nutrition and cancer prevention · 2016 over 1.6 million new cases expected to be continue to rise...
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Oncology Nutrition
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prevention/tx/case studies
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Case Studies… will have a few
2016 over 1.6 million new cases Expected to be continue to rise
Most Common: Breast, lung, prostate, colon/rectal, bladder, melanoma, lymphoma, thyroid, renal, leukemia, endometrial, pancreatic
Survivors: 14.5 million in 2014 Expected to rise to 19 million by 2024
The Numbers
Cost of cancer care 2010 in US: 125 billion- expected to be 158 billion by 2020
1/3 of all cancers related to smoking
1/3 of all cancers related to obesity, overweight, inactivity and/or poor nutrition
Cancer Stats….
Carcinogenesis: when normal cells transform into cancer cells
Role of Nutrition in Cancer
Cancer Prevention
Treatment Symptom
Management
Survivorship
Prevention/Survivorship
What do you think is the risk factor that oncology dietitians focus on the most in relation to cancer prevention/survivorship?
Treatment
What 3 treatment related side effects do you think we spend the most time counseling on?
What cancers diagnosis do you guess we spend the most time on?
What is the most common “myth” we are currently educating patients on in relation to diet and cancer?
What do you think are some of the most common supplements patients are self prescribing during treatment and survivorship?
Achieve and maintain a healthy
weight.
Engage in regular physical activity.
Eat a healthy diet, with an emphasis
on plant foods.
ACS Guidelines on Nutrition and Physical Activity for cancer Survivors
Prevention/Survivorship
What do you think is the risk factor that oncology dietitians focus on the most in relation to cancer prevention/survivorship?
As of 2014….
70% of US adults overweight
36.5% obese
1994 only 56% overweight or obese
https://www.cancer.gov/about-cancer/causes-prevention/risk/obesity/obesity-fact-sheet
OBESITY
Problem with Obesity
Increased Estrogen
Inflammation
Increased serum glucose
Decreased insulin resistance
BMI 18.5-24.9 (higher if older)
100# for 5 feet plus 5# per inch…. PLUS or minus 10%
Keep in mind YOUR weight history
Any amount of weight loss no matter how small is beneficial
Achieve and maintain a “healthy
weight”
Evidence indicating that body fatness is a cause of postmenopausal breast cancer is convincing
Adult weight gain and abdominal fatness are probable causes of postmenopausal breast cancer
Obesity has been associated with decreased survival from breast cancer in both pre/post menopausal women
Obesity and Breast Cancer… always use EVIDENCE
Esophageal Cancer
Obese are 2x as likely and extreme obese 4x
Endometrial Cancer
Obese and overweight are 2-4 times more likely
Gastric Cancer
Obese are twice as likely to get cancer in the cardia
Liver Cancer
Obese are twice as likely- especially for men
Pancreatic Cancer
Overweight or obese 1.5 times more likely
Gallbladder, thryroid, ovarian and multilple myeloma
Obesity is linked to…
Serum glucose control
Does improved BG reduce risk of disease and/or recurrence?
Recent Mayo Clinic Study showed ovarian cancer patients on Metformin longer survival
Prostate pt who received RT only may have less recurrence
? Reduce risk of breast, lung and colorectal cancer
ALWAYS REMEMBER
All variables are almost impossible to control for….
Is obesity the cause of my cancer????
Smoking
Dietary contents
Genetics
DM or other diseases
Environmental exposure………..
Achieve and maintain a
healthy weight.
Engage in regular physical activity.
Eat a healthy diet, with an emphasis on plant foods.
ACS Guidelines on Nutrition and Physical Activity for cancer Survivors
Avoid inactivity and return to normal daily activities as soon as possible following diagnosis.
Aim to exercise at least 150 minutes per week.
Include strength training exercises at least 2 days per week.
Be Physically Active
Why Exercise??
Now linked with decreased risk of 13 cancers- overall 7% decrease
Risk regardless of BMI or smoking
People who exercise do have healthier lifestyles
Helps with fatigue
https://www.nccn.org/patients/resources/life_with_cancer/exercise.aspx
Esophageal Liver
Lung Kidney
Gastric Myeloid leukemia
Myeloma Colon
Head and neck Rectal
Bladder Breast
endometrial
Exercise/obesity
Achieve and maintain a
healthy weight.
