Nutrition of the HSCT patient:

a specific nursing challenge

Sónia Velho
Instituto Português de Oncologia
Francisco Gentil, Lisboa, Portugal

Arno Mank
Academic Medical Centre
Amsterdam, Netherlands
 PROGRAM

z Sónia
{ Nutrition before HSCT
z Nutritional Screening and assessment
{ Nutrition during HSCT
z Dietary counselling
z Artificial nutrition
z Specialized nutrition
{ Nutrition after HSCT
z Arno
{ Bacterial translocation
{ Low bacterial diet
{ Gastrointestinal complications
{ GVHD
{ Social and psychological aspects
{ Education
z Workshop
 BEFORE
HEMATOPOIETIC STEM CELL TRANSPLANT

1. Nutritional assessment: Why and how?

NUTRITIONAL RISK ASSESSMENT: WHY?

z Conditioning therapy has deleterious

consequences on the integrity of the
gastrointestinal tract:
{ Anatomical and functional

z Allogeneic HSCT patients

{More persistent symptoms due to probable GVHD

Increased risk of malnutrition

 NUTRITIONAL RISK ASSESSMENT: WHY?

z Patients with hematologic malignancies are usually well

nourished

Impaired nutritional status

before transplantation is a
negative prognostic factor for
HSCT outcome

White M and col, BMT (2005) 35,775-9

 NUTRITIONAL RISK ASSESSMENT: HOW?
Nutritional
Screening
Nutritionist /Dietist or
Nutrition Support Team

Malnutrition Universal
Screening Tool- MUST Nutritional Assessment
•Unintentional weight loss?
•Body Mass Index?
•Dietary intake? Nutritional Intervention

Davies M, Eur J Oncol Nurs (2005), 9:S64-7

 NURITIONAL ASSESSMENT: HOW?

z History (medical, dietary, social)

z Physical examination

z Body composition assessment (DEXA, Oxide

deuterium, BIA, Subjective Global Assessment-
questionnaire, anthropometry)

z Biochemical index (blood, urine)

Davies M, Eur J Oncol Nurs (2005), 9:S64-7

DURING CONDITIONING REGIMEN AND
ENGRAFTMENT PERIOD

1. Aims of nutritional support

2. Strategies for nutritional support:
o Dietary Counseling
o Artificial nutrition support
o Specialized nutrition support
 AIMS OF NUTRITIONAL SUPPORT
z Maintenance of nutritional status

z Adequate and specialized nutrition may also:

{ Improve tolerance to chemotherapy
{ Prevent and reduce mucositis
{ Reduce septic complications
{ Modulate the biological response
 STRATEGIES FOR NUTRITIONAL
SUPPORT

z Nutrition support
{Tailored for each patient

z Strategies:
{ Dietary counseling
{ Artificial nutrition

{ Specialized nutrition
 DIETARY COUNSELING
z Low bacterial diet (discussed later in this
presentation)

z Modification of foods:
{Food preferences
{Eating ability
{Symptoms

z Oral nutrition supplements (hyper caloric,

lactose free, hyperproteic, etc)

Our experience...
First days in the Unit:

“ I really enjoyed my meal…”

After a few days:

“I have no appetite, everything tastes funny...I can’t stand

the smell of food!”
Food supplements: “I don’t like the
taste of food supplements, they’re
too sweet…”
 ARTIFICIAL NUTRITION SUPPORT (ANS)

1. Can the patient eat? Diet ± Supplements

2. Evaluate intake
3. Insuficient (< 50%) vs sufficient (>50%)

•Duration
Monitor
•Nutritional status
Consistenly low
•Disease severity ?

Artificial Nutrition
Planas M and col, Clinic Nutr (2002) 21(4):355-61
 TIMING OF ARTIFICIAL NUTRITION
Risk factores Early < 3 days Delay <7-10 days
Age Children Adult
Sex Male Female
Diagnosis Chronic Acute
Disease High Low
severity index
Nutritional Malnutrition/obesity Adequate
Status
Weight loss Acute Slow
Previous 50% 50-75%
nutrient intake
Planas M and col, Clinic Nutr (2002) 21(4):355-61
 ARTIFICIAL NUTRITION SUPPORT (ANS)

