The prevalence of malnutrition in patients with cancer varies considerably (up to 83%); depending on cancer type, the stage of the disease and patient age17-18.
Figure 1 outlines the definitions of disease-related malnutrition, sarcopenia and cachexia and how they relate to one another.
The negative impact of malnutrition is well-documented and includes increased postoperative recovery times, increased risk of infections, longer hospital admissions, poorer response to treatment and diminished overall survival
The ‘Impact of Malnutrition in Cancer’ section (below) provides an overview of the negative sequelae associated with malnutrition.
Figure 1: The relationship between disease-related malnutrition, sarcopenia and cachexia
Malnourished patients with cachexia and/or sarcopenia have a higher risk of treatment-related toxicity, treatment discontinuation, poor response to treatment (including surgery), lower activity level, impaired quality of life (QoL) and poorer prognosis21.
Immune function impairment | Weight loss negatively affects the immune competence of a patient12,22 |
Reduced performance status | Malnutrition and skeletal muscle mass loss in cancer patients are associated with reduced functional capacity23,24 |
Depression, anxiety | Malnutrition and skeletal muscle mass loss in cancer patients are associated with psychosocial symptoms23,25 |
Fatigue | Fatigue is common in patients with cancer and can hinder the purchase and preparation of food and affect appetite22. Low levels of essential nutrients e.g. iron (ferritin), vitamin D or magnesium can exacerbate or contribute to fatigue – levels can be checked when bloods are taken and corrected through targeted supplementation26. |
Decreased response to chemotherapy and increased chemotherapy-induced toxicity | Loss of skeletal muscle mass has a detrimental effect on patients’ response and tolerance to anti-cancer treatment27-32 |
Increased frequency and severity of complications |
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Reduced quality of life |
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Reduced survival time | Malnutrition and skeletal muscle mass loss are associated with increased mortality39-40 which is also observed in those who are overweight or obese41 |
Increased demands on health services, increased cost of care |
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The nutritional status of patients will vary from patient to patient at diagnosis and at points in their journey. Improving nutritional care for people with cancer is reliant on 3 main steps18,27,45:
Regular nutritional screening can be undertaken using a tool such as ‘MUST’
MUST: FURTHER INFORMATIONQuestioning for the presence of diet-related issues can help to identify malnutrition risk and diet-related distress that can then be managed at the earliest opportunity46. There are a variety of tools that have been validated for use in oncology patients10, 47-49. They generally take into account dietary intake, diet-related issues (nutrition impact symptoms), weight and weight loss over time18,27. A variety of tools are available including SUBJECTIVE GLOBAL ASSESSMENT (SGA) and the PATIENT GENERATED SUBJECTIVE GLOBAL ASSESSMENT (PGSGA). Some may be more suitable than others depending on your healthcare setting.
The Global Leadership Initiative on Malnutrition (GLIM) recommends a two-step approach for the diagnosis of malnutrition, this involves screening to identify risk status by the use of any validated screening tool, and then an assessment for diagnosis and the grading of the severity of malnutrition50. Phenotypic characteristics such as unplanned weight loss, low body mass index, and reduced muscle mass should be considered alongside etiologic criteria such as reduced food intake, absorption and inflammation or disease burden. To diagnose malnutrition at least one phenotypic criterion and one etiologic criterion should be present50.
Regardless of the tool used a thorough symptom assessment (see Nutrition Impact Symptoms and their Management section) can identify factors contributing to poor intake and malnutrition.
Unintentional weight loss should alert healthcare professionals to take action and undertake further assessment to determine the severity of weight loss and whether the weight lost is muscle or adipose tissue (fat). Preserving muscle not just weight, is considered a key goal in cancer in improving outcomes such as response to treatment and preserving quality of life45.
In hospital, sophisticated methods to assess body composition, including muscle mass, may be available e.g., DEXA scanning, CT scans, bio-impedance. Where these are not available, functional measures such as sit to stand, walk test, hand grip strength and patient directed questions about reduced ability to perform daily activities or changes in fitness, can help to indicate if loss of muscle mass and strength has occurred and guide decisions on treatment.
STEP BY STEP INSTRUCTIONS for conducting the sit to stand, 4 stage balance test and timed up and go test – under the 'functional assessments' section.
Instructions on administering a TWO MINUTE WALK ENDURANCE TEST and a FOUR METRE WALK GAIN SPEED TEST
SARC-F QUESTIONNAIRE - a five item questionnaire that helps determine the likelihood of sarcopenia.
