A Food Fight For Life: Diet and Nutrition at the Children's Blood and Cancer Center

Getting a healthy child to eat vegetables takes a patient parent. Getting a child with cancer to eat anything takes professional help. Getting that child to eat something that's also nutritious takes a village.

Despite the importance of nutrition for cancer patients, an eye-opening recent paper in Nutrition and Cancer reveals that the nutritional information offered by the member institutions of the National Comprehensive Cancer Network is a complete mess.

We expect physicians to know all about nutrition but in fact not a medical school in the United States includes among its core curriculum a class on human nutrition. Expecting one's doctor to know much about nutrition is like expecting the medical billing office to give you a second opinion on your diagnosis.

As many adults find out following a cancer diagnosis, in terms of getting nutritional support, oftentimes they're on their own. This despite the increasing scientific evidence of the connection between diet, cancer, cancer prevention and cancer recovery.

PEDIATRICS

Pediatric oncology takes a far more serious view of the value of nutrition before, during and after cancer treatment. In few places is this more evident than at the Children's Blood and Cancer Center (CBCC) at Dell Children's Hospital, and few people are more knowledgeable, determined or enthusiastic than the center's pediatric dietitian specialist, Heather Garza.

Garza is a Board Certified Specialist (CPS) in Pediatric Nutrition as well as a Licensed Dietitian (LD). The latter is required in the state of Texas to provide nutritional care in credentialed medical settings.

She is also a Registered Dietitian (RD), as opposed to a nutritionist. This is an important distinction. RDs require education, certification, and continuing education. Nutritionists don't require any education or training. The title "Nutritionist" has as much value as the title "Esquire".

Garza kindly took some time to talk to me about nutrition, pediatric patients and her role at the CBCC.

First things first, let's bust a myth: Does sugar feed tumors and can cutting sweets starve a tumor?

Every cell in our body needs sugar or glucose to live. That includes healthy cells and tumor cells. There’s no getting around that.

But too much glucose at once causes a surge of insulin to be released from the pancreas allowing the excess sugar into the cells. Insulin is a hormone that signals cells to grow. Signaling healthy cells to grow is a natural physiological process. When tumor cells are present, insulin can stimulate them to grow as well. An excess of insulin may trigger a tumor cell to grow more. Therefore, maintaining normal insulin levels may keep cancer cells from growing too rapidly.

This does not mean you should avoid sugar. Food such as fruits, vegetables, beans and whole grains are complex carbohydrates that contain cancer-fighting nutrients. In addition, foods that contain protein, fiber, and fat slow down the rate at which the body processes sugar and can reduce the amount of insulin your body releases.

Following a few guidelines can help you prevent the release of excess insulin: limit simple and concentrated sugars such as juices, sodas, cakes, candy, and other baked goods; if you eat sweet treats, keep them at a sensible amount a few times a week and pair them with lean protein, fiber or healthy fat; fill your plate with whole, unprocessed carbohydrates such as fruits, vegetables, legumes and whole grains.

At the same time, occasionally if your child wants a Snickers bar, let them have a Snickers bar. It's not the end of the world. Do they have to have a king-sized one? No.

I do.

Well you might, but the fun-sized ones go a long way!

So tell me about your role at the CBCC.

Primarily I'm here to maintain the nutritional health of the patients while they're going through treatment.

Nutrition is so important in children with cancer. Children, unlike adults, are still growing. The life-saving treatments they receive also impair their ability to thrive. I strive to not only maintain their health and energy throughout treatment but to also promote normal growth and development as if they weren't receiving toxic chemotherapy.

In addition, a well nourished child is able to better tolerate treatment, improve drug action and have a higher quality of life.

What kind of hurdles do you run into?

The majority of the hurdles are caused by chemotherapy side effects such as nausea, vomiting, appetite loss, weight loss, taste changes, mouth sores, diarrhea, etc., making it more difficult to stay well nourished. These side effects do not typically manifest individually. They often times come in combo packages and support one another. For example, a child that experiences nausea will also suffer from a loss of appetite due to the nausea and then may lose weight due to the loss of appetite. Part of my job is to help patients and families manage side effects so they can maintain or obtain a well nourished state.

“How do I feed my child?” is the most popular question parents ask me, followed by “what do I feed my child?” Feeding a child is not only a normal parental task, but it is also an area of cancer treatment that they can actively participate in, 100 percent. When a parent struggles to feed their child, it is very devastating for them, and that is where I step in and help them do what they would normally do naturally.