Engage in regular physical activity.
Eat a healthy diet, with an emphasis on plant foods.
ACS Guidelines on Nutrition and Physical Activity for cancer Survivors
Choose foods and drinks in amounts that help you get to and maintain a healthy weight.
Limit how much processed meat and red meat you eat.
Eat at least 2½ cups of vegetables and fruits each day.
Choose whole grains instead of refined grain products.
Eat a healthy diet with emphasis on plant foods
• Anti-initiation: • Alter carcinogen metabolism
• Enhance carcinogen detoxification
• Scavenge reactive oxygen species
• Enhance Immunity
• Weight management
Targets for Cancer Prevention Strategies
Targets for Cancer Prevention Strategies
Anti-promotion/progression strategies Scavenge reactive oxygen
species Decrease inflammation Suppress proliferation Enhance immunity Discourage angiogenesis
Weight management
Scavange free radicals: alpha-tocopherol, carotenoids, selenium, polyphenols (tea)
Alter Oncogene/Supressor Gene Expression: Retinoids, isoflavones, folate, calorie restriction
Decrease inflammation: Vitamin E compounds, reservatrol, caloric restriction, EPA
Induce Differentiation: Retinoids, calcium Suppress Proliferation: Selenium, isoflavones, cal restr. Encourage Apoptosis (cell death) Retinoids, genistein, caloric
restriction Discourage Angiogenesis (growth of new blood vessels):
Genistein, caloric restriction Block invasion/metastasis: Vitamin E compounds
Examples of Agents which may alter Promotion/Progression Events
Bottom Line is Color and Variety
Inflammation: A Double Edged Sword
Good
Removes damaged tissue
Kills pathogens
Bad
Tissue damage
Scarring
Cancer
Inflammatory Disease Cancer
Ulcerative colitis colorectal
Pancreatitis pancreatic
Gastritis stomach
Cystitis bladder
Chronic skin irritation skin
Asthma lung
Nutrition and Cancer Prevention: A Biological Perspective, K.W. Hance and C.J. Rogers, NIH, 2006
Inflammation is a Risk Factor
Plant Based including herbs Herbs: green tea, tumeric, ginger
etc Omega- 3 FA fats Limit processed foods including
meats
Anti-Inflammatory Diet
promote cellular differentiation decrease cancer cell growth stimulate cell death reduce angiogenesis (tumor blood vessel
growth) ? Reason breast, colon and prostate cancer
often more aggressive and have a higher occurrence in darker skinned persons
No studies to support high doses- two ongoing with over 20,000 participants
Vitamin D …. Thought to be preventative
Presently
600 IU under 51
600 IU 51-70
800 IU those over 70
?Likely to go to 1000
? Need lifetime consumption (like soy?)
RDA- increased for children
Vitamin D content of foods
• Herring 3oz 1380 IU
• Salmon 3oz 530 IU
• Lt tuna 3oz 200 IU
• Shrimp 3oz 130 IU
• Egg yolk 25 IU
• Mushrooms (1/2c) 25 IU
• Milk 8 oz 100 IU • cow./rice/soy
Lower Risk of Cancer: Vegetarians 12% lower overall rate of cancer (British Journal of
Cancer, 2009).
Study linked plant-based diet to 20% lower breast cancer risk.
Lower Oxidative Stress & Inflammation
Longevity:- linked to longer lifespan
Weigh Less: BMI of fish eaters, vegetarians, and vegans is lower than meat eaters. Lots of fiber to fill you up
Many foods are high in volume and low in calorie
Reduced Risk of Heart Disease & Diabetes
Plant based diet Health Benefits
Other “hot” topics
Soy and Breast cancer
Organic vs non
AICR/WCRF’s latest continuous update report on breast
cancer (2010) said the evidence is suggestive, but too inconsistent to conclude that soy reduces risk of breast cancer
Currently no scientific evidence available to support use of isoflavone supplements by breast cancer survivors
If you are currently eating soy foods: no more than three servings per day is considered safe
Choose whole soy foods, such as tofu, soymilk, and edamame 1 cup soymilk, ½ cup cooked soybeans, 1oz soy nuts
The occasional soy protein bar or snack food is fine, but as with all plant foods, less processed is better.
Oncology nutrition website as a resource….
https://www.oncologynutrition.org/erfc/hot-topics/soy-and-breast-cancer/
Soy: Beneficial Or Harmful??
