August 2008 Issue
Managing Patients Diagnosed With Cancer and Diabetes
By Barbara Grant, MS, RD, CSO, and Alison Evert, MS, RD, CDE
Today’s Dietitian
Vol. 10 No. 8 P. 8
Suggested CDR Learning Codes: 3020, 5020, 5090, 5150, 5190, 5390; Level 2
Cancer and its treatment modalities (eg, chemotherapy, radiation therapy, surgery) can significantly impact patients’ nutritional well-being. While caring for oncology patients, dietitians should not disregard other diseases and conditions, such as diabetes mellitus and hyperglycemia, and need to be just as concerned about maintaining good glycemic control during treatment as they are about managing treatment-related side effects.
This article will educate oncology dietitians about the importance of providing medical nutrition therapy (MNT) to improve glycemic control and will inform dietitians working in diabetes care about cancer care and its impact on patients. It will also review diabetes management guidelines, highlight the importance of good glycemic control throughout the continuum of care, provide practical suggestions for managing blood glucose levels during care, and review the causes of hyperglycemia in patients with cancer and the effects of poor glycemic control on immune function, risk of infection, and overall survival.
Currently, there are no official guidelines regarding diabetes management for cancer patients, but the guidelines for diabetes care in general are appropriate for all individuals with diabetes.
Monitoring weight and blood glucose levels using prescribed glucose-lowering medications, physical activity, and MNT are integral to diabetes management and are important components of cancer care.1 Although not documented exclusively in oncology patients, emerging evidence suggests that poor glycemic control in hospitalized patients leads to adverse clinical outcomes, including infection complications, longer hospital stays, more costly care, and increased morbidity and mortality rates.2 Evidence obtained from patients in intensive care settings suggests that achieving glycemic control leads to better clinical outcomes.3
In the long term, optimal glycemic control may help prevent or slow the rate of complications. Macrovascular complications include hypertension, dyslipidemia, and vascular disease (ie, cardiovascular, cerebrovascular, peripheral). Microvascular complications can include kidney failure, neuropathies, and blindness.4
Comorbid Diseases: Cancer and Diabetes
Cancer survivors represent one of the largest groups of people living with a chronic illness.5 The National Cancer Institute estimates that in 2007, 10.5 million Americans were diagnosed with cancer. Survival for longer than five years is commonly defined as long-term survival or cure. The five-year survival rate for all cancers diagnosed between 1996 and 2002 was 66%, up from 50% between 1975 and 1977.6 In 2005, an estimated 20.8 million adults and children in the United States were diagnosed with diabetes.7
Cancer and diabetes share common risk factors: older age, obesity (particularly intra-abdominal obesity), physical inactivity, poor diet, and genetic and environmental factors.6,7 Diabetes and hyperglycemia have been associated with an elevated risk of certain types of cancer: type 1 diabetes with cervical and stomach cancer and type 2 diabetes with breast, colon, endometrial, liver, and pancreatic cancers and non-Hodgkin’s and Hodgkin’s lymphoma.3
Additionally, emerging evidence suggests that long-term cancer survivors may be at increased risk for developing diabetes and hyperglycemia. Researchers found that prostate cancer survivors undergoing long-term androgen-deprivation therapy are at increased risk for developing insulin resistance and hyperglycemia, as well as cardiovascular disease.8 Another study found that the intra-abdominal obesity and increased waist-to-height ratio observed in long-term survivors of childhood cancer, specifically those who received bone marrow transplants, were linked to an increased prevalence of hyperinsulinemia, impaired glucose tolerance, and diabetes.9 Numerous studies have also reported that individuals with diabetes and cancer have a higher risk of mortality than individuals without diabetes.10
Applying the Nutrition Care Process
The Nutrition Care Process (NCP) gives dietitians a systematic framework to provide nutrition care for individuals across the continuum of care. The following examples highlight how the NCP can guide the delivery of MNT for patients diagnosed with cancer and diabetes:
• Nutrition assessment: Timely and thorough nutrition screening and assessment of cancer patients and those with diabetes is well documented.1,11 Reviewing the medical chart and diet history should include careful assessment of goals for patient care, medical history, laboratory data, food/nutrition history, physical activities of daily living, and diabetes management regimen (eg, glucose-lowering medications, existing nutrition therapy).