KEY POINT:
Detecting nutritional issues at an early stage can help minimise or prevent deterioration in nutritional status and loss of muscle mass that may be resistant to intervention or irreversible later on. Members of the healthcare team should be trained to regularly observe and evaluate nutritional intake, record changes in weight and body mass index (BMI) and act on the findings, at cancer diagnosis and repeatedly thereafter along the patient journey, depending on the stability of the clinical situation.
Identifying the underlying factors contributing to a reduced dietary intake that can be managed or reversed to avoid further deterioration in nutritional status is a key element of nutritional care. The section on nutrition impact symptoms and their management below illustrates common problems experienced by patients along with practical tips, and links to resources, that can be used to help patients and families.
Advice should take into account the holistic needs of the patient, discussing with the patient and family members or carers, what is most bothersome and what matters to them. Issues identified, advice given and actions taken or recommended, should be documented in the patient record and communicated to members of the healthcare team particularly as the patient moves across care settings51, 52.
The information below contains advice to discuss with patients relating to prehabilitation.
An advice sheet to share with patients is available for download:
Prehablitation (prehab) is about getting your body ready for treatment, whether that is surgery, radiotherapy, chemotherapy or immunotherapy. It can involve improving your nutrition, physical fitness and psychological wellbeing. At your diagnosis your healthcare team may screen you for any problems in these three areas. Taking action early to address any problems can help you tolerate your treatment, have fewer side effects or cope better. In turn this can get you through your treatment journey and help you recover.
Some of the things you might wish to consider in relation to your diet in the weeks running up to treatment are outlined below:
Being as well-nourished as possible before you start your treatment can help you deal with problems that might arise along the way. Enjoying what you eat is important too.
A balanced diet needs to include food from all the food groups to make sure your body works well, these include beans, pulses, fish, eggs, meat and other proteins, starchy foods, fruit and vegetables and dairy foods such as milk, yoghurt and cheese or dairy alternatives.
Ideally you should eat enough calories (energy) and enough protein to keep your weight steady and keep as strong as possible. If you are underweight or have lost weight unintentionally then you may be advised to try and gain a little weight.
Even if you are overweight, losing weight at this time may not be recommended but instead ensure you avoid gaining more excess weight.
A balanced diet includes:
To help understand your individual needs the Malnutrition Pathway team has produced 3 leaflets that give further advice on diet:
Below is a list of common nutrition impact symptoms. Click on each issue for advice for patients and their families. Downloadable pdfs to print off are available at the bottom of relevant sections.
Seek advice from a doctor, nurse specialist, oncology pharmacist or the general care team when necessary.
Advice to consider
Advice to consider
Advice to consider
Loss of taste/taste changes are often temporary, occurring for days or weeks, but in some cases can continue for months and cause considerable distress and loss of enjoyment in eating and drinking. Foods can taste odd, metallic, too sweet or salty or unusually bland (have little taste). Some people find they are unable to tolerate strong flavours and actually prefer more bland food and drinks. As everyone's experience differs we have included a list of tips below for you to select the ones that suit your needs:
Swallowing issues can result from the cancer itself or the treatment. Some medications can cause a dry mouth or sleepiness that make eating and drinking more difficult.
Advice to consider
If swallowing is a problem, your GP can refer you to a speech and language therapist and/or Dietitian for a further assessment. You may be advised to change the consistency of food and drinks to make swallowing easier and safer. A thickener to add to drinks may be prescribed. These general tips may also help:
Further information on swallowing problems (dysphagia) is available: DYSPHAGIA: A HEALTHCARE PROFESSIONAL FACT SHEET
Advice to consider
Changes in bowel habit and stools can arise as a result of the cancer, be a side effect of treatment (even some months after treatment has finished) or arise as a result of an infection.
Advice to consider
Advice to consider
If smells of cooking are bothering you and make you feel less hungry, the following ideas might help:
Advice to consider
Patients should be under the care of a stoma care nurse – further information can be found HERE
Advice to consider
Heartburn is a burning feeling in the chest caused by stomach acid travelling up towards the throat (acid reflux). If it keeps happening, it's called reflux or gastro-oesophageal reflux disease (GORD). The main symptoms of acid reflux are:
Here are some suggestions to try to reduce heartburn and reflux:
If you are feeling sick or being sick:
Nausea and vomiting can be treated well using antiemetic drugs speak to your doctor or pharmacist about what is best for you
Advice to consider
Untreated and ongoing anaemia can impair immunity, affect energy levels, appetite and exacerbate fatigue. Ask your healthcare team to help identify the cause and treat if appropriate:
Advice to consider
This can arise in pancreatic cancers, pancreatic enzyme replacement therapy should be initiated and titrated according to food intake, symptoms and stool type. Further information can be found HERE
Advice to consider
The Royal College of Occupational Therapists provide so useful advice on conserving energy and pacing activity to manage fatigue: MORE
If you are constantly tired, try some of the energy saving ways from the list below to help you eat a balanced diet with sufficient calories and protein:
Note: If you are diabetic, ensure your diabetes is managed as well as possible as poor blood glucose control can make fatigue worse
The Royal Surrey Hospital has produced a number of 2-3 minutes videos which aim to support oncology patients through treatment by answering some on the commonly asked questions about diet and cancer. Topics covered include:
What should I eat if:
There are also videos explaining how to fortify foods and how to incorporate nutritional supplement drinks into the daily diet if they have been prescribed.
