https://doi.org/10.5812/modernc-123150

Nutritional Recommendations for Patients Undergoing Chemotherapy During the COVID-19 Pandemic

authors:

avatar Sarina Salemi ORCID 1 , avatar Moeina Afshari ORCID 2 , * , avatar Mohammadreza Afshari ORCID 3

School of Nutritional Sciences and Dietetics, Tehran University of Medical Science, Tehran, Iran
Faculty of Medicine in Hradec Kralove, Charles University, Hradec Kralove, Czech Republic
Faculty of Pharmacy in Hradec Kralove, Charles University, Hradec Kralove, Czech Republic
Modern Care Journal: Vol.19, issue 1; e123150
published online: April 12, 2022
article type: Review Article
received: February 5, 2022
accepted: March 16, 2022

How To Cite Salemi S, Afshari M, Afshari M. Nutritional Recommendations for Patients Undergoing Chemotherapy During the COVID-19 Pandemic. Mod Care J. 2022;19(1):e123150. https://doi.org/10.5812/modernc-123150.

Abstract

The world is currently in a large-scale outbreak, referred to as a pandemic, for the novel coronavirus disease SARS-CoV-2 and its variants. Patients having cancer have to combat their illness and its complications, but they also have to suffer a list of side effects due to chemotherapy. This article is written to suggest a list of nutritional considerations for chemotherapeutic patients at this stage of the COVID-19 pandemic to enhance their immune system. Nutrition has a decisive role in immune response, specifically in immuno-suppressed patients, such as those undergoing chemotherapy. Due to the complexity of designing a diet for the mentioned patients, we recommend a balanced and varied diet in the COVID-19 pandemic, including zinc, omega-3, vitamin D, whole grains, and skimmed dairy, which were discussed in great detail in the article.

1. Context

The world is currently in the midst of a large-scale outbreak, also referred to as a pandemic, of the novel coronavirus SARS-CoV-2 (COVID-19). Pandemics lead to clinical and social interruptions (1). From the clinical point of view, several risk groups are recognized. According to CDC, patients with cancer, immunocompromised state after organ transplant, cardiovascular disease, and type two diabetes mellitus are at increased risk of morbidity and mortality due to COVID-19. Patients having cancer have to combat their illness and its complications and must suffer a list of side effects due to the use of chemotherapy. Some of the nutrition-related side effects are as follows: infections, anemia, nausea, vomiting, change in appetite, diarrhea, mouth, tongue, and throat problems, and mucositis (2). These patients are immunocompromised due to chemotherapy-related neutropenia; therefore, they are at greater risk of infection (3). Consequently, they require greater support. This article is written to suggest a list of nutritional considerations for chemotherapeutic patients at this stage of the COVID-19 pandemic to improve their immune system.

2. Evidence Acquisition

Chemotherapy is usually associated with malnutrition. Due to many side effects caused by chemotherapeutic agents, patients will suffer from vomiting, loss of appetite, restrictive food intake, and subsequently protein catabolism (2). It is documented that malnutrition affects a patient’s immune system drastically and weakens the immune response in every phase of infection. In this regard, patients undergoing chemotherapy are more susceptible to viral infections, including COVID-19, and the first obstacle, which is needed to be overcome is malnutrition (4).

Chemotherapeutic patients also suffer from loss or reduced appetite. To alleviate this condition, patients are advised to take small calorie-dense portions of meals with increased frequency. As these patients are experiencing food aversion and hypersomnia, they might be extra sensitive to specific odors or tastes; thus, they will be avoiding some foods. In this case, it is advised to prepare their foods far from their residing spot to prevent their exposure to such a smell. These patients also experience an impaired sense of tasting as a side effect of chemotherapeutic agents. It is recommended to use proper additives and marinate their foods to make them more favorable to increase their food desire and, consequently, their intake (2). Another common side effect experienced by chemotherapeutic patients is different grades of mucositis due to their treatment (5). It should be considered not to use additives that might irritate the oral cavity and gastrointestinal tract, as mucositis might also lead to reduced food intake hence malnutrition. Studies have demonstrated that the general anti-inflammatory action of zinc sulfate supplementation could relieve mucositis (6). On the other hand, studies have documented the effect of zinc on the immune system in reducing inflammation (7). Additionally, the immuno-protective role of zinc has been noticed to be crucial in the COVID-19 pandemic. Zinc improves mucociliary clearance and antiviral and antibacterial immunity and reduces pulmonary inflammation in the upper and lower respiratory tracts (8, 9).