Is age a factor?

Yes. Younger children have a difficult time understanding they still need to eat even if they don’t feel well. They are also at a higher risk for undernourishment since they have less fat reserves to endure long stretches of inadequate food intake. Older children or adolescents tend to experience more nausea and vomiting, some of which is psychological since they are better able to understand their situation and treatment. In some instances, more invasive approaches have to be taken such as placing feeding tubes.

While we do know that certain meds are more prone to causing some side effects than others, ultimately each child is unique and can react differently. That’s something we tell patients and parents (even though most of the time, medications side effects are true to form).

Is the science of nutrition and chemo specific enough to where you can look into the future and say (and I'm just making this up) 'Ok, this patient is receiving drug X and we know drug X depletes potassium so let's work some potassium into their diets'?

In some instances the science of nutrition has gotten specific in its response to anticancer treatments. We know for example that vincristine causes severe constipation, so if we know they're going to be receiving vincristine we can respond to that before and during treatments with nutritional interventions.

We prefer to do that through whole foods, natural foods.

As opposed to say supplements?

Yes, absolutely. And I think the kiddos do too, they don't want to take another medication.

In terms of general nutrition, what guidelines do you use?

For “general” nutrition, I use AAP (American Academy of Pediatrics) and WHO (World Health Organization) Feeding Recommendations, USDA myplate.gov and DRI (Dietary Reference Intakes).

I use ASPEN (American Society for Parenteral and Enteral Nutrition) Clinical guidelines and DRI for the more critically ill child.

During treatment we stress a high calorie/high protein diet, since patients often struggle with poor appetite and weight loss.

What about new patients?

New patients and their families receive so much information at the beginning of treatment. Lots of the information they get verbally is typically lost in the confusion, especially nutrition since they tend to be so focused on starting chemotherapy or radiation.

So, when counseling new patients, I use a National Cancer Institute Book entitled Eating Hints: Before, During and After Cancer Treatment (pictured right) as a tool for families to use at home to trouble-shoot eating problems when they can't reach me.

It gives them an idea of what to expect before starting treatment, and being able to take home a reference is valuable for them.

Tell me about 'Food Fight For Life'. From a writer's perspective that's such a great name.

Like I said before, the question I hear most often is, "How do I feed my child?" So we started Food Fight For Life©, a program that provides at minimum four cooking classes a year.

The program teaches them how to make their meals nutrient-dense with the main goal of getting the kids more involved. When those kiddos are going through treatment they don't have the best relationship with food: Their taste buds have changed and their favorite foods aren't their favorite foods anymore. So we work on rebuilding those relationships, on making them positive relationships again.

We also try to expand their palette a bit and make them unafraid to try different foods. It can be amazing to see in these classes how the kids empower themselves, and how they empower each other.

They gain confidence from playing with the food, building meals, tasting food. If a parent asks a child to try something new, they're not likely going to try it. But seeing other kids that have been through the same thing that they have get involved is very motivating.

And it can be a profoundly moving experience for a parent to see their child, who maybe a couple months ago needed to receive nutrients through an IV, suddenly pick up a strawberry and eat it.

I opened this article by mentioning the fact that in medical oncology, there is very little for adult patients in the way of dietary help. In many places it isn't integral to their treatment. How different is the situation in pediatric oncology?

I can only speak for how it is here [at the CBCC], but our physicians are incredibly receptive. They recognize the important role nutrition plays not only while the child is being treated but also in the area of survivorship, as the child develops into adulthood.

Here, diet and nutrition are considered integral aspects of treatment. Patients and parents can schedule to see me as often as they feel they need to, and it costs them nothing. All my office visits are free.

You can definitely see a difference in a child’s overall energy, strength, and quality of life when nutrition intervention is started early, aggressively managed and an integral part of their treatment plan. They tend to have more “good” days than “bad”, recover quicker from treatment side effects and infections, and enjoy living life.

They are all going through a harsh situation where they are fighting for their life. The least we can do is help them get through it with as little suffering as possible.

All photo credits: CBCC

This is the fourth installment in my series on the Children's Blood and Cancer Center at Dell Children's Hospital in Austin, Texas. The first three are listed below:

• Introduction: Uncommonly Ordinary
• Part I: Not Your Average Prom
• Part II: Teenage Cancer: One Girl's Story