khac minh. dinh duong trong phong ngua....pdf
TRANSCRIPT
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THI KHC MINH
PH GIO S
TIN S
DC S
i hc Y Dc TP. HCM
Vit Nam
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DINH DNG TRONG
PHNG NGA V IU TR SUY MN
BNH NHN UNG TH
Thnh PhHCh Minh 19/5/2016
PGS. TS. DS. THI KHC [email protected]
ihcY DcThnh PhHCh Minh
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ihcY DcThnh phHCh Minh
ng ming
ng thng qua d dy
ng thng qua rut (Enteralduodenal/jejunal)
ng thng vi lng nh v tim truyn
Tim truyn ton phn
Cch cho ntt nht
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Tstcn n suy mn do ung th Dinh dngy hcchuyn bitcho
bnh nhn ung th Tngkt
Tng quan
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Tstcn n suy mn do ung th Dinh dngy hcchuyn bitcho
bnh nhn ung th Tngkt
Tng quan
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Stcn thngphbin:30-80% bnhnhn ung th
Bozzetti 2008 and 2001; Bosaeus 2001Laviano A, Meguid MM. Nutrition 1996;12:358-71
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Suy mn do ung th
@20%bnhnhn ung thchtdo suy mn (suydinh dngv mtc).@50% bnhnhn michnonung thc tnhtrngbingn.
30-80% bnhnhn ung th c st cn-Bnhl ung th(loi, giai on)- iutr
- Tui- Khnngnhycmcac nhn- Cng cnhgi
Nutrition; 12: 358-371, 1996
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Stcn bnh nhn ung th
Caro MM, Laviano A, Pichard, Clin Nutr 2007
Ung thGimlngthcn
Tm l cngthngaun
BingnRilonvgicKh nut
Bunnn v i maChngbngv to bn
Tiu chyv rilonhpthu
Thay ichuynha
TngnnglngChuynha cbn
Cytokin tinvim,neuropeptides,
Hormon
Carbohydrate:- Tngglucose- Khng Insulin
Chtbo:- Tngphn hychtbo- Mtcn bnggiato
v phn hylipid- Tngoxy ha lipid- Tnglipid huyt
Protein:- TngCRP
- GimProtein cbp- Cn bngNitm
Caro MM, Laviano A, Pichard, Clin Nutr 2007
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Stcn nng: gimthigian sngcn
Ann Oncol. 2011, 22(4):835-41.
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Stcn dnnktquiutrkm bnhnhn ung thngtiu ha
51% 49%cn nng bstcn
nnh
QoL score (0-100) 76 59 p
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Stcn l yuttin lngclpchossngcabnhnhn K phikhng tbo nhNSCLC
Bnhnhn K phikhng tbo nhcstcn thngkhng hon tt3tha tr
Dliucly bnhnhn giai onIII/IV NSCLC
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Cn nngnnhtrong ha trgpphnko di ssng
Dliucly bnhnhn giai onIII/IV
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Ha tr liu tiu chun v cc tr liu ung thkhc lm tng tnh trng st cn do ung th
+
CarmustineCarboplatinCisplatin5-Fluoruracil
DoxorubicinPaclitaxelSoraf inib
Everol imus
Radiat ionSurgery
Gimcn khi btuiutrung thlin quan vigimtlpngvtngctnh cathucv l mttiu ch quan trngtrong theo di tcdngphcatrliu.
US Dept Health and Human services NIH, NCI: CTCAE v4.0
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Tc dngphthnggpiutrung th
= iutrc tc dngphthnggp
iutr Stcn Mtmi Bunnn
Vimnimmc
ming
Thay ikhuv
To bn
Tl% 50% -
90%
70% -
100%
30% -
90%
40% -
100%
35% -
70%
40% -
50%
Ha tr
XTr
Phuthut
Liuphp
mindch
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Suy mn ung th (Cancer Cachexia)
Suy mn ung thcnhngha l mthichngc trngbis mt lin tc khi c
xng(c hay khng c km mtkhim) m
n skhngchiphchon ton bihtrdinh dng thng thng, din tin n suychcnng.
V mt bnh hc: cn bng nng lng vmmdo phihpca2 yutl- Gimcung cplngthcn(ngim); v- Chuynha btthng.
Fearon K et al. Lancet Oncol 2011; 12:489-495
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Cnpht hinsmduhiustcn!
