Monday, November 22, 2010
Monday, May 24, 2010
Taste and Smell in Cancer
The following content is intended
as a scientific explanation of the
breakdown in taste and smell.
Material contains facial photography
of sensitive, even described by
some as graphic, illustration
seen in chemotherapy and radiation
Viewer discretion is advised.
Luis F. Pineda, M.D., M.S.H.A.
Taste and Smell in Cancer:
With the aging process and prolongation of life, cancer is, and will
continue to be, a major health issue. One of many, not the least important, yet critical problems, is the ability of patients with cancer to support normal nutrition.
Basic assumptions are that cancer, a state of abnormal cellular behavior, imposes a catabolic state on the individual.
Documented further by recent technological development of the PET scan, we are able to obtain images of cancer cell locations on the basis of the incorporation of radioactively labeled glucose as the result of their hyperactive metabolism. If the individual is unable to keep up to the demand on the basis of incorporation or intake of nutrients, then malnutrition and weight loss ensues. There is a possible participation of endogenously released cytokines such as Interleukins or a tumor necrosis factor.
Additionally, the cancer treatment modalities of today are causes of substantial changes to taste, smell, and appetite by either psychological trauma, neurochemical changes or inflammatory cytolytic damage to the mouth, nose, or gastrointestinal tract. Things are further worsened by cancer therapy complications, including infection, nausea, and vomiting.
Palliative modalities of pain control, use of narcotic pain medications such as codeine, morphine and analogs, which directly affect the central nervous system (limbic system), affect the function of the gastrointestinal tract causing severe constipation, nausea and vomiting. Most culinary literature available addresses these issues by attempting to minimize the smell of preparation, the temperature, and color. By this, I mean, historically it was recommended to consume white, cold, and non smelly foods versus hot, red, and smelly foods. By garnishing and coloring the food we can now impact the taste and intake and create appeal.
Most nutritional literature available addresses these issues by the
drastic use of involuntary nutrition such as total parenteral nutrition or
TPN, tube feeding via gastrointestinal infusion through nasogastric or
percutaneous endoscopicly placed gastric tube (PEG). All of these are
unappealing and excessively expensive interventions. The use of high
calorie oral supplements such as puddings, bars, and boosters have
failed despite their easy availability. This failure is due to patient
intolerance, mostly because of the high carbohydrate content, which
makes the products excessively sweet.
Appetite stimulants such as Marinol® (tetrahydrocannabinol) or Megace® (megastrol) have the disadvantage of causing mental status changes and sedation. They are exceedingly expensive, or in the case of Megace, there is an inability to use it in cases of hormone dependent cancers (ex. prostate cancer - a very common cancer in adult males). There is also the potential for abnormal blood clotting which is already heightened in cancer.
The management of cancer induced taste alteration should be aimed at maintaining optimal nutrition (Brodie 1998), but above all, quality of life.
Flavor is a complex mixture of sensory inputs (Smith 2001). Its
components are gustation (taste), olfaction (smell, perhaps more
important than credited), and tactile (mechanics of chewing).
Traditionally described qualities of taste are sourness, sweetness,
bitterness, and saltiness. Some others may exist, notably Umami,
(Japanese translation “delicious”). This is most elicited by glutamate,
an enhancer of taste commercially available as monosodium
glutamate or MSG. In 1908, Ikeda from Japan, recognized it as the
tasting chemical component of the brown algae soup Kombu.
This Umami concept was developed by Chaudhari and Roper from
the University of Miami in 1998. Loosely implying a “meaty” taste, this
concept is still not widely accepted.
Most recent research has documented Umami receptors mediated via mGluR4 glutamate receptor, as well as mT2R8 denatonium receptors located in the mouth, glutamate related and cyclic AMP conducted via calcium channels. Sodium glutamate is a food enhancer that is very similar in taste to common cooking salt and definitely enhances the pleasantness of food by at least 50% or better at appropriate culinary levels (Yamaguchi, 1984). The main concern has been the flatulence and abdominal discomfort sometimes associated with it. It is blamed for obesity in oriental people and occasionally allergic reactions. Nonetheless, the significantly lesser amount of Sodium content when compared with regular cooking salt (65% less) has a potentially significant
impact in hypertension management and can be a great benefit.
For years it was believed the tongue was the source of taste receptors, all selectively located by geography and specificity (i.e. sweetness located at the tip or sourness to the side).
The fact is that all the mouth, not only the tongue, possesses
72 receptors that are capable of responding to different stimuli regardless
of the quality and nature. An example is the following salt receptor
diagram. It highlights the importance of the electrolyte channels and
the electrical nature of the transmission.