Timing of ANS
and
Enteral/Parenteral nutrition Nasogastric tube

TPN PPN

• Less well defined aspects Gastrostomy

tube

• Different practices in HSCT Jejunostomy

tube
units

Planas M and col, Clinic Nutr (2002) 21(4):355-61

 ENTERAL NUTRITION
z Integrity and functional GI status?
{ OK

z Indications:
{ ↓ Oral intake
{ Nutrient repletion
{ Support during transition phase after parenteral nutrition

z Contraindications:
{ Intestinal obstruction
{ High risk of aspiration
{ Severe uncontrolled diarrhea
{ Vomiting Frequent in HSCT pts
 ENTERAL NUTRITION COMPLICATIONS

z Mechanical z Metabolic
{ Nasopharyngeal mucosa { Dehydration
erosion { Glucose intolerance
{ Tube misplacement { Hipo/hiperkalemia
{ Aspiration pneumonia
{ Hipo/hipernatremia
{ Obstruction
{ Hipophosphatemia

z Gastrointestinal
{ Nausea
{ Vomiting
{ Diarrhea
{ Abdominal pain
{ Abdominal distention
 PARENTERAL NUTRITION
z Integrity and functional GI status?
{ Not OK

z Indications:
{ Perioperative support
{ Short bowel syndrome
{ Severe pancreatitis
{ Mechanical intestinal obstruction
{ Severe malabsorption
{ Hyperemesis Frequent in HSCT pts

z Contraindications:
{ Prognosis not consistent with agressive nutrition
{ Risks overweigh benefits
PARENTERAL NUTRITION COMPLICATIONS

z Metabolic z Septic
{ Abnormalities in liver { Catheter (contaminated by
function tests, namely a remote source or primary
SGOT, SGPT, bilirubin, source of infection)
alkaline phosphatase
{ Hepatic steatosis z Technical
{ Cholestasis { Associated with catheter
{ Bacterial translocation insertion
{ Hyperglicemia { Phlebitis
{ Refeeding syndrome
{ Hyperlipidemia
{ Dehydratation/fluid
overload
 ARTIFICIAL NUTRITION SUPPORT

z Extensive use of Parenteral Nutrition (PN):

{ Severity of gastrointestinal toxicity
{ Availability of central venous access

z PN is associated to:
{ Better nutritional status compared with oral diet with
simultaneous IV hydration
{ Higher rate of infection, costs and hospital stay

Lipkin A and col, Nutr Clinc Prac (2005), 20:423-39

 Parenteral (PN) vs Enteral Nutrition (EN)

z ESPEN guidelines: PN during BMT

z Recent data suggest that EN may overcome
risks associated to PN
{Enhancement of gut-barrier function
but
{Insufficient data that supports EN

Arends J et al, Clinic Nutr (2006) 25:245-259;Lipkin A and col, Nutr Clinc Prac (2005), 20:423-39
Parenteral vs Enteral Nutrition

{EN can be challenging:

zDislodgement of nasal tubes (vomiting),
zDelayed gastric emptying,
zInfections at gastrostomie tube sites,
zInability to feed in the presence of large volume
diarrhea post conditioning or GVHD
zThrombocytopenia and/or neutropenia

Artificial nutritional support should not be a

standard procedure
 ARTIFICIAL NUTRITION SUPPORT

PN is not clearly superior to individualized

enteral feeding

Szeluga DJ and col, Cancer Res (1987), 47:3309-16

 SPECIALIZED NUTRITIONAL SUPPORT

z Glutamine

z Antioxidants (vitamin E, A and β Carotene)

z n-3 Fatty acids (Eicosapenthaenoic acid)

 GLUTAMINE
z Major subtract used by cells of the GI
epithelium and the immune system

z Effect on:
Blood count recovery?
Mucositis?

z Previous studies in HSCT patients:

{ IV glutamine
{ Oral glutamine
{ Glutamine suspension and mucositis

Contradictory data
Ziegler T, BJ Nut (2002),87, Suppl. 1 S9-S15;Anderson PM e col, BMT (1998), 22, 339-44
 ANTIOXIDANTS

Chemotherapy and radiation therapy are associated with:

↑ Oxygen species
↓ Plasma and tissue antioxidants

↑ Oxygen species → Oxidative stress → Cellular injury

Antioxidants supplementation during HSCT?