Bnhthng
Tinsuymn
Stcn 5%BMI2% hayHC. Suy mn vst>2%
Thngnungkm/ vim tonthn
Mcsuy mn adngBnhung th: dha vkhng pngviiutrung thimchsthchtthp
Tin lngsngcn
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Tiu chunbtbuc
Stcn 5%/ tia
12 thng
(HocBMI
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Dinh dngcho bnhnhn ung th
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Can thipdinh dng
Smtrong tinsuy mn v suy mn
iutrngch(am thc):iutrung thchiu(phuthut, ha, xtr)iutrphihpnhgimau, nn
iutrdinh dng:Cithincung cpdinh dngbnhnhniuha pngchuynha lin quan vim (dngchtcbit
v thuc)Vnngcth(exercise ikhng- Resistance exercise)
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Dinh dngcho bnhnhn ung th
dinh dng
Cng thciuha chuynha
ChnPP dinhdngthch hp
Bsung DD ngming DD qua ngthng DD tnhmch(PN)
NL: 25-30kcal/ kg/ngy m: 1,2-1,5g/ kg/ ngy
(max 2g) 50% NL khng tm
Acid bo omega 3 Thuc(khng vim, ni
titt)
ESPEN Guideline 2006- 2009; ASPEN Guideline 2009
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Chnphngphp dinh dngESPEN Guideline 2006- 2009; ASPEN Guideline 2009
C chnhcan thipDD
TvnDD:
Bsung DD quangming(sip feeding)
Dinh dngquangthng(Tube feeding)
Dinh dngqua
tnhmch(Parenteralnutrition)
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Trong xhay ha x tr: Tvndinh dng tch
ccv bsung dinh dngqua ngmingtngkhuphnnv phng ngastcn do iu
trv ngnngagin oniutr(Grade A)
tsonde nui nnuung thu, mtc, thc
qun gy tc nghn hoc nu c th tin lng
cvim nim mckhu tr (Grade C)
Chnphngphp dinh dngESPEN Guideline 2006- 2009; ASPEN Guideline 2009
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Bn SDD hay iko di >1 tunv khng thdng DDqua sonde (Grade C)
Bn vim nim mchay vim rutxtrnng(Grade C)
Bsung DDTM khi tin lngkhnngnunghay DDqua sonde
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Tstcn n suy mn do ung th Dinh dngy hcchuyn bitcho
bnh nhn ung th Tngkt
Tng quan
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Chng ta cho bnhnhn nnhthno??
Can thipbngdinh dngtheo cch thngthngtchiuqugiihn
Cc snphmdinh dngngungtiu chun
Cho nqua ngthngDinh dngtim truynton phn
Can thipbngdinh dngtheo cch thngthngkhnggiiquytccchtimncagimcn trong ung th
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Chng ta cho bnhnhn nnhthno??
Can thipbngdinh dngtheo cch thngthngkhnggiiquytccchtimn
cagimcn trong ung th
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Tngcung cpdinh dngnthunKHNG c hiuqu
2
1.5
1
0.5
0
0.5
1
1.5
2
0 1 2 3 4 5
ctvn
i chng
Chang
einWeight(kg)
Tng lng nng lng np vo khng b tr c
nhng thay i chuyn ha dn ti suy mn.
