Pancreatic cancer, nutrition, activity and improving the way you feel

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Tel No: 01223 216655

Side effects of pancreatic cancer and its treatment include weight loss, reduced appetite, nausea, fatigue, increased blood glucose levels and changes in bowel habit. These can be difficult to manage and mean it is harder for you to feel well. The following leaflet provides information about how to optimise your fitness and minimise loss of muscle and strength. This may help you to have more energy and feel better. Being better nourished may also help you to cope with treatment such as chemotherapy, radiotherapy and surgery.

In order for our bodies to be nourished, several steps need to happen. We need to eat and drink nourishing foods and drinks, these need to be digested in our guts and then absorbed so they can be used by our bodies. Having pancreatic cancer can make each stage of this process harder. This information sheet gives you information about things you can do to help you to ease these difficulties and optimise your fitness while you have pancreatic cancer.

The first goal is usually to help you to digest and absorb the nutrition you are eating and drinking at the moment. We discuss this first.

Are you digesting the food and drink you are having?

The pancreas plays an important role in the digestion of food. It produces digestive juices which contain enzymes that help to break down food so that it is small enough to be absorbed through the wall of your gut. Having pancreatic cancer can mean the pancreas makes less of these enzymes or it can block those made from getting into the gut. This means you are less nourished by the food you eat and can lead to changes in your bowel habit and malnutrition. This is particularly likely for people with a tumour in the head of their pancreas.

Pancreatic enzymes can be given in capsules which you take when you eat and drink. These help you to digest what you have eaten and therefore be nourished by that food. We recommend these are taken by everyone with a head of pancreas tumour. People with a tumour elsewhere in their pancreas may also benefit from taking these enzyme capsules.

The following symptoms can be a sign that you need more pancreatic enzymes;

• Losing weight even though you are eating well
• Loose and/ or urgency to open bowels
• Pale, orange, yellow, oily or larger stools
• Foul smelling stools
• Stools which float and/ or are difficult to flush away
• Tummy pain, discomfort, wind and/ or bloating
• Lower blood glucose levels than usual

If any of these symptoms occur it is important to mention them to your Dietitian, Doctor or Specialist Nurse. The brand names of these enzyme capsules are Creon® and Nutrizym 22®. If you are prescribed these, you will be given more information about how and when to take them. Some people do not have any of these symptoms but are still not absorbing their nutrition well, so benefit from taking them.

Do you experience sickness or vomiting?

If you are experiencing regular sickness and/ or vomiting please discuss this with your medical team. They may be able to give you medication to resolve this or adjust your current medication. Anti-sickness medications are usually more effective if they are taken regularly rather than waiting until you feel sick. It is also often helpful to take anti-sickness medication half an hour before eating as you then feel less sick at your meal time and it helps you to eat more.

Some people find that food and drinks containing ginger or peppermint can be soothing if they feel sick. Often plain, cold foods can be easier to manage than stronger smelling foods when you feel sick, as do softer foods that require ‘less work’ to eat.

Are you eating less than you usually would?

If you are eating less than you usually would, the following tips may help you have a little more.

• Be positive about what you do eat – every extra mouthful helps.
• Try not to get out of the habit of eating. Eating stimulates your appetite.
• Make the most of the times you feel like eating, even if it is at unusual times. Some people like to ‘breakfast like a king’, eating a larger than usual breakfast and then less later in the day when they are more full and more tired.
• Experiment with different foods. You may find that you like things you don’t usually eat, particularly if your sense of taste has changed.
• Sometimes the smell of food will be appetising while at other times it may put you off. If this happens, try to keep away from the kitchen while food is being prepared, or eat cold foods, which often have less smell.
• Accept offers from friends and family to help with cooking and shopping.
• Convenience foods and ‘meals on wheels’ are a useful standby and can be just as nourishing.
• Try to not spend long periods of time sitting or lying down during the day if you can, this will help to preserve your muscles and can also stimulate your appetite.
• Some people are put off by large portions and actually eat more with less on their plate.
• Some people prefer to have food given to them than be asked what they’d like to eat, as the talking about it before hand can be off-putting.

Eat “little and often”

If you have a reduced appetite and can only manage small portions at a time try eating more often. Try to include snacks between meals and before bed. Keeping snacks at home and in your bag when out may help you to eat more often.