Recent studies have described more specific receptors for tasting
sensations and further research continues.
Taste buds, receptors and conductors will respond to a sensation
in particular, but to all sensations to a certain degree. So, the receptor
for sweet will respond to mostly sweet taste, but to bitter, sour, and salty to a lesser degree (Wickham 1999). The locations of the receptors are the tongue, soft palate, glossopalatine arch, and the posterior portion of the pharynx. Most taste receptors are located on the tongue. They are located within the papillae projection giving the tongue its velvety appearance. Several geographical areas on the tongue are identified. As shown, the tip is rich in mushroom like taste buds. The taste buds on the back of the tongue are flat circumvallates distributed in an inverted V. The taste buds on the lateral portion of the tongue are foliates. The filiform lack tasting receptors, yet provide tactile sensations. The concept of the geographic tongue (sweet, hot, salty) is no longer sustainable as each receptor is capable of reacting to more than one kind of stimuli 73
at a time. They are not unique to a given taste, nor are they
geographically distributed as previously thought.
The taste buds contain about 50 to 100 taste cells. They are
arranged in an onion shaped fashion with small microvilli poking
through the opening at the top (taste pore).
The vehicle for taste is the saliva (Schiffman 1994). Tastants, or
food chemicals dissolved in saliva, contact the receptors via the pore,
activating the chemical G-protein (gustducin and transducin)
receptors (ion channels) that transform into electrical impulses that
are then sent to the brain.
The process of depolarization activates the receptors. The inside
and outside of the cells are in constant electrical balance. In the case
of taste receptors, they are negatively charged inside. The contact
with the stimulating agent tends to neutralize or turn the inside
positive. This creates a cascade of electrical current, which gets
passed through the nerve line, the end of which releases a chemical
neurotransmitter to communicate in relay to the next nerve cell until
it arrives at its destination in the brain.
As the receptor, nerve line, relay points, and end stations are
electrically activated they become unable to respond to another stimuli
(taste) until delivery, and then become depolarized again. This is called
the refractile or recovery phase. The impulses from the taste are then
transmitted to the cerebrum via cranial nerves V, VII, IX, and X
Chorda tympani (CT) are the primary innervation pathway for the
anterior tongue receptors in addition to providing the taste receptors
structural and functional fitness (McCluskey 2002). Surgical
alteration of the tongue leads to loss of sweet and salty receptors.
Surgery of the palate can alter sour and bitter receptors (Grant 2000).
The final receptor, thought to be the parietal operculum near the
Rolando’s fissure, is now believed to be mostly located in the insula
The likelihood is that there is not a single taste center in the
brain, but it is likely the electrical interaction of many areas allowing
the brain to construct a global sensation.
Smell has played a very special role in the natural evolution of
animals, especially the mammals. Many of them are nocturnal and
they had to depend on olfactory guidance to detect food, avoid
predators, recognize territories, social groups, and even sexual contact
The human olfactory area is approximately 16 square centimeters
as compared with almost 150 square centimeters in dogs.
S mell and taste cannot be separated. “Smell and taste form a
single sense, of which the mouth is the laboratory and the nose is the
chimney. To be more specific, of which, one serves for the tasting of
actual bodies and the other for the savoring of their gases”
Little has been known about smell until recent years.
Researchers have earned two major Noble prizes in physiology
and medicine (Linda Buck and Richard Axel 2004) by defining
the olfactory receptor protein as shown.
This system still depends on receptor activation, transmission of
electrical impulses via cyclic AMP (amino mono phosphate), and
electric exchange interaction with sodium exchange.
Often misunderstood, the act of smelling does not happen
exclusively by inhaling aromas via the nose, but rather by a
pheromontal action. This mixture of combined saliva, product, and
evaporation penetrates the back of the nose via the back soft palate
and activates the smell receptors.
The human sense of smell depends on the functioning of cranial
nerve I or the olfactory nerve, for qualitative odor sensations such as
the smell of roses, lemon or grass and the ophthalmic and maxillary
portions of cranial nerve V the trigeminal nerve for somatic sensory
overtones of odorants such as warmth, coolness, sharpness, and
The olfactory neuroepithelium is located over the cribiform plate,
the superior septum and a segment of the superior turbinate and is
rich in smell receptors.
A s in the case of taste, odors attach to and dissolve within the
covering mucus layer to obtain contact with the receptors (Doty R.L.