Time (months)
105 bnhnhn ung thphitbo nh, bungtrnghocung thv.Tngcalo ln 1,5-1,7 lnREE.tngdung npngk, nhng tngcn khng ngk
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70% c thay i v gic (TA) trong ha tr& cctriu chng khng gim sau ha trnhiuthng
Ung th phi 54% Nghin cu gia ngy 0 v 30 ca CTUng thtuyn ty 19%Ung thi trc trng 26%Tui: 65 nm; Nam 57%
N=197
Thay ivgic theo thigian
Zabernigg et al, Taste alterations in in Cancer
Patients receiving Chemotherapy,The Oncologist CME program 2010
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Lin quan gia thay i v gic v chtlngcucsng(QoL)
Zabernigg et al, 2010
Thay ivgic lin quan ng kvi:
- Mt cmgic thm n
- Mt mi
- Bun nn/ i ma
- Chc nngnhn thc
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Thch thc trong vic nung
Thay i v gic thng gp nhng bnh nhn ung th dobnh tt v / hoc iu tr
68 % bnh nhn ha tr liu c thay i vgic1:
- Mi v thc n gingba cacton hoc giy nhm- Qu mn
- Qu ngt- Qu chua- Qu cay ng- V kim loi
1 Wickham et al, 19992 Ijpma et al, Cancer Treat Rev 2014
T lc v kim loi dao ng 9,7- 78% ty loiung th, phngphp hatr, v giai on iutr 2
Carbohydrat: trehalose
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ihcY DcThnh phHCh Minh
Ngibnh
ung th
pngmindchivikhiung th:snxutcytokine vim nhIL-1, IL-6,
TNF-, INF gama
cmgicthm n
pngproteinpha cp(CRP)
nung REE (tiu hao NLlc ngh)
Btthngchuynha ng, m,
bo
Hichngsuy mn ung th
Khiung
th
Cc yutdha
chiuu (PIF, LMF)
Phn hyc, m
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ihcY DcThnh phHCh Minh
Ung th
ngha >>> DhaNgibnh:
Dha >>> ngha
Khng bingibnhung
th!Cancer cachexia
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ihcY DcThnh phHCh Minh
Ngibnh
ung th
pngmindchivikhiung th:snxutcytokine vim nhIL-1, IL-6,
TNF-, INF gama
cmgicthm n
pngproteinpha cp(CRP)
nung REE (tiu hao NLlc ngh)
Btthngchuynha ng, m,
bo
Hichngsuy mn ung th
Khiung
th
Cc yutdha
chiuu (PIF, LMF)
Phn hyc, m
EPA
EPA
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Bsung EPA (-3) bo c thgip nnhcn bnhnhnung thc chnungtngcng, stcn khng ch.
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LiuEPA cho bnhnhn ung th
< 2 g EPA/ngy: KHNG HIU QU2 g EPA/ngy : LIU TI U6 g EPA/ngy : KHNG HIU QU HN 2g
Liu2g/ngy EPA l thch hp gip nnhthtrngbnhnhn, yli stcn dnnsuy mn
Khuynco cahidinh dnglm sng Hoa K(ASPEN):
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Bsung EPA: cithincn nngv hotngcth bnhnhn ung ththcqun
0
20
40
60
80
100 Active
Control
*p < 0.05
Improved Stable Worsened
ChangeinECOG
score(%o
fpat
ients)
Active Control
0.00
0.25
0.50
0.75
1.00
1.25
1.50
1.75
*p < 0.05A
Bodyweightchange(kg)
Thay i cn nng im s nh gi hot ngPerformance score
J Cachexia Sarcopenia Muscle. 2015 , 6(1):32-44
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Overall survivalTime to progression
Tngcngktquha trbngFEC 75cho bnhnhn ung thv di cn
Nghin cumcpngv an ton: 1,8 gr DHA l khng c tc dng ph v ci thin kt qu ca ha tr liu khi
dng liucao kt hp
KthpviDHA liucao (n=12) cho thytlpngiutrv kh
nngsngst cao hnso vinhm kt hpDHA liuthp(n=13)Bougn oux et al., Br J Cancer 2009
i hc Y Dc
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ihcY DcThnh phHCh Minh
Suy mn do ung thv 3
Gut. 2003 52(10):1479-86.
i hc Y Dc
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ihcY DcThnh phHCh Minh
Eur J Clin Nutr. 2012, 66(3):399-404
i hc Y Dc
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ihcY DcThnh phHCh Minh
Khng lm gimnguy ctvong
Can thipdinh dng bnhnhn ung thsuy dinh
dng: tngquan hthngv nghin cugp
J Natl Cancer Inst. 2012;104(5):371-85
Oral nutritional interventions and
mortality meta-analysis.
i hc Y Dc
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ihcY DcThnh phHCh Minh
Can thipdinh dng bnhnhn ung thsuy dinh
dng: tngquan hthngv nghin cugp
Cithinchtlng
sngcn
J Natl Cancer Inst. 2012;104(5):371-85
Oral nutritional
intervention and global
quality of life
metaanalysis
i hc Y Dc
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ihcY DcThnh phHCh Minh
Can thipdinh dng bnhnhn ung thsuy dinh
dng: tngquan hthngv nghin cugp
Gip bnhnhn tng
cn
J Natl Cancer Inst. 2012;104(5):371-85
Oral nutritional
interventions and
weight gain meta-
analysis.
