The Spectrum of Malnutrition/Cachexia/Sarcopenia in Oncology According to Different Cancer Types and Settings: A Narrative Review

Nutritional status in oncological patients may differ according to several modifiable and non-modifiable factors. Knowledge of the epidemiology of malnutrition/cachexia/sarcopenia may help to manage these complications early in the course of treatment, potentially impacting patient quality of life, treatment intensity, and disease outcome. Therefore, this narrative review aimed to critically evaluate the current evidence on the combined impact of tumor- and treatment-related factors on nutritional status and to draw some practical conclusions to support the multidisciplinary management of malnutrition in cancer patients. A comprehensive literature search was performed from January 2010 to December 2020 using different combinations of pertinent keywords and a critical evaluation of retrieved literature papers was conducted. The results show that the prevalence of weight loss and associated symptoms is quite heterogeneous and needs to be assessed with recognized criteria, thus allowing a clear classification and standardization of therapeutic interventions. There is a large range of variability influenced by age and social factors, comorbidities, and setting of cures (community-dwelling versus hospitalized patients). Tumor subsite is one of the major determinants of malnutrition, with pancreatic, esophageal, and other gastroenteric cancers, head and neck, and lung cancers having the highest prevalence. The advanced stage is also linked to a higher risk of developing malnutrition, as an expression of the relationship between tumor burden, inflammatory status, reduced caloric intake, and malabsorption. Finally, treatment type influences the risk of nutritional issues, both for locoregional approaches (surgery and radiotherapy) and for systemic treatment. Interestingly, personalized approaches based on the selection of the most predictive malnutrition definitions for postoperative complications according to cancer type and knowledge of specific nutritional problems associated with some new agents may positively impact disease course. Sharing common knowledge between oncologists and nutritionists may help to better address and treat malnutrition in this population.     

The presence of malnutrition in community‐living older adults receiving home nursing services

Aim: To determine the extent of malnutrition and malnutrition risk among community‐living older people (aged 65 years and over) who are receiving care from a metropolitan home nursing service in Victoria, Australia. Method: Over a 3‐month period (May–July 2009), 235 clients aged 65 years and over from a community nursing service providing home nursing care were assessed for malnutrition using the Mini Nutritional Assessment (MNA®, Nestle, Vevey, Switzerland). Results: Thirty‐four per cent (34.5%) of clients were identified as being at risk of malnutrition, while 8.1% were found to be malnourished. There was no significant relationship between nutrition risk and gender, country of birth or living arrangements. Conclusion: Malnutrition and nutrition risk was found to be an issue among this sample of community‐living older adults who were receiving home nursing care in Victoria, Australia. In this study, just over 40% of the participants were either at risk of malnutrition or malnourished, which highlights the vulnerability of this group of older people and the need for routine nutrition screening and a targeted intervention program to address nutrition issues.     

nutritionDay: An Australian hospital's participation in international benchmarking on malnutrition

Aim: Malnutrition is a significant issue for hospitals worldwide. This project examined malnutrition prevalence and associated factors including meal consumption in an Australian hospital. Methods: The cross‐sectional study was undertaken at a private hospital in Brisbane, Australia, for ‘nutritionDay in Europe’ 2009. Nutritional status (subjective global assessment), demographic, medical condition and intake data were collected from 147 inpatients across five medical specialties. Results: The present study found 19.7% (29) of patients were malnourished (17.7% mild to moderately malnourished, 2% severely malnourished). Unintentional weight loss was reported by 39.5% of patients (58) and 49% of patients (72) reported eating less than normal. There were 41.5% of patients (61) who reported not having their usual appetite, with 46.3% (68) eating half or less of a hospital meal. The likelihood of being malnourished increased 4.0 times (CI 1.4–11.6, P= 0.01) for patients who ate less than normal during the previous week and 15 times (CI 4.2–53.5, P < 0.001) for those patients who reported eating less than one quarter to nearly nothing. The likelihood of being malnourished increased 2.9 (CI 1.1–7.6, P= 0.026) and 4.8 (CI 1.6–14.3, P= 0.005) times for patients consuming less than half of breakfast and dinner respectively. Binary logistic regression modelling found a malnutrition screening tool score of ≥2 and average meal consumption of 50% or less were predictors of malnutrition. Conclusions: The present study provides evidence of the increased likelihood of malnutrition in relation to decreased meal consumption and provides insights for future interventions in the acute care setting.     