There is a lack of evidence to support Organic foods are less likely to
cause cancer than conventionally grown foods there are no studies on humans to show that organic foods can
prevent cancer
Pesticides and Herbicides: At this time there is no evidence that residues of pesticides and
herbicides at the low doses found in foods increase the risk of cancer. Overwhelming scientific evidence supports the overall health benefits
and cancer-protective effects of eating vegetables and fruits despite the possibility of low levels of these chemicals
Several studies have looked at the nutrient content of organic versus conventionally grown fruits or vegetables some studies suggest a higher nutrient content, others suggest no
difference. More studies are needed
BUT NO EVIDENCE ORGANIC IS HARMFUL
36
Should I go Organic?
Prevention Questions??
OBJECTIVES
Quick Cancer Overview
Assessing Nutritional Needs
Management of Symptoms
Treatment
Oncology – branch of medicine that deals with cancer
Hematology- branch of medicine that deals with diseases and blood disorders
Grouped together : Hem-Onc
Oncology vs. Hematology
TNM Classification (most common especially for solid tumors)
Tumor
Size and extent of tumor
Lymph Nodes
Extent of spread or local lymph nodes
Metastasis (spread to other parts of body)
Presence of metastatic disease
Cancer Staging To determine appropriate treatment plan
Grade Definition
Primary Tumor
TX Primary tumor cannot be evaluated
T0 No evidence of primary tumor
Tis Carcinoma in situ (CIS): Abnormal cells present. No spread to neighboring tissues **
T1-T4 Tumor not palpable or visible by imaging
Lymph Nodes
NX Regional lymph nodes cannot be evaluated
N0 No regional lymph nodes involvement
N1-N3 Involvement of regional lymph nodes
TNM
All patients should be screened for nutrition risk in both inpatient and outpatient settings.
Done primarily by nursing
Poor appetite Weight loss Diarrhea/constipation Nausea/vomiting Nutrition support initiation or changes Head and neck cancer patients Patient requesting education
Nutrition Screening of Patients
Treatment
What 3 treatment related side effects do you think we spend the most time counseling on?
What cancers diagnosis do you guess we spend the most time on?
What is the most common “myth” we are currently educating patients on in relation to diet and cancer?
What do you think are some of the most common supplements patients are self prescribing during treatment and survivorship?
Loss of appetite/weight loss
Disease State
Treatment side effects
Diarrhea/constipation
Dysphagia
Frequent Consults
Cancer
Tumor Products Endocrine Alterations
Metabolic Abnormalities
Lipolysis
Protein Loss
Cachexia
Anorexia
Systemic Inflammatory
Response (Cytokines)
Cachexia: Multifactoral syndrome characterized by an ongoing loss of
skeletal muscle (with or without fat loss) that CANNOT be reversed with conventional nutrition
New definition: “complex metabolic syndrome associated with an underlying illness and characterized by muscle loss with or without loss of fat mass” (Evans et al. Am J Clin Nutr Feb 2010)
Cachexia
Treatment
What 3 treatment related side effects do you think we spend the most time counseling on?
What cancers diagnosis do you guess we spend the most time on?
What is the most common “myth” we are currently educating patients on in relation to diet and cancer?
What do you think are some of the most common supplements patients are self prescribing during treatment and survivorship?
Occurs in approximately half of cancer patients
Lung, colorectal, pancreatic, and head and neck cancers
Seen less frequently in early stage hormonal cancers such as breast, prostate, ovarian, and uterine.
Prevalence as high as 86% at end stages of life
cancer cachesi: impact, mechanisms and emerging treatments.
J Cachesia Sarcopenia Muscle (2013) 4:95-109
Cancer Cachexia
Multifactorial:
Increase Cytokines A small protein released by cells that has a specific effect on the interactions between cells, on communications between cells or on the behavior of cells.
