PATIENT & CAREGIVER EDUCATON Diet and During Treatment for Esophageal Cancer

This information explains your nutritional care during your treatment for esophageal cancer at Memorial Sloan Kettering (MSK). It also explains the diet (eating and drinking) changes you can expect during and after your treatment. It’s important to get enough nutrition before, during, and after your cancer treatment. Getting enough nutrition can help you: • Maintain your strength • Keep your weight stable • Fight infection • Have fewer side effects • Heal after surgery Read through this resource at least once before your treatment. You may also want to use it as a reference during and after your treatment. You can use the table of contents to help you find the information that’s most useful at different times during your treatment.

Diet and Nutrition During Treatment for Esophageal Cancer 1 Table of Contents

About Your Nutritional Care...... 3 Your Clinical Dietitian Nutritionist...... 3 Contact Information for MSK Nutrition Services...... 3 Nutrition During Chemotherapy and Radiation Therapy...... 4 Tips for Eating More Calories and Protein...... 4 Tips for Eating More Food...... 6 Tips for Managing Treatment Side Effects...... 6 Diet and Nutrition After Your Esophagectomy...... 9 About Your Feeding Tube...... 10 Eating and Drinking After Surgery...... 11 Tracking Your Weight ...... 13 Tracking your Food and Liquid Intake...... 13 General Diet Guidelines After Your Esophagectomy...... 16 Guidelines for Eating...... 16 Guidelines for Drinking...... 16 Food Intolerances After Surgery...... 16 Tips for Managing Common Problems...... 18 Eating at Restaurants and Social Events...... 19 Resources...... 20 MSK Support Services...... 20 External Resources...... 20 Clear Liquid Diet...... 21 Full Liquid Diet...... 22 ...... 23 6-Meal Soft Diet Sample Menus...... 25 Daily Food and Drink Log...... 29

Diet and Nutrition During Treatment for Esophageal Cancer 2 About Your Nutritional Care

The usual treatment for esophageal cancer is an esophagectomy (surgery to remove all or part of your esophagus). Some people also have chemotherapy and radiation therapy before surgery. Having chemotherapy and radiation therapy before surgery is called induction therapy. Your doctor will talk with you about which treatment plan may be best for you. No matter what you decide, a clinical dietitian nutritionist will be available to help you during and after your treatment.

Your Clinical Dietitian Nutritionist Before you start treatment, a clinical dietitian nutritionist will plan your diet to make sure you get enough nutrition during and after your treatment. During your first meeting with your surgery team, you will fill out a form with questions about your diet. This form will help your clinical dietitian nutritionist know what to focus on when they create your nutrition care plan. If you’re having chemotherapy and radiation therapy before your surgery, your clinical dietitian nutritionist can: • Help you manage your symptoms by changing your diet. • Help you get enough nutrition. • Teach you about helpful diets to follow and foods to eat during your treatment. When your surgery is scheduled, your clinical dietitian nutritionist will call you to talk about your diet and nutrition after surgery. During this call, you can talk with them about your questions and concerns about your diet and nutrition. After your surgery, an inpatient clinical dietitian nutritionist will manage your diet and nutrition and teach you about eating and drinking while you’re in the hospital. After you leave the hospital, an outpatient clinical dietitian nutritionist will help you with your diet at home to make sure you get enough nutrition.

Contact Information for MSK Nutrition Services For more information about MSK’s nutrition services, visit www.mskcc.org/nutrition. To make an appointment with a clinical dietitian nutritionist, call 212-639-7312 or ask a member of your healthcare team to help you. MSK offers nutrition services in Manhattan and at many of our regional network locations.

Diet and Nutrition During Treatment for Esophageal Cancer 3 Nutrition During Your Chemotherapy and Radiation Therapy

Use the information in this section to make sure you get enough nutrition while you’re having chemotherapy and radiation therapy before surgery. If you have questions about your diet or nutrition, talk with your clinical dietitian nutritionist. If you’re having a lot of trouble swallowing, you may need to use a feeding tube to help you get enough nutrition. If you do, your doctor and clinical dietitian nutritionist will give you more information.

Tips for Eating More Calories and Protein If you find you’re eating less than usual during your chemotherapy and radiation therapy, follow a high-calorie, high-protein diet. A high-calorie, high-protein diet can help you stay at the same weight (if you’re at a healthy weight) or lose weight more slowly (if you’re overweight).

High-Calorie, High-Protein Foods Eat foods from the table below to add more calories and protein to your diet. Ask your clinical dietitian nutritionist for more menu ideas, if you need them. Choose foods that are easy for you to eat. If you’re having problems that affect how you eat, read the “Tips for Managing Treatment Side Effects” section.

Protein Food Group Food Calories (grams) Meat, beans, 1 cup cooked dried beans 240 4 and eggs ½ cup chicken salad 200 14 1 egg cooked with 1 tablespoon butter 175 6 3 ounces tuna canned in oil 170 25 ¼ cup egg substitute 25 5 Nuts and Seeds 1 ounce pecans (20 halves) 200 3 1 ounce macadamia nuts (10 to 12 nuts) 200 2 1 ounce brazil nuts (6 to 8 nuts) 190 4 1 ounce walnuts (14 halves) 185 4 1 ounce shelled sunflower seeds 175 6 1 ounce almonds (about 24) 165 4 1 ounce peanuts 165 7 1 tablespoon peanut butter 95 4 Dairy ½ cup canned evaporated milk (can be used instead of 160 8 water when cooking) 6 ounces sweetened yogurt 130 5 ½ cup premium ice cream 220 14 ½ cup creamed cottage cheese 115 7 ¼ cup (1 ounce) shredded cheese 100 2 ¼ cup half-and-half 80 2 ½ cup whole milk (can be used instead of water 75 4 when cooking) 1 tablespoon cream cheese 50 1 2 tablespoons sour cream 50 1

Diet and Nutrition During Treatment for Esophageal Cancer 4 Protein Food Group Food Calories (grams) 1 tablespoon butter, margarine, oil, or mayonnaise 100 0 2 tablespoons gravy 40 1 Sweets 1 tablespoon honey 60 0 1 tablespoon , jam, jelly, or chocolate syrup 50 0 Meal 1 meal replacement bar 200 15 Replacements 1 scoop (1 ounce) protein powder 100 15 1 tablespoon protein powder 40 5

High-Calorie, High-Protein Liquid Nutritional Supplements Your doctor or clinical dietitian nutritionist may suggest taking high-calorie or high-protein nutritional supplements. If they do, take the supplements between meals. If you take them with a meal, they can be filling and may keep you from eating more of your food. You can buy most of the products in the table below at any supermarket or pharmacy. If you don’t see a product in the store, ask a pharmacist or store manager to order it for you. You can also order these products online.