Carbohydrates are considered the principal source of energy. According to the Warburg effect, glucose is the main fuel for cancerous cells; thus, the consumption of simple carbohydrates with a high glycemic index should be restricted in these patients’ diets. Since simple sugars lead to further weakening of the immune system by the insulin-dependent mechanism, primarily, they must be avoided and replaced by whole grains (10, 11). Another possible intervention could be decreasing the patient’s carbohydrate intake by offering a low-carb diet. Studies have demonstrated the benefit of a ketogenic diet on the immune system. Therefore, ketogenic diets can also be recommended as they are commonly used in the treatment of brain cancers. On the other hand, it has been shown that ketogenic diets can boost the immune system against the influenza virus (12, 13). Recently, Kossoff et al. have provided some recommendations based on a ketogenic diet for patients suffering from epilepsy during the COVID-19 pandemic (14).

It is documented that saturated and trans fats lead to the development of inflammatory responses (15). These responses should be avoided during chemotherapy. Consequently, dietitians recommend reduced consumption of these harmful fats in animal products, such as red meat and high-fat dairy products. Splicing factor (SFA) also plays a role in the suppression of the immune system and inevitably increases the vulnerability to various viral infections (16). From this point of view, chemotherapeutic patients are recommended to consume zero percent fat dairy products and lean meat. Essential fatty acids, specifically n-3 PUFA, have been known for their anti-inflammatory effects. Enhancement of the immune system has also been observed; thus, greater ability to defeat viral infections can be achieved (17). This effect is caused by increasing the level of NADPH oxidase, protein kinase C, and some other accompanying mechanisms. The above-mentioned immune components increase the amount of superoxide produced by neutrophils, and thereupon, greater immune capacity is observed in chemotherapeutic patients (18). Additionally, omega-3 supplementation could decrease the reduction of the HLA-DR gene expression in monocytes of chemotherapeutic patients (19). Dietitians should consider the use of omega-3 in chemotherapeutic patients’ diets. Salmons and sardines, which are rich in omega-3, should be included in the patient’s diet as protein sources instead of red meat and poultry.

Vitamin D is crucial in immune system modulation. In carcinogenesis, vitamin D plays an important role in cell differentiation. Vitamin D boosts the immune system through different mechanisms. This enhancement is affected from the first line of defense in non-specific immunity to the cellular level in specific immunity. Studies have also indicated the effect of vitamin D on lower respiratory tract infections. Since the tissues of the lower respiratory tract are also the target of COVID-19 infection, thusly supplementation of vitamin D is considerable (20). The prevalence of vitamin D deficiency is highly reported in patients undergoing chemotherapy (21). Studies have shown that patients with a lower level of 25-hydroxy-D serum are predisposed to COVID-19 infection and also show increased morbidity and mortality throughout the infection (22). It is recommended to supplement these patients routinely to increase serum levels of 25-hydroxy-D serum from 40 - 60 ng.mL-1.

In the pandemic period, the public is recommended to consume a considerable proportion of vegetables and fruits to improve their immune system. Vegetables and fruits contain notable amounts of essential micronutrients, phytochemicals, and fibers (23). Antioxidants and polyphenols might be interfering with the mechanism of some chemotherapeutic agents and hindering their effects (24). Conversely, other studies have shown the positive effect of some of these phytochemicals on specific chemotherapeutic substances (25). When patients undergo chemotherapy, they will suffer from neutropenia (3). As neutropenia causes a great delay in immune response, it is recommended to carefully disinfect and later boil fruits and vegetables consumed. Due to the discrepancies among resources, moderate use of vegetables and fruits is recommended.

3. Conclusions

In conclusion, nutrition has a decisive role in immune response, specifically in immuno-suppressed patients, such as those undergoing chemotherapy. Due to the complexity of designing a diet for the mentioned patients, we recommend a balanced and varied diet in the COVID-19 pandemic, which includes all micronutrients and trace elements plus zinc, omega-3, vitamin D, and foods, such as whole grains and skimmed dairy, which was discussed in detail above.