Bromley, S.M. 1997). Taste, smell, and other impulses will make
their way via nerve conduction to the brain where the ultimate
arrangement of impulses gets coded for the final perception.
Thermal and Mechanical Receptors
Other minor receptors include:
• Mechanical: tactile sensing of texture (crunchy, soft, hard,
• Thermal: temperature sensation
All of this is aided by mastication, the mechanical dismembering
of the food bolus into smaller particles capable of being mixed with
saliva, and the carrying of particles to contact the taste receptors via
fluid or smell receptors via gases (pheromontal). The process of
mastication reduces the size of the particles to be swallowed and
mixes the saliva to bind all together in a safe bolus. This mixes the
food for better exposure to digestive enzymes.
Most people will chew about twenty times before swallowing;
however, under normal circumstances the more likable the food the
longer the mastication as a source of pleasure. The slower and longer
the mastication, the more opportunity for odorants, which are
volatile molecules, to travel up to the smell receptors via the back of
the mouth. This is relevant for the chewing gum industry.
Peppers are used in many cultures as a flavor enhancer. Capsaicin,
the active substance in peppers, increases the blood flow to
the mouth and activates VRI receptors, a membrane channel protein,
which exchanges calcium in and out of the cells. Capsaicin has four
different subunits, which located in different sites of the mouth,
count for the different effect in flavor by different kinds of peppers.
Being fat soluble and heat sensitive improves the taste for fatty foods.
Peppers are, if nothing else, taste enhancers. Their physiological
function is based on three principles.
• An overwhelming inducer of blood supply to the mouth (please
note to yourself what happens when exposed to a minimal amount of
peppers on your lips) that causes an increased production of saliva,
a vehicle to the distribution of elements of flavor in the mouth, and
rapid heart rate with an increase in bronchial secretions and indices
perspiration (cooling effect).
• They are depolarizers of the electrical charges to the taste and smell
• They are a direct stimulant of the brain via pain sensory pathways.
This is done by reducing the availability of substance P and
increasing levels of prostaglandins, both crucial elements of the
inflammatory human response.
All these enhance the brain capacityy for taste and smell. This
makes the act of eating more pleasurable.
Well known to other cultures, such as Latin America (jalapeno,
ancho), India (sanaam, dundicut), and China (tien tsin pepper), the
use of chilli peppers is intrinsically part of the culture.
Chilli peppers, originally from Latin America, were used by Maya,
Inca and Aztecs. Chilli peppers were taken to the old world by
Christopher Columbus as a substitute to the better-known peppers.
The medicinal effects were recognized early on by pre-Columbian
Mayan. They prepared chillatolli, maize flour mixed with chilli, for all
kinds of respiratory ailments. The Aztec would use the direct fruit
for toothache pain control. Tukano Indians in Colombia used it for the
treatment of hangovers and Mayans and Aztecs as infection control for
The assumption that peppers are an anti-cancer chemical is less
important. They are otherwise well recognized as a pain controller and
widely used in the United States of America as a localized anti-arthritis
medicine. Peppers are not just “hot” they are used as flavor
enhancers, for example Paprika.
They are all graded in the intensity of the heat according to the
Scoville Heat Unit System (Wilbur L. Scoville 1912). This scale is
human rated so consequently, this is subjective and liable to human
error. The scale establishes pungency by dilution and testing. In
essence, they attempt to document the number of dilution times in a
neutral liquid where a normal human being can no longer detect the
bite. The most scientific measurement is a high performance liquid
chromatography which extracts and measures capsaicinoid chemicals.
SCOVILLE HEAT UNITS SCALE
The following is a list of chiles, put into a scale to show the relative
pungency levels and their Scoville Heat Units.*
Name Pod Type Species Scoville Units
Orange Habanero Habanero C. chinense 210,000
Red Habanero Habanero C. chinense 150,000
Tabasco Tabasco C. frutescens 120,000
Tepin Tepin C annuum 75,000
Chiltepin Tepin C. annuum 70,000
Thai Hot A sain C. annuum 60,000
Jalapeno M Jalapeno C. annuum 25,000
Long Slim Cayenne Cayenne C. annuum 23,000
Mitla Jalapeno C annuum 22,000
Santa Fe Grande Hungarian C. annuum 21,000
Aji Escabeche A ji C. baccatum 17,000
Cayenne Cayenne C. annuum 8,500
Cayenne Cayenne C. annuum 8,000
Pasilla Pasilla C. annuum 5,500
Primavera Jalapeno C. annuum 5,000
Sandia N ew Mexican C. annuum 5,000
NuMex Joe E. Parker N ew Mexican C. annuum 4,500
Serrano S errano C. annuum 4,000
Mulato A ncho C. annuum 1,000
Bell Bell C. annuum 0
Chemical Structure of Capsaicin
Capsaicin is the most widely recognized chemically active
ingredient in chilli peppers. Contrary to popular belief, the heat is
not located in the seeds, but in the placenta, which are little sacs
located in the inner wall of the fruit. When opening the fruit they tend
to splash into the seeds since they are very fragile and easy to rupture.