Protein Water Lactose Nutritional Supplement Calories (grams) (mL) Free? Ensure® Original (8 ounces) 250 9 196 Yes Ensure® Clear (8 ounces) 240 8 — Yes Ensure Plus® (8 ounces) 350 13 180 Yes Orgain® Nutritional Shake (11 ounces) 250 16 — No Glucerna® Shake (8 ounces) 220 10 200 Yes Boost® Original (8 ounces) 240 10 200 Yes Boost Glucose Control® (8 ounces) 190 16 200 Yes Boost® Nutritional Pudding (5 ounces) 240 7 140 Yes Boost® VHC (Very High Calorie) (8 ounces) 530 22.5 168 Yes Boost Breeze® (8 ounces) 250 9 196 Yes Carnation Breakfast Essentials® Powder (1 packet) 130 5 — No Carnation Breakfast Essentials Ready-to-Drink (11 ounces) 250 14 285 No ScandiShake® (1 packet) without milk 440 5 — No ScandiShake Lactose Free (1 packet) without milk 430 8 — Yes ENU® Complete Nutrition Shake (11 ounces) 450 23 — Yes Kate Farms® Komplete® (10.8 ounces) 290 16 — Yes Benecalorie® (1.5 ounces) 330 7 — Yes Beneprotein® Instant Protein Powder (7 grams) 25 6 — Yes

High-Calorie, High-Protein Nutritional Shakes You can also make your own high-calorie, high-protein nutritional shakes. For more information, including shake recipes and other tips for increasing your calorie and protein intake, read the resource Eating Well During and After Your Cancer Treatment (www.mskcc.org/pe/eating_cancer_treatment).

Diet and Nutrition During Treatment for Esophageal Cancer 5 Tips for Eating More Food Chemotherapy and radiation therapy can cause taste changes, appetite loss, or both. This can make it hard to eat enough food. If you’re not eating enough food or are losing weight from treatment, follow the guidelines below. • Have small, frequent meals. − Have a half-sized meal every 2 to 3 hours. − Try to eat 6 to 8 small meals a day instead of 3 large meals. − Create and follow a meal schedule. Don’t wait to eat until you’re hungry. • Keep your favorite foods in your home where you can get to them easily. • Buy single-serving food items that you can eat easily, such as small bags of mixed nuts or trail mix. • Cook in batches so you have leftovers. − Keep 1 extra serving in your refrigerator for the next day, but not longer. − Freeze the other extra servings. When you’re ready to use a serving, thaw it in the refrigerator or microwave, not on the kitchen counter. Then, reheat it until it’s steaming hot. • Include many different food groups and food types in your diet, unless your doctor or dietician tells you not to. • Get more calories from liquids than solid foods. For example, have milkshakes or nutritional supplements such as Ensure or Carnation Breakfast Essentials. • Keep your dining experience pleasurable and non-stressful. • Think of your nutrition as being just as important as your medications.

Tips for Managing Treatment Side Effects Chemotherapy and radiation therapy can cause side effects such as dry or sore mouth or throat, difficult or painful chewing or swallowing, and nausea (feeling like you’re going to throw up). These things can make it harder for you to eat. If you have any of these side effects, follow the guidelines below. If you have new side effects or your side effects are getting worse, talk with your doctor or healthcare provider about how to manage them.

Problems With Chewing or Swallowing Examples of problems with chewing or swallowing include painful or difficult chewing or swallowing or a feeling like food is getting stuck in your throat. If you have any of these side effects: • Follow a puréed or mechanical soft diet. − Puréed foods are foods that don’t need to be chewed. They’re usually blenderized (put into a blender or food processer) to a smooth texture. − Mechanical soft foods are foods that need less chewing than most other foods. They’re usually diced or chopped.

Diet and Nutrition During Treatment for Esophageal Cancer 6 • Keep a blender (such as a Vitamix®) or food processor in your home. This is helpful if you need to purée your foods. • Have 1 or more high-calorie drinks every day. These can be ready-to-drink nutrition supplements (such as Ensure or Boost) or homemade milkshakes and smoothies. Talk with your clinical dietitian nutritionist about what may be best for you. For more information, read the resource Eating Guidelines for Pureed and Mechanical Soft Diets (www.mskcc.org/pe/pureed_mechanical_soft_diet).

Dry Mouth It can be hard to eat if your mouth is dry and doesn’t make enough saliva. If your mouth is dry: • Choose soft, moist foods. • Add gravies, sauces, applesauce, or other liquids to your foods. • Have a spoonful of warm soup or other liquid between mouthfuls of food. • Try foods prepared with gelatin, such as mousses. They tend to slide down your throat more easily. • Always carry a bottle of water with you. You can also try carrying a small, clean spray bottle filled with water. Spray water in your mouth throughout the day to keep it moist. • Try eating sugar-free mints or lemon drops or chewing sugar-free gum. These things can help you make more saliva. • Try an over-the-counter (not prescription) saliva supplement, such as Biotene® Oralbalance Moisturizing Gel. • If you’re having trouble keeping your weight the same, choose drinks that have calories instead of water. Examples are fruit juices, fruit nectars, and liquid nutritional supplements, such as Ensure. − If you have diabetes, talk with your doctor or clinical dietitian nutritionist before doing this. They may tell you to limit or avoid sugary drinks to help control your blood sugar.

Mouth Sores If you have mouth sores: • Avoid steaming hot foods and drinks. • Don’t eat acidic fruits (such as oranges, grapefruits, lemons, and limes) or drink acidic fruit juice. • Don’t eat spicy foods. • Don’t put vinegar (including salad dressings with vinegar) on your foods if it bothers you. • Suck on sugar-free candies. • Gently brush your teeth with a soft-bristle toothbrush before and after meals. • Rinse your mouth with saline solution (mild salt water). You can make the solution by mixing ¼ to ½ teaspoon of salt into an 8-ounce glass of warm water.

