I. Abstract CL is a 63-year-old white female with a diagnosis of stage III recurrent adenocarcinoma of the rectum.

She was originally diagnosed in 2011 and underwent an abdominoperineal resection with the placement of a permanent colostomy. CL has a medical history that includes type II diabetes, diabetic neuropathy, hypertension, congestive heart failure, cervical cancer, hip fracture, and presence of peristomal hernia. She has also had issues with her colostomy including the herniation of small bowel loops through the ostomy defect. CL is currently undergoing five weeks of radiation therapy to treat her recurrent rectal cancer. During the initial assessment in week one, CL expressed concerns over the possibility of diarrhea due to her colostomy. By the last assessment, at week two of treatment, CL had not experienced any changes in her stool output or consistency. By week three she had begun to experience decreased appetite and an increase in runny stool.

II. Pathophysiology Cancer is defined as a class of diseases characterized by abnormal cell growth and the ability of these cells to invade other tissues1. Normal cell division is closely regulated by a combination of factors including hormones, genetic controls, and growth factors. The type of cell dictates the normal rate of division. The epithelial cells that line the digestive tract are considered cycling cells because they are continuously dividing. The lifespan of epithelial cells in the colon and rectum ranges from 3-8 days2. During a normal cycle, the cells go through the highly controlled processes of proliferation, differentiation, and apoptosis. Mutations can increase proliferation, keep cells from differentiating, and/or block apoptosis. Any of these mutations can lead to uncontrolled growth and tumor progression3. The four most common causes of these mutations are heredity defects, carcinogen exposure, chronic inflammation, and sporadic

carcinogenesis3. The majority of gastrointestinal cancers develop through sporadic carcinogenesis4. Worldwide, colorectal cancer is the third most common form of cancer5. It is difficult to differentiate the incidences of colon and rectal cancer due to the fact that most epidemiological studies combine the two into one category. The American Cancer Society estimates that in the past year there have been 102,480 new cases of colon cancer and 40,340 new cases of rectal cancer diagnosed in the United States6. Last year, an estimated 50,830 people died in the U.S. from colorectal cancers6. Colorectal cancers can be separated by tumor type. The World Health Organization specifies four histological classifications of colorectal tumors, epithelial, non-epithelial, secondary, and polyp3. Among the epithelial tumors, the two most common sub-types are carcinomas and adenomas. Carcinomas are malignant tumors that have invaded the muscularis mucosae3, the thin layer of smooth muscle located directly under the epithelial layer in the gastrointestinal tract. Adenomas are benign tumors that tend to originate in glandular tissue. If left untreated, these tumors can become malignant. At this point the once benign tumor is now called an adenocarcinoma8. Ninety to ninety-five percent of all colorectal cancers are adenocarcinomas5. Adenocarcinomas generally consist of epithelial columnar cells arranged in a glandular pattern. If more that 50% of these glands produce mucin, the tumor is classified as a mucinous adenocarcinoma. Fifty percent of mucinous adenocarcinomas develop into Signet-ring cell carcinomas5. Signet-ring cells contain mucin-filled vacuoles that displace the nucleus. Adenosquamous carcinomas are a very unusual subtype of epithelial tumors. They exhibit features of both adenocarcinomas and squamous cell carcinomas5.