Anorexia/early satiety
Severe fat loss by enhancing lypolysis
Release of cortisol and catecholamines from adrenal gland leading to an increase in resting metabolic rate
Possible Mechanisms of Cancer Cachexia
Cachexia vs Starvation
Morely et al. Cachexia: pathophysiology and clinical relevance
Am J Clin Nutr 2006
Cachexia
Low serum albumin
Inflammation (↑CRP)
↑ Protein catabolism
Low or normal food
intake
↑ REE
↑oxidation stress
Resistant to ↑ dialysis
and nutrition support
Starvation
Normal or ↓ serum
albumin
No inflammation
↓ Protein catabolism
Low food intake
Normal REE
Minimal ↑ oxidative
stress
Reversed by adequate
dialysis and nutrition
support
^ Kcal intake: increases weight through water retention and replenish fat stores
Steroids: ? Negative impact on muscle retention- may effect BG
Nutrition Counseling: May increase caloric intake but not ^weight, QOL, or survival
However does help caregiver QOL,
TPN: little observed benefit
EPA- may be of benefit due to reduction of inflammation
Cachexia Treatments
Radiotherapy
Chemotherapy
Immunotherapy
Surgical
Modes of Treatment
C
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R a d i a t i o n T h e r a p y
Dysphagia Difficulty swallowing
Odynophagia Painful swallowing in mouth or esophagus
Xerostomia Dry mouth
Mucositis Painful inflammation and ulceration of the mucous
membranes lining the digestive tract
Stomatitis Inflammation of mouth and lips (w/ or w/out oral
ulceration)
Commonly used terms
Nutrition Related Treatment Toxicities
Chemotherapy
Nausea
Lack of Appetite
Mouth Sores
Taste Changes
Diarrhea
Constipation
Neuropathy
Neutropenia
Toxicities are less with immunotherapies such as monoclonal antibodies and immune checkpoint inhibitors
Radiation
Diarrhea
Dry Mouth
Dysphagia
Nausea:
Acute: within the first few hours of receiving chemo
Delayed: develops over the next few days following chemo
Anticipatory: symptoms appear before chemo is administered; often triggered by sights, sounds, and smells.
Chemotherapy /Immunotherapy Side
Effects All are graded on level of 0-5 (see RN assessment)
Each drugs classified in accordance to it’s emetic potential. This determines the anti-emetic regime the patient is given.
Level 5 very high (>90%)
Level 4 high (60-90%)
Level 3 moderate (30-60%)
Level 2 (low (10-30%)
Level 1 (very low (<10%)
Nausea
Seretonin (5HT3) antagonists: stop serotonin from signaling the brain
to feel nausea. Can be given p.o or I.V.Most given day of chemo before treatment with highly emetogenic regimens
Zofran (Ondansetron)
Anzemet (Dolasetron)
Kytril (granisetron)
Corticostreroids: used to help prevent delayed N/V- approved for moderately emetic regimens
Decadron (dexamethasone)
Nk-1 antagonist:Blocks the action of substance P which triggers nausea in the brain. Good for acute and delayed nausea in combination with other antiemetics
Emend (Aprepitant)
Classification of antiemetic drugs
Dopamine antagonists: long used medications for nausea and vomiting with many chemotherapy drugs. Reglan (metoclopramide) for mod. emetogenic drugs may cause
diarrhea in large amounts Compazine (prochlorperazine) for mod, emetogenic drugs- not used
in pediatrics as it is highly sedating Haloperidol for prevention of acute or delayed nausea
Benzodiazepines: help relieve anxiety Ativan Valium
Cannabinoids: Prevention of anticipatory nausea and vomitting Marinol (Dronabinol)- caution with elderly
Antiemetics drugs continued
Lack of Appetite Poor Appetite from Toolkit- Eating hints booklet Supplements
Boost, ensure, CIB, etc. Thoughts on this??
Mouth Sores/ Mucositis Salt water rinses
Altered Taste Plastic utensils Salty, sweet, sour, bitter
Chemo Side Effects
Often well tolerated
Many are beneficial if lactose intolerance
Many patients find them too sweet
Many are high in CHO
Some patients c/o increased mucus
Let’s try some!
Medical Nutrition Supplements
• Diarrhea: especially with Xeloda & Irrinotecan • Increase fluids and soluble fiber intake • Some suggest banana flakes • Reduce insoluble fiber intake- increase soluble fiber/ rice congee, brat
diet.
• Constipation • Increase insoluble fiber • Increase fluid intake • Increase activity • ? Need for laxatives • Smooth Moves Tea
Chemo Side Effects
Neuropathy
? Benefit from glutamine- 15 gm BID
? Benefit IV Mg and Ca?