• Nutrition diagnosis and intervention: Nutrition diagnoses and interventions provide individualized, safe, and effective care for patients.1,12 Proactive management of the symptoms and side effects of cancer and its treatment is essential. Cancer-related symptoms that impact nutrition include alterations in taste and smell, anorexia, cachexia, changed bowel habits, dysphagia, fatigue, mucositis, myelosuppression, nausea and vomiting, and xerostomia.13
Dietitians must ensure their assessments, interventions, and monitoring include the impact of cancer-related symptoms on their patients’ diabetes. For example, when a highly emetogenic (nausea- and vomiting-causing) chemotherapy regimen is prescribed, patients should be instructed how to manage days when consistent carbohydrate intake is challenging and an oral glucose-lowering agent may not be ingested due to vomiting.
Another example is recommending carbohydrate-controlled liquid nutrition supplements or formulas for head and neck cancer patients requiring between-meal supplements or enteral tube feedings via their percutaneous endoscopic gastrostomies.
• Monitoring and evaluation: Careful nutrition monitoring and evaluation is critical to the timely identification of side effects with nutritional implications. Treatment-related side effects with nutritional impact include anemia, oral infections (eg, candidiasis), lactose intolerance, malabsorption, and hyperglycemia.13
An example of proactive monitoring and evaluation is closely following patients with normal blood glucose levels who are at risk of steroid-induced hyperglycemia after being prescribed glucocorticosteroids (steroids) following neurosurgery to remove a brain tumor or patients receiving steroids as a part of their antiemetic regimens for highly emetogenic chemotherapy agents.
Chronic or late-occurring side effects of cancer treatment impacting nutrition intake may include pancreatic insufficiency and malabsorption after gastrointestinal surgery, lasting xerostomia and esophageal fibrosis after head and neck radiation therapy that causes difficulty with chewing and swallowing, and diabetes-related peripheral neuropathy, worsened by the effects of a taxane-based chemotherapy regimen (eg, paciltaxel, docetaxel).
It is imperative that nutrition care plans include interventions for managing chronic diseases and conditions, as well as interventions for cancer symptom management.
Glycemic Control
Several diabetes-related health organizations have established target glycemic recommendations for adults diagnosed with diabetes.4,14,15 While these recommendations may differ slightly, they all emphasize the importance of glycemic control for adults with diabetes throughout the continuum of patient care. Most importantly, dietitians working with patients diagnosed with cancer and diabetes must consider patients’ prognosis and their desire to achieve glycemic control when determining appropriate target blood glucose ranges.
Tight glycemic control is most likely not appropriate for patients referred to hospice care. Rather, the therapy goals should be to enhance quality of life, manage the disease or treatment-related side effects, and provide sufficient nutrition intake to maintain strength and energy.16 Minimizing overt glucosuria is also an important consideration in patients receiving palliative care. Blood glucose levels consistently higher than 200 milligrams per deciliter will increase patients’ need to urinate.
However, researchers of a retrospective study found patients undergoing bone marrow transplant benefited from tight glycemic control during their posttransplant recovery as evidenced by a significant reduction in their length of hospitalization.17 Whether patients are newly diagnosed or have existing diabetes, patients should be encouraged to seek medical care with their primary care physician or endocrinologist to closely manage their diabetes while they undergo cancer treatment.
Possible Causes of Hyperglycemia
In 2002, diabetes accounted for more than 4.6 million hospitalizations.18 The incidence of diabetes and hyperglycemia often goes unreported, as evidenced by the results of a retrospective chart review of 1,034 adults admitted to a large, urban hospital.19 The review showed that 13% of patients had blood glucose levels greater than 200 milligrams per deciliter, with 64% having a history of diabetes or newly diagnosed diabetes and 36% remaining undiagnosed at the time of discharge, despite frequent mention of hyperglycemia.