The progression from abnormal cell growth to a cancerous growth is considered a multistep process. The first step in the development of colorectal cancer is the appearance of distinct lesions on the epithelial wall called aberrant crypt foci (ACF). These lesions are microscopic and are generally not identified during routine colonoscopy screenings2. These lesions can eventually develop into a polyp. A polyp is defined as a mass of cells that project above the surrounding normal mucosa4. Polyps are considered adenomas due to the fact that they are benign. A small percentage of these benign masses will develop malignancy 2,4. CL has been diagnosed with an adenocarcinoma that progressed from a polyp through the multi-step process described above. Risk factors for developing colorectal cancer can be divided into two categories, modifiable and non-modifiable. Modifiable risk factors include diet, alcohol consumption, smoking status, activity level, and obesity5,10. Diet appears to be the greatest risk factor for developing colorectal cancer5,7. Studies have shown that diets high in red and processed meats and low in vegetable and fiber correlate with an increased risk of developing colorectal cancer9. Recent research has indicated that there may be a relationship between type II diabetes and the development of colorectal cancer11,12. Metabolic syndrome is also positively correlated with the development of colorectal cancer13. The non-modifiable risk factors include genetic conditions such as familial adenomatous polyposis (FAP), family or personal history, increased age, and gastrointestinal inflammatory conditions5,6. CL exhibits many of the modifiable risk factors discussed above. She has a BMI of 35.7, which classifies her as obesity stage II. She has diabetes and meets the criteria for metabolic syndrome. CL has always been somewhat sedentary, but now is more so due to her large peristomal hernia. A specific diet recall was not completed due to time constraints, so there is no clear evidence regarding her diet. She does, however, have a history of diabetic complications, which indicates that her blood sugar has not been well

controlled for a period of time. CL has a history of polyps dating back 15 years and was originally diagnosed with colon cancer two years ago. She has no other family history of colorectal cancers. The majority of colorectal cancers are diagnosed as the result of a routine screening such as a colonoscopy. The signs and symptoms associated with colorectal cancer are very nonspecific. They include changes in bowel habits, dyspepsia, lethargy, and unexplained weight loss5. If the tumor causes an obstruction, symptoms can include nausea, vomiting, intractable abdominal pain, and bloody stool. Chronic perforations can cause fistulas to form into the bladder, leading to chronic urinary tract infections2. Once a person has gone through treatment for colorectal cancer a lab value called carcinoembryonic antigen (CEA) may be monitored. CEA has a low predictive value for asymptomatic patients, but is often used during postoperative follow-up. In October of 2011, CL had surgery as part of her treatment for her initial diagnosis of rectal cancer. That month her CEA level was 2.8 ng/ml. In November of 2012 it had risen to 39.8 ng/ml. At this point, doctors started following her CEA levels every three months. In January 2013 it was 60.8 ng/ml, March 2013 108.3 ng/ml, and by June 2013 it was 143.3 ng/ml. A colonoscopy was performed in response to the increasing values and evidence was discovered indicating that the tumor had returned. CL did not report any symptoms besides lethargy at this time. Before treatment can begin, a cancer must be staged, generally using the TNM method. The stage of the tumor greatly effects a persons treatment options and prognosis. CLs cancer was staged as III pT3 pN2 M0. The T stands for primary tumor. This classification is based on the size of the tumor14. In colorectal cancers, this can range from no evidence of primary tumor (T0) to a tumor directly invading other organs or structures and/or perforating the visceral

peritoneum (T4)6. CLs cancer she is a T3, meaning the tumor has invaded through the muscularis propria. The N stands for regional lymph nodes and evaluated the degree to which the cancer has spread throughout the lymph system14. N0 indicates that there is no regional lymph node metastasis; N1 indicates that 1-3 nodes have been invaded, and N2 indicates that four or more nodes have been invaded5. CL has eight nodes that have evidence of metastasis, therefore, she has been staged as an N2. The M stands for metastasis. M0 means that there is no distant metastasis, whereas M1 means that there is metastasis to distant organ besides regional lymph nodes5. CL does not have distant metastasis (M0). The prefix P found before the T and N indicates that the cancer was staged based on the pathologic specimen. If a prefix of C was used it would indicate that the cancer was staged based solely off of a clinical examination of the patient (i.e. colonoscopy)14. The three main types of treatment for colorectal cancer are surgery, chemotherapy, and radiation. The type of surgery performed is largely based on where in the rectum the tumor is located. If the tumor is located in the upper portion of the rectum, closer to the colon, a low anterior resection is performed. This procedure involves removing the diseased portion of the rectum without affecting the anus15. Patients undergoing this procedure will generally have a temporary ostomy to allow the rectum to heal. The ostomy will be reversed in about two months. If the tumor is located in the lower portion of the rectum, an abdominoperineal resection will be performed. The procedure involved the removal of the anus, leaving the patient with a permanent colostomy16. After her original diagnosis, CL underwent the abdominoperineal resection and placement of a permanent colostomy. The main nutritional side effect from surgery is the resulting presence of either a temporary or permanent ostomy. The temporary ostomy placed during a low anterior resection is

