Nutritional support strategies for malnourished cancer patients

A large body of evidence exists, which demonstrates the importance of nutritional support in cancer. The nutritional needs of patients with cancer may differ from those of the healthy population due to hypermetabolism, impaired organ function, increased nutrient losses and therapy-related malnutrition. Patients with cancer often have increased requirements for both macro- and micronutrients due to long periods of undernutrition prior to diagnosis. The aim of nutritional support should be the prevention or reversal of malnutrition, and this should be initiated as early as possible to improve outcomes. Oral supplementation is a simple, non-invasive method of increasing the nutrient intake of those patients who are unable to meet nutritional requirements, despite dietary counselling. Enteral tube feeding is indicated for patients who are unable to meet their nutritional needs by oral intake alone, and has been shown to improve clinical outcomes. Novel approaches in oral supplementation include the use of eicosapentaenoic acid (EPA), a compound under investigation for its role in preventing and treating cancer-associated malnutrition. Individual studies suggest that EPA attenuates cancer-associated wasting and improves immune function. In addition, it has been shown to have anti-tumour effects and improve clinical outcomes. However, results are not consistent for all patient groups and further research is required

Ondervoeding in verpleeghuizen Prevalentie, preventie, behandeling en beleid

In developed countries there is growing awareness of the importance of recognizing, rating, and treating malnutrition in health care. The objective of this study was to provide data on a large scale concerning the prevalence, screening, treatment and quality indicators, with regard to malnutrition in nursing homes in the Netherlands, in 2006 This cross sectional multi-centre point prevalence study, performed in 2004, 2005 and 2006, included in 2006 10.923 patients of nursing homes .The results presented are part of The Annual Dutch Prevalence Study on Care Problems (LPZ) performed by Universiteit Maastricht. The study uses a standardised questionnaire which is divided in three parts: (1) the profile of the health care institution (kind of institution, quality indicators), (2) the profile of the department (kind of department, quality indicators), and (3) patient characteristics (demographic data, reason of admission, and prevention and treatment of 4 care problems: pressure ulcers, incontinence, intertrigo and malnutrition.). Nutritional status was assessed by BMI, undesired weight loss and nutritional intake In 2006, 202 health care organisations participated in the LPZ, including 78 nursing homes. Results show that one out of four patients was malnourished in the participating nursing homes. The older the patient was and the more diseases the patient had, the higher the prevalence rate of malnutrition. Less then 50% of the patients were screened for malnutrition and a dietician was consulted in less than 50% of the cases. Furthermore, focussing on the quality indicators reveals that there is no structural and uniform policy concerning malnutrition in most of the participating nursing homes. One out of four patients is malnourished in nursing homes.This requires actions towards a more structural nutritional policy in Dutch nursing homes to target this relevant care problem

Assessment of malnutrition parameters in head and neck cancer and their relation to postoperative complications

Background. Malnutrition is reported frequently in head and neck cancer patients. The impact of malnutrition on surgical outcome is not clearly understood. The purpose of this study was to define the usefulness of six different parameters in scoring malnutrition and to determine the nutritional parameter primarily related to postoperative complications. Methods. Sixty- four patients undergoing major surgery for advanced head and neck cancer were studied prospectively, and six different parameters were used to define malnutrition. Logistic regression was used to relate nutritional parameters to postoperative complications. Results. The parameters applied all identified different aspects of the nutritional status, as malnutrition varied between 20% and 67%. Logistic regression analysis identified a weight loss of more than 10% to be the most prominent predictive parameter for the occurrence of major postoperative complications. Conclusions. Patients with weight loss more than 10% during the six months before surgery are at a great risk for the occurrence of major postoperative complications

The impact of nutritional status on the prognoses of patients with advanced head and neck cancer

BACKGROUND. Malnutrition has been recognized as a poor prognostic indicator for cancer treatment-related morbidity and mortality in general, and it is reported to affect 30-50% of all patients with head and neck cancer. In this study, the correlation of nutritional status with 3-year survival was studied prospectively in 64 patients with T2-T4 carcinomas of the head and neck who were treated surgically with curative intent; the surgery was often followed by radiotherapy. METHODS. All patients underwent nutritional screening according to six different parameters on the day prior to surgery. Overall and disease specific survival analyses were performed with a follow-up period of at least 3 years. Survival analyses were performed with the log rank test and the Cox proportional hazards model. RESULTS. Lymph node stage, nonradical resection margins, and occurrence of major postoperative complications were demonstrated to affect disease specific survival for the group as a whole. None of the investigated nutritional parameters were correlated with survival. When men and women were analyzed separately, however, a preoperative weight loss of >5% did have a prognostic value for men. The combination of male gender, preoperative weight loss, and major postoperative complications were related to early death. CONCLUSIONS. Apart from the well-known prognostic parameters lymph node status (T classification) and status of surgical margins, preoperative weight loss and occurrence of major postoperative complications were also found to have a negative effect on the survival of male patients undergoing surgery for advanced head and neck cancer

