Episode 2 – Taste Alterations in Cancer, Wendy Wismer

00:00:11 --> 00:01:27 Bethany Hello and welcome to Clinical Nutrition Notes, a podcast where we speak with guest experts and opinion leaders about the art and science of clinical nutrition brought to you by Nestlé Health Science, Canada. This podcast is intended for health care professionals for education purposes.

I’m your host Bethany Hopkins, Medical Affairs Manager, with Nestlé Health Science.

Today we will be talking with Dr. Wendy Wismer about taste changes in cancer. Wendy Wismer PhD. is an Associate Professor in the department of Agricultural, Food and Nutritional Science, at the University of Alberta. She’s a food scientist with experience and expertise in sensory and consumer science. Wendy’s research program characterizes taste and smell alterations among people with cancer and their impact on food choice, nutritional status, quality of life and clinical outcomes. Dr. Wismer is passionate about improving the food related quality of life of patients with cancer through pragmatic interventions and support tailored to their unique taste and smell preferences.

Thank you for joining us today Wendy, to talk about this important sensory phenomena and the implications clinicians may consider when working with people who have cancer.

00:01:28 --> 00:01:30 Wendy Thank you Bethany, it’s a pleasure to join you.

00:01:33 --> 00:01:42 Bethany So Wendy to begin, can you briefly describe what taste alterations are experienced by people with cancer and what is known about why these taste changes happen.

00:01:42 --> 00:04:17 Wendy Sure, I think most people are quite surprised to learn that the changes in taste experienced by people with cancer are really unique to the individual. I think we often have an idea that it would be like the age-related reduction in taste and smell perception that we find among seniors. You know if you are thinking about music as an analogy it’s like turning the volume right down. But in actual fact for people with cancer, you know, some of the basic tastes might be reduced in that way. But they might also be absent, or they might be even stronger, or they could be completely altered so a different taste or smell could be perceived - and that combination is really different for each individual.

So you had asked about why they happen. You know there are a variety of hypotheses. There’s nothing that is conclusively linked as the cause to these taste alterations. But it’s essentially any of the treatments that are designed to destroy rapidly dividing cells which are cancer cells but also taste bud cells and olfactory neurons. So our taste buds and our olfactory neurons do rejuvenate every ten to fourteen days. So they are also destroyed with the therapy - and some of the chemotherapies particularly the taxane-based therapies are notorious for causing taste alterations. And then, of course, radiation therapy that’s designed to destroy those cancer cells can impact the salivary glands and destroy taste buds and then additionally surgeries for head and neck cancer can actually just simply physically remove taste buds and may alter the nasal passages and the olfactory pathways. So there are a variety of ramifications of the cancer treatment. And then additionally, it is suggested that inflammation is probably a cause of taste alterations and in fact that might be something that occurs very early on for the patient because we do find that there are some patients who come to treatment with taste alterations and they will tell you that that’s one of the reasons they knew that something was not right in their body - were these taste alterations.

00:04:18 --> 00:04:52 Bethany It is interesting as you were talking through that I was thinking for people with head and neck cancer, it sort of makes intuitive sense that they would experience taste and smell changes related to treatment and so on in the area that’s affected by their tumour - and although you did say other systemic treatments can cause taste and smell changes as well, Wendy. This is a phenomena that’s not unique to only head and neck cancer patients is it? It is for people with a wide variety of malignancies … whomay experience changes. Is that correct?

00:04:53 --> 00:05:02 Wendy Yes, absolutely, so no matter what the tumour type, really any treatment is going to generate taste and smell alterations.

00:5:03 --> 00:05:22 Bethany And you mentioned that for some people when they are diagnosed and before treatment begins, they may have these changes related to inflammation and other things that are happening - and how long do these changes normally persist when we think about courses of treatment and what happens along people’s cancer journey?

00:05:23--> 00:06:13 Wendy You know that is something else that is really unique to the individual. So we have people entering treatment with taste alterations and sometimes people will say that’s how they knew that something wasn’t quite right with their body and that eventually lead to the cancer diagnosis. But I think most frequently we see the taste alterations develop around the mid-point of therapy when we’ve had a couple of cycles of chemotherapy or a few rounds of radiation and then they seem to be quite intense until the end of therapy, after which for some people there’s a fairly rapid recovery, while for others they never feel that they gained their normal sense of taste and smell back. Again, it is a real individual journey.

00:06:14 --> 00:06:26 Bethany So much variability. Wendy, thinking about these taste and smell changes that are happening, what are some of the implications they have then, for people with cancer?

