Abstract
An estimated 1.5 million Americans were newly diagnosed with cancer in 2011. Chemotherapy medications are a common and effective treatment modality for many types of cancers. However, the side effects of many chemotherapy agents are debilitating and negatively affect the quality of life of the individuals receiving the treatment. Several options are available that can help lessen the severity of chemotherapy side effects, some of which are lifestyle medicine related. This review article provides details about lifestyle medicine strategies such as proper nutrition, physical activity, sleep, stress reduction, and hydration in the context of mitigating some of the most common side effects related to chemotherapy treatment.
In 2011, it was estimated that approximately 1 596 670 new cases of cancer (not including carcinoma in situ) were expected to be diagnosed in the United States. 1 The lifetime risk of developing cancer for US men is slightly less than 1 in 2, and for US women, it is a little more than 1 in 3. 1 The general methods for the treatment of cancer include surgery, radiation, chemotherapy, hormone therapy, biological therapy, and targeted therapy. 1
Treatment with chemotherapy works by stopping or slowing the growth of cancer cells that grow and divide quickly. Unfortunately, chemotherapy treatment can include a significant number of side effects that are often debilitating and negatively affect the patient’s quality of life. The specific chemotherapy side effects that a patient experiences will depend on the type of cancer, the chemotherapy drug used, and the patient’s concomitant health issues. However, some of the most common side effects of chemotherapy treatment include anemia, appetite changes, constipation, diarrhea, fatigue, nausea, and vomiting. 2
Lifestyle medicine activities can be an important part of chemotherapy treatment because they soften the severity of some chemotherapy side effects.
Lifestyle medicine activities can be an important part of chemotherapy treatment because they soften the severity of some chemotherapy side effects. Although there are many modalities for managing chemotherapy side effects, the purpose of this manuscript is to review the lifestyle medicine strategies that can mitigate some of the most common side effects that patients experience while receiving chemotherapy treatment.
Anemia
Chemotherapy treatment can significantly decrease the number of oxygen-carrying red blood cells in the body by making it more difficult for the bone marrow to produce new red blood cells. 2 As a result, the patient may feel short of breath, weak, dizzy, faint, or very tired. Lifestyle medicine strategies that can help manage anemia include the following 2 :
Sleep: It is recommended that patients receiving chemotherapy obtain at least 8 hours of sleep each night with 1 to 2 short naps (1 hour or less) during the day as needed.
Nutrition: An eating plan that includes an adequate number of calories specific for individual patient needs is recommended. Special attention should be made to protein consumption because it is important for tissue repair that may be necessary after chemotherapy treatment. 2 Consulting with a dietitian may be needed for many patients.
Appetite Changes
Appetite changes are a common side effect and often caused by other chemotherapy side effects such as nausea, mouth and throat problems, changes to the taste sensation, or from feeling depressed or tired. 2 Some patients experience weight loss because of a decrease in appetite, whereas others experience weight gain because of an increase in appetite. Lifestyle medicine strategies that can help with appetite changes include the following 2 :
Nutrition: It is recommended that patients eat 5 to 6 small meals or snacks each day rather than 3 larger meals. Adequate calorie, especially protein, intake should be monitored, and patients may want to set a daily schedule for eating rather than eating only when they feel hungry. 2
Physical activity: Even though increasing physical activity expends calories, it can also help increase appetite for those who experience a loss in appetite. Increasing physical activity may also be advantageous for those who experience an increase in appetite because of chemotherapy, to avoid significant weight gain during treatment. 2
Constipation
Constipation can occur as a result of the chemotherapy drug itself or as a result of taking pain medication. Constipation can also occur because of a lack of physical activity, decreased fiber intake, and from decreased fluid intake. Lifestyle medicine strategies to help manage constipation can include the following 2 :
Hydration: It is recommended that patients experiencing constipation caused by chemotherapy drink at least 8 cups of water or other fluids each day. Some patient may benefit from drinking warm or hot beverages such as coffee or tea, whereas fruit juices such as prune juice may help others. 2
Physical activity: Staying active by participating in walking, biking, and yoga on a consistent schedule has been recommended to improve constipation. If a patient cannot participate in these activities because of an inability to stand or sit on a bike for long periods of time, they may benefit from exercises done while sitting in a chair to stay active. 2
Nutrition: Eating foods high in fiber, such as whole grain breads and cereals, dried beans, raw vegetables, fresh and dried fruit, and seeds and nuts, can help soften stools. Patients should make sure that they drink more fluids when increasing fiber intake. 2
Diarrhea
Chemotherapy treatment itself can cause diarrhea by harming the healthy cells that line the walls of the small and large intestine. 2 Diarrhea can also be caused by taking other medications such as antibiotics and those used to treat constipation. Lifestyle medicine can help manage diarrhea in the following ways 2 :
Nutrition: It is recommended to eat 5 to 6 small meals and snacks each day rather than 3 large meals to improve diarrhea symptoms. 2 Eating foods such as bananas, white rice, white toast, and plain or vanilla yogurt may also help mitigate symptoms. In addition, diarrhea can cause a loss of sodium and potassium, which may need to be monitored by health care professionals. Foods high in sodium and potassium include bananas, oranges, peach and apricot nectar, and boiled or mashed potatoes. It is also recommended to avoid the following: drinks that are very hot or very cold; beer, wine, and other types of alcohol; milk or milk products such as ice cream, milk shakes, sour cream, and cheese; spicy foods such as salsa, chili, and curry dishes; greasy and fried foods such as hamburgers and French fries; foods or drinks with caffeine such as regular coffee, black tea, cola, or chocolate; foods that cause gas such as cooked dried beans, cabbage, broccoli, and soy milk and soy products; and foods high in fiber, such as raw fruits and vegetables, nuts, and whole grain breads and cereals. 2