Oncology healthcare professionals also may not recognize hyperglycemia caused by the stress of illness or treatment in their patients with or without diabetes. Possible causes of hyperglycemia in cancer patients include trauma, infection, emotional stress, intravenous fluids containing high concentrations of dextrose (eg, total parenteral nutrition), high carbohydrate-containing diets, exocrine pancreas dysfunction, and medications such as thiazide-containing diuretics, androgen-deprivation therapy, and steroids.20
Steroids are frequently prescribed to patients diagnosed with cancer as a component of antiemetic regimens to manage acute or delayed nausea and vomiting associated with chemotherapy, as an adjuvant care to treat cerebral edema following brain cancer surgery, and for the management of graft-vs.-host disease following stem cell transplant.
Steroid use can worsen glycemic control in patients with preexisting diabetes and impaired glucose tolerance and can precipitate diabetes in previously undiagnosed patients.20 Steroids can impair the suppression of glucose production and cause an inhibition of glucose uptake into fat and muscle, which can induce insulin resistance and alter glucose metabolism. According to these mechanisms, the glucose elevation is predominantly postprandial hyperglycemia, often with a notable lack of fasting hyperglycemia.
Treatment of steroid-induced hyperglycemia should include teaching patients a meal-planning method to quantify carbohydrate intake and instructing them to eat consistent amounts of carbohydrates and meals and perform premeal and postmeal blood glucose monitoring. Bedtime blood glucose tests are also recommended.
If diabetes medications are required to achieve optimal glycemic control, caretakers should keep the following in mind:
• Thiazolidenedione and/or biguanides may be beneficial, as these drugs work to reverse the specific metabolic abnormalities secondary to the steroids.
• Insulin secretagogues may be used to enhance insulin secretion to help lower postprandial blood glucose levels. Teach patients taking an insulin secretagogue and/or insulin to not delay or skip meals. Encourage these patients to eat a source of carbohydrate at all meals to reduce the risk of hypoglycemia.
• In preexisting diabetes, prandial or mealtime insulin may need to be initiated or increased to help reduce postprandial blood glucose levels. It is not uncommon for insulin-requiring patients to double their bolus or mealtime insulin doses.
• As the dose of medication is reduced or discontinued, hypoglycemia may occur.
In general, the glucose pattern consists of normal or minimally elevated fasting glucoses and extremely elevated glucoses in the afternoon and evening. The patterns are variable and often unpredictable. Blood glucose levels should be monitored premeal and postmeal to determine the extent of hyperglycemia. Note that as steroid doses are reduced and/or ultimately discontinued, hypoglycemia can occur if diabetes medications are not reduced concurrently.
Treatment of Hypoglycemia
It is extremely important to teach patients using diabetes medications about the causes and symptoms of hypoglycemia and how to treat it. Specifically, patients need to learn the following:
• The causes of hypoglycemia: eating too little or delaying a meal; taking extra diabetes medicine; engaging in unplanned or excessive physical activity; and drinking alcohol, especially if consumed on an empty stomach.
• The symptoms of hypoglycemia: feeling shaky and/or sweaty; nausea; extreme hunger; heart pounding or racing; blurred vision; confusion and/or inability to concentrate; and impaired judgment.
• The “Rule of 15”: Check blood glucose. If less than 70 milligrams per deciliter, treat with 15 grams of carbohydrate; if less than 50 milligrams per deciliter, treat with 30 grams of carbohydrate. Check again after 15 minutes. If still less than 70 milligrams per deciliter, repeat the treatment. If the next meal is not within one hour, eat a small snack with protein such as cheese and crackers or a small peanut butter sandwich.
• Types of carbohydrates to treat hypoglycemia, as shown in Table 3.
Patients should be taught not to treat hypoglycemia by eating high-fat foods such as candy bars, cookies, or ice cream because fat slows glucose absorption. They should notify their diabetes provider if they have severe or frequent hypoglycemia.