00:06:27 --> 00:08:41 Wendy You know the impacts can be quite intense in part because when taste and smell alterations occur, they are part of a whole suite of symptoms such as nausea, the early satiety, diarrhea, fatigue - and altogether they really impact food intake and the enjoyment of food. So, you have these alterations going on that are changing the taste of food and generally making it fairly unpleasant, and you have a whole lot of symptoms and the treatment, so it is more difficult to think about food choice and taking in food. So you have those two things that really are working against food intake, and so as a result clinically we see lower energy intake and lower protein intake to the point really where it is inadequate - decrease variety in food and so that reduces the diversity of micronutrients that an individual is taking in - so from the nutrition perspective it is really negative and there often is inadequate intake of calories to really tolerate treatment and then that results in poor progress or prognosis overall. So really not positive, just from that clinical nutrition standpoint. But then there is also food enjoyment and quality of life and the social benefits of food and that also really declines. Family and caregivers want to provide the patient with their favourite food and keep them strong and keep them healthy, but for the patient, because of these taste alterations, they often don’t enjoy their old favourite food - because it doesn’t taste like it should. So, sharing a meal and going to a buffet or a birthday party or something is not something that is enjoyable at all. So, it’s really overall a very negative experience.

00:08:42 --> 00:09:07 Bethany It is interesting isn’t it when you think about the role that food plays in our lives, it’s so much more than just sustenance isn’t it? That’s obviously very important particularly for someone who is going through cancer treatment -but then the whole pleasure of eating, the social aspects of eating can have a profound effect on people and, as you mentioned, their families and those that are close to them.

00:09:07 --> 00:09:08 Wendy Yes, exactly.

00:09:09 --> 00:09:20 Bethany So, thinking about some of these impacts that you discussed, what kinds of interventions or management strategies have been suggested that might help manage taste alterations?

00:09:21 --> 00:12:51 Wendy You know there are some sort of traditional ones I can tell you about and then a couple of advances that I have noted. So, I think typically we see things like tip sheets that are available from almost any clinic and there’s a lot of really good sort of tip sheet advice that is available online and there is some really great tried and true ideas but it is maybe a bit of a challenge for the patient to work through them and find those that fit best. I think we increasingly see support groups associated with different clinics, and that can be really helpful to have that first-hand experience and share ideas and insights among individuals who maybe share the same tumour experience, or maybe the geographic area and the support that’s available. And another one, I think, is really key is letting people know ahead of time what the taste change experience might be like or to be prepared for them and just know that a lot of the foods that you find comforting right now may be a lot less desirable over time. One of the recent advances I see in that area really takes off from that idea. There have been a few studies where taste alterations have been assessed either with tasting solutions and/or questionnaires, and then giving feedback to the patient so that they know in what way their taste and smell has changed. So the patient experience to start out with is “Ugh, you know, this is not good, I don’t like it, things don’t taste great, I can’t rely on my favourite food anymore. And then, when you go through the tip sheets and things like that, they are very specific…if you perceive a metallic taste, if things are too salty if they are too sweet... And for the patient they may not be there yet, they just don’t know what it is that’s changed, but they do experience the change. So, if we can do this basic sensory assessment either through those solutions or questionnaires and provide that feedback for the patient, then they may be able to take better action and use those tip sheets type of thing - or just know the way that things have changed and modify foods accordingly. So, by analogy the example I was thinking of, would be someone who normally consumes a regular coffee as a ‘double double’, two cream and two sugar - and if it turns out they have reduced bitter perception and heightened sweet perception that coffee is not going to taste great. So, when you put those together it would probably taste quite weak - and it would be too sweet. So, if the patient knew that their bitter perception was reduced and their sweetness perception was enhanced and then maybe, with a little support, they would then choose a coffee that had a stronger flavour like a dark roast, or something like that and not go for the ‘double double’, maybe they would just have the cream and cut out the sugar. So, I think there are things that we can do to modify the taste of foods for patients that are going to better align with those taste alternations. So, I think that’s a real avenue for support there.

00:12:52 --> 00:13:41 Bethany I think, as with so many things in cancer treatment and life in general, if we have an idea of what to expect, it can make a difference for people so that they understand, okay this is normal what I am going through and then help them to be able to differentiate and understand exactly what those alterations they are experiencing - so then they know what corrective action they may be able to take. Are we seeing, Wendy, from some of this newer research that this is having an impact on patient outcomes? Is it moving people in a slightly different direction in terms of what they’re able to eat and drink and achieve from nutritional or quality of life perspective?

00:13:43 --> 00:15:02 Wendy You know the few studies I have seen in this area have been very positive in that regard. So, we mentioned previously so that there is the food intake with the nutrients and then you can layer onto that the social enjoyment of the food. And providing that specific information about the way tastes have changed for a patient, does seem to be a really very positive thing. It does seem to allow more control, greater food intake, greater support from family and caregivers and more enjoyment of food. So, it is a real sort of spiral up kind of phenomena - and it’s certainly is something that I think it would be valuable to explore more widely. I think one of the challenges too as an individual we don’t really know much about our sense of smell and the taste. So, we have probably heard of sweet, sour and bitter - but if you were to evaluate some solutions and I asked you which one was which, that could be a little more challenging. So, with a little bit of education about taste and smell in general, I think we can really empower patients to manage the taste and smell alterations.

