Gastric Cancer Nutrition prior to surgery

More than 70% of patients with gastric cancer develop malnutrition, depleting muscle mass, slowing healing and limiting the immune system.

Part 1.  Working around nutrition problems during chemotherapy and radiation

The growth of any tumor within the stomach will limit intake and create problems with the digestion of food.  Unfortunately, malnutrition can begin early, since diagnosis can be delayed due to symptoms that are shared with other more common causes.  Complaints include feeling extremely full after small amounts of food and abdominal pain or heartburn.  Nausea and vomiting are inevitable when there is tumor blocking either the gastro-esophageal junction or gastric outlet.  Fatigue can result from iron deficiency anemia duet to problems with iron absorption.

Typical treatments include a combination of chemotherapy and radiation prior to surgery, and may be given after surgery as well.  Side effects include inflammation, pain, nausea and vomiting which can further reduce the ability of patients to eat and maintain their weight.

Recommendations and strategies that may help you eat better, avoid excess loss of weight and muscle and stay on treatment:

• Schedule 5 – 6 times to eat each day to make up for the smaller volumes eaten. The physical capacity of the stomach is reduced by the tumor and later by surgery.  Without a system of reminders to eat every 2 ½ to 3 hours, these opportunities are often missed, and unfortunately, the limited volumes tolerated by the stomach make it impossible to make it up at a later meal.  Cell phone alarms work quite well, as we keep them nearby.
• Choose softer foods. The stomach usually breaks down solid foods into smaller pieces through muscular contractions and acid secretion, but both can be limited by the cancer. Consider foods that are pre-processed like shredded meats, canned or cooked fruits and vegetables.  Take advantage of foods that are already in a soft/“pureed” texture, like fish, refried beans, most dairy products, eggs, mashed potatoes, winter squash.
• Make it slick. Moister foods, or those with gravies and sauces spread taste through the mouth, increasing acceptability.  They also slide down easier.
• Make it easy. There are many prepared foods that will work for you, so tour the aisles of the grocery store with your goals in mind. Frozen/prepared pasta dishes, mini-quiche, and microwavable mashed potatoes, soups and breakfast dishes are available. Friends and family often offer their help which can be coordinated through websites like mealtrain.com or lotsofhelpinghands.com.  Provide the recipes so you’re sure you will like the dish that arrives.
• Include liquid calories. They slip through narrow openings and are less likely to distend the walls of the stomach.  There are many options including the usual milk-like oral supplements which are usually lactose free, if that is a concern.  Choose the “plus” versions for an extra 100 calories and higher protein levels.  Where milk is tolerated, many enjoy Carnation Instant Breakfast powder, stirred in and adding 130 calories.  Scandishakes will add 440 calories and are well liked.  Clear liquid drinks include Boost Fruit Breeze and Ensure Clear, which some people also enjoy mixed with carbonated clear sodas.  In the produce area of the grocery store, fruit based drinks such as Odwalla, Naked Juice and Bolthouse Farms make protein containing versions that add some variety to your choices. All of these can be used as a base for smoothies, which should always include some source of protein.
• Create a list. It can be stressful to come up with ideas for what to eat at the moment that you need to make a choice. Creating a list of options for your refrigerator (or wallet) can help. It avoids problems with falling back on the same thing over and over, which can lead to “burning out” (never wanting to see that particular food again).  Including the “extras” that add calories can help make sure each bite counts, by reminding you to add the cheese when you warm up refried beans or scramble an egg, or walnuts or peanut butter to the oatmeal.  Include ideas for days when you struggle, so you can always choose something off the list.  Use the list when making shopping lists, so foods are available to you when you want them.
• Adjust your list by tolerance. Never cross something off your list until it has failed you more than twice.  However, if you notice that higher fat or high fiber foods cause food to “sit” on the stomach for long periods of time, you may try lowering the content of fat/fiber in the food you eat and see if that is helpful.  Journaling can help you see patterns.
• Keep food safe. Many patients with gastric cancer will be on acid suppressive therapies or have less secretion of acid as the result of their cancer.  Without acid in the stomach, you have less protection from bacterial contamination in food.  Be careful to take precautions to keep food safe: avoid letting food sit at room temperature (keeping it cold or hot), washing your hands frequently, and avoiding cross contamination by keeping surfaces clean and using separate cutting boards for raw meats and foods that won’t be cooked.  Be cautious with self-service salad bars and high risk foods.  Use left overs within 48 hours.
• Talk to your team about anything that is getting in the way of eating. They will have some solutions if you are having problems with nausea/vomiting, constipation, dehydration, sleeping, or anything else that is limiting your ability to eat.  They can guide you about over the counter and prescriptions that are available to help, or schedule you for IV fluids or other procedures to deal with the problems.  Waiting never resolves anything!