generally an ileostomy. Fluid and electrolyte loss is a major concern with an ileostomy because there is no longer reabsorption taking place in the colon. There may also be concerns with certain with the absorption of nutrients17. Fortunately these ostomies are reversed in 6-8 weeks, allowing the patient to resume normal intake and fluid reabsorption. The permanent colostomy that is placed after the abdominoperineal resection comes with its own set of complications besides the fluid and electrolyte loss. A parastomal herniation can occur if a person gains a significant amount of weight a. This is an incisional hernia that occurs at the site of a stoma16. In severe cases the hernia can impede a persons ability to walk. CL has a very large parastomal hernia and she often complains that it is painful and impedes her mobility. There are two main types of chemotherapy, systematic and regional. Systematic chemotherapy drugs are either infused into a vein via a peripheral catheter line or taken by mouth. This therapy affects the entire body. Regional chemotherapy drugs are injected into a vein leading straight to the part of the body being targeted. For example, with liver cancer patient, the chemotherapy drugs can be infused directly into the portal vein. Adjuvant chemotherapy is given after surgery to remove any residual tumor and keep chances of recurrence low. Neoadjuvant chemotherapy is given prior to surgery to help reduce the size of the tumor. Chemotherapy can also be used in advanced cancers to prolong a persons life. The main nutritional side effects of chemotherapy are loss of appetite, mouth sores, diarrhea, nausea, and vomiting18. CL is not currently receiving chemotherapy. It was recommended by her doctor, however she chose not to undergo the treatment. Radiation therapy uses ionizing radiation to destroy cells in a specific area. Radiation can be used as a curative, palliative, or prophylactic therapy. In most colorectal cancers, the goal is curative. If the cancer were to metastasize and travel to the bone, the therapy would be

considered palliative. In that instance, the goal would be to reduce pain, not necessarily to cure the cancer. Prophylactic therapy is often used for people with small cell lung cancer because it has a very high chance of metastasizing to the brain. As a result many people choose to preemptively receive treatment to help stop the cancer from spreading to the brain Radiation treatment to the pelvic region has many nutritional side effects. The gastrointestinal tract is very sensitive to radiation and can become inflamed. Some of the most common side effects are diarrhea, nausea, vomiting, loss of appetite, colitis, enteritis, and malabsorption. Due to its close proximity, the bladder is often affected as well19. Radiation treatments can also cause burning of the skin, although this is most common in head and neck cancers. CL is currently receiving radiation therapy. She is three weeks into five total weeks of treatment. During the first week of treatment CL was very nervous about the possibility of experiencing diarrhea due to the presence of her colostomy. During week two of treatment, CL reported that she was not experiencing any digestive side effects. At this time she did begin to experience increased and painful urination. She was diagnosed with cystitis (bladder inflammation) and started on antibiotics due to the risk of infection. By week three, she was beginning to experience stool that was very runny. CL has not experienced any skin changes. The specific combination of treatments for rectal cancer patients is based on the stage of their tumor. Stage 0 tumors are usually polyps and can be removed during a routine colonoscopy. Stage 1 tumors are generally only treated with surgery. There are occasions when chemotherapy and radiation will be recommended after surgery. Stage II and III tumors usually require chemotherapy and radiation prior to surgery, followed by another round of chemotherapy after surgery. Treatment for stage IV tumors is dependent on the amount of metastasis and the wishes of the patient. Aggressive treatment may be indicated for a relatively young and healthy patient

as apposed to patients who are already nearing end of life. In any case, treatment of stage IV is more often palliative than curative20.