Diet and Nutrition During Treatment for Esophageal Cancer 7 If the things above don’t control your mouth pain, tell your doctor or healthcare provider. They may prescribe a liquid numbing medication to help.

Nausea Most healthcare providers will prescribe medication to treat nausea or keep it from happening. You can also follow the guidelines below to help manage nausea. • Don’t eat spicy foods. • Don’t eat high- foods, especially fried foods, such as donuts, french fries, pizza, and pastries. • If the smell of food bothers you, try eating your food at room temperature or cold. Avoid foods that are too hot. They often have a stronger smell that can make nausea worse. • Eat small, frequent meals. • Chew your food well to make it easier to digest. • Don’t drink large amounts of liquids at once. This will keep you from getting too full, which can make nausea worse. • Try sipping on ginger tea, ginger ale, non-alcoholic ginger beer, or sucking on candies containing real ginger. Ginger may be soothing and help with nausea. • Try eating low-fat, starchy foods. These foods may be less likely to make you feel nauseous. For example, try rice, white toast, crackers, cheerios, melba toast, or angel food cake. • Try eating salty foods, such as pretzels or saltine crackers.

Diet and Nutrition During Treatment for Esophageal Cancer 8 Diet and Nutrition After Your Esophagectomy

During your esophagectomy, your doctor will remove part of your esophagus, move your stomach up, and connect your stomach to the remaining part of your esophagus (see Figures 1 and 2). They will place a feeding tube in the part of your small intestine called the jejunum (see Figure 2). The feeding tube is called a jejunostomy tube or J-tube. You will use it to get nutrition while your esophagus and stomach heal after surgery.

Esophagus

Esophagus Stomach

Stomach

Small J-tube Intestine Small Intestine

Figure 1. Your esophagus and stomach before Figure 2. Your esophagus, stomach, and J-tube your surgery. after your surgery.

After your esophagectomy, your doctor and thoracic team will keep track of your recovery and decide when you’re ready to start drinking and eating again. You may start drinking and eating while you’re in the hospital, or you may start at home after you’re discharged from the hospital. Your doctor and inpatient clinical dietitian nutritionist will tell you what to expect. While you’re in the hospital, an inpatient clinical dietitian nutritionist will manage your nutritional care. They will: • Check to make sure you’re getting enough nutrition. • Teach you about your diet and tube feeding schedule.

Diet and Nutrition During Treatment for Esophageal Cancer 9 • Tell your case manager which diet and nutrition supplies you’ll need at home. Your case manager will order these supplies for you. • Be available to talk with you and answer your questions. After you’re discharged from the hospital, an outpatient clinical dietitian nutritionist will start managing your nutritional care. They will: • Call you within 48 hours (2 days) of your discharge. • Talk with you regularly to help you manage your diet at home. • Be available to talk with you and answer your questions.

About Your Feeding Tube Right after your surgery, you won’t be able to eat or drink anything. You will get all of your nutrition from liquid formula put into your small intestine through your feeding tube. The formula can be digested and absorbed by your small intestine. It has all the nutrients your body needs.

Tube Feeding Rates Your tube feeding rate is the amount of formula you get through your feeding tube per hour. It’s measured in milliliters (mL) per hour. Your goal feeding schedule is the tube feeding rate and number of hours that gives you the right amount of calories, protein, and fluids. Your inpatient clinical dietitian nutritionist will calculate your goal feeding schedule based on your height and weight. At first, you will have a low tube feeding rate. Your tube feeding rate will slowly be increased to your goal rate or schedule.

Tube Feedings After Discharge You may get some nutrition from tube feedings after you’re discharged from the hospital. This may be because you’re following a liquid diet, can’t get enough nutrients just from eating, or haven’t yet started drinking or eating. Your tube feedings make sure you get all the protein and calories you need to have a successful recovery. If you will have tube feedings after discharge, your inpatient clinical dietitian nutritionist will tell your case manager which formula and supplies you will need at home. Your case manager will work with a home care company to arrange for your tube feeding formula and supplies to be delivered to your home. Before you leave the hospital, a person from the home care company will visit your hospital room. They will teach you and your caregiver how to use your tube feeding pump. Your nurse and inpatient clinical dietitian nutritionist will also give you the resource Tube Feeding With a Pump (www.mskcc. org/pe/tube_feeding_pump) and be available to answer your questions. Make sure you and your caregiver feel comfortable using your tube feeding pump before you’re discharged. After you’re discharged, you will probably use the same formula that you did in the hospital. You will be on a 16-hour tube feeding schedule. As you heal, you will use the feeding tube for fewer hours. Your outpatient clinical dietitian nutritionist will tell you how many hours you should use your feeding tube. Having a few hours without tube feedings each day will help increase your appetite so you can wean off of the tube feedings more quickly.

Diet and Nutrition During Treatment for Esophageal Cancer 10 Eating and Drinking After Surgery As your esophagus and stomach heal, you will slowly start drinking and eating. You will follow different diets as you’re able to drink and eat more things. • Clear liquid diet: This diet includes only liquids that you can see through. Clear liquids are easiest for your body to digest. • Full liquid diet: This diet includes all the liquids in a clear liquid diet, as well as liquids that are thicker or not clear. • Soft diet: This diet includes all the liquids in a full liquid diet, as well as foods that are physically soft. This means less chewing is needed to get the food into a texture that’s smooth and easy to swallow. At first, you will also get nutrition from your feeding tube while you’re following these diets. As you’re able to get more of your nutrition from drinking and eating, your tube feeding volume will be decreased. Eventually, your tube feedings will be stopped. There are more guidelines for each of these diets in the “Resources” section near the end of this resource. If you follow any of these diets while you’re in the hospital, you will get a menu explaining which foods these diets include. Your doctor will decide when you’re ready to start each new diet. They will also tell you which diet to follow when you go home. Most people follow a clear liquid while still having some tube feedings when they’re discharged.

Stomach Changes Your stomach won’t be able to hold as much as it did before surgery, and it will be higher in your chest. It may also empty more quickly or slowly for the first few months after surgery. These things mean that you will get full more quickly. Since your stomach is now in your chest, the feeling of fullness might be different. Pay attention to subtle signs of fullness or pressure behind your breastbone. This will help you keep from eating too much and having reflux.