Hydration: It is recommended to drink 8 to 12 cups of clear liquid each day for diarrhea to prevent dehydration. 2 Clear liquid drinks include water, clear broth, ginger ale, and sport drinks. Extra water can be added to drinks that cause increased thirst or nausea. The drinks should be consumed slowly and at room temperature and those with carbonation should lose their fizz before they are consumed. 2
Fatigue
Fatigue from chemotherapy can range from mild symptoms to an extreme feeling of being tired. 2 Symptoms of fatigue can include feeling weak, weary, worn out, heavy, or slow. Patients typically experience fatigue symptoms during chemotherapy treatment. For some patients, however, the symptoms may last for weeks or months after treatment is completed. The cause of fatigue may come from the type of chemotherapy being used during treatments and from other factors such as frequent visits to health care professionals and feelings of stress, anxiety, and depression. Patients who receive radiation therapy along with chemotherapy may experience more fatigue than those receiving chemotherapy alone. It is important to understand that resting alone does not always alleviate the feeling of fatigue. 2 Lifestyle medicine modalities that can improve the symptoms of fatigue include the following 2 :
Nutrition: It is recommended to eat 5 to 6 small meals per day rather than 3 large meals to reduce fatigue. Foods that are prepared at home should be easy to fix and not require a lot of standing when fatigue symptoms are extreme. 2
Hydration: It is recommended that chemotherapy patients stay well hydrated to reduce the symptoms of fatigue and consume at least 8 cups of water or juice daily. 2
Stress reduction: Activities such as meditation, prayer, yoga, guided imagery, and visualization are recommended to reduce fatigue symptoms that are related to stress. 2
Physical activity: Research has shown that mild to moderate exercise can reduce the symptoms of fatigue and allow for a more restful sleep. It is recommended that patients receiving chemotherapy participate in 15 minutes of walking, riding an exercise bike, or doing yoga each day to mitigate fatigue symptoms. 2 Patients should plan their physical activity at the time of day when they have the most energy. Each individual should talk with their health care providers to make sure that it is safe to exercise and to discover ways to be active while receiving chemotherapy treatment. 2
Sleep: It is recommended that patients receiving chemotherapy get about 8 hours of sleep each night. 2 In general, most patients will require more sleep then they did before chemotherapy to reduce fatigue symptoms. Regular physical activity is highly recommended to achieve and maintain good sleep quality. Additionally, resting more often may also be helpful. It is not recommended that patients take naps greater than 1 hour in length because it may disrupt their nighttime sleeping habits. A planned resting period of 10 to 15 minutes during the day may work better than a nap for many patients. 2
Nausea and Vomiting
Certain types of chemotherapy drugs are associated with higher incidences of nausea and vomiting than others. 2 Nausea and vomiting can occur while a patient is receiving chemotherapy, immediately after treatment, or many hours or days later. Most patients do not experience nausea and vomiting related to chemotherapy medications on days when they are not receiving chemotherapy treatment. Many patients will require antiemetic medication in conjunction with chemotherapy to decrease the incidence of nausea and vomiting. Some patients have also experienced positive results with acupuncture to decrease these side effects. There are, however, some lifestyle medicine–related activities that can also help mitigate nausea and vomiting related to chemotherapy treatment 2 :
Nutrition: Consuming foods that are bland and easy to digest such as crackers, toast, and gelatin are recommended on chemotherapy treatment days to prevent nausea. 2 Some patients feel less nausea if they eat a small amount of food prior to treatment, whereas others experience fewer symptoms when receiving treatment on an empty stomach (nothing to eat 2 to 3 hours before treatment). After treatment, it is recommended not to eat or drink for at least 1 hour. 2 Consuming 5 to 6 smaller meals is also recommended rather than eating 3 larger meals. Patients should not drink a lot of fluids before or during meals and are also recommended not to lie down after eating to prevent nausea and vomiting. Food and drink with strong smells such as coffee, fish, onion, and garlic should also be avoided. Additionally, consuming foods at a medium temperature (not hot or cold) can reduce the nausea and vomiting symptoms. Many patients also experience decreased symptoms by consuming small bits of popsicles or fruit ice or by sucking on sugar-free mints or tart candy (except with mouth or throat sores present). 2
Stress reduction: Relaxation techniques such as meditation, breathing exercises, mental imagery, and listening to music are recommended to decrease nausea and vomiting symptoms related to chemotherapy treatment. 2
Feasibility of Lifestyle Interventions During Chemotherapy Treatment
A study published in 2011 by von Gruenigen et al 3 was designed to assess the feasibility of implementing a lifestyle intervention program during adjuvant chemotherapy treatment for patients with ovarian cancer. Patients enrolled in the study received physical activity and nutrition counseling at every chemotherapy visit for 6 cycles. The results of the study showed that the study participants were able to increase both their physical activity level and fruit and vegetable intake over the 6-cycle treatment period. Additionally, increases in moderate to strenuous physical activity participation were positively and significantly correlated with a higher physical well-being score during chemotherapy treatment (r = 0.48; P = .037). 3 The authors concluded that lifestyle counseling during adjuvant chemotherapy in patients with ovarian cancer is feasible and may improve physical activity and nutrition quality. 3
Conclusion
The lifetime risk for cancer in both men and women in the United States is relatively high. Cancer treatment with chemotherapy agents can be effective for many types of cancer but often comes with debilitating side effects. Lifestyle medicine activities such as proper nutrition, physical activity, stress-reducing techniques, and adequate sleep quantity and quality may help patients receiving chemotherapy reduce some of the side effects associated. Health care professionals who regularly work with patients receiving chemotherapy should become familiar with the lifestyle medicine strategies that can help mitigate chemotherapy side effects in order to better serve their patients.