Dietary Recommendations in Post-Gastrectomy Adjuvant Treatment

It is recommended to consume about 1.5 litres of liquid per day, but because that is not always easy, it is preferable to try to reach the maximum that each person can tolerate.

In many cases, water alone is not well tolerated, so other liquids should be drunk, such as broth, diluted juice or diluted vegetable and fruit smoothies.

It is advisable to always drink outside of meals and in small amounts and sips, and not to drink within 30 to 60 minutes before or after meals.

Ice creams and jellies can also be a good way to help hydrate, and a good choice for when taste is altered.

Sometimes carbonated beverages can lower the sensation of nausea (sparkling water, cola or ginger ale, etc.), although it will depend on each person’s tolerance and the evolution of rapid gastric emptying (dumping syndrome).

It is important to eat more meals per day to ingest different foods and a higher proportion of nutrients. Thus, at a minimum, the feeding should be divided into breakfast, mid-morning snack, lunch, afternoon snack, dinner and after-dinner snack. In some cases, even more small meals eaten every two hours may be needed.

Even if you have no appetite, it is essential to think about the need to eat. How much you eat in a single meal matters less than the total you have managed to eat by the end of the day, so it is important to set small goals that can be met throughout the day.

It is advisable to avoid prolonged fasting, so ideally you should have a snack before bedtime in order to reduce the fasting time.

It is essential to chew food very well and mash it into a purée before swallowing.

Fruits, dairy, starchy foods (cereals, tubers, legumes*, etc.), protein-rich foods (eggs, fish, meat, tofu, tempeh, seitan, textured protein) and healthy fats (virgin olive oil, nuts**), depending on tolerance.

Incorporate vegetables, in small amounts at first, since they are very filling and provide few calories.

*Legumes should be incorporated in puréed form (creams, purées, etc.) or mashed with a fork to facilitate digestion.

** Nuts should be incorporated ground or crushed.

It is common for a liquid diet to be eaten during the hospital stay and then to progress to a puréed diet when patient goes home. There, a diet with soft-textured foods can be started, which can be mashed if they are not tolerated in solid form. The type of food and textures needed may progress day by day, according to the specifications of the medical team.

Even in small amounts, always ensure the presence of starchy, protein-rich foods, vegetables in small amounts and fruit, as indicated in the plate method at lunch and dinner. A dessert dish can be used as the basis for a main course, a first or second course or a tapas-style meal.

Keep in mind that vegetables provide few calories, so it is important to consume them in small amounts, and always well-seasoned and/or accompanied by more nutritious foods.

White rice, pasta, potato, carrot, toast, oatmeal or legumes.
Please note the following instructions:

• Eat legumes in the form of purée.
• Eat toast, which usually sits better.
• Eat pasta and rice well cooked, not al dente.
• Avoid wholegrain or wholemeal versions (brown rice, wholegrain pasta, wholegrain bread, etc.).
• In case of nausea and vomiting, dry foods are usually better tolerated: toast, breadsticks, rice or corn cakes, crackers, etc.
• To increase calorie and nutrient intake, pasta, rice and potatoes should always be accompanied with a good splash of virgin olive oil, sauces, cheese, individually-wrapped cheese, minced meat, shredded chicken, tuna, etc.

Meat, fish, seafood, eggs and soy are the highest quality protein-rich foods. At least the main meals should contain these proteins: at lunch and dinner, such as any dish containing white fish, seafood, meat (mainly lean), eggs, soy or soy by-products (tofu, texturised soy, etc.), depending on tolerance. Other foods that are also a good source of protein, such as dairy products, should be included in other meals, depending on tolerance.

Examples of protein-rich foods:

Avoid very tough or fibrous meats, as they tend to be unpalatable and require more effort. Meat-based dishes, such as hamburgers, meatballs or mild stews, are a good option.

Meat and fish puddings or cakes are also a good alternative, due to their soft texture, as are egg dishes.

In the case of taste alterations, it is important to prepare dishes that help to mask the taste, combined with other foods to ensure sufficient protein intake.

Accompanying meat or fish with sauces will help to increase the dish’s caloric value.

People who follow an exclusively plant-based diet, with very little or no animal-based food (vegan, strict vegetarian, etc.), should check with their referring dietician-nutritionist to study how to adequately cover the proteins, vitamins and minerals that the organism needs to deal with the whole oncological process.

Prioritise mild and low-fat cooking, such as boiled, microwaved, en papillote or very mild stews.

Avoid spicy and irritating condiments.

In the case of nausea:

• Avoid cooking that generates more fumes and odours, such as fried, sautéed or grilled foods. Fried foods not only give off a stronger odour that can be annoying but are also more difficult to digest and may cause more nausea.
• If odours are bothersome, avoid cabbage and cauliflower and cook in a way that generates little smoke and odours, such as en papillote and microwaved, boiled or marinated foods. Avoid foods that are fried or grilled at high temperature.

In general, dishes are best tolerated at room temperature (neither too cold nor too hot).

In the case of nausea, cold dishes are better tolerated because they give off less odour than hot ones: pasta salads, sandwiches, cold soups, home-made ice cream, etc.