INCONCLUSIVE

Jonas C et al, Am J Clin (2002) 72:181-9

Jonas C et al, Am J Clin (2002) 72:181-9
 EICOSAPENTHANOIC ACID (EPA)

• Anti-inflammatory

• Complications of HSCT are related to

systemic inflammatory response
syndrome

Suppression of inflammatory cytokines (TNFα, IFN),

prevention of vascular endothelial damage

16 Consecutive HSCT patients: 1,8g/day of EPA; 3 weeks before till Day + 180
↓ leucotriene B4, tromboxane A2, prostaglandin I2 (p<0,01)
↓ TNFα, IFN, IL10 (p<0,05)
↑ Survival rate (p<0,01)
Muscaritoli M and col Am J Clin Nutr (2002), 75:183-90;Takatsuka H et al BMT (2001) 28, 769-774
 POST-TRANSPLANT
(AFTER RECOVERING BLOOD COUNTS)

1. Survival
2. Body Composition
 AFTER HSCT
z ↑ Mortality:
{ Day +150; pts with weight < 85% or 85%-95% of their ideal weight

z ↓ Lean body mass:

{ 4-6 years post-HSCT, 38% of pts were below pre- HSCT lean body
mass index
Fatigue? Daily living? Quality of life?
z ↑ Body fat:
{ Pts treated with cranial irradiation: Body fat percentage was
increased
Increased risk of other diseases? Diabetes? Dislipidemia?

Kyle et al BMT (2005), 35: 1171-7,Nysom K BMT(2001), 27:817-20,Deeg HJ and col BMT (1995) 15, 461-68
 CONCLUSION

z Nutritional screening is important for

identification of patients at nutritional risk

z Patients at risk should be assessed by a

Nutritionist /Dietist → Individualized Nutrition
Support Plan

z Artificial Nutrition should be used according to

individual needs
 CONCLUSION

z More studies are warranted to clarify the role of

specialized nutrition in HSCT

z HSCT can change substantially body

composition:
{Reduction in strength,
{Effects on health status and
{Possibly negative influence on quality of life
 PROGRAM

z Sónia
{ Nutrition before HSCT
z Nutritional Screening and assessment
{ Nutrition during HSCT
z Dietary counselling
z Artificial nutrition
z Specialized nutrition
{ Nutrition after HSCT
z Arno
{ Bacterial translocation
{ Low bacterial diet
{ Gastrointestinal complications
{ GVHD
{ Social and psychological aspects
{ Education
z Workshop
 BACTERIAL TRANSLOCATION
z Bacteria in the gastrointestinal tract can travel
through the mucosa to infect the mesenteric lymph
nodes and body organs

z Bacterial overgrowth, immunosuppresion, physical

disruption of the gut, slowed peristalsis, trauma and
endotoxemia contribute for bacterial translocation
 BACTERIA FOUND IN FOODS

z More commonly reported bacteria found in

foods:
{E. Coli, Pseudomonas Aeruginosa, Klebsiella (fresh
fruits and vegetables);
{Other pathogens: Enterobacter agglomeran,
Enterobacter colacae, Citrobacter, Salmonella,
Shigella, Campylobacter;
{Aspergillus (food, water and ice)
 Sterile diet or low risk
immunosuppressed diet?

{ Sterile diet- foods with no bacteria and fungal growth

{ Low- microbial diet- pathogen containing foods are
eliminated

Different practice in all HSCT Units

 FOOD SAFETY/ ACCEPTABILITY:
OUR EXPERIENCE

Sterile Diet Symptoms

Altered Anorexia
consistency
Altered taste
Different taste
Nausea
Odor

↓ dietary intake, ↑nutritional impairment

European Questionnaire on Low Bacterial
Food (on behave of the EBMT)
N= 108
z most of the hospitals use guidelines
z have a dietician connected to the ward (77%)
z The way and who patients are informed is well
organised.
z 1 hospital use no low bacterial diet
z 3 hospitals use
a very mild from of diet

(accepted) Mank, A.P., Davies, M. Examining Low Bacterial Dietary Practice: A European
Survey on Low Bacterial Food European Journal of Oncology Nursing. 2008
Are there guidelines during hospitalisation/ After discharge?

100
90
80
70
60
Autologous
50
Allogeneic
40
RIST
30
20
10
0
During After
Under which conditions does the guideline suggest that
low bacterial food should be given?

