisposition (HLADQB1 present in majority of both people) ~2-10% coeliac have T1DM T1DM with GI disturbances or ?anaemia - poss coeliac
Conditions linked with Coeliac disease	Grave's (Hyperthyroidism) Hashimoto's thyroiditis (Hypothyroidism) Abnormal liver function (++transaminase) Biliary cirrosis Down's syndrome Dermatitis herpetiformis
Management guidelines for CD	Children - BSPGHAN (2006) Adults - BSG (2010)
Dietary management of CD	GF Diet advice from dietitian experienced in CD (BSG, 2010) Exclusion of all dietary gluten education on naturally GF foods GF alternatives balanced diet which maintains health and prevent/manage associated diseases esp. osteoporosis Coeliac UK advice
COdex GF	Foods containing <20ppm gluten
Coeliac dietetic consultation	explanation of the disorder diet history information on Coeliac UK gluten-free foods - prescribable / non-prescribable season ticket for prescriptions letter to GP including estimation of prescription

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