III. Nutritional Care Process A. Assessment CL is a 63 year-old white female who has recently been diagnosed with stage III recurrent adenocarcinoma of the rectum. She has a past medical history that includes cervical cancer, CHF, diabetes, diabetic neuropathy, hypertension, and hip fracture. She has a surgical history that includes an abdominoperineal resection with the placement of a permanent colostomy. CL is 53 and currently weighs 200 pounds. Her BMI is 35.7, which classifies her as obese grade II. Her usual body weight prior to her initial rectal cancer diagnosis in 2011 was approximately 160 pounds. She gained 40 pounds in the year following her diagnosis and surgery, but her weight has been stable at 200 pounds for the past year. This 40-pound weight gain was secondary to a hip fracture that she experienced shortly after her surgery in 2011. The weight gain then caused a peristomal hernia. This hernia can be very painful and impedes CLs mobility. As a result, CL is very sedentary. There are no labs available to help assess hydration status. CL has a colostomy, so fluid and electrolyte levels could be a concern. CL states that she tries to keep a bottle of water with her at all times, so that she can sip on it throughout the day. She indicates that if she drinks a lot at one time, she experiences an increased watery output in her colostomy bag. Hydration status may become problematic as CL progresses through her treatment. One of the side effects of radiation therapy to the colorectal region is diarrhea. Diarrhea by itself can lead to dehydration. When coupled with the fact that CL has a colostomy, dehydration could occur more rapidly than someone with a fully functional digestive system21.

During the initial assessment, CL was on four drugs with nutritional implications. They were Lasix, metformin, novolin 70/30, and hydrocodone. Lasix is a loop diuretic that works by inhibiting sodium chloride reabsorption in the loop of Henle. As a result less water is reabsorbed by the kidneys. Lasix is considered a potassium-depleting diuretic22. CL is on this drug due to edema secondary to congestive heart failure. Possible nutritional implications include dehydration, hyponatremia, hypokalemia, and hypomagnesemia23. Metformin is an oral antihyperglycemic agent used to treat type II diabetes. It increases the effect of insulin, decreases the amount of glucose that is absorbed in the gastrointestinal tract, and decreases the amount of glucose produced in the liver. Possible nutritional implications include hypoglycemia, nausea, vomiting, diarrhea, and flatulence23. Novolin 70/30 is a mixed insulin that contains both a fast acting and regular insulin. It is used to treat hyperglycemia. The main possible nutritional side effect is hypoglycemia. Hydrocodone is an analgesic that is used for pain management. It can cause constipation. During week 3 of treatment, CL developed a urinary tract infection and was placed on the antibiotic ciproflaxin. Ciproflaxin can cause nausea, vomiting, and diarrhea. This drug should be taken at least two hours before and six hours after consuming calcium-containing foods or multivitamins. It is also important to insure adequate fluid intake. In October 2011 CL underwent an abdominoperineal resection. A permanent colostomy was placed because the lower portion of her rectum, where the tumor was located, and her anus were removed. CL has had several complications with the ostomy since its placement. Shortly after the procedure, CL broke her hip. This led to a forty-pound weight gain. While recovering from the hip fracture, portions of her small bowel became herniated through the ostomy defect. As a result, she was unable to eat for several days prior to having the herniation fixed. Within the past, year CL has developed a very large peristomal hernia. This has greatly affected her