Here are some snack ideas:

• Biscuits, cakes, halva,fun-sized chocolate bars and cereal bars
• Sandwiches, boiled eggs, tinned fish
• High protein breakfast cereals (e.g. Special K Protein Plus®, Weetabix Protein®, Oats so simple protein®)
• Fruit (fresh, tinned, or dried) with yogurt, cream, ice cream, or custard
• Crackers with cheese or pâté, cheese straws or cubes, peanut butter, nut butter
• Bhajis, pakoras, spring rolls, sausage rolls, scotch eggs, mini pork pies’ slice of pizza, quiche
• Ready-made desserts such as yogurt, crème caramel, trifle, mousse, cheesecakes, Greek-style or high-protein yogurt
• Crisps, nuts, popcorn, Bombay mix, olives, savoury biscuits, bread sticks with humus or dips
• Crumpets, scones, bagels, muffins, croissants, toast, breakfast cereal

Fortifying your food

If you are managing smaller portions than usual, the following tips may help you to get more calories from what you eat and drink. Remember that when you add more calories, particularly in the form of fat, you will need to also increase the number of pancreatic enzyme supplements you have with them.

Start by buying full fat foods. Avoid “light” or “diet” versions of foods and drinks, these are not appropriate for you at the moment. If you have diabetes continue to avoid high sugar drinks, you should not usually need to restrict your diet further than this. You may wish to discuss which of the following foods are appropriate with your Dietitian, Doctor or Specialist Nurse.

• Milk: Add 4 tablespoons of milk powder (such as Marvel or supermarket own brands) to 1 pint of milk (ideally full cream milk). This can be used in place of usual milk in drinks, on cereals, in sauces and puddings.
• To savoury foods add cheese, cream cheese, fortified milk, milk powder, pulses, cream, crème fraîche, oil, pesto and butter/margarine.

Some examples are given below:

• Beans or pulses to soups and casseroles
• Cheese and/or milk and/or butter/margarine/olive oil and/or high protein yogurt to mashed potato
• Butter, cheese or white sauce on vegetables
• Milk powder to creamy or cheese sauce
• Grated cheese, cream, milk, plain yogurt or crème fraîche to soup
• Cream, sour cream or crème fraîche to casseroles
• Tofu to stir fries, soups and curries
• Mayonnaise, salad cream or pesto to sandwiches or have two fillings, such as: egg mayonnaise and bacon, cheese and ham or avocado and hummus
• Add butter to both sides of your toast
• To sweet foods add fortified milk, sugar, cream, honey, syrup, ice cream or evaporated milk. Note that if you have diabetes it may be better to avoid adding sugar, honey and syrup, but you can discuss this with your Dietitian, Doctor or Specialist Nurse first as different people manage their diabetes differently.

Some examples are given below:

• Cream/ custard/ ice cream/ evaporated milk with pies, cake or fruit
• Sprinkle sugar or drizzle honey/ syrup over desserts, cereals and porridge
• Add dried fruit and/ or nuts, a spoon of peanut butter or chocolate spread to porridge
• Make jelly with fortified milk, instead of water
• Add 2 tablespoons of milk powder to a portion of porridge, milk puddings and custard
• Add tofu to smoothies and desserts
• Make use of nourishing drinks:

Including regular nourishing drinks throughout the day can be an easy way of having extra nutrition.

Some examples are given below:

• Hot drinks such as: hot chocolate, Horlicks, Ovaltine, milky coffee, instant soups. These can all be made with fortified milk
• Cold drinks such as: milk shakes, smoothies, ice cream soda
• Nutritional supplement drinks such as Complan®, Meritene®, Nutrament®, Nurishment®, Weetabix-on-the-go Protein® UFIT®, Avonmore protein milk® and Alpro Plant Protein® are available from most supermarkets and chemists. Alternatively there are supplement drinks available on prescription. If you think that these would be helpful, please ask your dietitian for advice. Many of these supplement drinks are available in a variety of sweet and savoury flavours. The powdered versions can also be added to foods to increase their nutrient content.

Do things taste differently from usual?