00:15:03 --> 00:15:29 Bethany It is an exciting possibility and something that could be quite practical for people and make a difference. Thinking about that Wendy, how this is evolving, what else do you see in term of what is happening in the field of taste and smell alterations? How our understanding is changing and then, what might be on the horizon for this field?

00:15:30 --> 00:18:16 Wendy You know, I see a couple of things, so one would be that there’s greater examination of the genetics of taste and smell alterations and it’s possible that individuals who have certain genes switched on for taste, so maybe a super taster, which is someone with a generally heightened sense of taste, you know, maybe those are the individuals who experience taste alterations as most bothersome and most troublesome. So, people who are super tasters often with this heightened sense of taste, are more likely to be foodies and so they would be more negatively impacted by not being able to enjoy their favourite foods, or by having the flavour of foods, you know, sort of off. So that would be another thing that would be quite important to know, is if you could have some idea ahead of time, who might be most negatively impacted, can we start supporting you right away? And then the other area I see where there are some really great advances are in developing food products for patients. So, providing the nutrients that are needed in the cancer setting – so more protein, omega-3’s, things like that. Also choosing flavours that are novel and different and are going to be more accepted. So, we have traditionally stuck with chocolate, strawberry and vanilla - which gets a bit tiresome, but I noticed that there are a lot more, sort of, peach, mango, maybe softer fruit flavours or something like that, and then I think the other thing with those flavours is that we don’t, they are not so common and so we don’t have so many expectations about them. So chocolate, for us is ubiquitous, and we have in our mind a real expectation of what chocolate should taste like. So, when you have your liquid oral supplement and it is chocolate - it might not be the chocolate that you want - but if I gave you raspberry/vanilla or something like that, you might not have any expectations about that - or peach/mango - and so you are a lot more likely to be satisfied because you didn’t have this rigid standard of what you were expecting. So there is that, and I also see more snacks and beverages that are more traditional but with those added nutrients, portable, convenient, etc. for patients with cancer.

00:18:17--> 00:20:30 Bethany Yes, it is an area that has been certainly evolving, I can certainly speak from a food production perspective, we are seeing that. And it is interesting Wendy, when I used to work as a clinician in oncology I would often try to get a sense of what people’s relationship with food was like and at that time, I didn’t necessarily think of people as foodies but I definitely saw what you are talking about - that people that had this real interest in food and the pleasure in eating all the sort of tactile different aspects of eating, they did have a harder time, generally speaking when that changed. I really like and appreciate that idea of expectations because it’s so true, we have all grown up eating and drinking and we have certain ideas of what things taste like or should taste like. So, introducing a different flavour or combination of flavours, that’s an approach that for some people, like you said, they may not have the expectations about what that tastes like and so it becomes more acceptable. I hadn’t really thought of it quite that way before, so that’s really interesting.

I want to thank you Wendy, for taking your time today to provide us with a better understanding of taste alterations and the implications that they can have in cancer care and as you have talked about these sensory changes are common among cancer patients and they really can interfere with, not only appropriate and adequate delivery of nutrition - but also that aspect that is really important in terms of quality of life and the social aspects of eating -and it is nice to hear that some simple strategies and even just starting with discussing what to expect with people can have a positive impact on outcomes. And I think it is something that can be doable in a clinical environment. So, before we sign off, I do want to take a minute to ask you one last question so our listeners can get to know you a little bit better. Can you tell us how you first became interested in the field of nutrition?

00:20:31 --> 00:21:27 Wendy Sure, so I have always been interested in food, all my life and I think sort of healthy living and I didn’t pay a lot of attention to nutrition until I studied taste and smell, particularly as a motivation for food choice. So, when I was growing up, we had always been told eat to Canada’s Food Guide and I always tended to think of that as a huge factor of food choice. You know you should choose what is healthy and then, of course, what is available - maybe what is appropriate for the situation, that kind of thing. But I didn’t really think about the impact of taste as a driver of food - and now that that area is growing, this nutrition sensation area, I have become a lot more interested in nutrition.

00:21:29 --> 00:21:59 Bethany There is so much to be said for if things are enjoyable. I think, one of the things that we sometimes hear is that if something is healthy, it doesn’t taste good. There are all these different ideas or perceptions, in some cases, misperceptions around food and nutrition and taste. But they are so intimately connected and ultimately most people do want food to be … and eating and drinking to be a pleasurable experience.

00:22:00 --> 00:22:01 Wendy Yes, absolutely.

00:22:01 --> 00:22:20 Bethany So on that note we will conclude this podcast . I want to thank you, again, Wendy for joining us, and thank all our listeners.

This concludes our episode of the Clinical Nutrition Notes podcast. For more podcast episodes, visit Clinical Nutrition Notes at NestleHealthScience.ca.