mobility. The consistency and frequency of her stool output has normalized since placement of the ostomy. Currently, CL is undergoing radiation therapy. The side effects associated with radiation therapy are dependent on the area being treated, surrounding areas affected, and the total dose used19. CL is having the upper portion of her rectum treated. The colon will likely be affected due to its close proximity, as well as possibly the small intestines and the bladder. Diarrhea is the most common side effect. It is caused by inflammation to the colon from the radiation therapy. Nausea and vomiting are possible if the small bowel also becomes inflamed. Cystitis (bladder inflammation) is also common with radiation to the rectum22. During the initial assessment, CL was not experiencing any side effects. During week two, she was diagnosed with cystitis. At week three, CL reported that her stool was more runny than normal. CL has type II diabetes and is currently on both an oral medication and insulin to help control her blood sugar. The recommended diet for a person with diabetes includes consuming 25-30g of fiber per day24. CL follows a low-fiber/residue diet due to her colostomy. It is also recommended that individuals with type II diabetes participate in 90-150 minutes of moderateintensity aerobic activity each week and take part in resistance training three times per week24. CL is unable to participate in any physical activity due to her hernia. There is no documentation of CLs blood glucose control in the form of an A1C. She states that her blood sugar is normally under 140 mg/dl. She does, however, suffer from diabetic neuropathy, which is a long-term consequence of poor blood glucose control. Psychologically, CL seems anxious and worried. On the initial visit with her, the possible side effects of her treatments were discussed. She expressed great concern over possible

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diarrhea. She stated that she was afraid of her colostomy bag exploding. She did seem somewhat relieved when told that the RD would be following up with her on a weekly basis. CLs estimated basal energy expenditure based on the Harris-Benedict equation is 1525 kcal. With an activity factor of 1.2, her needs are estimated at 1830 kcals per day. The Clinical Guide to Oncology nutrition recommends that non-stressed sedentary cancer patients consume 25-30 kcal per kg body weight25. Using CLs adjusted body weight of 158 pounds (72kg), her estimated needs would be 1800-2160 kcal per day. The Clinical Guide to Oncology Nutrition recommends 1.0-1.5 grams of protein per kg body weight25. Using her adjusted body weight, her estimated protein needs are between 72-108 grams per day. A diet history is not available to determine adequacy. In the three weeks of treatment her weight has been stable, indicating that she is meeting her kilocalorie needs. Patient care in the Cancer Center is a team approach. The MD provides weekly updates on skin changes and labs when available. Changes to a persons skin integrity can affect their estimated needs. The nurses are continually updating the RDs on any digestive issues that the patient may not have been comfortable talking to the RD about. The RD meets with the patients in a waiting area near the radiation room. There are times that there are other people waiting as well. This can make talking about certain issue uncomfortable. The radiation therapists are also a great source of information. They see the patients five days a week for several weeks during treatment and tend to build a great rapport. B. Diagnosis Original PES Statement: Altered GI function related to abdominoperineal resection secondary to rectal cancer as evidenced by patient on low-residue diet and currently with colostomy. Updated PES Statement (Week 3): Altered GI function related to abdominoperineal resection secondary to rectal cancer as evidenced by patient experiencing increased ostomy output and changes in stool consistency.

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Altered GI function is defined according to the IDNT reference manual as any change in digestion, absorption, or elimination26. During the first week of treatment, CL was at her baseline. She was eating well, had no complaints of nausea, vomiting, or diarrhea, and she had not had any recent weight changes. She was also fairly knowledgeable on what foods she could and could not tolerate. As a result a diagnosis in the intake or behavioral-environmental domain was not suitable at that time Due to her colostomy, she was at in increased risk should any digestive complications arise during the course of her treatment. Additionally, CLs main concern regarding her treatment was increased stool output and the possibility of her bag bursting, which has happened before. With this diagnosis, the interventions could include strategies to help with the quantity and consistency of her stool output. CL exhibited several indicators listed in the IDNT reference manual for the altered GI function diagnosis. These included increased changes in stool, avoidance of certain foods (low-residue), colorectal cancer diagnosis, and bowel resection surgery. C. Intervention Week 1 1.) General healthful- Encourage patient to continue to consume at least 75% of current diet as tolerated during treatment. 2.) Purpose of Nutrition Education- CL was provided with education on potential side effects related to radiation therapy of the pelvic region. CL was receptive to the education and verbalized understanding. The recommendation of the American Academy of Nutrition and Dietetics in reference to colorectal cancer patients receiving radiation therapy is to provide weekly medical nutrition therapy to patients. This individualized counseling should focus on the consumption of regular