Capsaicin binds directly to the receptors in tasting but can be unbound
by casein, a protein obtained from milk, beans, nuts, and chocolate
that is used as a moderator of pungency.
To date, there are fourteen different capsaicins named
capsaicinoids. Each one has a quite unique and characteristic property
on the nature of the bite, the location in the mouth that gets activated,
and the duration of its action.
• Nordyhydrocapsaicin gives a mellow warming effect, rapidly on
and off, mostly at the front of the mouth and the palate.
• By comparison, dihydrocapsaicin is more potent and affects the
middle of the mouth and palate.
• Homohydrocapsaicin is a harsh, sharp irritant, with a slow onset
but a longer duration at the throat and back of the tongue.
L ikewise, heating of the tip of the tongue produces a sweet taste,
while cooling elicits a sour sensation.
Taste and Smell Behavior
Most flavor preferences and aversions are learned. There is an
innate liking to sweetness perhaps associated with common eating
of fruits, and a disliking to bitterness that is mostly associated with
poisonous and bitter alkaloids. Social customs, opportunities, and
private associations with pleasant and painful moments are imprinted
from early childhood. This has been experimentally exemplified in
well-known studies such as the case of Pavlov and his experiences with
dogs. There are repeated reports of food “cravings” rich in needed
fundamental electrolytes or nutritional items. For example, water and
salt in dehydration, water and carbohydrates in cases of Diabetes
Mellitus, and pregnancy cravings.
Preabsorptive Satiety refers to the point in time when a sense of
fulfillment of eating arises. Several mechanisms are believed 82
associated with this since the actual biochemical satisfactions of need
cannot be corroborated, so pressure receptors in the wall of the
stomach, chemical receptors in the wall of the intestine, or
downgraded affinity of the tasting receptors via blood glucose has
been sited (this could be nonetheless overridden by cultural pressures,
for example obesity in the USA). It is unclear why someone becomes
full after a meal or why a given desired food intake becomes sickening
when taken in excess.
The life span of a taste cell is approximately ten days. Because
of this rapid proliferation, they become highly susceptible to cellular
destruction during chemotherapy (Strohl 1984). In cancer patients in
general, there is a higher taste threshold as a result of a decrease in
the number of taste buds (Stubbs 1989).
Cytokines are proteins manufactured by the body. They influence
the cellular behavior by inducing specific cellular functions. Cancer
drives up the production of them (Interleukins, tumor necrosis factor).
They are known for lowering the threshold for bitter sensations
Radiation therapy to the head and neck area is known to cause
alteration of taste: initially at 20Gy (the unit of measurement in
radiation) you experience alteration of taste. This increases 50% at 30Gy and Becomes permanent at 60Gy (Madeya 1996). Radiation directly reduces the number of taste buds and damages the 83 microvilli of the cells. Initially this impairs the bitter and salty sensations and later to a lesser degree the sweet taste (Mossman K.
Chemotherapy, on the other hand, lowers the threshold for bitter
tastes and increases it for the sweet tastes (Madeya 1996). Many
patients complain about a metallic taste. The main offending agents
are Nitrogen Mustard, Cisplatin, Cyclophosphamide, and Doxorubicin.
Repeated adverse reaction to chemotherapy has been known to
develop into a behaviorally adverse reaction by the patient according
to Pavlov’s mechanism (Bender 1999).
Damage by chemotherapy:
Damage by Infections:
Herpes Zoster Infection
Damage by Radiation Therapy:
Does it make any difference?
Beyond the issue of pure quality of life and the enjoyment of
eating, would nutrition make any difference? For most anyone,
including medical or neophytes, the answer is yes. Usually, this
question is not primarily addressed and sometimes priority is the
second or third tier in nutritional importance.
Food for thought:
• The fundamentals are misunderstood in importance.
• The Positron Emitting Tomography (PET scan), the up-to-date
technological tool in oncology, precisely depends on the cellular
utilization of glucose by cancer cells.