Morbidity and Mortality
As previously mentioned, the consequences of poor glycemic control and hyperglycemia in hospitalized patients are immunosuppression, increased risk of infection, increased length of hospitalizations, more costly care, and increased morbidity and mortality.2 For oncology patients undergoing immunosuppressive cancer therapy, these consequences can have tremendous implications for morbidity and mortality.
A pivotal prospective, randomized study published in 2001 found strict glycemic control led to significant improvements in clinical outcomes for critically ill surgical patients.21 The study showed a 43% reduction in intensive care unit mortality and a 34% reduction in overall hospital mortality when blood glucose levels were maintained at a targeted range of 80 to 110 milligrams per deciliter.
Patients with blood glucose levels between 180 and 200 milligrams per deciliter exhibited the highest overall mortality and had higher incidence of sepsis and acute renal failure when compared with patients within the targeted range. The literature clearly documents that tight glycemic control in critically ill hospitalized patients has been shown to decrease infection.2 In a prospective study of 265 patients undergoing hepato-biliary-pancreatic cancer surgery, researchers found that patients who exhibited poor postoperative blood glucose control had an increased incidence of surgical site infections.22
Diabetes Management for Cancer Patients
Dietitians with experience in diabetes care are most likely familiar with the medical management guidelines for diabetes. Thus, the following information is provided to assist oncology dietitians who are not as knowledgeable about established criteria and guidelines for patient assessment and management. Dietitians should also provide patients with appropriate educational materials and resources and referrals to members of the interdisciplinary healthcare team (eg, primary care physicians, endocrinologists, diabetes providers or educators) to ensure optimal diabetes care.
The American Diabetes Association (ADA) states that the goal of diabetes therapy is to control blood glucose in an effort to achieve normal or near-normal levels.4 The management of diabetes includes MNT, physical activity, monitoring, medications, and self-management education.1
Diabetes MNT and Medication Management
General guidelines for patient education include the following:
• Teach patients how macronutrients (ie, carbohydrates, protein, fat) impact blood glucose control. Carbohydrates have the predominant blood glucose-raising effect. Protein adds satiety to the meal, and fat should be consumed in moderation.
• Teach patients a meal-planning approach to enable them to quantify carbohydrates, such as the carbohydrate counting meal-planning approach, the ADA’s “Choose Your Foods: Exchange Lists for Meal Planning,” or the plate method.
• Encourage patients to consume a diet controlled in carbohydrates to minimize postprandial blood glucose excursions and to be as physically active as possible to enhance insulin sensitivity. Patients should be discouraged from being overrestrictive with carbohydrate intake to achieve desirable glycemic control. In this situation, patients may need to initiate diabetes medications to reach target blood glucose levels.
• Encourage patients to eat at regular times and spread meals and snacks throughout the day. Suggest water or other sugar-free beverages to quench thirst.
• Advise patients to self-monitor their blood glucose levels and, if indicated, take their glucose-lowering medications (eg, oral agents, insulin therapy) as prescribed. Long-term glycemic control is assessed using a glycoslyated hemoglobin A1C, which assesses patients’ mean plasma glucose levels over the past two to three months.
For patients with diabetes, understanding the possible toxicities of cancer and its treatment is essential to developing patients’ nutrition care plans.1,4
MNT for Cancer Symptoms and Side Effects
Side effects of cancer and cancer therapy are detrimental to normal appetite, digestion, and absorption. The following guidelines can help:
• MNT for anorexia should include providing protein-containing meals and snacks, with attention to consistent carbohydrate content.
Protein-containing, carbohydrate-controlled liquid nutrition supplements, shakes, or smoothies consumed between meals help patients avoid feeling too full at mealtime.
Patients should have a pleasant environment in which to eat meals or snacks and can try light physical activity or exercise (as able) to stimulate appetite.