With Oxaliplatin (colorectal ca) pt must avoid all cold foods for 48 hours
Vitamin B- may benefit from 100mg/d >200mg/d
may increase risk of neuropathy
Chemo Side Effects
“An abnormally low level of neutrophils “
Increases risk of developing infections
CAUSES:
Chemotherapy causes bone marrow to not work well -> lowering production of neutrophils
Cancer itself affects bone marrow directly
Radiation therapy – specifically if radiating legs, pelvis, chest, or abdomen
http://www.fsis.usda.gov/wps/portal/fsis/topics/food-safety-education/get-answers/food-safety-fact-sheets - Food Safety Education Sheets by USDA
NEUTROPENIA
Lacks evidence
Still in use in many facilities
Not used for Pediatrics Why??
Neutropenic Diet
Diarrhea: with RT to intestines, colon and prostate (recommendations for diet vary)
“Pelvic Diet”
Mouth sores/Mucositis
Magic mouth rinse
Soft, room temp foods
? Glutamine up to 10mg TID
Side Effects: Radiation
Dry Mouth Biotene
Increase fluids
Papaya juice or enzymes
Dysphagia: may take months to come off TF after RT Thicker liquids
Supplements
?Speech consult
Radiation Side Effects Con’t
Signs they are needed
Diarrhea Floating stools Abdominal pain Foul smelling stools Kahki colored stools Weight loss Dosage Start with .5 units lipase per kg
Pancreatic Enzymes
Energy metabolism varies greatly
Tumor site and type does not predict energy needs
Best to use clinical judgment and individualize estimates based on full assessment.
Harris-Benedict may overestimate
Mifflin-St Jeor may be considered
Ireton-Jones may underestimate
Kcal/kg lacks evidenced based validation: but may be used for initial estimates and adjusted based on activity
Assessment of the Adult Oncology Patient: Energy Requirements
Mifflin St. Jeor Men: REE= 10W + 6.25Ht – 5A + 5 Women: REE= 10W + 6.25Ht – 5A – 161 (wt in Kg, Ht in cm, Age in years)
Activity and injury factors Activity Factors:
Vent support 1-1.1 Bedridden 1.2 Ambulatory 1.3
Injury Factors: Mild starvation 0.85-1.0 Cancer-based on severity of illness 1.1-1.45 Cancer wt maintenance 1.15-1.3 Cancer wt gain/nutritional repletion 1.5 Vent support/catabolic 1.5 Sepsis 1.5
Caloric Requirements
Estimated Caloric Needs Based on Body WT
Condition Kcals/Kg
Cancer, nutritional repletion/wt gain 30-35
Cancer non-ambulatory 25-30
Cancer hypermetabolic/stressed 35
Sepsis 25-30
Stem Cell Transplant 30-35
Protein Needs Condition Estimated Protein
Needs (gm/kg)
Normal maintenance 0.8-1.0
Non-stressed Ca pt 1.0-1.2
Hypercatabolism 1.2-1.6
Severe stress 1.5-2.5
Requiring nutrition
support
1.6-2.0
Stem cell transplant 1.5-2.0
Normal maintenance 0.8-1.0
Non-stressed cancer pt 1.0-1.2
Hypercatabolism 1.2-1.6
Severe Stress/nutrition support 1.5-2.0
Stem cell transplant 1.5-2.0
ARF .6 (1.0 with dialysis)
Dialysis 1.0
Hemodialysis or Peritoneal Dialysis 1.2-1.5
Hepatic Failure 1.0-1.5
ESLD with Cirrhosis 1.0-1.2
Determining Protein Needs
May vary based on side effects of treatment (such as diarrhea with Xeloda, 5-FU, RT, etc)
May use RDA method 1ml fluid per kcal energy needs or BSA, or ADA : 16-30yrs active: 40mL/kg
31-55 years: 35mL/kg
56-75 years: 30mL/kg
76 years or older: 25 mL/kg
Fluid Needs
Fluid Requirements
Age Fluid requirement
(ml/kg)
16-30 40
31-55 35
56-75 30
>76 25
Or 1ml fluid per 1kcal per estimated needs
Often patients with head and neck CA receive PEG tube placement before start treatment- as well as some lung pts
Not all patients end up using PEG Mainly given for all stage 3 or 4 head and neck cancer
patients who are getting chemo with RT Many esophageal patients start to eat better as tumor
shrinks with treatment
Some esophageal and stomach CA patients receive PEJ or PEG before treatment.
