*Nóra Galló1, Mária Varga2, Andrea Molnár3, Róbertnè Csajbók1, Katalin Tátrai-Nèmeth1, Erzsèbet Pálfi1
Difficulties and opportunities related to the nutrition of cancer patients
1Department of Dietetics and Nutrition Sciences, Faculty of Health Sciences, Semmelweis University, Budapest, Hungary
Head of Department: prof. Katalin Tátrai-Nèmeth, PhD
2Department of Dietetics, Szent Imre Teaching Hospital, Budapest, Hungary
Head of Department: Kyri Herscovicinè Vass, Dietitian
3Health Sciences Research, Doctoral School of Pathological Sciences, School of PhD Studies, Semmelweis University, Budapest, Hungary
Head of Health Sciences Research: prof. Gyula Domján, MD, PhD
Summary
Introduction. The tumour and treatments have effects on metabolism, nutrition and thus the nutritional status.
Aim. To reveal nutritional difficulties leading to malnutrition, sarcopenia and to explore possibilities of dietetic intervention. To survey patients’ nutritional status and malnutrition risk. Moreover, to assess patients’ energy and nutrient intake and their nutrition habits regarding quantity and quality. The question of clinical nutrition was also raised.
Material and methods. Inpatients (64.33 years ± 18.62, 22 males/23 females) and outpatients (63.38 ± 16.08, 9 males/15 females) were involved, since patients should be provided with different dietetic services in these areas. Malnutrition risk screening was performed with NRS 2002. Nutritional status was determined based on measured anthropometric parameters and body composition analysis. Diet changes were measured by 3-day food diaries and 24-hour food recalls.
Results. All inpatients are at risk of malnutrition (60% moderately 12% severely). The decrease in muscle mass can be estimated based on calculated values. 16% of the outpatients are at risk of mild malnutrition and 8% had anorexia. 72% of the outpatients are overweight-obese, however, beside fat dominance, loss of muscle mass is also likely in 80%. Inpatients consumed 1,800 kcal, including supplementary feeding. 22% received supplementary formulas, still only 50-75% of the recommended amount is consumed. 41% of severe risk patients do not get ONS at all.
Conclusions. The nutritional status of cancer patients should be examined thoroughly. The provision of supplement formulas, tube or parenteral nutrition should be started timely.
Introduction
Cancer is now recognised as a chronic disease since the number of patients living with cancer is increasing. Developed treatments enhance survival rates significantly and also prolong lifetime (1).
Nutrition of cancer patients is vital from the diagnosis onwards. The risk of nutritional depletion is high for the following reasons. Due to the metabolic changes the tumour triggers, muscle wasting and weigh loss occur in patients (2). Symptoms and side effects, such as pain, stomach discomfort, diarrhoea, nausea, vomiting etc. patients usually suffer from, especially during treatment, might impair food intake, not to mention they may cause nutrient losses and may prevent nutrient absorption. The psychological effects, most often depression and anorexia, have a negative effect on appetite, consequently the energy and nutrient intake is much less than the desired amount. For all the above mentioned factors, the risk of weight loss and malnutrition is high. Approximately 40% of cancer patients have been found to have substantial protein energy malnutrition (3).
The role of malnutrition which increases morbidity and mortality in aging, as well as in patients with chronic diseases such as cancer, has been long recognized (4, 5). It is “a state resulting from the lack of uptake or intake of nutrition leading to altered body composition (decreased fat free mass) and body cell mass leading to diminished physical and mental function and impaired clinical outcome from disease” (6).
Furthermore, sarcopenia is a key feature of disease-related malnutrition. Currently the proposed criteria for sarcopenia assessment in a clinical setting include the determination of muscle mass, strength and physical performance (7). It is a syndrome characterised by progressive and generalised loss of skeletal muscle mass and strength with a risk of adverse outcomes such as physical disability, poor quality of life and death. Diagnosis is based on the documentation of low muscle mass, low muscle strength and low physical performance (8).
Another factor is cachexia which is widely recognised in older adults as severe muscle wasting accompanying chronic diseases, such as cancer. Cachexia has recently been defined as a complex metabolic syndrome, associated with underlying illnesses and characterised by loss of muscle with or without the loss of fat mass (9, 10).
Aim
Our objectives were to reveal the nutritional difficulties of cancer patients leading to malnutrition and sarcopenia; and to explore the possibilities of dietetic interventions focusing on nutritional status, body composition assessment and malnutrition risk screening. Moreover, we wanted to prove that the results of validated risk screening methods should be complemented with complex nutritional status assessment and body composition analysis in order to explore muscle loss which plays an important role in cancer cachexia. We raised the question as to which patient is given clinical nutrition, such as formula-fed supplements (ONS), tube or parenteral feeding.
Material and methods
The study was performed on 45 inpatients (23 females, 22 males) and 24 outpatients (15 females and 9 males) aged 64.33 years ± 18.62 and 63.38 ± 16.08 respectively.
A wide range of techniques can be used to assess body composition and malnutrition (11). However, we have selected the measuring methods which are also applied by dietitians in their daily clinical practice. First of all, body composition was measured by a 4-point OMRON BF 500 Bioimpedance analysis (BIA) device. Secondly, body weight was recorded in light clothing, standing barefoot on the machine. Thirdly, body height was measured separately, with the help of a wall-mounted stadiometer. The test itself is inexpensive, easy to use, readily reproducible and appropriate for both ambulatory and bedridden patients, although some clinical studies assume that BIA cannot reliably assess skeletal muscle mass in patients with body fluid abnormalities (12).