40
35
At admission
30
As chemotherapy
25
is started
20 As certain blood
value is reached
15
As preventive
10 antibiotics starts
5 Others

0
Autologous Allogeneic
 Start and Stop

Conditions LBD should be started Admission Start chemo Dependant on blood value Start AB others
(Autologous SCT)
37/34.3 25/23.1 27/25.0 9/8.3 5/4.6

Conditions LBD should be started Admission Start chemo Dependant on blood value Start AB others
(Allogeneic SCT)
33/30.6 23/21.3 20/18.5 9/8.3 5/4.6

Conditions LBD should be stopped Discharge Dependant on blood value Stop AB others
(Autologous SCT)

28/25.9 39/36.1 9/8.3 22/20.4

Conditions LBD should be stopped Discharge Dependant on blood value Stop AB others
(Allogeneic SCT)

18/16.7 24/22.2 7/6.5 38/35.2

 No Yes

n/% Forbidden Product Process Total

restriction restriction

1 Bread 55/ 50.9 - 20/ 18.5 31/ 28.7 51/ 47.2

2 Breakfast cereals 52/ 48.1 3/ 2.8 26/ 24.1 22/ 20.4 51/ 47.2
3 Meat and poultry 25/ 23.1 3/ 2.8 26/ 24.1 53/ 49.1 82/ 75.9
4 Butter or margarine 58/ 53.7 2/ 1.9 40/ 37.0 6/ 5.6 48/ 44.4
5 Jam, marmalade or peanut butter 48/ 44.4 - 32/ 29.6 27/ 25.0 59/ 54.6
6 Bottled water 56/ 51.9 6/ 5.6 14/ 13.0 28/ 25.6 48/ 44.4
7 Tap water 24/ 22.2 41/ 37.9 - 38/ 35.2 79/ 73.1
8 Cold drinks 41/ 38.0 - 10/ 9.3 51/ 47.2 61/ 56.5
9 Fresh fruit 6/ 5.6 14/ 12.9 21/ 19.4 61/ 56.5 96/ 88.9
10 Raisins, Nuts and other dried fruits 25/ 23.1 46/ 42.6 20/ 18.5 7/ 6.5 73/ 67.6
11 Raw vegetables 15/ 13.9 48/ 44.4 16/ 14.8 22/ 20.4 86/ 79.5
12 Cheese 7/ 6.5 41/ 38.0 31/ 28.7 23/ 21.3 95/ 88.0
13 Spices 32/ 29.6 7/ 6.5 28/ 25.9 35/ 32.4 70/ 64.8
14 Wrapped ice-cream 45/ 41.7 21/ 19.4 11/ 10.2 25/ 23.1 57/ 52.8
15 Foods brought by visitors 13/ 12.0 32/ 29.6 6/ 5.5 50/ 46.3 88/ 81.5
16 Hot meals prepared at home 23/ 21.3 38/ 35.2 - 39/ 36.1 77/ 71.3
17 Candy and chocolate 37/ 34.3 7/ 6.5 19/ 17.6 39/ 36.1 65/ 60.2
18 Alcoholic drinks 30/ 27.8 51/ 47.2 13/ 12.0 - 64/ 59.3
Are there restrictions on
Fresh Fruit?

19
no
12
forbidden
77
58 product restrictions
6 process restrictions

Peeled
Soft Fruit
Guidelines (N=108)

{BMI: 5
{Weight: 52 (10% loss)
{Nutritional intake: 15
{TPN: 9
{Nutritional supplements: 7
{Calories: 6
Cochrane Review 1.

Cochrane
Central
Medline to Embase to Cinahl to
Register of
December December December
Controlled Trials
2006 2006 2006
to December
2006

58
potential titles
identified 3 reviewers
independently
read the
abstracts and
Inclusion criteria
applied the
- RCTs
inclusion criteria
- quasi-RCTs
- cohort studies
- case control studies
- both adults and children
(> age 1 year) with
compromized immune
systems who
receive chemotherapy
causing neutropenia

3 studies identified
for systematic
review
Cochrane review 2. (preliminary results)

z Van ‘t Veer, 1987 N=42 RCT No statistically difference between

patients receiving standard
hospital food or a cooked-food
diet

z Moody, 2006 N=19 RCT Infection rates for children with

cancer on neutropenic diet similar
to those for children following food
safety guidelines

z De Mille, 2006 N=16 prospective No evidence that the neutropenic

study diet makes a difference in overall
rates of infection
Conclusion-Neutropenic diet

zProtect from pathogens

{Pseudomonas, E-Coli, Klebsiella & Proteus

zVariety in implementation

zNo firm evidence base

zFurther restricts choice

 Gastrointestinal complications

zCytoreductive therapy.
zMedications (anti infectious and/or
immunosuppressive agents) may cause
anorexia, nausea, vomiting and diarrhoea.
zInfections.
zGraft Versus Host Disease.
zVenooclusive disease of the liver
Infection