• MNT for constipation should include eating at regular intervals throughout the day and increasing fluid intake to 8 to 10 cups per day. Hot beverages are a bowel stimulant, but caffeine is a diuretic, which can decrease intestinal hydration, making stools hard. Increasing physical activity and exercise as able is good, as is increasing dietary fiber and using a bulk-forming agent such as psyllium (eg, Citracel, Metamucil) or a fiber supplement (eg, Benefiber).
• MNT for diarrhea should include increasing fluid intake to at least 8 cups of fluid per day and 1 cup of water for each diarrhea stool. If diarrhea is severe, increasing consumption of high potassium-containing foods and high sodium-containing foods is indicated. Try commercially prepared bouillon, broths, and clear soups (eg, chicken and white rice or noodle) or sports drinks (eg, Propel, Gatorade, Powerade, Recharge).
Adding pectin or water-soluble fiber-containing foods to the diet at regular intervals and in controlled amounts can help. Try foods such as applesauce, bananas, cooked carrots, potatoes, noodles, and white rice.
Patients should eat small, frequent meals and snacks throughout the day and avoid alcohol, caffeine, and greasy, fried, spicy, or very rich foods. If diarrhea is severe, patients should avoid sugar-free gum or candies made with sorbitol or xylitol, as these foods can contribute to osmotic-type diarrhea.
• MNT for difficulty with chewing or swallowing should include consuming soft, moist, or puréed foods or foods that are uniform in consistency; avoiding chunky or lumpy foods or beverages; and eating small, frequent meals and snacks throughout the day. If the patient is at risk for aspiration, referral to a speech pathologist to ensure safe swallowing is indicated.
• MNT for early satiety should include eating small, frequent meals and snacks throughout the day; consuming protein-containing meals and snacks with attention to consistent carbohydrate content; consuming protein-containing, carbohydrate-controlled liquid nutrition supplements, shakes, or smoothies between meals (to avoid feeling too full at mealtime); avoiding fried, greasy, or rich foods (which take longer to digest and absorb); and avoiding gassy foods and carbonated beverages that can cause bloating. Trying light physical activity or exercise as able to stimulate digestion is also suggested.
• MNT for mucositis should include consuming soft, moist foods and avoiding spicy, acidic, dry, coarse, or rough foods. Also, rinsing the mouth throughout the day with a baking soda/saline solution (1 teaspoon of salt and 1 teaspoon of baking soda in 1 quart of water) and avoiding alcoholic beverages and alcohol-containing mouthwashes are recommended.
• MNT for nausea should include trying small, frequent feedings of dry, starchy, and/or salty foods (eg, pretzels, saltines, potatoes, noodles, cooked or dry cereals) and avoiding sweet, rich, greasy, and/or spicy foods. In addition, eating room temperature or cool foods rather than icy cold or hot foods is recommended, as is avoiding strong odors and large amounts of fluid on an empty stomach.
Avoiding lying flat after eating (keeping head above shoulders for at least one hour) is advisable.
• MNT for vomiting should include taking small sips of water (1 to 2 tablespoons) every 15 to 30 minutes. Ample fluids are needed to prevent dehydration. If patients cannot tolerate regular foods, they should try liquid or soft carbohydrate-containing foods such as regular drinks, soups, juices, or ice cream. Eating about 10 to 15 grams of carbohydrate every one to two hours is recommended.
If vomiting persists and the patient is unable to take fluids for longer than four hours, notify the healthcare team or diabetes provider.1,19,23
Nutrition Support
Diabetes patients receiving nutrition support in conjunction with cancer therapy or surgery present special challenges. While this article format is inadequate for a complete discussion of the many issues involved, dietitians should be aware of the following guidelines:
• Enteral nutrition (EN): Unless otherwise medically directed, patients should be advised to take their glucose-lowering medications (eg, injectable, oral) as prescribed. Patients taking oral glucose-lowering medications who are unable to swallow should be referred to their diabetes provider for appropriate medical management. Consult with a pharmacist to determine whether medications can be crushed or if liquid alternatives are required.