Reflux Reflux is when foods or liquids that you swallow come back up your throat into your mouth. This happens because the valve between your esophagus and stomach was removed during your surgery. To keep from having reflux, sit up straight during meals and for at least 60 minutes after you’re finished. Eat your last meal of the day at least 2 hours before your bedtime, and have your last drink of the day at least 1 hour before your bedtime. For more information about how to avoid reflux, read the “Tips for Managing Reflux” section of this resource.

Clear Liquid Diet You will start following a clear liquid diet around 6 days after your surgery. For information about what you can drink while following this diet, read the “Clear Liquid Diet” section near the end of this resource.

Diet and Nutrition During Treatment for Esophageal Cancer 11 When you first start following a clear liquid diet, your tube feeding schedule will be shortened from 24 hours per day to about 18 hours per day. When you’re discharged home, your tube feeding schedule will be shortened to 16 hours a day. This will help increase your appetite during the day. Drink small amounts at a time and drink slowly as you learn your limits. This will help you keep from having reflux. Start with 4 ounces (½ cup) at a time. Aim to drink 4 ounces of liquids 6 to 8 times a day (24 to 32 ounces total) when you first start a clear liquid diet.

Full Liquid Diet If you’re able to follow a clear liquid diet, you will start following a full liquid diet around 10 days after your surgery. For information about what you can drink while following this diet, read the “Full Liquid Diet” section near the end of this resource. When you start following a full liquid diet, your outpatient clinical dietitian nutritionist will tell you how to adjust your tube feeding schedule. Most people keep the same tube feeding rate but lower the number of hours they get tube feeds to 12 hours per day. You may not be able to drink some or all dairy products after your surgery. Pay attention to the way you feel after having dairy (such as milk and yogurt), and avoid the things that cause discomfort. For more information, read the “Food Intolerances After Surgery” section of this resource.

Soft Diet Your outpatient clinical dietitian nutritionist will tell you when you should start following a soft diet. Usually, this is around 13 days after your surgery. For information about what you can drink and eat while following this diet, read the “Soft Diet” section near the end of this resource. You can also follow the 6-meal soft diet sample menus included in the “Soft Diet” section. When you start following a soft diet, your outpatient clinical dietitian nutritionist will tell you how to adjust your tube feeding schedule. Most people keep the same tube feeding rate but lower the number of hours they get tube feeds to 8 hours per day. When you start following a soft diet, you should also start tracking your weight and keeping a food and drink log. For more information, read the “Tracking Your Food and Liquid Intake” section of this resource. You may not be able to eat some foods that you could eat before surgery, such as sweets and dairy. Pay attention to the way you feel after eating different foods and keep notes in your log. For more information, read the “Food Intolerances After Surgery” section of this resource.

Stopping Your Tube Feedings Your outpatient clinical dietitian nutritionist will follow up with you often to see how many calories you’re eating and drinking. They will help you slowly reduce the amount of tube feeding formula you get as you get more nutrients from eating and drinking. The goal is for you to stop having any tube feedings and be able to follow a soft diet in small, frequent meals. Your doctor will remove your feeding tube once you’re able to get enough nutrition from your diet. The goal is to remove your feeding tube during your first follow-up appointment after surgery. This is usually about 2 weeks after you’re discharged from the hospital.

Diet and Nutrition During Treatment for Esophageal Cancer 12 Diet and Nutrition Timeline These are goals for your recovery. Your experience may not follow this timeline exactly. Follow your doctor or clinical dietitian nutritionist’s instructions for changing your diet.

Days After Surgery Diet and Nutrition Goal • Start tube feedings. 2 • Use your feeding tube for 24 hours a day. • Start having small sips of clear liquids. 5 • Use your feeding tube for 18 hours a day. 6 • Start following a clear liquid diet. • Leave the hospital following a clear liquid diet and using your feeding tube 7 for 16 hours a day. • Start following a full liquid diet. 10 • Use your feeding tube for 12 hours a day. • Start following a soft diet. 13 • Start keeping a food and drink log. • Use your feeding tube for 8 hours a day. • Ask your doctor when you can start following a regular-textured diet. 16 • The outpatient clinical dietitian nutritionist will tell you when to stop using your feeding tube.

Tracking Your Weight It’s important to track your weight after surgery. Weigh yourself about every 3 to 5 days, or as often as your outpatient clinical dietitian nutritionist asks you to. It’s best to weigh yourself around the same time each day. Make sure you’re wearing the same amount of clothes each time. It’s normal to lose weight right after you’re discharged from the hospital. When you’re first recovering from your surgery in the hospital, your body may hold onto more fluids than usual. This can make your weight go up. After you’re discharged, you will lose this fluid weight. Your weight should return to your normal or slightly below your normal weight. These changes are normal. Your outpatient clinical dietitian nutritionist will work with you to help keep you from losing too much weight. In the months following surgery, tell your healthcare team if you’re losing weight without trying. Remember that you can make an appointment with an outpatient clinical dietitian nutritionist if you need help with your diet.

Tracking Your Food and Liquid Intake After your esophagectomy, you may feel full quickly or have other digestive changes that affect your eating. Keeping a food and drink log will help you see what foods and portion sizes are easiest for you to eat. It will also help you make sure you’re getting enough calories. In your food and drink log: • Keep track of all the foods you eat and liquids you drink. Write down: − The time you eat or drink. − The amount (portion) and type of food or drink. − The number of calories in the food or drink. Diet and Nutrition During Treatment for Esophageal Cancer 13 • Write down any symptoms or problems you have after eating or drinking. − Are you feeling too full? − Do you have pressure in your chest? − Are you having reflux? − Are you having pain in your abdomen (belly) or diarrhea (loose or watery bowel movements)? See Figure 3 for an example of a food and drink log. There is also a blank log for you to use in the “Resources” section.

Time Portion Size Description Calories Symptoms? 7:00 4 oz Apple juice 60 None 1 jumbo Scrambled egg 100 8:00 None 5 oz Mashed potatoes 160 10:00 6 oz Yogurt 105 None 5 oz Mashed potatoes 160 2:00 None 4 oz Vanilla pudding 110 4:00 1 jumbo Scrambled egg 100 None 6 oz Mashed potatoes 92 5 oz Soft cooked butternut squash 75 Very full, unable 6:00 ¼ cup Stewed chicken 58 to finish meal ¼ cup Gravy 50 Daily total 1130 Cal Figure 3. Sample food and drink log Measuring Foods To accurately measure foods, use measuring spoons, measuring cups, or a food scale. You can also use the guidelines below to estimate amounts of some foods (see Figure 4).