Effect of perioperative nutrition, with and without arginine supplementation, on nutritional status, immune function, postoperative morbidity, and survival in severely malnourished head and neck cancer patients

Background: Malnourished head and neck cancer patients are at increased risk of postoperative complications. Objective: We studied the effect of perioperative, arginine-supplemented nutritional support on nutritional status, immune status, postoperative outcome, and survival in severely malnourished (weight loss > 10% of body weight) head and neck cancer patients undergoing major surgery. Design: Forty-nine patients were randomly assigned to receive 1) no preoperative and standard postoperative tube feeding, 2) standard preoperative and postoperative tube feeding, or 3) arginine-supplemented preoperative and postoperative tube feeding. Results: Patients in both prefed groups received ≈9 d of preoperative tube feeding, resulting in energy intakes of 110% and 113% of calculated needs (compared with 79% in the control group; P = 0.007). Compared with no preoperative feeding, preoperative enteral nutrition did not significantly improve nutritional status or any of the studied biochemical or immunologic indexes. Major postoperative complications occurred in 53%, 47%, and 59% of patients in study groups 1,2, and 3 (NS). A trend was seen toward better survival in the arginine-supplemented group (P = 0.15). Secondary analysis showed that survivors had better human leukocyte antigen-DR expression on monocytes (P = 0.05) and higher endotoxin-induced cytokine production (P = 0.010 for tumor necrosis factor α and P = 0.042 for interleukin 6) at the start of the study than did patients who died. Conclusions: Nine days of preoperative tube feeding, with or without arginine, did not significantly improve nutritional status, reduce the surgery-induced immune suppression, or affect clinical outcome in severely malnourished head and neck cancer patients. Patients supplemented with arginine-enriched nutrition tended to live longer. Some markers of immune function may distinguish patients with good or bad prognoses

A carbohydrate-rich beverage prior to surgery prevents surgery-induced immunodepression: A randomized, controlled, clinical trial

Background: Fasting before surgery is still common care in a lot of western hospitals. Overnight fasting can induce postoperative insulin resistance. Insulin resistance has been shown to be related to infectious morbidity. It was shown that postoperative insulin resistance can be attenuated by preoperative intake of a clear carbohydrate-rich beverage. The aim of this study was to investigate whether preoperative intake of carbohydrate-rich beverages could postoperatively influence the immune system. Methods: In this randomized, controlled study, we investigated the effect of surgery on the postoperative immune response in 10 preoperatively fasted patients (control) and 2 groups of 10 patients receiving 2 different carbohydrate-rich beverages preoperatively, by measuring human leukocyte antigen (HLA)-DR expression on monocytes on the day before and on the day after surgery. Furthermore, we studied perioperative fluid homeostasis and preoperative well-being of the patients. Results: HLA-DR expression decreased significantly after surgery in the control group. Patients receiving any of the 2 carbohydrate-rich beverages did not show this postoperative decrease. Fluid homeostasis was not affected in any of the groups, and well-being tended to be better in patients receiving carbohydrate-rich beverages compared with controls. Conclusion: This study suggests that preoperative intake of a carbohydrate-rich beverage can prevent surgery-induced immunodepression and thus might reduce the risk of infectious complications

Development and validation of criteria for determining undernutrition in community-dwelling older men and women: The Short Nutritional Assessment Questionnaire 65+

SummaryBackground & aimsThere is no valid, fast and easy-to-apply set of criteria to determine (risk of) undernutrition in community-dwelling older persons. The aim of this study was to develop and validate such criteria.MethodsSelection of potential anthropometric and undernutrition-related items was based on consensus literature. The criteria were developed using 15-year mortality in community-dwelling older persons ≥ 65 years (Longitudinal Aging Study Amsterdam, n = 1687) and validated in an independent sample (InCHIANTI, n = 1142).ResultsGroups distinguished were: (1) undernutrition (mid-upper arm circumference <25 cm or involuntary weight loss ≥4 kg/6 months); (2) risk of undernutrition (poor appetite and difficulties climbing staircase); and (3) no undernutrition (others). Respective hazard ratio’s for 15-year mortality were: (1) 2.22 (95% CI 1.83–2.69); and (2) 1.57 (1.22–2.01) ((3) = reference). The area under the curve (AUC) was 0.55. Comparable results were found stratified by sex, excluding cancer/obstructive lung disease/(past) smoking, using 6-year mortality, and applying results to the InCHIANTI study (hazard ratio’s 2.12 and 2.46, AUC 0.59).ConclusionsThe developed set of criteria (SNAQ65+) for determining (risk of) undernutrition in community-dwelling older persons shows good face validity and moderate predictive validity based on the consistent association with mortality in a second independent study sample