Nutrition support and diet therapy can comprise dietary counselling, dietary modification (food fortification, texture modification), oral nutritional supplementation (ONS), enteral tube feeding (ETF) or parenteral nutrition (PN).
Although nutrition support is often required for cancer patients to prevent and manage malnutrition and sarcopenia and improve treatment efficacy; dietary advice may also alleviate the side effects of the cancer treatment, this dual effect helps improve quality of life53-55.
Nutrition support may need to be commenced at diagnosis, during prehabilitation, treatment or at any point throughout the patient journey. Care should be taken to ensure that nutrition support is not withdrawn at a time that it is still of benefit e.g. tube feeding is sometimes stopped as soon as a patient is able to eat and drink but if food intake is slow to increase or if it is anticipated that oral intake will be insufficient to meet requirements, nutrition support might need to be continued to support oral intake.
The European Society for Parenteral and Enteral Nutrition has produced practical guidelines on nutrition in cancer patients45 MORE It recommends that the energy expenditure of patients with cancer should be similar to healthy individuals – ranging between 25 and 35 kcal/kg/day. Protein requirements should be above 1g/kg/day and if possible up to 1.5g/kg/day. More information on increasing protein intake can be found HERE
Aerobic and resistance exercise have been shown to be effective strategies to improve upper and lower body muscle strength56. Where feasible, physical activity should be encouraged alongside nutritional care. The more active patients are, the greater the benefits to overall mood, stress levels and long-term health57,58. Building in activity through small changes to daily routines and creating new habits can help; aiming to be active every day will bring about the best physical and mental health benefits. Any activity is better than none; even 10 minutes at a time can add up throughout the day and the week and provides a foundation to build upon.
In clinical practice, oral nutrition is the preferred route of choice if it is possible and feasible to take nutrition and fluid via this route. Dietary counselling, with or without ONS, may be necessary to compensate for reduced food intake, addressing the nutritional deficit to prevent deterioration in nutritional status and preserve function during treatment and beyond. In individual’s with poor appetite or a restricted ability to eat and drink, or in whom a rapid deterioration in oral intake is anticipated, ONS may need to be initiated early in their management in conjunction with dietary advice to avoid weight loss and irreversible deterioration in nutritional status and functional ability.
Dietary advice should be based on the issues presenting, those most bothersome to the individual, and should consider and address taste changes, swallowing problems, diarrhoea, constipation, eating when breathless or eating with a dry mouth (see section on nutrition impact symptoms and their management).
Providing timely advice on managing eating difficulties can alleviate concerns and nutritional issues, and can also play a significant role in helping to maintain socialisation, for example by supporting the patient to eat more comfortably with family members or friends. Individualised advice adapted to the patient’s circumstances can also empower a patient and their carers. Referral to a dietitian or healthcare professional with the appropriate experience should be offered particularly when problems are complex, or the patient does not gain improvement from first line advice.
In the late stages of cancer (advanced cancer), where appetite is very poor and weight gain is less likely or not possible, explaining why the issues are arising e.g. as a result of factors produced by a tumour, can go some way towards alleviating anxiety amongst patients and their carers59.
If an individual is following a special diet for another medical condition, such as heart disease, gastrointestinal conditions, diabetes or renal failure, has a colostomy or ileostomy, or is really struggling with eating, refer to a dietitian.
Dietary counselling by a skilled practitioner (e.g. dietitian) takes into account the patient’s habitual diet, diet history, medical history, clinical information, presence of medical conditions, cooking abilities, access to food, psychological, cultural, religious and social factors that influence food choice, to create a tailored individualised approach to nutrition.
It should be noted that in some areas access to dietitians can be limited - other members of the multidisciplinary team should therefore initiate advice where possible to optimise intake.