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Diet and Nutrition During Treatment for Esophageal Cancer 14 Finding Calorie Information You can find the calorie information for packaged foods on the nutrition facts label (see Figure 5).

Nutrition Facts Nutrition Facts Serving Size 2/3 cup (55g) Servings Per Container About 8 8 servings per container Serving size 2/3 cup (55g) Amount Per Serving Calories 230 Calories from Fat 72 Amount per serving % Daily Value* Calories 230 Total Fat 8g 12% % Daily Value* Saturated Fat 1g 5% Total Fat 10% Trans Fat 0g 8g 5% Cholesterol 0mg 0% Saturated Fat 1g Sodium 160mg 7% Trans Fat 0g Total 37g 12% Cholesterol 0mg 0% 4g 16% Sodium 160mg 7% 1g Total Carbohydrate 37g 13% Protein 3g Dietary Fiber 4g 14% Total Sugars 12g 10% Includes 10g Added Sugars 20% 8% Protein 3g 20% Iron 45% Vitamin D 2mcg 10% * Percent Daily Values are based on a 2,000 calorie diet. Your daily value may be higher or lower depending on Calcium 260mg 20%

your calorie needs. Calories: 2,000 2,500 Iron 8mg 45% Total Fat Less than 65g 80g Sat Fat Less than 20g 25g Potassium 235mg 6% Cholesterol Less than 300mg 300mg Sodium Less than 2,400mg 2,400mg * The % Daily Value (DV) tells you how much a nutrient in Total Carbohydrate 300g 375g a serving of food contributes to a daily diet. 2,000 calories Dietary Fiber 25g 30g a day is used for general nutrition advice.

Figure 5. Where to find calorie information on a Nutrition Facts label

If a food doesn’t have a nutrition facts label, you can look up the calorie information on a nutrition resource website, such as CalorieKing.com or myfitnesspal.com. You can also download the MyFitnessPal application to your smartphone. Your clinical dietitian nutritionist can also calculate the calorie information for you during your scheduled follow-up appointments. Make sure you write down what you eat and drink and how much you have so they can calculate the calories.

Diet and Nutrition During Treatment for Esophageal Cancer 15 General Diet Guidelines After Your Esophagectomy

After your surgery, your stomach won’t be able to hold as much as it did before surgery. You will need to have 6 or more small meals a day instead of 3 main meals. This will help you eat the right amount of food, even though your stomach is smaller. When you first start eating after surgery, you will follow a soft diet. Eventually, most people can start following a regular textured diet. Your doctor will tell you when it’s safe to do this. You will still need to eat small, frequent meals. You may also need other vitamin and mineral supplements. If you do, your doctor or clinical dietitian nutritionist will discuss this with you. Tell your doctor and clinical dietitian nutritionist if you’re losing weight without meaning to.

Guidelines for Eating • When you first start eating, you may only be able to comfortably eat a ½ to 1 cup portion of food at a time. Over time, you will be able to have larger portion sizes. • Chew your food well. This helps with digestion. • Eat slowly. This way, you will stop eating before you get too full and feel uncomfortable. • Don’t drink more than 4 ounces (½ cup) of liquid during your meals. This will allow you to eat enough solid food without getting too full. It will also slow down the digestion of your food. Remember that soup counts as a liquid.

Guidelines for Drinking • Drink most of your liquids at least 1 hour before or 1 hour after your meals. This helps you avoid feeling too full and prevents dehydration. • Aim to drink about 8 to 10 (8-ounce) glasses of liquid each day. Avoid carbonated (fizzy) drinks if they make you feel full.

Food Intolerances After Surgery A food intolerance means you’re not able to have certain types of foods or drinks. After your surgery, you may have some food intolerances that you didn’t have before surgery.

Sugar Intolerance Some people have cramping, stomach pain, or diarrhea within about 20 minutes of eating foods or drinks that are high in sugar. This is called dumping syndrome. Some people feel weak, hungry, nauseated, anxious, shaky, or sweaty 1 to 2 hours after eating a sugary meal. This is caused by low blood sugar. Dumping syndrome and low blood sugar can be controlled by changing your diet and watching what you eat. Ask your clinical dietitian nutritionist for more information.

Diet and Nutrition During Treatment for Esophageal Cancer 16 Foods and drinks high in sugar include: • Sodas • Cakes • Fruit juices • Honey • Candy • Syrups • Ice cream • Jams

Fat Intolerance Some people have trouble digesting large amounts of fat. Try having small amounts at first, and then increase the amount of fat in your diet slowly. Foods high in fat include: • Butter, margarine, and oils • Gravies • Mayonnaise • Potato chips and corn chips • Creamy salad dressings • Rich desserts • Cream cheese • Fried foods If your bowel movements smell worse than usual or are pale, greasy, or floaty, you may not be digesting fats well. If you have any of these symptoms, talk with your doctor or outpatient clinical dietitian nutritionist. You may need a medication to help you digest fats. This is rare.

Lactose (Dairy) Intolerance Lactose is a type of sugar found in dairy or milk products. Some people have trouble digesting lactose after having an esophagectomy. This is called lactose intolerance. Symptoms of lactose intolerance include gas, bloating, and diarrhea. These symptoms can happen 30 minutes to 2 hours after having dairy products. After surgery, slowly bring dairy products back into your diet. Milk, ice cream, and soft cheeses have high amounts of lactose. Hard cheeses, yogurt, and butter have smaller amounts of lactose. To test your tolerance to dairy foods, start by drinking a 4-ounce (½ cup) serving of milk. • If you don’t have any of the symptoms of lactose intolerance, you can start eating more dairy foods. • If you have any of the symptoms of lactose intolerance, you may still be able to eat foods with smaller amounts of lactose. Pay attention to how you feel after having different dairy products. If you think you may be lactose intolerant: • Try using a product to help you digest dairy products (such as Lactaid® tablets or drops). • Try dairy products that are processed to remove the lactose from them (such as Lactaid milk, cottage cheese, and ice cream). • Ask your clinical dietitian nutritionist for help, if needed. Sometimes, lactose intolerance that develops after surgery goes away with time. You may want to try dairy products again in a couple of months to see if your stomach can handle them.