Clinical Implications of Malnutrition in the Management of Patients with Pancreatic Cancer: Introducing the Concept of the Nutritional Oncology Board

Pancreatic cancer represents a very challenging disease, with an increasing incidence and an extremely poor prognosis. Peculiar features of this tumor entity are represented by pancreatic exocrine insufficiency and an early and intense nutritional imbalance, leading to the highly prevalent and multifactorial syndrome known as cancer cachexia. Recently, also the concept of sarcopenic obesity has emerged, making the concept of pancreatic cancer malnutrition even more multifaceted and complex. Overall, these nutritional derangements play a pivotal role in contributing to the dismal course of this malignancy. However, their relevance is often underrated and their assessment is rarely applied in clinical daily practice with relevant negative impact for patients’ outcome in neoadjuvant, surgical, and metastatic settings. The proper detection and management of pancreatic cancer-related malnutrition syndromes are of primary importance and deserve a specific and multidisciplinary (clinical nutrition, oncology, etc.) approach to improve survival, but also the quality of life. In this context, the introduction of a “Nutritional Oncology Board” in routine daily practice, aimed at assessing an early systematic screening of patients and at implementing nutritional support from the time of disease diagnosis onward seems to be the right path to take.     

Recognition by medical and nursing professionals of malnutrition and risk of malnutrition in elderly hospitalised patients

Objective:  To determine the prevalence of malnutrition in a population of elderly hospitalised patients and to explore health professionals' perceptions and awareness of signs and risks of malnutrition and treatment options available.
Subjects and design:  One hundred elderly patients and 57 health professionals from medical wards of a tertiary teaching hospital. Quantitative and qualitative study design using a validated malnutrition assessment tool (Mini Nutritional Assessment) and researcher-designed questionnaire to assess health professionals' knowledge of nutrition risk factors.
Main outcome measures:  Mini Nutritional Assessment score, nutrition risk category and themes in health professionals' knowledge and awareness of malnutrition and its risk factors.
Results:  Thirty per cent of patients were identified as malnourished while 61% were at risk of malnutrition. Documentation by health professionals of two major risk factors for malnutrition—recent loss of weight and appetite—were poor with only 19% and 53% of patients with actual loss of weight or appetite, respectively, identified by staff and only 7% and 9% of these patients, respectively, referred for dietetic assessment. While health professionals' knowledge of important medical risk factors for malnutrition was good, their knowledge of malnutrition risk factors such as recent loss of weight and loss of appetite was poor. Medical staff focused on biochemical factors when assessing nutrition status, while nursing staff focused on skin integrity and turgor.
Conclusion:  Malnutrition in elderly hospitalised patients remains a significant problem with low rates of recognition and referral by medical and nursing staff. Considerable scope exists to develop training and education tools and to implement an appropriate nutrition screening policy to improve referral rates to dietitians.     

Effects of Internet-Based Nutrition and Exercise Interventions on the Prevention and Treatment of Sarcopenia in the Elderly

Effective nutrition and exercise interventions may improve sarcopenia in the elderly. The purpose of our study was to investigate the effectiveness of Internet-based nutrition and exercise interventions in the elderly with sarcopenia. Participants were divided into 4 groups: control, nutrition, exercise, and comprehensive (nutrition plus exercise) groups; there was at least 50 participants in each group. Our trial lasted 12 weeks. We conducted dietary and exercise interventions through an app and collected feedback from the participants every three weeks. Information on the diet, skeletal muscle mass, and muscle function was collected before and after the interventions. The comprehensive group had higher high-quality protein intake than the control (p = 0.017) and exercise (p = 0.012) groups. After the interventions, we obtained differences in skeletal muscle mass, skeletal muscle mass/height², skeletal muscle mass/weight, muscle mass/BMI, and skeletal muscle mass/body fat percentage (p < 0.05). Changes in average daily energy and total daily protein intakes were not significantly different; however, there was an overall improvement in the intervention groups relative to baseline data. There were no changes in the average daily time of moderate physical activity. The Internet was an effective tool of nutrition intervention in the elderly with sarcopenia. The Internet-based nutrition intervention improved high-quality protein intake and skeletal muscle mass in the elderly with sarcopenia.     

Good Nutrition for Cancer Recovery – a nutritional resource for the treatment of cancer‐induced weight loss

Cancer‐induced weight loss is a debilitating condition which affects 31–87% of patients with cancer and is recognised to be a negative prognostic indicator for a range of malignancies. Although intensive nutritional intervention has been shown to play a beneficial role in weight stabilisation, one‐to‐one dietetic counselling is not available for all patients. The aim of the ‘Good Nutrition for Cancer Recovery’ initiative was to produce an Irish resource that translates clinical nutrition recommendations into simple information and nutritious recipes appropriate for patients with cancer‐induced weight loss. High‐protein, high‐energy recipe guidelines, based on recommendations for nutritionally vulnerable patients, were developed and distributed to all members of the Irish Nutrition and Dietetic Institute, specialist oncology dietitians and nurses, patients and carers, as well as professional chefs from across Ireland. The resulting recipes were analysed and professional chefs consulted in order to optimise the nutritional composition of these meals. This process resulted in a 120‐page resource for patients with cancer‐induced weight loss, containing nutrition information, advice and a bank of nourishing recipes. Recipes were enriched and portion sizes adjusted to ensure that meals were nutrient dense and appropriate in size for patients with small appetites. Nineteen thousand copies of the resource were printed and distributed to >74 locations and made available to patients free of charge. An extensive outreach campaign was launched in order to disseminate the information to all relevant stakeholders. This extensive resource is now widely available to facilitate patients in achieving the energy and protein levels required to attenuate cancer‐induced weight loss.     