For oncology patients, use clinical judgment for formula based on needs and volume estimate.
Tube Feedings in RT
Treatment
What 3 treatment related side effects do you think we spend the most time counseling on?
What cancers diagnosis do you guess we spend the most time on?
What is the most common “myth” we are currently educating patients on in relation to diet and cancer?
What do you think are some of the most common supplements patients are self prescribing during treatment and survivorship?
Cancer cells like all other cells in the human body use “sugar” or glucose as fuel Tumors can and will make their own glucose for fuel
Keto diet:
Finding more patients interested in this during treatmet
Theory is based on tumor cells having altered mitochondria that are not able to utilize fatty acids and ketones for energy- thus “starving the tumor”
Few studies with very few patients-
Mixed results
Compliance issues
Does Sugar Feed cancer?
Sugar increases calorie intake without providing any of the nutrients that reduce cancer risk.
By promoting obesity, a high sugar intake may indirectly increase cancer risk.
Eating more sugar causes insulin levels to rise. Consistent high levels of insulin have been linked to increased risk for certain
cancers
White (refined) sugar is no different from brown (unrefined) sugar or honey with regard to their effects on body weight or insulin levels.
Limiting foods such as cakes, candy, cookies, and sweetened cereals, as well as sugar-sweetened drinks such as soda and sports drinks can help reduce calorie intake
ADVICE: Limit simple sugars
Supplements During Treatment
Recommendations vary per practitioner/facility
Current LVHN recommendations: no more than RDA for anti-oxidants via supplement
Treatment
What cancers diagnosis do you guess we spend the most time on?
What 3 treatment related side effects do you think we spend the most time counseling on?
What is the most common “myth” we are currently educating patients on in relation to diet and cancer?
What do you think are some of the most common supplements patients are self prescribing during treatment and survivorship?
St John’s Wart known to interfere with cytoxic agents
Milk thistle recently shown to reduce hepatotoxicity in children receiving chemo
Ginger shown to compliment anti-emetics in reducing nausea during chemotherapy but not blood thinners
Curcumin- depending on other meds, treatment ? DM
Theoretically, many herbs MAY alter chemo…bottom line is that we do not know NCCAM great handouts http://nccam.nih.gov
Sloan Kettering: http://www.mskcc.org/mskcc/html/58481.cfm#M
NCCAM
Popular Supplements
BREAK?
57 year old male. Recently diagnosed with tongue cancer. PEG placement two days ago. To undergo 30 treatments of radiation Presently having some difficulty chewing. Taking mainly soft foods, milkshakes and water. Does NOT want to use PEG. Complains of dry mouth and taste changes
Height: 5’9” Weight 156# Weight History: recently lost 10# Lives with wife and daughter. Presently not working. Meds: Percocet, magic mouth rinse and prilosec. Stopped multivitamin. c/o mild dysphagia, constipation, fatigue and frequent dizziness
Needs Suggestions including enteral formula Labs you would look for Nutrition Diagnostic Statement
Case Study
• 56 year old female with pancreatic cancer post whipple. • Ht 5’7” Wt 124# UBW 145# Wt loss of over 20# over
past 6 months- continued at a rate of 1-2# per week last month
• Diet recall indicates bland, low protein, moderate fat, diet with CIB at all meals.
• Presently undergoing radiation • Meds: Prilosec, ativan, MVI, Vitamin C 500mg • Symptoms: c/o fullness after meals, foul smelling stools,
gas pains
Needs Suggestions Labs you would look for Nutrition Diagnostic Statement
Case Study
53 year old post-menopausal who finished chemo and radiation for breast cancer last year.
Height 5’3” Present wt 155# Wt History: In 30’s 125-130# 40’s 130-140# Gained 10 # during chemo Has gained 5# over past 6 months Daily Meds: MVI, calcium with vitamin D,2,000 IU vitamin D , Tamoxifen, black
cohosh for hot flashes Medical history: two children ages 24 and 26 NKA, menopause at 48 years of age Works as a secretary 4 days a week in a doctors office. Skips breakfast. Complaints: fatigue, constipation, sweet-tooth Calculate needs Diagnostic statement What are you recommendations
Case Study/Discussion: Survivor/Prevention