Diet and Nutrition During Treatment for Esophageal Cancer 17 Gluten Intolerance Gluten is a protein found in , rye, and barley. A very small number of people have trouble digesting gluten after surgery. This is called gluten intolerance. Symptoms of gluten intolerance include pain in your abdomen, bloating, and diarrhea or constipation. These symptoms can also be caused by many other things after an esophagectomy, so you shouldn’t stop eating gluten unless your doctor instructs you to do so.

Tips for Managing Common Problems The following are common problems after an esophagectomy. Keeping a food record and writing down any symptoms or problems you have may help you realize why the problems are happening. You can use the blank daily food and drink log in the “Resources” section. If the tips below don’t help, ask your clinical dietitian nutritionist or doctor for advice.

Tips for Managing Reflux • Sit up straight during meals and for at least 60 minutes after you’re finished. • Wear loose-fitting clothes around your abdomen. • Eat your last meal of the day at least 2 hours before your bedtime. • Have your last drink of the day at least 1 hour before your bedtime. • Always keep the head of your bed at a 30-degree angle or higher. Use a wedge to keep your upper body and head raised up. You can buy a wedge at a surgical supply store or online. • When you bend down, try bending at your knees instead of your waist. • Don’t eat or drink too much at one time.

Tips for Managing Nausea • Avoid foods that are too rich, spicy, or greasy. • Don’t eat or drink too fast. Try putting your fork down between bites. • Don’t have too much to eat or drink at one time. • Don’t lie too flat after meals. Remember that you should be at a 30-degree angle or higher whenever you lie down.

Tips for Managing Fullness • Don’t have too much to eat or drink at one time. • Don’t drink too much during your meals. • Don’t eat or drink too fast. Try putting your fork down between bites. It takes 20 minutes for your brain to realize that you’re full. • If you’re having trouble having 6 smaller meals instead of 3 large meals, make a meal schedule with set times for meals. • If you’re finding yourself going back to the larger portions you had before your surgery, try preparing mini-meals ahead of time so they’re readily available. Diet and Nutrition During Treatment for Esophageal Cancer 18 Tips for Managing Diarrhea • Try eating less sugar, then less dairy, then less fat. Pay attention to see if the diarrhea gets better when you cut back on any of these things. If it does, eat less of those foods. • Try eating foods with soluble fiber, such as canned fruits, bananas, and . • Make sure you’re keeping foods safe at home. − Put leftovers in the refrigerator or freezer right away. − Throw away refrigerated leftovers after 2 days. − Throw away frozen leftovers after 6 months. − Thaw frozen leftovers in the refrigerator or microwave, not on the kitchen counter. Reheat them to safe food temperatures until they’re steaming hot.

Tips for Managing Trouble Swallowing • Choose soft, moist foods. • Chew your foods well. If you try following these tips but are still having trouble swallowing or feel like food is getting stuck in your throat, tell your doctor, nurse, or clinical dietitian nutritionist. You may need to have a procedure to stretch your esophagus (a dilatation) to fix this problem. If you need a dilation, your doctor and nurse will give you more information about what to expect.

Eating at Restaurants and Social Events Food is the focus of many social events. Remember that portions served at events and restaurants tend to be large. It usually takes some time to get used to eating out at restaurants or attending events like weddings and dinner parties. • If you finish an appetizer, you may find that you need to take home your entrée. • If you skip the appetizer, try eating half of the entrée and taking the rest home. You can also share an entrée with a friend. • You may have to choose either a small soup or a drink as your fluid allowance. Or, you can choose to have just a few sips of both. • If you want to have dessert after your meal, you may want to have it as your evening snack, along with a 4-ounce drink, 2 ½ to 3 hours later. Read the “6-Meal Soft Diet Sample Menus” section for examples of how you can plan your meals and snacks.

Diet and Nutrition During Treatment for Esophageal Cancer 19 Resources

MSK Support Services Esophageal Cancer Online Support Group This is a live, online support and education group for people who have had surgery for esophageal cancer. It offers the opportunity for to discuss issues that may arise during and after treatment, to share personal experiences, and to provide practical and emotional support for one another. Discussions are led by a social worker and a nurse. The group meets every other month on the second Monday of the month from 1:00 to 2:00 pm. For more information, or to register, email [email protected]. Integrative Medicine Service 646-888-0800 www.mskcc.org/integrative-medicine Our Integrative Medicine Service offers many services to complement (go along with) traditional medical care, including music therapy, mind/body therapies, dance and movement therapy, yoga, and touch therapy. They also provide counseling on nutrition and dietary supplements. Resources for Life After Cancer (RLAC) Program 646-888-8016 At MSK, care doesn’t end after active treatment. The RLAC Program is for patients and their families who have finished treatment. This program has many services, including seminars, workshops, support groups, counseling on life after treatment, and help with insurance and employment issues.

External Resources Academy of Nutrition and Dietetics (AND) www.eatright.org/public AND is a professional organization for registered dietitians. The website has information about the latest nutrition guidelines and research and can help you find a dietitian in your area. The academy also publishes The Complete Food and Nutrition Guide, which has over 600 pages of food, nutrition, and health information. American Institute for Cancer Research www.aicr.org 800-843-8114 For information on diet and cancer prevention research and education. FDA Center for Food Safety and Applied Nutrition www.fda.gov/AboutFDA/CentersOffices/OfficeofFoods/CFSAN/default.htm For helpful information on food safety.

Diet and Nutrition During Treatment for Esophageal Cancer 20 Clear Liquid Diet A clear liquid diet includes only liquids you can see through. These liquids are easy to swallow and digest. Examples are listed in the table below. While you’re following this diet: • Don’t eat any solid foods. • Don’t drink liquids that you can’t see through. • Drink plenty of liquids besides water, coffee, and tea. • Don’t drink sugar-free liquids unless you have symptoms of dumping syndrome.