i hc Y Dc
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ihcY DcThnh phHCh Minh
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T st cn n suy mn do ung th
FortiCare cung cp hm lngcao protein v du c(n -3 EPA)
n -3 EPA gip gimsuy mn, gim vim vh
tr chc nng min dchNng lng v protein pngnhu cu giatng bnh nhn ung th
Hngvthch hp, khi lng nh (gip tngs
tun th)
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Nghin cutiVitNam
Nghin cungdng lm sng, ngunhin c nhm chng
trn 60 bnhnhn
Stcn trung bnh 3,3 kg/thng trckhi vo nghin cuBnhnhn ung thitrctrng c suy dinh dng, suy mn theobngnhgi SGA tnh trngC (cn nng, chn n, teo c):
St> 5% cn nngtrong 6 thng qua,
Teo ctuhoccdenta,Mtlpmdida ctam uhocvngxngsnditiimgiavng nc
+ Tiu chun loi:Khng st cn trn hoc bng 3,3 Kg/thng hoc khng c du hiu suy mnSuy cc chc nng gan, thn, bnh ni tit chuyn ha. Thiu 1 phn c th ( ct
tay, chn ) .
a im:Khoa ngoi C Bnh vin K.Trung tm dinh dnglm sng BnhvinBchMaiKhoa ung bu v chm sc gim nh , BV HY H ni
Thi gian: thng 12/2012 6/2015
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Nghin cutiVitNam
iu tr phc EPA (2g/ngy) gip bnh nhnung thitrctrng chnggimcn v suy mn:tngtrnglngtrung bnh camibnhnhn ln3 kg sau 8 tuniutr.
iutrEPA gip bnhnhn ung thitrctrng tngprotein cac th, ngnngasging ha protein cac th: Bnh nhn c tng chu vi vng cnh tay; tngnngAlbumin trong mu sau iutr(40,4 so vitrc
can thipl 29,0 g/l).Can thip dinh dng b sung EPA gp phn ci thincht lng sng cho BN UTTT: 100% BN c cm gicngon ming, bnhnhn tngtrung bnh 3 kg , tngkch
thcchu vi vng cnh tay, cithinAlbumin mu.
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Nghin cutiVitNam
Phc iutrEPA cho bnhnhn ungthitrctrngLiulng: iutrlin tc
Protein trung bnh 1,51,7g/kg/ngy
Nnglngtrung bnh 35 Kcal/kg/ngyEPA 2g/ngy
Kinngh: EPA nn cavo trong iutr
nhngBN stcn do UTTT v dphng suymn v chmsc gimnhtrong UTTT giaionmun
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Hiu qu ca iu tr bng EPA trongdinh dngbngngungphthucvo s tun th ca bnh nhn. Bn
cnhvicchn n, victun thiutrcabnhnhn vidngdinh dngcaonnglng, cao protein v bsung EPAbgiihnbiv thngxuyn gpphimi vkh chu(caduc).V vy, viccn thit l ci thin thin tnh ngonming, dchucadngdinh dngbsung EPA ci thin s tun th cabnhnhn viiu trv mang lihiu
qutrliu.
i hc Y Dc
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ihcY DcThnh phHCh Minh
Thc n m khngcn th khngbao gi l dinh
dng!Prof Jeya Henri
i hc Y Dc
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ihcY DcThnh phHCh MinhCC CCH CUNG CP
> 2 GRAM EPA/NGY
nlnglnmc C trch, c ng, c thu, c mi,
Vin duc
Dngsakthpgiadinhdngvi lngv alng
ihcY Dc
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c cThnh phHCh Minh
FORTICARE: CCH TINLICUNG CPDINHDNGQUAN TRNGCHO BNHNHN UNG TH
Dinh dngchuyn bitcho bnhnhn ung th:
Dinh dngiutr
Nnglngcao
Hm lngprotein cao
Hdinh dnghon chnh
ChsGI thp
Thtch nh
nhtthp
Bsung nhiuEPA
Hngvtuytvi
p ng nhu cu bnh nhn mt cch
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p ng nhu cu bnh nhn mt cchthun tin
Nhu cu cth Stin liKhi lng nh
Dinh dnghon chnhCn bng
nht thp
Hng v ph hp
Nnglng caoGiu protein
Protein chtlngcaoCht dinh dngv m
Vi chtEPA (200 g c trch
2 con c trch/ ngy 2.2 gr EPA/ngytrong FortiCare
=
Cht x
ihcY Dc
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Thnh phHCh Minh
Chnh: Bnhnhn ung th, suy mn do ung th Bnhnhn suy dinh dng, nkm, chn n itngcnnhu cudinh dngcao Bnhnhn cntngcn chunbphuthut; Bnnhn huphu, kcphnc thai, sinh con Sdngccho bnhitho ng, tngng
huyt. Bnhnhn tiungcnchia nhban.