Acknowledgements

References

  • 1.

    Madhav N, Oppenheim B, Gallivan M, Mulembakani P, Rubin E, Wolfe N. Pandemics: Risks, Impacts, and Mitigation. In: Jamison DT, Gelband H, Horton S, Jha P, Laxminarayan R, Mock CN, et al., editors. Disease Control Priorities: Improving Health and Reducing Poverty. 3rd ed. Washington (DC); 2017. eng. https://doi.org/10.1596/978-1-4648-0527-1_ch17.

  • 2.

    Chui PL. Cancer- and Chemotherapy-Related Symptoms and the Use of Complementary and Alternative Medicine. Asia Pac J Oncol Nurs. 2019;6(1):4-6. [PubMed ID: 30599008]. [PubMed Central ID: PMC6287385]. https://doi.org/10.4103/apjon.apjon_51_18.

  • 3.

    Hashiguchi Y, Kasai M, Fukuda T, Ichimura T, Yasui T, Sumi T. Chemotherapy-induced neutropenia and febrile neutropenia in patients with gynecologic malignancy. Anticancer Drugs. 2015;26(10):1054-60. [PubMed ID: 26267078]. [PubMed Central ID: PMC4588600]. https://doi.org/10.1097/CAD.0000000000000279.

  • 4.

    Katona P, Katona-Apte J. The interaction between nutrition and infection. Clin Infect Dis. 2008;46(10):1582-8. [PubMed ID: 18419494]. https://doi.org/10.1086/587658.

  • 5.

    Curra M, Soares Junior LAV, Martins MD, Santos P. Chemotherapy protocols and incidence of oral mucositis. An integrative review. Einstein (Sao Paulo). 2018;16(1):eRW4007. [PubMed ID: 29694618]. [PubMed Central ID: PMC5968807]. https://doi.org/10.1590/s1679-45082018rw4007.

  • 6.

    Rambod M, Pasyar N, Ramzi M. The effect of zinc sulfate on prevention, incidence, and severity of mucositis in leukemia patients undergoing chemotherapy. Eur J Oncol Nurs. 2018;33:14-21. [PubMed ID: 29551172]. https://doi.org/10.1016/j.ejon.2018.01.007.

  • 7.

    Maywald M, Wessels I, Rink L. Zinc Signals and Immunity. Int J Mol Sci. 2017;18(10). [PubMed ID: 29064429]. [PubMed Central ID: PMC5666901]. https://doi.org/10.3390/ijms18102222.

  • 8.

    Skalny AV, Rink L, Ajsuvakova OP, Aschner M, Gritsenko VA, Alekseenko SI, et al. Zinc and respiratory tract infections: Perspectives for COVID19 (Review). Int J Mol Med. 2020;46(1):17-26. [PubMed ID: 32319538]. [PubMed Central ID: PMC7255455]. https://doi.org/10.3892/ijmm.2020.4575.

  • 9.

    Gritsenko VA, Alekseenko SI, Svistunov AA, Petrakis D, Spandidos DA, Aaseth J, et al. Zinc, respiratory tract infections and COVID-19–July 2020. Int J Mol Med. 2020;46(1):17-26.

  • 10.

    Smith R, Tran K, Richards K, Luo R. Dietary Carbohydrates that Modulate the Immune System. Clin. Immunol. Endocr. Metab. Drugs. 2015;2(1):35-42. https://doi.org/10.2174/221270700201151216151927.

  • 11.

    Vander Heiden MG, Cantley LC, Thompson CB. Understanding the Warburg effect: the metabolic requirements of cell proliferation. Science. 2009;324(5930):1029-33. [PubMed ID: 19460998]. [PubMed Central ID: PMC2849637]. https://doi.org/10.1126/science.1160809.

  • 12.

    Goldberg EL, Molony RD, Kudo E, Sidorov S, Kong Y, Dixit VD, et al. Ketogenic diet activates protective gammadelta T cell responses against influenza virus infection. Sci Immunol. 2019;4(41). [PubMed ID: 31732517]. [PubMed Central ID: PMC7189564]. https://doi.org/10.1126/sciimmunol.aav2026.

  • 13.

