Nutrition and lymphoma 

By Natalie Harris and Clare Shaw

Natalie Harris is a state registered dietician working at the specialist cancer centre at The Royal Marsden, primarily with haematology patients.  She was one of the health professionals featured in ‘Stem Cell Transplantation – what will it be like?’ a video produced by The Royal Marsden hospital and Chugai drug company.  She also helps to run a rehabilitation and support group for patients who have had a stem cell or bone marrow transplant

Clare Shaw joined the Royal Marsden in 1987 and has specialised in working with people diagnosed with cancer (including haemato-oncology patients). In 2004 she became the UK's first Consultant Dietitian in Oncology.

Patients with lymphoma can experience many nutritional problems before, during and after treatment. It is difficult to generalise about these potential problems as lymphomas differ widely in their presentation and treatment. Below we have tried to cover some of the main points.

Research into diet and the cause of lymphoma

Research into the link between diet and the occurrence of lymphoma is limited as it is complicated, expensive and time consuming because it needs to be conducted over many years with large numbers of people.  The strongest evidence suggests that diet may contribute to the incidence of some lymphomas. The most current research indicates that a diet rich in fruit, vegetables and dietary fibre may protect against non-Hodgkin lymphoma.^1,2,3.

Some studies suggest that people suffering from coeliac disease and dermatitis herpetiformis can reduce their risk of getting lymphoma by following a strict gluten-free diet ⁴. 

There is no research looking at the ideal diet to follow once lymphoma is in remission. However, eating a varied diet containing at least five portions of vegetables and fruit each day, wholegrain products and a moderate amount of fat is the best way of reducing your risk of many cancers including lymphomas as well as other chronic diseases ⁵.

Nutrients

Energy (calories)

The body needs adequate amounts of energy to function normally. People with low energy intakes can experience weight loss, fatigue and reduced blood counts. People with lymphoma often have high energy needs. Energy requirements may be increased by the lymphoma (especially if accompanied by night sweats), treatments such as chemotherapy and also if infection and raised temperatures occur.  Good sources of energy are sugar, starchy foods and fat e.g. cakes, biscuits, puddings, crisps and other snacks, chips, potatoes, rice and pasta, butter, margarine, cream etc.

Protein

Protein is important for keeping healthy and is essential in making cells and muscles, wound healing etc. Many patients have increased protein requirements following treatment. Good sources of protein are meat, fish, milk, cheese, eggs, nuts, beans and pulses.

Vitamins and minerals

Vitamins and minerals are essential for good general health and are found in a wide range of foods. They are required in very small amounts. A well balanced, varied diet will provide all the vitamins and minerals that the body needs. However, during illness the needs for certain vitamins and minerals may be increased. Vitamins and minerals can be harmful if taken in large quantities.  Patients should always let the doctor, pharmacist or dietician know if they are taking supplements as some of them may react with medication.

Importance of nutrition during treatment

Weight loss and malnutrition

Treatment, particularly chemotherapy, is better tolerated by well nourished patients ⁶.  Research suggests that well nourished patients experience fewer delays in treatment (for example this can happen when the blood count is too low to administer the next course of chemotherapy safely), fewer episodes of very low blood counts and infection, and tolerate higher doses of chemotherapy (Bozzetti, 2001⁶).  Malnourished people tend to tire more quickly and feel ‘down’.  Often, by reversing the weight loss patients can feel better in themselves.  It is therefore important to try to be as well nourished as possible and there are ways to achieve this.

Food intake

More emphasis has been placed recently on improving the quality of food in hospitals.  The Better Hospital Food programme (www.betterhospitalfood.com) has addressed some issues about the nutritional quality and availability of food in hospitals so you may find that this has influenced the catering service in your hospital. 

Obviously the easiest way to regain weight and become better nourished is to eat a high energy, high protein diet. This involves eating ‘fattening’ foods and trying to snack between meals.  Some people may worry that this is not ‘healthy eating’ but when weight gain is a priority then this is the recommended diet to follow.  It is also possible to ‘fortify’ normal foods to increase their energy and protein content. For suggestions on ways to increase energy intake see the ideas in table 1.

Side effects may affect the ability to eat and drink particularly during treatment. These may include poor appetite, sore mouth, nausea or taste changes. Ideas to help with such problems are listed in table 2 (The Lymphoma Association have free information sheets available on these side effects - please call the Helpline).  For individual advice patients can ask to be referred to a State Registered Dietician.