zCommon complication
zFever-loss of appetite
zVRE& C Diff- diarrhoea
zIncreased cytokine release
zIncreased metabolism
zTissue damage
Frequently occurring nutritional problems in
HSCT patients
z Sore throat and mouth
z Decreased salivation and dry mouth
z Lack of appetite (anorexia)
z Nausea, vomiting and food aversion
z Early satiety
z Alteration in smell and taste
z Loss of taste
z Mucositis / oesophagitis
z diarrhea
z Malabsorption
Taste changes

zTaste and smell changes are frequent

zCaused by
{direct injury to papillary mucosa
{cytokines (IL-1ß and TNF-α)
{drugs: cyclophosphamide, metronidazole
{Trace element deficiencies: zinc, nickel
{Metallic taste common during chemotherapy
zDietary adaptation to taste alterations
effective
Nausea & vomiting

zRemains a problem despite modern anti-

emetics
zLimits oral intake
zLoss of nutrients
zMakes enteral tube feeding difficult
Mucositis

z Frequent complication
60-100%
z Ulceration, pain,
thickened saliva,
bleeding
z Often require opiates
z Main indication for
artificial nutrition
Mucosal barrier injury
(MBA)

zDisruption of growth and repair of GI

endothelium
zMalabsorption
zWatery diarrhoea
zProtein loss in faeces
zNitrogen losses
Acute GVHD

z Occurs 7-10 days – 100 days post SCT

z 30-60% of allogeneic patients

z Intestinal GVHD - destruction of intestinal crypts

{ Severe diarrhoea, abdominal pain, vomiting, nitrogen loss

z Liver GVHD – destruction of small bile ducts

{ Cholestasis, elevated bilirubin and impairment of other liver
function
 NUTRITIONAL THERAPY AND GI
COMPLICATIONS: OUR EXPERIENCE
Sterile Diet
Symptoms
Monotonous
Mucositis
Need for ↑
variety Nausea
Altered Diarrhea
consistency
Anorexia
Different taste
Altered taste
Odor
↓↓↓dietary intake, ↑↑↑nutritional impairment
Social and psychological aspects

zDepression
zIsolation Loss of
appetite
zFear
zLearned behaviour
Environmental-Isolation

z Continually eating alone

z No social aspect to meal

time

z Encourage family to visit

for meals
Environmental-Hospital food

z Hospital meals not

palatable

z Repetitive menus

z Limited choice

z Set meal times

Environmental-Education

zNutrition not seen as high priority by health

professionals
zScreening and assessment not performed
adequately

zMalnourished patients missed

zNot treated appropriately
Education

zVital aspect of nutrition care

zOngoing training required
zIntegral part of practice
zImportance of nutrition needs to be
recognised
 What can we do to stimulate the appetite?

z Start from products which the patient likes and which are
easy to eat and drink.
z Use small meals and take snacks frequently.
z Encourage the patient to eat something every day.
z Offer the patient the possibility to choose from a broad
selection of foods.
z Of course a pleasant presentation of the food is
important.
Coffee break
Workshop on Nutrition and
Hematopoietic Stem Cell
Transplantation
Program

Sonia
z Nutritional risk assessment
z Oral nutritional supplements
{ Indication
{ Supplements vs regular food stuffs
z Artificial Nutrition
{ When to start?
{ Type of Artificial Nutrition?
Arno
z Low bacterial Diet
z Nutritional Therapy for GI complications associated with HSCT
z Nutrition Guidelines
 NUTRITIONAL RISK SCREENING?

z Do you assess the nutritional risk of your

patients?
z How do you assess the nutritional risk? Adults?
Children?
z After nutritional risk assessment what do you do
next?
NUTRITIONAL RISK SCREENING- ADULTS
MALNUTRITION UNIVERSAL SCREENING TOOL
BMI Score Weight loss score
BMI kg/m2 Unplanned weight loss in
>20(>30 Obese) = 0 past 3-6 months
18.5 -20 = 1 <5% = 0
<18.5 = 2 5-10% = 1
>10% = 2

Acute disease effect score

If patient is acutely ill and
there has been or is likely
to be no nutritional
intake for >5 days
Score 2
 NUTRITIONAL RISK SCREENING- ADULTS
MALNUTRITION UNIVERSAL SCREENING TOOL

Add Scores together to calculate overall risk of malnutrition

Score 0 Low Risk Score 1 Medium Risk Score 2 or more High Risk

0 Low Risk 1 Medium Risk 2 or more High Risk

Routine clinical care Observe Treat
 NUTRITIONAL RISK SCREENING- ADULTS
MALNUTRITION UNIVERSAL SCREENING TOOL
0 Low Risk-Routine clinical care
Repeat screening weekly