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foods and has been shown to improve protein and calorie intake, nutrition status, and quality of life and reduce symptoms of anorexia, nausea, vomiting, and diarrhea27,28. Week 3 3.) OTC Medications- Encourage patient to us Imodium daily during treatments to treat and prevent watery ostomy output. D. Monitoring & Evaluation 1.) Food and Beverage Intake Patient will consume adequate (>75%) oral intake of foods and beverages 2.) Weight- Patient will maintain a stabilized weight during treatment with stabilized meaning no more than a 1% loss in one week. 3.) GI Profile- Patient will maintain a moderate amount and consistency of stool output

CL was reassessed during week two and three of her radiation treatment. During week two, CL stated that her appetite was good and she was eating the same amount and types of food that she had prior to treatment. CL lost one pound since her initial assessment a week earlier. This was not a significant weight loss as it was only 0.5% of her body weight. CL stated that there was no change in the frequency or consistency of her stool output. At week three, CL reported that her appetite was slightly lower and that she was probably consuming about 75% of her normal intake. Her weight had increased by two pounds. At this time, CL reported that her stool output was more runny than normal. It was recommended that she consume foods such as white rice and applesauce to thicken her stool. CL expressed concern over the white rice due to the fact that she had been told not to eat it because of her diabetes. CL was questioned about her recent blood sugars and she stated that they are usually under 140mg/dl. It was recommended that as long as her blood sugars stayed within normal range, it

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was okay for her to consume white rice during treatments to help thicken her stool. It was also recommended that she take the over the counter drug, Imodium, to help treat her runny stool. IV. References 1. National Cancer Institute. Defining Cancer. National Institute of Cancer. http://www.cancer.gov/cancertopics/cancerlibrary/what-is-cancer. Updated February 2013. Accessed October 5, 2013. 2. Johnson LR, Barrett KE, Ghishan FK, Merchant JL, Said HM, Wood JD, eds. Physiology of the Gastrointestinal Tract: Volume 1. Burlington, MA: Elsvier Academic Press; 2006. 3. LaFond RE, eds. Cancer: the Outlaw Cell. New York, NY: Oxford University Press; 2012. 4.Tanaka T. Colorectal carcinogenesis: Review of human and experimental animal studies. J Carcinog. 2009;8:5. 5. Zampini MG, Labianca R, Beretta GD, Magni E, Gatta G, Leonardi MC, Chiappa A, Biffi R, de Braud F, Wils J. Rectal cancer. Crit Rev Oncol Hemat. 2009;70:160-182. 6. American Cancer Society. Cancer Facts & Figures 2013. Atlanta: American Cancer

Society; 2013.
7. Hamilton SR, Aaltonen LA, eds. World Health Organization: Classification of Tumours. Lyon, France: IARC Press; 2006. 8. Weich T and Werner M. Pathology of rectal cancer. Berlin, Germany: Springer-Verlag; 2010. 9. Ferrari P, Jenab M, Norat T, et al. Lifetime and baseline alcohol intake and risk of colon and rectal cancers in the European prospective investigation into cancer and nutrition (EPIC). Int J Cancer. 2007;121: 2065-2072. 10. Chan AT and Giovanncucci EL. Primary prevention of colorectal cancer. Gastroenterology. 2010;138:2029-2043. 11. Erbacj M, Mehnert H, Schnell O. Diabetes and the risk for colorectal cancer. J Diabetes Complicat. 2012;26:50-55. 12. Youhara H, Steinmaus C, Cohen SE, Corley DE, Tei Y, Buffler PA. Is diabetes mellitus an independent risk factor for colon cancer and rectal cancer? Am J Gastroenterol. 2011;106:19111921. 13. Aleksandrova K, Boeing H, Jenab M, Bas Bueno-de-Mesquita H, Jansen E, van Duijnhoven FJ, Fedirko V, Rinaldi S, Romieu I, Riboli E et al. Metabolic syndrome and risks of colon and rectal cancer: the European prospective investigation into cancer and nutrition study. Cancer Prev Res. 2011;11:1873-1883. 14