 Table 2  Problems that may affect food intake and some suggestions on overcoming such difficulties

Nutritional Supplements 

For patients who cannot eat a lot of food or have difficulty maintaining their weight, there is a wide range of nutritional supplements and powders available in the form of drinks, soups and puddings.  Some supplements are available in the supermarket e.g. Build Up, Complan or Recovery.  These drinks may be taken in place of food or in addition to meals. 

There are also supplements that are available on prescription from the GP.  It would be helpful to see a dietician who can assess the most suitable supplements and give an idea of the quantity that should be taken each day.  Some examples of the various types of supplements are in table 3.

Table 3  Nutritional supplements

Nutritional supplement drinks are constantly changing with new flavours and types becoming available.  They are produced in many different flavours, both sweet and savoury, and can be modified to vary the taste and texture.  See ideas in Table 4.  Many of the manufacturers of these drinks produce recipe leaflets for cocktails.

Table 4 Suggestions for modifying dietary supplements

There are also a number of energy supplements, glucose or fat, that are particularly helpful for patients who have lost weight. 

Nutritional Support

For patients who have swallowing problems or are unable to eat or drink enough food there are two methods of nutritional support that can be used:

Tube Feeding (enteral feeding)

This involves using a narrow, soft feeding tube to deliver nutrition directly into the stomach or intestine. The tube can be passed down the nose and back of the throat into the stomach for short term feeding. Placing the tube is not a pleasant experience. However, once the tube is in place, most patients find the tube to be comfortable after a day or two. The feeding tube is usually connected to a feeding pump and special feed is slowly dripped into the feeding tube. The feed provides energy, protein, vitamins and minerals.  If this method of feeding is required for any length of time, e.g. more than a few weeks, then a tube placed directly into the stomach may be considered.  This type of tube is known as a gastrostomy.

A gastrostomy is a very easy way to provide nutrition for someone who is struggling with food and it gives the patient a rest from well -meaning nurses, doctors, dietician, friends and relatives nagging them to eat! It is relatively easy to have this type of feeding at home once the appropriate teaching has been completed.

Intravenous feeding (parenteral nutrition)

This is used for patients whose guts are not functioning properly and they are unable to eat. It is generally not used if the patient is likely to start eating well within five days. It can be used after gut surgery, high dose chemotherapy, bone marrow transplantation, or high doses of radiotherapy to the gut. It usually involves dripping special sterile mixtures of amino acids, glucose and fats directly into the blood via a central venous catheter. Intravenous feeding solutions are made in the pharmacy and have quite a short shelf life. The procedure does carry some risks to  patients and it is difficult to be fed this way at home.

There are a number of side effects of lymphoma treatment that can cause nutritional problems. Often modifying the diet, changing medication and occasionally using artificial feeding can help resolve the problem.

At the other end of the spectrum…

Weight gain and increased appetite

Some patients, especially those taking steroids, have very good appetites and can gain a lot of weight.  Eating a diet containing more vegetables and fruit and less fat, sugar and alcohol can help to control or reverse excessive weight gain.

Patients taking steroids may also develop steroid-induced diabetes.  Diabetes is characterised by excessive thirst and urination, tiredness and blurred vision although not all of these symptoms are always experienced. 

Patients can help to control the level of glucose in the bloodstream by avoiding sweet foods and drinks containing sugar (fruit juice may need to be limited).  If you have been diagnosed with this condition you may find it helpful to see a dietician who can advise you on modifying your diet.  This condition usually reverses shortly after you stop taking steroids.

Frequently Asked Questions

Should I be following a special diet?

There are many different diets described in books, newspapers and magazines that are aimed at cancer patients.  They may claim to help control or cure the cancer or just be aimed at making people feel better.  It is sometimes difficult to decide whether to follow these diets which may exclude a number of foods from the diet such as red meat, fats, dairy products, sugar and additives. 

There have been few clinical trials or research studies to see if these diets do what they claim.  If you are considering following one of these diets then do discuss with your doctor or a dietician who will help you weigh up the advantages and disadvantages for you.

Do I need a vitamin and mineral supplement?