These are some tips for coping with taste changes

• Eat the foods that you do like the taste of and avoid those that you don't. Re-try any 'problem' foods after a few weeks as your taste may have returned to usual.
• Using stronger seasonings may help or try adding lemon juice, yeast extract spread, parmesan, black pepper, chili sauce, other spices.
• Sharp tasting foods such as grapefruit or lemon and drinks such as bitter lemon may help stimulate your taste buds, increase the flow of saliva and get rid of any unpleasant taste in your mouth before eating.
• If meat tastes bitter or metallic try marinating it before cooking. For example: in fruit juice, wine, barbecue or sweet and sour sauce.
• Cold meats may taste better served with pickle or chutney.
• If you are unable to eat meat at all make use of other sources of protein such as eggs, cheese, fish, beans, lentils, tofu, milk and yogurts.
• Avoid using metallic utensils and cutlery, try using plastic, bamboo or wooden instead.
• Some people find cold or warm foods easier to manage and more palatable than hot.
• If tea and coffee taste strange, try milky drinks, fruit juices or fizzy drinks. (Drinks containing artificial sweeteners sometimes leave a metallic taste in the mouth, avoid them if they do).
• Try to drink plenty of nourishing fluids and keep your mouth and tongue clean. Brushing your teeth regularly, and using a soft toothbrush to clean your tongue if necessary, particularly before meals, can help.

Are you more thirsty than usual?

The pancreas produces hormones which help to keep the balance of glucose (a sugar) in your blood. Damage to the pancreas by cancer can disrupt this and lead to high blood glucose levels and diabetes. If you experience an increase in thirst, passing more urine, changes in your vision or extreme tiredness then ask your doctor or specialist nurse to check your blood glucose level. If this is high then it can be treated to improve these symptoms and the treatment will be discussed with you.

Alternative diets

There are a number of diets that claim to treat or even cure cancer. Many of these diets claim to flush out ‘toxins’ from the body, to ‘starve’ the cancer or change the acidity of the body. People with cancer of course wish to do whatever they can for themselves to help treat their condition. Unfortunately there is no evidence that these diets can cure cancer or help people with cancer to live longer and they can be hard to follow which places a burden on people.

Many of these diets are very restrictive and may make it difficult for you to get all of the nutrition you need. Diets that are high in fibre and low in calories are likely to lead to muscle loss and for most people with pancreatic cancer this is not appropriate and could be damaging. Additionally these diets can be time consuming, less enjoyable, expensive and could impair your quality of life. If you want to follow one and would like help to minimise nutritional losses while doing so, please discuss with your dietitian.

Some diets advocate taking very high doses of vitamins or minerals. However, there is no evidence that taking large doses of vitamins is helpful in treating cancer, and in some cases this can be harmful. For example, there is some evidence that large doses of vitamin C may affect how well your chemotherapy or radiotherapy works. If you are considering a diet like this please discuss it with your doctor or specialist nurse.

Are you active?

Most people reduce their activity levels after a diagnosis of pancreatic cancer. This is because they feel less well, more tired, want to stay home to be near a toilet or are low in mood. There is a lot to deal with following a diagnosis like this and this reduction in activity is very understandable. Looking forward to what can help you to have more energy and manage treatments, activity is part of that. The advice is to reduce sedentary time. Rest is very important but if you can, get up and move at least once every 40 minutes.

Depending on your fitness levels, it is beneficial to push yourself slightly with activity so that you are a little out of breath, for example walking faster, gardening, housework or a sport you enjoy. The little and often approach is more beneficial than doing a lot in one go and then needing a long rest afterwards.

Do you feel fatigued?

It is common to feel fatigued (tired all or most of the time) when you have cancer or have had cancer treatment. Having enough ‘fuel’ for the body in terms of nutrition and fluids can help increase your energy levels. It can also be helpful to consider how to conserve your energy where possible. For example planning what you do and when you do it; pacing yourself by breaking activities into smaller tasks and taking regular rest breaks; and sitting down to do activities like chopping vegetables, washing or grooming. You can apply these principles to preparing meals or eating meals too by planning what, when and how to eat and prepare them, and taking your time if needed. Batch cooking, using ready meals, or preparing food earlier in the day can all help to save energy. In addition to this it can be helpful to consider other ways, as well as increased nutrition, to ‘recharge’ when feeling fatigued. Engaging in meaningful and valued activities can be a way to do this. Relaxation, mindfulness or being in nature can also help to support your energy levels and there are lots of relaxation resources available to try, or speak with your specialist nurse or local Maggies Centre.

If you wish to discuss any of this further please contact your Dietitian, Doctor or Specialist Nurse.

Further information sheets available include:

• Information for people taking pancreatic enzyme replacement therapy
• Information for people who are unable to swallow their pancreatic enzyme replacement therapy supplements
• Type 3c Diabetes and reduced appetite
• Eating after a duodenal stent
• Pancreatic disease and physical activity
• Coping with sickness
• Nourishing fluids
• Modified texture diet, IDDSI level 5 and 6 (for people who would benefit from softer foods)
• Sore mouth
• Taste changes
• High energy, high protein diet

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