Foods and Drinks to Include Foods and Drinks to Avoid Soups • Clear broth, bouillon, or consommé • Any products with pieces of dried food or seasoning Sweets • Gelatin (such as Jell-O®) • All others • Flavored ices • Hard candies (such as Life Savers®), sucked on, not chewed Drinks • Water • Juices with pulp • Clear fruit juices (such as lemonade, • Nectars apple, cranberry, and grape juice) • Milk or cream • Soda* (such as ginger ale, 7-Up®, Sprite®, • Alcoholic drinks and seltzer) • Sports drinks (such as Gatorade®) • Tea • Clear oral nutritional supplements (such as Boost Breeze, Ensure Clear, and Diabetishield®)

*If soda makes you feel full or gives you gas, try letting it sit out until the bubbles go away or avoid it altogether.

Diet and Nutrition During Treatment for Esophageal Cancer 21 Full Liquid Diet A full liquid diet includes all of the things allowed in a clear liquid diet, as well as the foods and drinks below.

Foods and Drinks to Include Foods and Drinks to Avoid Soups • Smooth blenderized soups (such as • Soups with whole food pieces cream of potato, carrot, and broccoli) Dairy • Pudding • Dairy that has fruit, nuts, granola, or • Smooth ice cream whole food pieces • Smooth yogurt (such as plain, vanilla, lemon or coffee flavors) • Milk, Lactaid milk, soy milk, almond milk, and rice milk • Milkshakes Grains • Hot (such as , strained • Grains that have fruit, nuts, granola oatmeal, grits, Cream of Rice®, and or whole food pieces Wheatena®) Nutritional • High-calorie, high-protein nutritional • Supplements with added fruit, nuts, supplements supplements (such as Ensure, Boost, granola, or whole food pieces Carnation Breakfast Essentials drinks, and Boost pudding) Miscellaneous • Mild mustard, ketchup, mayonnaise, • Bubble teas sugar, salt, or a dash of pepper blended • Mustard with seeds into the foods and drinks above

Diet and Nutrition During Treatment for Esophageal Cancer 22 Soft Diet A soft diet includes only foods that are physically soft. The goal of a soft diet is to limit the amount of chewing needed to get food into a smooth, easy-to-swallow texture. Examples of foods and drinks to include in a soft diet are listed in the table below. You can also use the menus in the “6-Meal Soft Diet Sample Menus” section below.

Foods and Drinks to Include Foods and Drinks to Avoid Drinks • Juice • Drinks that aren’t blended smooth • Coffee • Drinks that have seeds • Tea • Bubble teas • Soda • Nutritional supplements (such as Ensure or Glucerna)

Breads • Well-moistened breads, biscuits, • Dry bread, toast, and crackers muffins, pancakes, and waffles. Add • Tortillas enough syrup, jelly, margarine, butter, or • Tough, crusty breads (such as French gravy or dip in a liquid to soften. bread and baguettes) • Breads with dried fruits, nuts, or coconut Cereals • All well-moistened hot or cold cereals • Coarse or dry cereals (such as shredded wheat and All-Bran™) Soups • All soups except those on the avoid list • Soups with tough meats • Corn or clam chowder, if strained • Unstrained corn or clam chowder • Soups that have large chunks of meat or tough, undercooked vegetables Milk and • Milk, buttermilk, eggnog, milkshakes, • Hard cheeses (such as cheddar or Dairy smoothies, evaporated or condensed Swiss ) milk, and malts • Cheeses with seeds or fruit • Yogurt • Yogurt with nuts, seeds, dried fruits • Soft cheeses (such as cottage cheese, or coconut pot cheese, farmer’s cheese, and ricotta cheese ) • Processed cheeses (such as American cheese, cream cheese, and cheese sauces) • Grated and shredded cheeses • Sour cream • Pudding, custard, ice cream, and frozen yogurt • Liquid nutritional supplements (such as Ensure and Carnation Breakfast Essentials)

Diet and Nutrition During Treatment for Esophageal Cancer 23 Foods and Drinks to Include Foods and Drinks to Avoid Meat and • Thin-sliced, tender, or ground meats • Tough, dry meats and poultry Meat and poultry • Large chunks of meat Substitutes • Well-moistened fish • Dry fish or fish with bones • Eggs prepared in any way • Chunky peanut butter • Stews or casseroles with small chunks of meat, ground meat, or tender meat • Tender tofu or tempeh • Smooth nut butters (such as smooth peanut butter) eaten with another moist food or drink Potatoes and • All potatoes and except those • Tough, crisp-fried potatoes Starches on the avoid list • Potato skins • Cooked plain white rice • Dry bread dressing • Mashed or baked potato without skin • Wild rice • Potato salad without celery or onions • Undercooked rice or potatoes Vegetables • All tender cooked vegetables • All raw vegetables except shredded • Shredded lettuce lettuce • Peeled canned tomatoes without seeds • Non-tender or rubbery cooked • Vegetable juices vegetables • Fried vegetables • Corn • Peas Fruits • All canned and cooked fruits • Fresh fruits that are hard to chew • Soft, peeled fresh fruits (such as peaches, (such as apples and pears) nectarines, kiwi, cantaloupe, honeydew, • Stringy, high-pulp fruits (such as and seedless watermelon) papaya, pineapple, and mango) • Soft berries with small seeds (such as • Fresh fruits peels that are hard to strawberries) chew (such as grapes) • Avocados • Uncooked dried fruits (such as prunes, apricots, and raisins) • Fruit leather, fruit roll-ups, fruit snacks, and dried fruits Desserts • All desserts except those on the avoid list • Dry or chewy cakes and cookies • Desserts with nuts, seeds, dried fruits, coconut, or pineapple Oils • Olive, canola, and other vegetable oils • Spreads with nuts, dried fruits, or • Margarines and spreads pineapple • Salad dressings • Mayonnaise • Butter • Gravy and sauces Miscellaneous • All mild seasonings and sauces • Nuts, seeds, coconut, and dried fruits • Non-chewy candies without nuts, seeds, • Chewy caramel or taffy-type candies and coconut • Spicy or peppery seasonings or • Jams, jellies, preserves, honey, and other sauces sweeteners