The most recent research has found that taking single ormultivitamins does not decrease the risk of developing lymphoma.⁸ If you are eating well and include a variety of foods in your diet then you probably do not need a vitamin and mineral supplement.  If your appetite is poor then you may need a vitamin and mineral supplement to meet your daily requirement.  Some of the nutritional supplement drinks contain vitamins and minerals without the need to take a separate tablet or capsule.

What about other supplements?

If you have lymphoma and are thinking of taking other supplements then it is always best to discuss this first with your doctor or pharmacist. Care must be taken as these may interact with medications or may not be suitable, e.g. those that claim to boost the immune system may not be desirable.

Food Safety

Twenty years ago it would have been inconceivable to most of us that runny eggs, cold meats and Brie would have been at the centre of food poisoning outbreaks. Food poisoning is on the increase in this country, particularly in the home.  Whilst this results in a minor illness for the majority of ‘healthy’ individuals, for patients with lymphoma it can be debilitating and in some cases life-threatening (e.g. the E.coli outbreak in Scotland in 1996). It is therefore essential for patients with lymphoma to follow high standards of food hygiene.

Recently some treatment centres have allowed patients to consume foods as freely in hospital as they do at home.  However, many hospitals treating patients with lymphoma will restrict access to some foods when patients’ white blood cell counts are low. Unfortunately, there is very little research in this area and no national guidelines and, therefore, hospitals vary greatly in the foods they restrict and the duration of the restriction.  The government does advise that any person with a poorly functioning immune system, including those receiving chemotherapy, should avoid the foods in table 6.

Table 6 Foods to be avoided by people with low immunity/white blood cell count*†

*source: Department of Health and Food Standards Agency

†The Lymphoma Association has a list with further suggestions on foods to avoid when you have a low white blood cell count (neutropenia). Please call 08 08 808 5555 for this information.

Getting further advice.

1.   Advice on diet

All hospitals employ or have access to dieticians. They are specially trained in giving dietary advice and can also advise about nutritional supplements. If you would like to speak to a dietician ask your doctor or nurse to make a referral to your local dietician.

 2.  Booklets

Diet and the cancer patient and CancerBACUP Recipes
Both booklets published by CancerBACUP, 3, Bath Place, Rivington Street, London EC2A 3JR. Free to cancer patients and their families through their freephone Helpline 0808 800 1234. Email: info@cancerbacup.org

Eating well when you have cancer.
Available from the Rehabilitiation Secretary, The Royal Marsden NHS Trust, Fulham Road, London SW3 6JJ.  Tel: 020 7808 2831 or through their website www.royalmarsden.org

After Treatment: a guide for cancer patients. 
Available from the Rehabilitiation Secretary, The Royal Marsden NHS Trust, Fulham Road, London SW3 6JJ.  Tel: 020 7808 2831 or through their website www.royalmarsden.org

The Balance of Good Health
Published by the Food Standards Agency.
Tel: 0845 606 0667

Catering from home safely. 
Published by Food Standards Agency.  Tel: 0845 606 0667.

References

¹Zheng T et al. Diet and Nutrient Intakes and Risk of Non-Hodgkin's Lymphoma in Connecticut Women. American Journal of Epidemiology, 2004; 159: 454-466

²Zhang SM et al. Intakes of fruit, vegetables and related nutrients and the risk of non-Hodgkin's lymphoma among women. Cancer Epidemiology, Biomarkers & Prevention 2000; 9:477-485

³ Tavani A et al. Diet and risk of lymphoid neoplasms and soft tissue sarcomas. Nutrition & Cancer, 1997; 27(3): 256-60,

⁴ Holmes GK. Coeliac disease and malignancy. Digestive and Liver Disease 2002; 34 (3): 229-37

⁵Department of Health Report on Health and Social Sciences 48
Nutritional Aspects of the Development of Cancer. Report of the Panel on Dietary Reference Values of the Committee on Medical Aspects of Food and Nutrition Policy
HMSO 1998

⁶Deeg et l.  Impact of patient weight on non-relapse mortality after marrow transplantation.
Bone Marrow Transplant 1995; 15 (3): 461-468

⁷ Bozzetti F. Nutrition support in patients with cancer. In:  Artificial nutrition support in clinical practice. Ed. Payne-James J, Grimble G, Silk D. Greenwich Medical Media Ltd, London (2001)

⁸Zhang et al. Vitamin Supplement Use and the Risk of Non-Hodgkin's Lymphoma among Women and Men. American Journal of Epidemiology, 2001; 153(11): 1056-1063.