Nutrition Problems After Transplant

We all need food and water to thrive. The calories in food provide the fuel our organs and tissues need to grow and function. Protein-rich foods enable the body to build and repair muscle and body tissue. Vitamins and minerals keep blood, skin and the nervous system functioning properly.

Bone marrow and peripheral stem cell transplant patients have unique nutritional requirements. Prior to transplant, patients undergo high dose chemotherapy, with or without total body irradiation (TBI), to destroy the disease and/or make room for healthy new bone marrow or stem cells. High dose chemotherapy and TBI severely stress the body’s organs and tissues. In order to withstand this stress, to repair any organ or tissue damage that might occur and to fight fever, patients need to increase their calorie and protein intake.

Typically, transplant patients require 50 to 70 percent more calories and twice as much protein in their diets than healthy individuals of similar age and sex. This need for increased calories and protein usually persists at least 50 days post-transplant. If a patient develops an infection or graft-versus-host disease (GVHD), even more protein and calories may be needed until the problem resolves.

Monitoring Food Intake

Before a patient undergoes a bone marrow or stem cell transplant, her caloric and protein requirements are assessed by a dietitian. A nutrition care plan is designed to ensure that the patient receives sufficient calories, proteins, vitamins, minerals and fluids during the recovery period. The patient’s age, gender, normal body weight, weight history, diagnosis, treatment history, current medications, dietary restrictions (eg., allergies), and past and current eating problems are all considered when developing the nutrition plan.

Dietitians use a number of tests to track the amount of fluid, calories, protein and other nutrients the patient consumes while hospitalized. Daily records of the patient’s weight, fluid intake and urine output are maintained. The type and amount of food the patient consumes are also monitored. Several blood tests enable the dietitian to monitor glucose, protein stores and electrolyte levels, as well as liver and kidney function.

Consuming sufficient calories, protein and fluids can be difficult, particularly during the first few weeks post-transplant. Side effects of TBI, chemotherapy, some antibiotics, drugs used to control GVHD, and some pain medications can make food unappetizing or painful to swallow. Often, patients are fed intravenously during this period to ensure they receive sufficient calories, protein, vitamins, minerals and fluids. The intravenous feeding is called total parenteral nutrition (TPN) and may supply all the patient’s nutritional requirements, or supplement those he is able to consume on his own.

“If patients are still not interested in eating four to five weeks post-transplant, and their intestinal tract is working normally (ie., there’s no nausea, vomiting or diarrhea), they may be fed through an enteral feeding tube,” says Karen Ringwald-Smith, Nutrition Support Specialist, St. Jude Children’s Research Hospital, Memphis, Tenn. “Feeding tubes deliver necessary nutrients until a patient can eat on his own.”

Oral Problems

Many patients experience mouth and throat sores two to four weeks after transplant. The sores are usually caused by TBI or chemotherapy. However, infection, GVHD and drugs such as methotrexate can also be the source of the problem. Mouth sores usually heal once the patient’s white blood cell count returns to normal. However, some patients who develop chronic GVHD continue to have mouth sores or oral sensitivity a year or more post-transplant.

Mouth and throat sores can make eating and swallowing difficult. Both oral and intravenous medications are available to ease the pain. Avoiding coarse foods, acidic, salty, spicy, very hot and caffeinated foods and beverages is advised while mouth sores persist.

TBI may also cause dryness in the mouth, temporarily alter the taste of food and/or cause thick saliva to form in the mouth and throat. Dry mouth may also be caused by some anti-nausea medications, antihistamines and oral GVHD. Some drugs, pain medications and antibiotics may temporarily alter the taste of food. Avoiding dry foods, very hot foods and beverages, and alcohol can help ease dry mouth. Adding sauces to foods, and stimulating saliva production by including citric acids in the diet, or by sucking ice chips or hard candies can also help.

Nausea & Vomiting

Nausea and vomiting are common problems experienced by transplant patients. Nausea and vomiting may be caused by TBI, chemotherapy, some antibiotics, pain medications, drugs used to treat GVHD such as cyclosporine or methotrexate, interferon or interleukin-2. Gastrointestinal GVHD and mucous drainage from the mouth and sinuses may also contribute to nausea and vomiting. Sometimes, psychological stress triggers an episode of nausea and vomiting.

Severe nausea can be controlled with medications such as Compazine®, Zofran®, Reglan®, Ativan®, Inapsine®, Phenergan® and Benadryl®. Temporary changes in diet such as eliminating spicy, overly sweet, fatty and strong-smelling foods can control less severe cases of nausea and vomiting.

Lack of Appetite

TBI, chemotherapy, infection, depression and fatigue can cause decreased appetite and weight loss. While in the hospital, the patient’s weight is closely monitored. If weight loss occurs or oral intake is inadequate, the patient is usually maintained on TPN until sufficient calories can be consumed.

Lack of appetite may continue to be a problem long after discharge from the hospital. Continued use of some antibiotics, infection and GVHD can contribute to appetite and weight loss. Anxiety and depression may also be responsible. “If weight loss occurs, it should be reported immediately,” says Sue Fredstrom, Nutrition Support Coordinator, University of Minnesota Hospitals & Clinics, Minneapolis, Minn. “Severe weight loss is much more difficult to reverse than minor weight loss.”

Diarrhea/Constipation

TBI, chemotherapy, gastrointestinal GVHD, infection, some antibiotics, and drugs used to promote bowel activity often cause diarrhea. Some chemotherapies and/or narcotics cause constipation.

Eating foods high in potassium and low in fiber can help control diarrhea. It’s also wise to avoid dairy products, unless they’ve been treated with Lactaid®, as well as foods that cause gas or cramps.

“It’s important to increase your oral fluid intake during periods of diarrhea, unless the diarrhea is caused by GVHD,” says Jan Miller, Clinical Dietitian, Baylor University Medical Center, Dallas, Texas. “Excess fluid loss can result in dehydration. If severe, the patient may have to be re-admitted to the hospital for treatment.”

Increasing fluid intake, particularly warm beverages, may ease constipation. Eating high-fiber foods and engaging in light exercise may also help. If the problem is severe, stool softeners or laxatives may be prescribed by the doctor.

Changing Diet

Some patients consider making major dietary changes before their transplant. Some attempt to shed excess weight. Others increase their intake of foods that have been associated with a lower incidence of cancer. Still others turn to macrobiotic or other diets that restrict the types of food consumed.

“Patients should ask their doctor for a referral to a registered dietitian who can evaluate the nutritional adequacy of the new diet before making a change,” says Paula M. Charuhas, Research Dietitian, Fred Hutchinson Cancer Research Center, Seattle, Wash. “Some diets, such as macrobiotic diets, contain inadequate protein or other nutrients required by a recovering transplant patient.”

“Using herbs and roots such as alfalfa and goldenseal can be dangerous for all individuals, especially people undergoing transplantation,” cautions Karen Ringwald-Smith, St. Jude’s Children’s Research Hospital. “Consult your doctor or dietitian before using these products.”

“Quick weight loss is also usually discouraged,” says Sue Fredstrom, University of Minnesota Hospitals and Clinics. “Many patients lose weight while hospitalized. Limiting food intake before a bone marrow or stem cell transplant could cause a serious nutrient deficiency.”

Several studies have suggested a relationship between types of foods consumed and the risk of developing cancer, according to Jan Miller, Baylor University. “However, no study has proven changing your diet can cure cancer. Eating a balanced diet that is low in fat, contains lots of fresh fruits and vegetables, and includes fiber from a variety of sources is a patient’s best bet.”

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