The estimation of skeletal muscle mass (SMM) was calculated with the equation of Lee et al. (body weight and height model). This equation was cross-validated with the independent samples of obese subjects. Prediction equations have been validated for multi-ethnic adults. The Lee et al. equation is the following:
SM (kg) = (0.244 x BW) + (7.80 x Ht) – (0.098 x age) + (6.6 x sex) + (race - 3.3)
BW in kg, Ht in m, sex = 1 for male and 0 for female, race = 1.2 for Asian, 1.4 for African American, and 0 for white or Hispanic (13).
Cut-off points depend on the chosen measurement technique and on the availability of reference studies as well. The EWGSOP recommends the use of normative (healthy young adults) rather than other predictive reference populations. The selection of measurement tools for research studies relies on availability and access to data for relevant reference populations (considering age, gender and ethnicity). Cut-off points can be used in case of skeletal muscle mass (SMM) and skeletal muscle mass index (SMI) (8).
According to ESPEN diagnostic measures are only needed for those patients who score positive for nutritional risk. In order to diagnose malnutrition there are two alternative ways:
– alternative 1: BMI < 18.5 kg/m2,
– alternative 2: weight loss (unintentional) > 10% indefinite of time, or > 5% over the last 3 months combined with either BMI < 20 kg/m2 if < 70 years of age, or < 22 kg/m2 if ≥ 70 years of age or FFMI < 15 and < 17 kg/m2 in women and men respectively (14).
Malnutrition risk screening was performed with the help of NRS 2002. The changes in diet were measured by validated 3-day food diaries and 24-hour food recalls. The energy and nutrient intake was compared to recommended necessities.
Results
It is recommended by ESPEN that subjects at risk of malnutrition should be identified by validated screening tools, moreover should be assessed and treated accordingly. Based on the NRS 2002 scores all the clinical patients proved to be at risk of malnutrition: 28% mildly, 60% moderately and 12% severely. In case of the first two risk categories it is desired to rescreen patients weekly but if e.g. a major operation is scheduled, a preventive nutritional care plan is considered to avoid the associated risk status. However, if the Score is ≥ 3, a nutritional care plan is indicated and it should be initiated as early as possible. Regarding outpatients and their NRS 2002 Score, 16% was at risk of mild malnutrition.
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Piśmiennictwo
1. Cancer Research UK (CRUK): Cancer Mortality Statistics. Retrieved from 2015-01-27: http://www.cancerresearchuk.org/cancer-info/cancerstats/mortality/. 2. Laviano A, Preziosa I, Fanelli FR: Cancer and nutritional status. [In:] Shaw C (ed.): Nutrition and cancer. Wiley-Blackwell Publishing Ltd, Oxford 2011: 13-26. 3. Ravasco P, Monteiro-Grillo I, Vidal PM, Camilo ME: Nutritional deterioration in cancer: The role of disease and diet. J Clin Oncol 2003; 15(8): 443-450. 4. Biolo G, Guadagni M, Ciocchi B: Does cachexia prevention improve outcome of chronic disease and cancer? Intern Emerg Med 2011; 6: 101-103. 5. Raslan M, Gonzalez MC, Torrinhas RS et al.: Complementarity of Subjective Global Assessment (SGA) and Nutritional Risk Screening 2002 (NRS 2002) for predicting poor clinical outcomes in hospitalized patients. Clin Nutr 2011; 30: 49-53. 6. Van Bokhorst-de van der Schueren MAE, Soeters PB, Reijven PLM, Allison SP, Kondrup J: Diagnosis of malnutrition – Screening and Assessment. [In:] Sobotka L (ed.): Basics in Clinical Nutrition. Galèn, Czech Republic 2011. 7. Biolo G, Cederholm T, Muscaritoli M: Muscle contractile and metabolic dysfunction is a common feature of sarcopenia of aging and chronic diseases: From sarcopenic obesity to cachexia. Clin Nutr 2014; 33(5): 737-748. 8. Cruz-Jentoft AJ, Baeyens JP, Bauer JM et al.: Sarcopenia: European consensus on definition and diagnosis: Report of the European Working Group on Sarcopenia in Older People. Age Ageing 2010; 39(4): 412-423. 9. Evans WJ, Morley JE, Argilès J et al.: Cachexia: a new definition. Clin Nutr 2008; 27: 793-799. 10. Dank M: Tumoros anorexia/cachexia szindróma. Magyar Onkológia 2011; 45: 431-436. 11. Thorne F, Baldwin C: Multimodal interventions including nutrition in the prevention and management of disease-related malnutrition in adults: A systematic review of randomised control trials. Clin Nutr 2014; 33: 375-384. 12. Norman K, Stobäus N, Pirlich M, Bosy-Westphal A: Bioelectrical phase angle and impedance vector analysis – clinical relevance and applicability of impedance parameters. Clin Nutr 2012; 31: 854-861. 13. Lee RC, Wang Z, Heo M et al.: Total-body skeletal muscle mass: development and crossvalidation of anthropometric prediction models. Am J Clin Nutr 2000; 72: 796-803. 14. Cederholm T, Bosaeus I, Barazzoni R et al.: Diagnostic criteria for malnutrition – An ESPEN Consensus Statement. Clin Nutr 2015; 34: 335-340.