• In 1998 a double blind, random study with a small sample,
showed that administration of zinc sulfate three to four times per
day restored not only the acuity of taste but also slowed the
worsening of taste alterations and taste bud anatomy (Ripamonti
• Monosodium Glutamate, commonly used in oriental food, is
becoming a good candidate as a “flavor enhancer”, not only
because of its salty taste but it stimulates Umami, the latest
recognized taste, triggering release of glucagons and insulin
Alcohol and Health
The relationship between alcohol and health has been long-lived
and controversial. For years medical schools have taught students the
serious adverse effects including alcoholism and its social
consequences, as well as the more physical impacts including liver
cirrhosis and fetal alcohol syndrome.
For moderate drinkers, indications show a mortality rate 16%
lower than the 28% seen in non-drinkers (Boffetta, Fuchs). The
National Institute on Alcohol Abuse and Alcoholism has established
the greatest longevity with the consumption of one to two drinks per
day (Ellison 1993). A drink is defined as a five-ounce glass of wine,
one ounce of hard alcohol or one can of beer.
The most protective effect is on the cardiovascular and circulatory
systems by increasing levels of HDL (high density lipoprotein) or the
good cholesterol, decreasing thrombosis, reducing fibrinogen,
increasing fibrinolysis and reducing arterial spasm during stress
Moderate alcohol consumers suffer a lesser number of heart
attacks and arteriosclerosis. They have a lower risk for dementias
including Alzheimer’s disease (Mukamal 2003), and there is a lower
incidence for metabolic syndrome (Matthew 2004). They all seem
associated with the presence of resveratrol, a phytoalexin
chemical found in the skin of the red grapes used in the production
of red wines.
For our purposes, alcohol seems to have an enhancing property to
appetite and taste, interestingly enough, by enhancing the sense of
What healthy people like:
• Taste of fat (concept of marveling)
• Taste of sugar (concept of caramelizing)
• Because of the described metallic taste, use plastic utensils
• Patients should eat small and frequent meals throughout
the day (Sherry 2002).
• Chilled or frozen foods are more acceptable than warm food
• Mouth care is of crucial importance (Sherry 2002).
• Provide rapid shifting tastes:
1. By enhancing receptors activities (chilli pepper).
2. By cleansing of receptors
3. By use of sauces of the nature of coulis
(fruit based sauce with no fat)
• Portions should be small.
• Presentation should be simple and colorful.
• Drink a glass of red wine before a meal. (Alcoholic beverages
are used as an appetite stimulant.)
This paper is not intended to be a scientific presentation in as
much as a compilation of information and ideas in the attempt to
improve quality and perhaps quantity of the lives of patients afflicted
The hope is to provide a simple, superlative, and better quality of
life to patients afflicted with cancer.
My quest in taste and smell in patients afflicted with cancer has been
accomplished with the help of God and those patients for whom this
manuscript is dedicated and intended.
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Wednesday, April 28, 2010
Cooking with Cancer is a program designed specifically for cancer care of those persons who are afflicted with cancer, care givers of the patients, and all of those who work in the healthcare industry. The content is recipes researched and tested on patients undergoing chemotherapy and radiation.
Our goal is to provide a greater understanding of the breakdown in taste, smell and digestion so recommendations for patients are most effective.
In 2003, tired of seeing the same full cans of supplements on daily rounds and untouched meal trays, Dr. Luis F. Pineda enrolled in Culinard Institute to combine the art of cooking with the knowledge of medicine. His motivation is the patients past and present he has provided care for through his 26 plus years as an oncologist.
Some of our goals in the area of taste and smell include:
Developing taste and smell laboratory dedicated to patients suffering with cancer.
Fund clinical research dedicated to establish the causes, nature and treatment of the changes which cancer treatment introduces to the break down of patients taste and smell.
Developing of recipes with Institutions of Education in Nutrition and incorporating cooking during training sessions.
Developing scholarship aimed to favor career changes oriented to the catering of patients with cancer and their needs.
Developing curriculum changes, in colleges and universities, to recognize and study taste and smell changes of patients suffering of cancer and treatments.
Our company's utilization of profits:
- Never to be utilize for financial gain of the officers.
- Always reinvest into the corporation.
- Developing of new programs.
- Payment of expenses.
- Printing of literature.
- Developing scholarship in Nutritional Education for cancer cooking, recipe and research development.
- Direct assistance for patients in financial or nutritional needs.
Nutrition and Recipes for Cancer Patients - Cooking With Cancer
Thanks for reading,