Category: Nutrition

Pancreatic insufficiency

I confess I do not know much about pancreatic insufficiency or to give it its full title exocrine pancreatic insufficiency (EPI).  However, according to this article I, like other oesophagectomy patients, could already have an element of this as soon as 3 months after surgery or could be at risk in the future. It is not confined to oesophagectomy patients, anyone who undergoes any surgery or disruption to the GI tract is potentially at risk.

The reason it occurs is because the lovely balance of the GI tract, as described at the beginning of the previous post on nutrition, is mightily disrupted by surgery. It causes a reduction in the levels of enzymes produced by the pancreas. This results in food not being broken down properly and the full dose of nutrients does not get absorbed by the small intestine. In particular the absorption of fat and fat soluable vitamins suffer and results in a charming thing called steatorrhea – fatty stools. 

It does not take a genius to work out that if you do not absorb fat you will lose weight and loss of vitamins like A, D, E and K is not an insignificant knock to an already compromised physiology.

Testing for EPI from what I gather is in the form of stool and blood samples. 

If your levels are found wanting, you can be offered pancreatic enzyme replacement therapy (PERT). Sounds amazing but it is simply taking additional enzymes with meals to support your pancreatic function. CREON seems to be the drug of choice in the UK and this is only available on prescription. The Creon website describes in delightful detail the other symptoms of EPI so enjoy.

Over the counter digestive enzymes

What I do not know is whether over the counter digestive enzymes do the same thing as Creon. They will almost certainly need to be enteric coated. I will do some digging online.

 

 

 

Post-surgical nutritional deficiencies and testing

This is such a massive topic, so bear with me.

Despite the modern pressure to go vegetarian or vegan, the brains of our ancesters would not have increased to the size and complexity that they are if we continued on the same diet as gorillas. We have evolved to be omnivores and there is evidence to suggest fat extracted from brains and marrow contributed to a nutrient rich diet. We are unlikely to get the digestive system of ruminants in the not too distant future. Even Tibetan monks in the Himalayans eat the occasional yak.

We have the acid containing stomach like carnivores to break down meat and protein; a pancreas and liver to break down carbs and fats, a long small bowel to absorb nutrients and a large bowel to absorb water and process fibre. If it all works, it is a finely tuned engine.  Clearly oesophageal cancer patients have this lovely dream-like scenario blown clean out of the water when they get diagnosed, leaving them with a whole host of new stuff to deal with. As we eat smaller meals, everything we eat has to count in terms of calories and nutrition. Unless you know what you are doing, this is not the time to stop eating meat. 

The evidence

It is not surprising that after oesophagectomy (partial gastrectomy), nutritional status can go into decline due to stomach reduction or removal altogether. A number of patients are not warned about deficiencies. Is this because some dieticians are in denial that deficiencies occur or are they only involved for such a short period of time, they never get chance to see the scale of the problem? Whatever the reason, some forward thinking dieticians in London have done two pieces of work and admit that they still do not know how best to address longer-term deficiencies in post-oesophagectomy patients.

This enlightening audit by Alice Kidd in 2014 is well worth a read. In addition in 2017, a team at Imperial College London published this paper on the same subject. They report that two thirds of oesophagectomy patients get deficiencies in ferritin, B12, vitamin D and zinc and recommend regular screening but they do not specify a frequency.

I feel very strongly about the empowerment of patients over their nutrition, so much so that I am going to stick my neck out here and say three things:-

(i) be proactive and get to know your blood results and what is normal for you, preferably before any treatment starts

(ii) do not rely on dieticians or specialist nurses to remember to test you. They will only do it when clinical symptoms arise and by then you will be feeling unwell.

(iii) ask for tests regularly or get them done privately.

OK – let’s break this down.

Baseline blood tests

I have already recommended getting a baseline blood test in an earlier post on preparing for surgery.  Ideally get one done before chemotherapy starts. The key values as shown in the papers above are iron, ferritin, calcium, magnesium, vitamin D and vitamin B12. You could throw in a fasted cholesterol and also a HbA1c plus liver and kidney function and bone profile for good measure. 

Bloods are done prior to each chemo appointment so ask for the results, ask questions and keep an eye on any changes.  Any doctor or health professional who can look you in the eye and tell you, you might die from sepsis or on the operating table, should not have any problem sharing your blood results with you or what they mean. Most of the time, the lab will flag up any values that fall outside the ranges, whether it be low, high or just on the cusp. It is also worth noting that trends or obvious declines or increases are what to watch not the odd fluctuation. This is why a baseline is good as it shows what is normal for you to start with. The caveat for this is if the illness is already causing problems with swallowing and eating in general and levels of certain vitamins and minerals like iron have dropped.

What do the numbers look like?

Below is a table showing each parameter, units and range to give an overall feel for what you are looking at. It is worth noting that different hospital and indeed GP labs have slightly different ranges but we are only talking very small amounts. It is the lower and upper end of the scales you need to keep an eye on. I will provide links to valuable sources of information but there is so much pseudoscience on the internet – suffice it to say that if these are all in range – you can say that you are biochemically sound even if you feel a bit off kilter.

ParameterValueRange MeaningSource
Vitamin D64nmol/L (50-200)AdequateNHS Labs
Vitamin B12612ng/L (180-910)NormalNHS Labs
Folate8ng/mL (>5.4)NormalNHS Labs
Iron17umol/L (5-33)NormalNHS Labs
Ferritin189ug/L (10*-291)NormalNHS Labs
Calcium2.4mmol/L (2.2-2.6)NormalNHS Labs
HbA1c37mmol/mol (<42)NormalNHS Labs

Going forward

I will endeavour to get my bloods done every 6-12 months. If you are in decent shape before surgery and can eat relatively well after or have a jej feeding tube, your nutritional status should be OK for the first few months. It may go into slight decline when you start on real food. This can be due to the reduced volume of food, insuffient enzymes to break macronutrients down or reduced acid due to reduced stomach capacity or acid reducing medication like omeprazole.