Nutritional intervention with ONS can improve energy and protein intake and reduce weight loss in cancer60-63, improve QoL in patients who are malnourished and may also result in cost savings 55,62,64,65. Systematic reviews and NICE Clinical Guidance (CG32) indicate the clinical efficacy and cost effectiveness of ONS in the management of malnutrition, particularly in those patients with a low Body Mass Index (BMI<20kg/m2) 51,54,65-67. ONS are energy-dense preparations which have demonstrated efficacy in improving nutritional outcomes when administered alongside dietary counselling18
There are a wide range of ONS styles (milkshake, juice, yogurt, savoury), formats (liquid, powder, pudding, pre-thickened), types (high protein, low volume, fibre containing,) energy densities (1-2.4kcal/ml) and flavours available to suit a wide range of patient needs. Most ONS provide approximately 300kcal, 12g protein and a full range of vitamins and minerals per serving68. Many patients requiring ONS can be managed using 1.5-2.4 kcal/ml. The amount of fluid in a standard ONS is approximately 200ml; however, for those with a small appetite and/or those who are breathless or who have difficulty drinking larger volumes of fluid, there are more concentrated supplements available which contain the same amount of nutrition, but in a lower volume e.g. 125ml rather than 200 ml. Further information on types of ONS available can be found HERE
When commencing ONS the considerations outlined below are important:
If a patient has been discharged from hospital on a specific ONS, it is advisable to contact the dietetic department before switching products as there may be clinical and patient-centred reasons determining the choice as well as predicted adherence. Seek clarity from the professional recommending the ONS on the goals of treatment, likely duration and who is responsible for review and monitoring70. Whilst switching products may bring short term cost savings, the merit of this should be weighed against meeting the patient’s specific needs and supporting adherence to manage their malnutrition effectively, which can include avoiding hospital admissions/re-admissions and GP visits, all of which affects the patient’s QoL70, as well as increasing costs to the wider healthcare economy.
A number of nutritional supplements are available for self-purchase in supermarkets, pharmacies and online. Consider how accessible these may be to patients.
Before recommending powdered ONS to patients consider the following73:
If there is concern with the above, then a ready-made ONS may be more appropriate.
Further nutrition information and advice for patients with cancer and their carers is available to download HERE. This includes practical tips for eating and managing common symptoms, advice on managing a poor appetite and how to get the most out of oral nutritional supplements if they are prescribed.
Enteral nutrition (EN), or enteral tube feeding (ETF), is indicated if oral nutrition remains inadequate (less than <60% of nutritional requirements)19 despite nutritional intervention (nutritional counselling, ONS)18,20. Such inadequate intake may occur in patients with tumours that impair oral intake, digestion and absorption in the upper gastrointestinal (GI) tract27. ETF may be delivered through trans-nasal (nasogastric or nasojejunal tube) or percutaneous endoscopic, radiologically inserted, surgical gastrostomy or jejunostomy route21. ETF may be given preoperatively, both European and American guidelines recommend immune-enhancing formulas in cancer patients undergoing major head-neck or abdominal surgery 8,54,74. Postoperatively, ETF is recommended for patients who are malnourished at the time of resection, in those who cannot reinitiate oral nutrition early, or in those who have inadequate food intake for more than 10 days21. All ETF patients should be under the care of a dietitian and ideally a nutrition nurse too.
Parenteral nutrition (PN) is indicated in patients receiving cancer therapy who are facing a period of over 7 days of inadequate energy intake when nutritional counselling, ONS or EFT are not feasible, contraindicated or are ineffective due to impaired GI functionality8,19,21,75. PN is administered intravenously, requiring a catheter in order to administer nutritional preparations. The National Institute for Health and Care Excellence (NICE) recommend that PN should be introduced progressively, closely monitored and should cease as soon as a patient has received their nutritional recommendations orally or enterally51.
PN may be administered at home (HPN), in suitable patients in whom their cognitive and physical wellbeing, life expectancy (over 2–3 months) and home environment has been assessed and deemed suitable19,27. HPN has a positive impact on health care costs, mainly by reducing the number and length of hospitalisations76.
While PN may improve patient QoL and functionality, its administration should be considered with caution. Routine use is strongly not recommended21 and all HPN patients should be under the care of a nutrition team.
The Managing Adult Malnutrition in the Community pathway provides GUIDANCE AND RESOURCES that are appropriate for use in patients with cancer.
A selection of publications for use by healthcare professionals, patients and carers are available in the resources section of the website.
A number of resources are available that have been developed to support patients and carers.
A number of resources are available that have been developed to assist healthcare professionals supporting patients at risk of malnutrition as a result of a specific condition. These include:
We can be contacted regarding the malnutrition pathway materials and website
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