    Weber DD, Aminazdeh-Gohari S, Kofler B. Ketogenic diet in cancer therapy. Aging (Albany NY). 2018;10(2):164-5. [PubMed ID: 29443693]. [PubMed Central ID: PMC5842847]. https://doi.org/10.18632/aging.101382.

  • 14.

    Kossoff EH, Turner Z, Adams J, Bessone SK, Avallone J, McDonald TJW, et al. Ketogenic diet therapy provision in the COVID-19 pandemic: Dual-center experience and recommendations. Epilepsy Behav. 2020;111:107181. [PubMed ID: 32512472]. [PubMed Central ID: PMC7247448]. https://doi.org/10.1016/j.yebeh.2020.107181.

  • 15.

    Lopez-Garcia E, Schulze MB, Meigs JB, Manson JE, Rifai N, Stampfer MJ, et al. Consumption of trans fatty acids is related to plasma biomarkers of inflammation and endothelial dysfunction. J Nutr. 2005;135(3):562-6. [PubMed ID: 15735094]. https://doi.org/10.1093/jn/135.3.562.

  • 16.

    Hubler MJ, Kennedy AJ. Role of lipids in the metabolism and activation of immune cells. J Nutr Biochem. 2016;34:1-7. [PubMed ID: 27424223]. [PubMed Central ID: PMC5694687]. https://doi.org/10.1016/j.jnutbio.2015.11.002.

  • 17.

    Calder PC, Grimble RF. Polyunsaturated fatty acids, inflammation and immunity. Eur J Clin Nutr. 2002;56 Suppl 3:S14-9. [PubMed ID: 12142955]. https://doi.org/10.1038/sj.ejcn.1601478.

  • 18.

    Bonatto SJ, Oliveira HH, Nunes EA, Pequito D, Iagher F, Coelho I, et al. Fish oil supplementation improves neutrophil function during cancer chemotherapy. Lipids. 2012;47(4):383-9. [PubMed ID: 22160495]. https://doi.org/10.1007/s11745-011-3643-0.

  • 19.

    Motoori M, Yano M, Yasuda T, Miyata H, Peng YF, Yamasaki M, et al. Relationship between immunological parameters and the severity of neutropenia and effect of enteral nutrition on immune status during neoadjuvant chemotherapy on patients with advanced esophageal cancer. Oncology. 2012;83(2):91-100. [PubMed ID: 22777298]. https://doi.org/10.1159/000339694.

  • 20.

    Schwalfenberg GK. A review of the critical role of vitamin D in the functioning of the immune system and the clinical implications of vitamin D deficiency. Mol Nutr Food Res. 2011;55(1):96-108. [PubMed ID: 20824663]. https://doi.org/10.1002/mnfr.201000174.

  • 21.

    Fakih MG, Trump DL, Johnson CS, Tian L, Muindi J, Sunga AY. Chemotherapy is linked to severe vitamin D deficiency in patients with colorectal cancer. Int J Colorectal Dis. 2009;24(2):219-24. [PubMed ID: 18830610]. [PubMed Central ID: PMC2715947]. https://doi.org/10.1007/s00384-008-0593-y.

  • 22.

    Grant WB, Lahore H, McDonnell SL, Baggerly CA, French CB, Aliano JL, et al. Evidence that Vitamin D Supplementation Could Reduce Risk of Influenza and COVID-19 Infections and Deaths. Nutrients. 2020;12(4). [PubMed ID: 32252338]. [PubMed Central ID: PMC7231123]. https://doi.org/10.3390/nu12040988.

  • 23.

    Kaur C, Kapoor HC. Antioxidants in fruits and vegetables - the millennium’s health. Int. J. Food Sci. Technol. 2008;36(7):703-25. https://doi.org/10.1111/j.1365-2621.2001.00513.x.

  • 24.

    Sak K. Chemotherapy and dietary phytochemical agents. Chemother Res Pract. 2012;2012:282570. [PubMed ID: 23320169]. [PubMed Central ID: PMC3539428]. https://doi.org/10.1155/2012/282570.

  • 25.

    Lawenda BD, Kelly KM, Ladas EJ, Sagar SM, Vickers A, Blumberg JB. Should supplemental antioxidant administration be avoided during chemotherapy and radiation therapy? J Natl Cancer Inst. 2008;100(11):773-83. [PubMed ID: 18505970]. https://doi.org/10.1093/jnci/djn148.