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Value-Based Oral Nutritional Supplement Approach

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As high as 85 percent of patients with cancer are suffering from malnutrition. Malnutrition has been associated with longer length of hospital stay, higher mortality rate, increased re-admission rate, increased risk of infection and poorer outcome in general. Many of my cancer patients rely on oral nutritional supplement to sustain their lives. However, according to the Centers for Medicare and Medicaid Services (CMS), oral nutritional supplement and tube feed formula are not covered by insurance unless it is a sole source of nutrition. Therefore, once a patient has a gastrostomy feeding tube placed, doctors are hesitant to let their patients eat by mouth again because the patient may have lost insurance coverage for the tube-feeding supplies. In fact, multiple randomized controlled trials (RCT), a highly respected clinical research method, have demonstrated the cost effectiveness, improvement of health outcome and increased survival rate of an oral nutritional supplement. These...
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No Stomach For Cancer

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You may probably have heard of prophylactic mastectomy and hysterectomy in women with BRCA mutations, thanks to Angelina Jolie for bringing us the awareness. This article caught my eye because of this prophylactic surgery: total gastrectomy, complete removal of the stomach of people carrying CDH1 gene mutation. The stomach is one of the main organs of the gastrointestinal tract that breaks down and digests food to extract necessary nutrients you need. The protein, carbohydrates and fat are broken down in small enough amounts to be absorbed into the bloodstream through the wall of the intestine. When gastric cancer strikes, it is difficult to treat because of the rapid growth of the tumor and malnutrition is also not uncommon among patients with gastric cancer because the stomach is a key player of the digestive system. After a gastrectomy, prophylactic or not, the person has less room to hold food in the remaining part of the stomach. Cramping, diarrhea, bloating, nausea, vo...
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The Myth of Artificial Nutrition in End of Life Care

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As a cancer survivor and a registered dietitian, it is difficult for me to see my oncology patients not able to tolerate food. One of my patients with incurable cancer was admitted with bowel obstruction and therefore unable to tolerate any liquid, not to say solid food. After numerous unsuccessful trials of liquid, this patient decided to get a venting gastrostomy for palliative care and go home with hospice service. However, because of guilt of seeing their loved one suffer from starvation, one of the family members brought up the idea of parenteral nutrition to go home with, which contradicts with the medical team's recommendation. Parenteral nutrition is a form of artificial nutrition and hydration in which nutrition and fluid are delivered via an intravenous catheter to provide partial or total nutrition support. However, artificial nutrition and hydration require the patient to undergo uncomfortable procedures for the nutrition support to be started. It has known s...
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The Truth Behind the Sugar-Cancer Connection

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Many of my oncology patients ask me: Does sugar cause cancer? The fact is sugar does not directly cause cancer or promote faster growth of cancer cells. However, eating excessive amount of added sugar can lead to weight gain which eventually increases the risk of obesity. Obesity promotes inflammation which damages DNA which in turn increases the risk of cancer. The misunderstanding of sugar probably originated from the misinterpretation that cells that use more energy, including cancer cells, absorb more glucose-based radioactive tracer in positron emission tomography (PET) scans. Therefore, it was wrongly concluded that cancer cells grow faster when they were provided with sugar. For this reason, many of my cancer patients are starving themselves from sugar and many of their favorite foods. In fact, a patient with cancer going through surgery, radiation, chemotherapy or stem cell transplant often requires additional calories just to maintain their weight. In fact, all cell...
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My Response to The New York Times Article

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Corn syrup and maltodextrin... just to name a few ingredients of a typical oral nutritional supplement. A bottle of oral nutritional supplement typically contains about 20 to 23 grams of sugar. Sounds terrible, right? Yes, making fruit smoothies with yogurt may be a great substitution for conventional liquid oral nutritional supplement. All the fresh ingredients and probiotics in one drink. Imagine all of your patients getting one of these smoothies everyday. It would take three extra full-time equivalents just to make smoothies all day. In reality, it's not economical, it's ideology. The idea of telling my acutely sick patients to only eat healthy food seems to be the equivalent of telling my patient who did not eat well for days to just eat a celery stick because it's healthy. When one is sick, they often lose his/her appetite and eat inadequately. A high protein, high calorie liquid oral nutrition supplement becomes a quick fix to such patient. But an experience...
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Fiber Mania

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On the day that I came back from a conference, I got a consult from a nurse practitioner. He said patient AB was status post allogenic stem cell transplant but with poor food intake, therefore he was newly initiated on enteral nutrition (tube feed) but experiencing diarrhea. The nurse practitioner asked me if there was any other formula that we could switch to to improve AB's diarrhea. During our conversation, I found out AB was ordered on a fiber-containing enteral nutrition formula. Instead of recommending a much more expensive semi-elemental enteral nutrition formula, I recommended that the nurse practitioner switch AB to a fiber-free formula and AB's diarrhea was resolved overnight. The question is: Is fiber good you? The answer is: It depends. According to the Institute of Medicine's Dietary Reference Intake (DRI), an average adult needs about 25 to 38 grams of dietary fiber a day. But most Americans struggle to eat an adequate amount of fiber which is only an...
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My Response to The Wall Street Journal Commentary

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First of all, I want to thank Ms. Del Castillo's husband for his military service to our country. He sacrifices for our safety and freedom. It is important to note, however, that food is medicine. When getting dietary advice, it is best to speak with a specialist who has: Completed a minimum of a bachelor's degree with coursework through an Accreditation Council for Education in Nutrition and Dietetics (ACEND) accredited Didactic Program in Dietetics (DPD) or Coordinated Program in Dietetics (CP) Completed 1,200 hours of supervised practice through an ACEND accredited Dietetic Internship Passed a national examination administered by the Commission on Dietetic Registration (CDR) Completed continuing professional educational requirements to maintain registration Many registered dietitians, like myself, are Certified Nutrition Support Clinicians (CNSC), and hold additional certifications in specialized areas of practice. I question the qualification of Ms. Del Cast...
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