Diet and Nutrition During Treatment for Esophageal Cancer 24 6-Meal Soft Diet Sample Menus The sample menus on the following pages show a soft diet in 6 small meals. They include 4 ounces of liquid with each meal (to keep you from feeling too full during meals) and 8 ounces of liquid between meals (to keep you well-hydrated). Keep in mind that soup also counts as a liquid. • Not all of the menu items are sugar-free. If you have diabetes, high blood sugar, or are having dumping syndrome: − Use sugar-free or “light” yogurt in place of regular yogurt. − Limit fruit juices. − If you drink fruit juices, dilute them with water. • Menu items with an asterisk (*) have lactose. If you’re lactose-intolerant: − Try Lactaid milk, cottage cheese, or ice cream. − Take Lactaid tablets or drops before having dairy products. − Choose almond milk, rice milk, or soy milk and non-dairy cheeses. 6-Meal Soft Diet Sample Menu 1

Time Meal Foods and Liquids 7:30 am Breakfast • ¾ cup of corn flakes softened in ½ cup of whole milk* • ½ of a banana 9:00 am Drink • ½ cup of juice mixed with ½ cup of water 10:00 am Snack • ½ cup of cottage cheese* • ½ cup of canned fruit 11:30 am Drink • 1 cup of whole milk* 12:30 pm Lunch • ½ cup of chicken soup • ½ of a tuna salad sandwich on untoasted bread with extra mayonnaise as needed to moisten 2:00 pm Drink • 1 cup of tomato juice 3:00 pm Snack • Fruit yogurt* • ½ cup of cranberry juice 4:30 pm Drink • ½ cup of apple juice mixed with ½ cup of water 5:30 pm Dinner • 2 ounces of baked chicken • 1 small baked potato (without the skin) with sour cream* • ½ cup of cooked carrots • ½ cup of almond milk 7:00 pm Drink • 1 cup of water 8:00 pm Snack • 1 ounce of American cheese* • 1 slice of bread • Mayonnaise • ½ cup of apple juice 9:30 pm Drink • ½ cup of cran-apple juice with ½ cup of water

Diet and Nutrition During Treatment for Esophageal Cancer 25 6-Meal Soft Diet Sample Menu 2

Time Meal Foods and Liquids 7:30 am Breakfast • 1 scrambled egg • 1 slice of untoasted bread with 1 teaspoon of margarine or butter* • ½ cup of orange juice 9:00 am Drink • 1 cup of tomato juice 10:00 am Snack • 1 tablespoon of smooth peanut butter • ½ soft roll • ½ cup of whole milk* 11:30 am Drink • ½ cup of juice mixed with ½ cup of water 12:30 pm Lunch • ½ of an egg salad sandwich on untoasted bread with extra mayonnaise as needed to moisten • ½ cup of milk* 2:00 pm Drink • 1 cup of broth 3:00 pm Snack • 2 tablespoons of hummus • ½ soft roll • ½ cup of pineapple juice 4:30 pm Drink • ½ cup of fruit punch mixed with ½ cup of water 5:30 pm Dinner • 2 ounces of baked fish • ½ cup of mashed potatoes • ½ cup of cooked green beans with 2 teaspoons of margarine or butter • ½ cup of apple juice 7:00 pm Drink • 1 cup of water 8:00 pm Snack • ¼ cup of cottage cheese* • 1 slice of bread • ½ cup of cranberry juice 9:30 pm Drink • ½ cup of mixed berry juice with ½ cup of water

Diet and Nutrition During Treatment for Esophageal Cancer 26 6-Meal Soft Diet Sample Menu 3

Time Meal Foods and Liquids 7:30 am Breakfast • 1 egg omelet with 1 ounce of cheese and 1 slice of chopped ham • ½ cup of orange juice 9:00 am Drink • 1 cup of water 10:00 am Snack • 1 cheese blintz with 1 teaspoon of margarine or butter* • ½ cup of apricot nectar 11:30 am Drink • ½ cup of grape juice mixed with ½ cup of water 12:30 pm Lunch • 2 ounces of ground beef or turkey • 1 ounce of American cheese* • ½ cup of mashed potatoes made with milk* and margarine or butter* • ½ cup of whole milk* 2:00 pm Drink • ½ cup of cranberry juice mixed with ½ cup of water 3:00 pm Snack • 1 scoop of whey protein powder mixed with 1 cup of whole milk*, ½ of a banana, and 1 tablespoon of smooth peanut butter 4:30 pm Drink • ½ cup of grape juice mixed with ½ cup of water 5:30 pm Dinner • 1 slice of ham and cheese* quiche without crust • ½ cup of apple juice 7:00 pm Drink • ½ cup of guava nectar mixed with ½ cup of water 8:00 pm Snack • ½ cup of premium ice cream* with ½ cup of whole milk* 9:30 pm Drink • 1 cup of water

Diet and Nutrition During Treatment for Esophageal Cancer 27 6-Meal Soft Diet Sample Menu 4

Time Meal Foods and Liquids 7:30 am Breakfast • ½ of an untoasted English muffin topped with 2 tablespoons of smooth peanut butter and 2 teaspoons of honey • ½ cup of whole milk* 9:00 am Drink • 1 cup of water 10:00 am Snack • 6 ounces of full-fat Greek yogurt* • ½ of a banana or canned fruit • 1 tablespoon of ground flax seed or ground almonds 11:30 am Drink • ½ cup of apple juice mixed with ½ cup of water 12:30 pm Lunch • 1 cup of tuna casserole made with ½ cup of canned tuna, ¼ cup condensed cream of mushroom soup*, 1 teaspoon of margarine or butter*, ½ cup of egg noodles, and a splash of milk* • ½ cup of apple juice 2:00 pm Drink • ½ cup of cherry juice mixed with ½ cup of water 3:00 pm Snack • ½ mashed avocado rolled in 2 ounces of thin sliced turkey breast • ½ cup of pear nectar 4:30 pm Drink • ½ cup of peach nectar mixed with ½ cup of water 5:30 pm Dinner • 2 ounce slice of meatloaf • ½ cup of sweet potato baked with 2 teaspoons of coconut oil • ½ cup of creamed * • ½ cup of grape juice 7:00 pm Drink • 1 cup of whole milk* 8:00 pm Snack • ½ cup of vanilla pudding* topped with ½ of a sliced banana and whipped cream* 9:30 pm Drink • 1 cup of water

Diet and Nutrition During Treatment for Esophageal Cancer 28 Daily Food and Drink Log

Time Portion Size Description Calories Symptoms?

Total:

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