14. National Institute of Cancer. Cancer Staging Fact Sheet. National Institute of Cancer. http://library.stkate.edu/pdf/citeAMA.pdf. Reviewed May 2013. Accessed October 12, 2013. 15. American Cancer Society. Surgery for colorectal cancer. American Cancer Society. http://www.cancer.org/cancer/colonandrectumcancer/detailedguide/colorectal-cancer-treatingsurgery. Last revised July 2013. Accessed October 12, 2013. 16. Perry WB, Connaughton JC, Abdominoperineal resection: How is it done and what are the results? Clin Colon Rectal Surg. 2007;20:213-220. 17. Parrish CR. The Clinician's Guide to Short Bowel Syndrome. Pract Gastroenterol. 2005;31:67-106. 18. American Cancer Society. Chemotherapy for Colorectal Cancer. American Cancer Society http://www.cancer.org/cancer/colonandrectumcancer/detailedguide/colorectal-cancer-treatingchemotherapy Last revised July 2013. Accessed October 12, 2013. 19. Academy of Nutrition and Dietetics. Treatment Modalities: Radiation Therapy. Nutrition Care Manuel. http://www.nutritioncaremanual.org.ezproxy.lib.vt.edu:8080/topic.cfm?ncm_category_id=1&lv1 =22938&lv2=145088&ncm_toc_id=145088&ncm_heading=Nutrition%20Care. Accessed October 12, 2013. 20. American Cancer Society. Treatment by stage of rectal cancer. American Cancer Society. http://www.cancer.org/cancer/colonandrectumcancer/detailedguide/colorectal-cancer-treatingby-stage-rectum. Last revised July 2013. Accessed October 12, 2013. 21. Academy of Nutrition and Dietetics. Colostomy. Nutrition Care Manuel. http://www.nutritioncaremanual.org.ezproxy.lib.vt.edu:8080/topic.cfm?ncm_toc_id=19799. Accessed October 12, 2013. 22. National Institute of Health. Lasix Descriptor Data. National Library of Medicine. http://www.nlm.nih.gov/cgi/mesh/2011/MB_cgi?mode=&term=Loop+Diuretics. Revised July 2011. Accessed October 13, 2013. 23. Pronsky ZM and Crowe JP. Food-Medication Interactions. 16th ed. Brunville, PA: FoodMedication Interactions;2010. 24. American Diabetes Association. Nutrition recommendation and interventions for diabetes: A position statement of the American Diabetes Association. Diabetes Care. 2008;31 (Suppl 1): S94-S102. 25. McCallum PD, Polisena CG. The Clinical Guide to Oncology Nutrition. Chicago, IL: American Dietetic Association:2000. 26. Academy of Nutrition and Dietetics. Pocket Guide for International Dietetics and Nutrition Terminology (IDNT) Reference Manual. Chicago, IL; Academy of Nutrition and Dietetics:2013.

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27. Academy of Nutrition and Dietetics. Recommendations Summary: Colorectal Cancer, Radiation and Medical Nutrition Therapy. http://andevidencelibrary.com/template.cfm?template=guide_summary&key=1750. Revised March 2006. Accessed October 13, 2013. 28. Ravasco P, Monteiro-Grillo I, Vidal P, Camilo M. Dietary counseling improves patient outcomes: A prospective, randomized, controlled trial in colorectal cancer patients undergoing radiotherapy. J Clin Oncology. 2005; 23: 1,431-1,438.

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