Dairy products are a good source of protein and other nutrients. They are easy to eat and combine with many other ingredients, so it is advisable to incorporate protein-rich natural yoghurt, cottage cheese, fresh cheese and soft cheese into the diet (with or without lactose, depending on tolerance and progression).

Assess tolerance to other dairy products (yoghurt with fruit, custard, flan, mousse, etc.), according to the progression of the dumping syndrome.

It is important to eat two or three pieces of fruit a day.
If raw fruit is tolerated, include small amounts (without skin and seeds) of apples, grapes, pears, bananas, peaches and watermelon, in pieces, mashed or blended.

If not, consume the fruit cooked or in a compote.

If the digestive function after gastrectomy has already gone back to normal, tolerance to acidic fruits (pineapples, oranges, grapefruits, tangerines, strawberries) can also be tested.

Prepare fruit-based smoothies with other ingredients, such as dairy, nuts or biscuits to increase calories and protein.

Do not eat too many loquats, plums with skin, raisins, pineapple, persimmons, oranges and tangerines.

Nutrient-dense dishes include a large amount of calories and nutrients within a very small volume of food.

• Prepared chicken or cod croquettes, or frozen empanadas (meat, tuna, egg, cheese, etc.) can be fried or reheated on the spot. You can also have nutritious legume pâtés to spread on toast or sandwiches; calorie-filled soups, which can be kept in the refrigerator and eaten directly (hot or cold); and sweet dishes to be eaten as dessert or between meals, such as flan, pudding or Greek-style or protein-rich yoghurt.

• Prepare complete protein-rich shakes with fresh fruit, dairy or plant-based milk, nuts, dried fruit, biscuits, legumes, eggs, etc.

• Enrich dishes with high-calorie and/or high-protein foods to increase their nutritional density. The following table has enrichment ideas.

Have foods accessible for snacking; if left in the field of vision, they may be consumed more frequently: grapes, bananas, apples, breadsticks, toast, Maria-style biscuits, puffed rice flakes, yoghurt (plain, Greek, high protein – with more than 15 g of protein per container, such as Yopro ®, Hacendado ®, Pastoret ®, Skyr ®, etc.) or individually-wrapped cheese.

Mucositis is the inflammation of the mucosa of the mouth and/or throat and the appearance of sores as a consequence of lower defences caused by chemotherapy. It may cause pain and discomfort when eating. If these sores appear, avoid all foods and beverages that may irritate the mucosa:

• Foods that are dry or have a strong consistency (crusty bread, toast, biscotti, breadsticks, nuts, dry crackers, crisps, dry or aged cheese, fibrous or dry meat, raw vegetables and breading or gratin-style cooking).
• Gummy or sticky foods: sliced bread, pre-cooked baguettes, pizza dough, thick mashed potatoes, croquettes, bananas, chocolate, etc.
• Alcoholic beverages, coffee, carbonated beverages and other acidic or irritating soft drinks (cola drinks).
• Acidic foods (tomatoes, raw bell pepper, kiwis, lemons, oranges, strawberries, tangerines, mangos, pineapples, vinegar, pickled foods, etc.).
• Highly seasoned, spicy or salty foods.

In some cases, the texture of food may have to be adapted according to the severity of the mucositis.

• When it is mild, preferably eat foods with a soft texture (stew, soup, creamy dishes, flan, fresh or very soft cheese, ripe and sweet fruit, pasta and rice, fish and very tender meat). Cook foods until they are soft and accompany them with sauce, broth or au jus, especially the driest ones, to make them easier to swallow. Cut the ingredients into very small pieces and chew them slowly. Soft-textured foods such as puddings, omelettes or meat or fish cakes are also good choices.
• When the mucositis is severe, you may have to mash dishes and solid foods to achieve a texture that is easy to swallow.

It may also help to numb the mouth before meals with crushed ice, very cold water, frozen jellies, popsicles or ice cream to reduce pain.

These can sometimes be useful because they require less digestion and can also help to eat more when fatigue sets in.

Tiredness and a lack of drive engage in tasks and activities is called asthaenia, which is related to cancer or treatment. It is an overwhelming and persistent feeling of tiredness or exhaustion, which diminishes or prevents the capacity for mental or physical work with daily activity.

When a balanced and varied diet is difficult to achieve, it is important not to be anxious about it. It is essential to eat to ensure that you ingest at least part of the calories and nutrients needed.

For more information on ideas to help you cope with eating during these days, see the following section: ‘Tiredness or extreme fatigue’.

• Avoid drinking one hour before or after meals.
• Lie down for about 30 minutes after meals (if you have acid reflux, recline without lying prone).
• Avoid alcoholic beverages, caffeinated beverages (coffee, stimulating soft drinks) and tea, because they increase the speed of gastric emptying.
• Avoid eating foods with simple sugars:
  • Do not add sugar (white or brown sugar, honey, agave, syrup, etc.) to dishes.
  • Avoid foods containing simple sugars (white or brown sugar, honey, agave, syrup), such as commercial juices, soft drinks, cakes or pastries, commercial sauces, sweetened yoghurt or dairy desserts (flan, custard, mousse, ice cream, etc.).
  • Limit the intake of natural fruit juices.