B12 needs something called intrinsic factor in the stomach to be absorbed from food – so without exception, all gastrectomy patients will need lifelong B12 injections and probably iron supplementation. Iron is problematic as the body does not absorb it too well anyway. Try to eat iron rich foods where possible alongside something with vitamin C to help absorption. Ferritin levels represent stored iron and if these remain optimal you should be OK. In the table above it says that over 10 is OK for ferritin but there is some anectdotal evidence to suggest that below 20 and your hair may start to suffer. It is also worth noting that one in 200 people have a gene for haemochromatosis which is the over storage of iron in the blood so it is a good idea to have iron levels checked as unnecessary oversupplementation can also be extremely harmful.

Partial gastrectomy patients as stated above have been shown to need regular B12 and iron. You could try eating a bowl of Ready Brek each day which is fortified with B12, iron and folate. I do not know if this is enough to keep deficiencies at bay but do not wait for their values to bottom out, as by then you will feel unwell and you already have enough to deal with.

Vitamin D is important for the uptake of calcium into the bones. Being in full sunshine for 20 minutes a day helps to make vitamin D in the skin or you can absorb it from food.

Private testing

If your health team or GP are not forthcoming on the testing, exercise your consumer rights and buy your own. Vitamin D testing can be done cheaply and simply via a prick test.

For general health tests, Micki Rose has a great service and is very knowledgable over a whole wealth of tests. I have used Micki’s site a few times to order tests.

There is a new service on the market called Thriva.co – I have tried using them but the amount of blood required is impossible for me to extract via a simple prick test. You may have better luck.

These are just ideas – the best people to do your tests are your GP or at the hospital at the time of a follow up.

Fortifying food

After surgery, dieticians recommend fortifying food by adding calories to smaller portions.

The main recommendation is to use dairy products as they pack a punch when it comes to energy from fat and protein, as well as vital minerals such as calcium and iron. Some people develop temporary lactose intolerance after oesophagectomy so dairy is out. Instead, coconut or olive oil could be used to add calories but care should be taken as too much fat can cause dumping syndrome.

I was lucky as I could eat dairy with no issues but had to go easy drinking milk to avoid an upset stomach. When I first came home I added grated cheese or butter to pureed veg, mash potato and soups. Cream is also good but I found it frequently caused me problems so even though I love cream – I give it a wide berth even now.

Marvel

Marvel ingredients

Another recommended method which for me resulted in some weight gain (albeit only a pound or two) was the addition of a few spoonfuls of powdered skimmed milk (Marvel) to full fat milk. This can boost the calorific value by another third and it does not change the taste.  I had this on cereal, in tea and sometimes drank it straight in small quantities. Most supermarkets stock Marvel.

You could also mix protein powder as used by body builders into foods. Marvel has vitamins A and D and although some protein powder contain vitamins, often they contain sugar.

Homemade smoothies


Homemade smoothies are an easily way to eat fruit and vegetables that can not be eaten with meals. They can be prepared using a Nutribullet or smoothie maker or even handheld blender. You should however proceed with caution with smoothies as if they are too sweet or taken in too quickly, they may move through your intestines too fast. It is best to not overload your smoothie with fruit, especially the very sweet tropical varieties like bananas and mangoes. Keeping it to the size of a small glass like the one shown (300 ml) is also a decent volume.  So far, I have not had any problems with the following recipe, a handful of one or two types of berries (eg strawberries, raspberries and blueberries), a handful of baby spinach or kale and an avocado blended with some yoghurt/kefir. You can also add a handful of nuts or a spoonful of Marvel to add calories.

Ready Brek

Another great fortified food is Ready Brek. Before this year, I had not given Ready Brek a second thought since primary school. However it has all the goodness of porridge plus all the B vitamins, calcium and iron and is easy to make and more importantly, easy to get down. I had been having Ready Brek most mornings since my op and I do not take any supplements and my bloods are good for iron and B12. I usually stick to the recommended 30g portion. This can be weighed out and then milk added then in the microwave for 1.5 mins. If I am feeling lazy I buy the sachets.

I usually stick to 30g as more than that causes me to have a few dumping symptoms, like palpitations and being over full. Please note Ready Brek is a fine powder so will get broken down and absorbed quicker than rolled oats. However normal oats lack the fortified vitamins so in the short-medium term it is a good staple.

Sugary stuff, Complan and the abhorrent Fortisip drinks

Prior to being ill, I mostly avoided sugar but to bulk up before surgery, I slipped off the sugar wagon and had Complan, home made trifle and chocolate. After surgery, all of these gave me dumping syndrome so I have avoided them since.

I tried one Fortisip drink before surgery and thought it was truely hideous. If you can stomach them (I could not) they are the equivalent to whole meals so can sustain you. However I do not know why they make them so sweet and with so much sugar so they cause fewer issues in patients who have had gastric surgery and have issues with sugar.

I now eat the odd cake but they have to dense and not have fillings (like jam or cream) or toppings (like buttercream or icing). Scones and dense cakes like banana loaf do not seem to affect me aslong as I do not have too much and I eat them slowly.

I usually have a Nine Pumpkin and Sunflower bar in my bag and can eat them with a latte or cup of tea. They contain 220 calories per bar and are full of nuts and seeds as well as being a great source of magnesium. Flapjacks and granola bars are also really nutritious, however I would not recommend you eat these until at least 8 weeks post-op as they are quite lumpy and when you do, you must chew them many times before swallowing.