1 Medium Risk-Observe
Document dietary intake for 3 days,
If no improvement – clinical concern → follow local policy
Repeat screening weekly

2 or more High risk- Treat

Refer to dietitian, Nutritional Support Team or implement local policy
Improve and increase overall nutritional intake;
Monitor and review care weekly
Childeren at risk of
malnutrition
 LOW BACTERIAL DIET:WHEN TO START AND STOP?
Conditions LBD should be started Admission Start chemo Dependant on blood value Start AB others
(Autologous SCT)
37/34.3 25/23.1 27/25.0 9/8.3 5/4.6

Conditions LBD should be started Admission Start chemo Dependant on blood value Start AB others
(Allogeneic SCT)
33/30.6 23/21.3 20/18.5 9/8.3 5/4.6

Conditions LBD should be stopped Discharge Dependant on blood value Stop AB others
(Autologous SCT)

28/25.9 39/36.1 9/8.3 22/20.4

Conditions LBD should be stopped Discharge Dependant on blood value Stop AB others
(Allogeneic SCT)

18/16.7 24/22.2 7/6.5 38/35.2

Which are the conditions in your hospital

Is everybody satisfied (Doctor, Nurse, Patient)
What can be changed and how will you do this?
 No Yes

n/% Forbidden Product Process Total

restriction restriction

1 Bread 55/ 50.9 - 20/ 18.5 31/ 28.7 51/ 47.2

2 Breakfast cereals 52/ 48.1 3/ 2.8 26/ 24.1 22/ 20.4 51/ 47.2
3 Meat and poultry 25/ 23.1 3/ 2.8 26/ 24.1 53/ 49.1 82/ 75.9
4 Butter or margarine 58/ 53.7 2/ 1.9 40/ 37.0 6/ 5.6 48/ 44.4
5 Jam, marmalade or peanut butter 48/ 44.4 - 32/ 29.6 27/ 25.0 59/ 54.6
6 Bottled water 56/ 51.9 6/ 5.6 14/ 13.0 28/ 25.6 48/ 44.4
7 Tap water 24/ 22.2 41/ 37.9 - 38/ 35.2 79/ 73.1
8 Cold drinks 41/ 38.0 - 10/ 9.3 51/ 47.2 61/ 56.5
9 Fresh fruit 6/ 5.6 14/ 12.9 21/ 19.4 61/ 56.5 96/ 88.9
10 Raisins, Nuts and other dried fruits 25/ 23.1 46/ 42.6 20/ 18.5 7/ 6.5 73/ 67.6
11 Raw vegetables 15/ 13.9 48/ 44.4 16/ 14.8 22/ 20.4 86/ 79.5
12 Cheese 7/ 6.5 41/ 38.0 31/ 28.7 23/ 21.3 95/ 88.0
13 Spices 32/ 29.6 7/ 6.5 28/ 25.9 35/ 32.4 70/ 64.8
14 Wrapped ice-cream 45/ 41.7 21/ 19.4 11/ 10.2 25/ 23.1 57/ 52.8
15 Foods brought by visitors 13/ 12.0 32/ 29.6 6/ 5.5 50/ 46.3 88/ 81.5
16 Hot meals prepared at home 23/ 21.3 38/ 35.2 - 39/ 36.1 77/ 71.3
17 Candy and chocolate 37/ 34.3 7/ 6.5 19/ 17.6 39/ 36.1 65/ 60.2
18 Alcoholic drinks 30/ 27.8 51/ 47.2 13/ 12.0 - 64/ 59.3

Your situation, stricter or less stricter? Other ingredients.

What can be changed and how will you do this?
 ORAL NUTRITION SUPPLEMENTS?

z Do you use oral nutritional supplements?

z When do you start?

z Witch kind of supplements do you recommend

when GI complications arise?

 TYPE and TIMING OF ARTIFICIAL
NUTRITION?

z Enteral vs Parenteral nutrition, what are your

beliefs?? Main problems?
z When do you start artificial nutrition?
z When do you stop artificial nutrition?
z Should it be taillored for each patient?
 GUIDELINES?

{ BMI: 5
{ Weight: 52 (10% loss)
{ Nutritional intake: 15
{ TPN: 9
{ Nutritional supplements: 7
{ Calories: 6

z Are guidelines important or can you work without

them?
z Do you have those guidelines in your hospital? If yes
is implementing a problem?
z Do you need other guidelines?