Most patients tolerate standard EN formulas without difficulty, and diabetes-type formulas are usually not necessary. However, to improve glycemic control, try using a diabetes tube-feeding formula (carbohydrate controlled) or a tube-feeding formula that contains more complex carbohydrates such as fructose, cornstarch, and/or fiber.
• Parenteral nutrition (PN): It is important to avoid overfeeding; begin at 20 to 25 kilocalories per kilogram or less. Limit the dextrose to no more than 3 to 5 milligrams per kilogram per minute, particularly in critically ill patients. Limit the total amount to 200 grams until the patient’s serum glucose level is in the desired target range.
Effective insulin therapy is essential to keep a patient’s serum glucose level in the target range. Follow institution-specific guidelines (eg, continuous insulin infusion, insulin added to the PN, sliding scale insulin). To control hyperglycemia, consider the following: Decrease dextrose content and increase the lipid content, add insulin, or increase the duration of the infusion. Monitor blood glucose levels one hour after starting PN, at midcycle, and one hour after stopping.
In addition, be aware of changes in clinical status or doses of medications (eg, steroids) and that patients with existing diabetes usually require insulin added to their daily PN.24,25
Surmounting the Challenge
Providing MNT to a patient diagnosed with cancer and diabetes can be complex and challenging. When developing a patient’s individualized nutrition care plan, dietitians need to be knowledgeable of not only the patient’s diagnosis, prescribed cancer treatment plan, and prognosis but also anticipated side effects of treatment and possible medications/agents used for medical management.
A more thorough understanding of the causes and management of hyperglycemia in a patient diagnosed with cancer can help dietitians provide the most appropriate care for improving glycemic control. Ultimately, the proactive management of cancer-related side effects, including the management of hyperglycemia, may lead to improved clinical outcomes, as evidenced by reductions in infectious complications, and improvements in immune function and quality of life.
— Barbara Grant, MS, RD, CSO, is the outpatient oncology dietitian at Saint Alphonsus Regional Medical Center Cancer Care Center in Boise, Idaho. She has more than 25 years of experience in oncology nutrition and is a board-certified specialist in oncology nutrition. She is a member and past chairperson of the Oncology Nutrition Dietetic Practice Group of the American Dietetic Association and is an associate member of the Oncology Nursing Society.
— Alison Evert, MS, RD, CDE, is a diabetes nutrition educator at the University of Washington Medical Center Diabetes Care Center in Seattle. She has more than 25 years of experience in diabetes nutrition care and is a board-certified diabetes educator. She is a member and past chairperson of the Diabetes Care and Education Dietetic Practice Group of the American Dietetic Association and a professional member of the American Diabetes Association.
References
1. Franz M. Medical nutrition therapy for diabetes mellitus and hypoglycemia of nondiabetic origin. In: Krause’s Food & Nutrition Therapy, 12th edition. St. Louis: Saunders Elsevier; 2008:764-809.
2. Hirsh IB, Braithwaite SS, Verderese CA. Practical Management of Inpatient Hyperglycemia. Lakeville, CT: Hilliard Publishing; 2005.
3. Richardson LC, Pollack LA. Therapy insight: Influence of type 2 diabetes on the development, treatment, and outcomes of cancer. Nat Clin Pract Oncol. 2005;2(1):48-53.
4. American Diabetes Association. Nutrition recommendations and interventions for diabetes: A position statement of the American Diabetes Association. Diabetes Care. 2007;30 Suppl 1:S48-S65.
5. Stovall E. Cancer survivorship in the year 2013: A survivor’s perspective. In: Horizons 2013: Longer, Better Life Without Cancer. Brown HG, Seffrin JR, Bezold C, eds. Atlanta: American Cancer Society; 1996.
6. American Cancer Society. Cancer facts and figures 2008. Available at: http://www.cancer.org/downloads/STT/2008CAFFfinalsecured.pdf
7. Eyre HJ, Kahn R, Robertson RM. Preventing cancer, cardiovascular disease, and diabetes: A common agenda for the American Cancer Society, the American Diabetes Association, and the American Heart Association. CA Cancer J Clin. 2004;54(4):190-207.