2014年中国恶性肿瘤发病和死亡分析

目的比较一级亲属癌症史对胃癌、结直肠癌的遗传倾向影响大小。方法采用面对面调查的方法依据《人群疾病家族史和病史调查表》对苏州市某6个乡镇的胃癌、结直肠癌患者进行调查,内容包括：一般情况、一二三级亲属家系构成及一二三级亲属患癌症情况。结果一级亲属有癌症史,个体患胃癌的风险高于结直肠癌55%,调整OR(95%CI)为1.551(1.021,2.356);如一级亲属有消化道癌症史,这种风险会增加至104%,调整OR(95%CI)为2.037(1.279,3.246)。一级亲属有癌症史的男性患胃癌的风险高于结直肠癌91%,调整OR(95%CI)为1.911(1.080,3.381);如一级亲属有消化道癌症史的男性,这种风险会增加至156%,调整OR(95%CI)为2.559(1.337,4.897)。胃癌患者的一级亲属患癌症的人数多于结直肠癌,Z=-6.873,P < 0.001;一级亲属患消化道癌症的人数亦多于结直肠癌,Z=-6.137,P < 0.001。结论胃癌患者的一级亲属患癌症史、消化道癌症史均比结直肠癌患者普遍,健康教育时有必要对一级亲属有癌症史、消化道癌症史的男性进行重点宣教,提倡其改变生活习惯、定期体检,以减少胃癌的发生。     

An evaluation of a community dietetics intervention on the management of malnutrition for healthcare professionals

Background: Healthcare professionals working in the community setting have limited knowledge of the evidence‐based management of malnutrition. The present study aimed to evaluate a community dietetics intervention, which included an education programme for healthcare professionals in conjunction with the introduction of a community dietetics service for patients ‘at risk’ of malnutrition. Changes in nutritional knowledge and the reported management of malnourished patients were investigated and the acceptability of the intervention was explored. Methods: An education programme, incorporating ‘Malnutrition Universal Screening Tool (MUST)’ training, was implemented in eight of 10 eligible primary care practices (14 general practitioners and nine practice nurses attended), in seven private nursing homes (20 staff nurses attended) and two health centres (53 community nurses attended) in conjunction with a community dietetics service for patients at risk of malnutrition. Nutritional knowledge was assessed before, immediately after, and 6 months after the intervention using self‐administered, multiple‐choice questionnaires. Reported changes in practice and the acceptability of the education programme were considered using self‐administered questionnaires 6 months after the intervention. Results: A significant increase in nutritional knowledge 6 months after the intervention was observed (P < 0.001). The management of malnutrition was reported to be improved, with 69% (38/55) of healthcare professionals reporting to weigh patients ‘more frequently’, whereas 80% (43/54) reported giving dietary advice to prevent or treat malnutrition. Eighty‐percent (44/55) of healthcare professionals stated that ‘MUST’ was an acceptable nutrition screening tool. Conclusion: An education programme supported by a community dietetics service for patients ‘at risk’ of malnutrition increased the nutritional knowledge and improved the reported management of malnourished patients in the community by healthcare professionals.     

中国5岁以下儿童营养不良现状及其变化趋势的研究

目的分析中国5岁以下儿童的营养不良状况及变化趋势。方法采用多阶段分层整群随机抽样的方法,按照东、中、西三类地区和城市、农村的分层原则,在全国选取17 607名5岁以下儿童,测量儿童的身高(长)和体重。结果2006年中国5岁以下儿童生长迟缓率为9.9%,低体重率为5.9%,消瘦率为2.2%;儿童生长迟缓率农村是城市的5.3倍,低体重率农村是城市的4.6倍,差异有显著性(P<0.05);中、西部地区儿童营养不良率显著高于东部地区(P<0.05);与2002年相比,2006年儿童生长迟缓率下降了30.8%,儿童低体重率下降了24.4%。结论中国5岁以下儿童营养不良率逐年下降,下降速度城市高于农村。西部地区农村儿童营养不良问题仍有待改善,同时中部地区农村儿童的营养不良状况也应得到充分关注。