Liudng: ty theo nhu cubnhnhn Bsung dinh dng: 1-3 chai/ngy. Bnhnhn ung th: tithiu3 chai/ngy
Chngchnh: Trem di3 tui, dngthnh phn
ihcY DcH TR DINH DNG VI
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Thnh phHCh Minh
EPA PH HP CHO BNHNHN UNG TH
Ti sao: ci thin kt qu ca iu tr ung th v nng
cao cht lng cuc sng cho bnh nhn.
Khi no: Kim sot tnh trng dinh dng ca mi ln chn on ung thv la chn can thip tt c cc giai on ung th.
Nh th no: H tr dinh dng chuyn su vi cc cht dinh dng ph hp
v iu ha chuyn ha mt cch nhanh chng tin li v ngonming (kch thch v gic).
Th so snh gi tr
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Thso snh gi tr
=
=
+ +
(BS. LmcHongBnhvinUng buTPHCM)
http://www.google.com/url?url=http://websosanh.vn/loa-the-nho-hinh-bao-thuoc-marlboro/1067122918/so-sanh.htm&rct=j&frm=1&q=&esrc=s&sa=U&ei=d3egVe2GCc2JuATJopeoDg&ved=0CB4Q9QEwBDgU&sig2=2Q9ONbxzUvAqJW3oXIR2rg&usg=AFQjCNFuQthaFMrGYUsPGH7BHL-vto6OPghttp://www.google.com/url?url=http://donavi.com.vn/hai-san/dau-ca-hoi-tuoi-1414.html&rct=j&frm=1&q=&esrc=s&sa=U&ei=OXigVY2QOpGTuASWtrO4AQ&ved=0CBYQ9QEwAA&sig2=BomPxWpF-mB1VbUNo5EGdw&usg=AFQjCNFSzdUxFpaxzC3CimV5ggqTP-tsIQhttp://www.google.com/url?url=http://websosanh.vn/loa-the-nho-hinh-bao-thuoc-marlboro/1067122918/so-sanh.htm&rct=j&frm=1&q=&esrc=s&sa=U&ei=d3egVe2GCc2JuATJopeoDg&ved=0CB4Q9QEwBDgU&sig2=2Q9ONbxzUvAqJW3oXIR2rg&usg=AFQjCNFuQthaFMrGYUsPGH7BHL-vto6OPghttp://www.google.com/url?url=http://www.hamruou.net/bia-nhap-khau/chi-tiet/Heineken-ha-lan_355.html&rct=j&frm=1&q=&esrc=s&sa=U&ei=qnSgVZnQIs62uQTUxLnIAg&ved=0CB4Q9QEwBA&sig2=-SMg5rP_MTXuDcQtR7V45w&usg=AFQjCNGCVvrGO-E-h2fu9NU6h4OqVIKC4Q -
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Tstcn n suy mn do ung th Dinh dngy hcchuyn bitcho
bnh nhn ung th Tngkt
Tng quan
Tng kt: Dinh dng cho
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Tngkt: Dinh dngchobnhnhn ung th
Cnpht hinsmduhiustcn, suy mn do ung thttccc giai on.
Suy mn ung thnhhngnktquiutr(pngkmiutr),tnggiihn liuc, liu lngiutr t hn, gin
oniutr Dinh dngthng thngkhng giiquytccchtimn
gy suy mn trong ung th
Dinh dng giu nng lng, giu m v b sung EPA liu2g/ngy.
Mi vv stun thiutrdinh dngbsung Tngnghuytl phbincc bnhnhn ung thv cn
sdngmtsnphmph hpviGl thp
ihcY Dc
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Thnh phHCh MinhHy thucl thcphmv thcphml thuccacon ngi.
Hippocrates of Cos, Greece
460-377 B.C.
ihcY Dc
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Thnh phHCh Minh
CM N S CH LNGNGHE CA QU V!