8. Basaria S, Muller DC, Carducci MA, Egan J, Dobs AS. Hyperglycemia and insulin resistance in men with prostate carcinoma who receive androgen-deprivation therapy. Cancer. 2006;106(3):581-588.
9. Neville KA, Cohn RJ, Steinbeck KS, Johnston K, Walker JL. Hyperinsulinemia, impaired glucose tolerance, and diabetes mellitus in survivors of childhood cancer: prevalence and risk factors. J Clin Endocrinol Metab. 2006;91(11):4401-4407.
10. Doyle C, Kushi LH, Byers T, et al. for The 2006 Nutrition, Physical Activity and Cancer Survivorship Advisory Committee. Nutrition and physical activity during and after cancer treatment: An American Cancer Society guide for informed choices. CA Cancer J Clin. 2006;56(6):323-353.
11. McCallum PD. Nutrition screening and assessment in oncology. In: The Clinical Guide to Oncology Nutrition, 2nd edition. Elliott L, Molseed LL, McCallum PD, Grant B, eds. Chicago: American Dietetic Association; 2006:44-53.
12. Elliott L. The nutrition care process and medical nutrition therapy. In: The Clinical Guide to Oncology Nutrition, 2nd edition. Elliott L, Molseed LL, McCallum PD, Grant B, eds. Chicago: American Dietetic Association; 2006:39-43.
13. Grant B. Nutrition in Cancer Treatment: Continuum of Care, 2nd edition. Ashland, Ore.: Nutrition Dimension; 2007.
14. American Diabetes Association. Standards of medical care in diabetes—2007. Diabetes Care. 2007;30 Suppl 1:S4-S41.
15. Garber AJ, Moghissi ES, Bransome ED Jr, et al. American College of Endocrinology position statement on inpatient diabetes and metabolic control. Endocr Pract. 2004;10(1):77-82.
16. McCallum PD, Fornari A. Nutrition in palliative care. In: The Clinical Guide to Oncology Nutrition, 2nd edition. Elliott L, Molseed LL, McCallum PD, Grant B, eds. Chicago: American Dietetic Association; 2006: 201-207.
17. Garg R, Bhutani H, Alyea E, Pendergrass M. Hyperglycemia and length of stay in patients hospitalized for bone marrow transplantation. Diabetes Care. 2007;30(4):993-994.
18. Hogan P, Dall T, Nikolov P; American Diabetes Association. Economic costs of diabetes in the US in 2002. Diabetes Care. 2003;26(3):917-932.
19. Levetan CS, Passaro M, Jablonski K, Kass M, Ratner RE. Unrecognized diabetes among hospitalized patients. Diabetes Care. 1998;21(2):246-249.
20. Oyer DS, Shah A, Bettenhausen S. How to manage steroid diabetes in the patient with cancer. J Support Oncol. 2006;4(9):479-483.
21. Van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in critically ill patients. N Engl J Med. 2001;345(19):1359-1367.
22. Ambiru S, Kato, A, Kimura F, Shimizu H, Yoshidome H, Otsuka M, Miyazaki M. Poor postoperative blood glucose control increases surgical site infections after surgery for hepato-biliary-pancreatic cancer: A prospective study in a high-volume institute in Japan. J Hosp Infect. 2008;68(3):230-233.
23. Appendix A: Tips for managing nutrition impact symptoms. In: The Clinical Guide to Oncology Nutrition, 2nd edition. Elliott L, Molseed LL, McCallum PD, Grant B, eds. Chicago: American Dietetic Association; 2006:241-245.
24. Malone A. Enteral formula selection. In: ADA Pocket Guide to Enteral Nutrition. Charney P, Malone A, eds. Chicago: American Dietetic Association; 2006: 83-85.
25. Roberts S. Initiation, advancement, and acute complications. In: ADA Pocket Guide to Parenteral Nutrition. Charney P, Malone A, eds. Chicago: American Dietetic Association; 2007: 84-85.
Learning Objectives
After completing this article, the student will be able to:
1. Explain why diabetes is often overlooked in cancer patients.
2. Discuss therapeutic interventions that are integral to diabetes management.
3. List common risk factors for cancer and diabetes.
4. Define glycemic control.
5. Discuss the established target glycemic recommendations for adults diagnosed with diabetes.
6. Discuss the impact of poor glycemic control in patients diagnosed with cancer.
7. List and discuss the causes of steroid-induced hyperglycemia in patients diagnosed with cancer.
8. List and discuss three diabetes medical nutrition therapy (MNT) and medication strategies for managing hyperglycemia and hypoglycemia.
9. List and discuss three MNT strategies for managing cancer symptoms and side effects of cancer treatment.
10. List and discuss two MNT strategies for patients diagnosed with cancer receiving nutrition support.
Examination
1. Which of the following interventions are integral to diabetes management?
a. Monitoring weight and blood glucose levels
b. Using prescribed glucose-lowering medications
c. Regular physical activity
d. Individualized medical nutrition therapy (MNT)
e. All of the above
2. In the long term, optimal glycemic control may help prevent or slow the rate of the following complications:
a. Osteopenia and osteoporosis
b. Myelosuppression and fatigue
c. Cardiovascular disease and neuropathy
d. Fibrosis and xerostomia
3. Emerging evidence suggests that long-term survivors of cancer are at a greater risk of developing diabetes and hyperglycemia.
a. True
b. False
4. When developing a nutrition care plan for improving a cancer patient’s glycemic control, which of the following factors should be considered when determining appropriate blood glucose ranges?
a. Type of cancer
b. Diagnosis
c. Length of treatment
d. Prognosis
5. Which of the following medications can worsen glycemic control in cancer patients with prediabetes or impaired glucose tolerance?
a. Glucocorticosteroids
b. Insulin secretagogues
c. Thiazolidenedione
d. Taxane-based chemotherapy
6. Studies indicate that tight glycemic control in critically ill hospitalized patients leads to which of the following clinical outcomes?
a. Decreased length of stay
b. Decreased risk of infection
c. Both a and b
d. None of the above
7. The “Rule of 15” should be used to manage which of the following conditions?
a. Hyperglycemia
b. Insulin resistance
c. Hypoglycemia
d. Insulin hypersensitivity
8. An insulin-dependent patient diagnosed with cancer is receiving highly emetogenic chemotherapy. Which of the following MNT interventions should be suggested to help manage chemotherapy-induced vomiting?
a. If regular foods are not tolerated, try liquid or soft carbohydrate-containing foods such as regular drinks, soups, juices, or ice cream; eat about 10 to 15 grams of carbohydrate every one to two hours to prevent dehydration.
b. If vomiting, drink small sips of fluid every three to four hours.
c. If regular foods are not tolerated, try liquid or soft carbohydrate-containing foods such as regular drinks, soups, juices, or ice cream; eat about 30 to 45 grams of carbohydrate every one to two hours.
d. If vomiting, drink ample amounts of fluids every three to four hours to prevent dehydration.
9. According to the American Diabetes Association’s established guidelines, which of the following blood glucose level ranges is recommended for critically ill inpatients?
a. As close to 180 milligrams per deciliter and generally less than 300 milligrams per deciliter
b. 130 to 180 milligrams per deciliter
c. As close to 110 milligrams per deciliter as possible and generally less than 180 milligrams per deciliter
d. 90 to 130 milligrams per deciliter
10. According to the American Diabetes Association’s established guidelines, which of the following premeal blood glucose ranges is recommended for outpatients?
a. As close to 180 milligrams per deciliter and generally less than 300 milligrams per deciliter
b. 130 to 180 milligrams per deciliter
c. Less than 180 milligrams per deciliter
d. 90 to 130 milligrams per deciliter
Click here for tables on this subject.
