November 2016 Issue

Combating Cancer Malnutrition
By Suzanne Dixon, MPH, MS, RDN
Today's Dietitian
Vol. 18, No. 11, P. 42

Part One of a Two-Part Series

Learn about the special nutrition needs of patients
and strategies for symptom management.

Cancer treatment can have a profound impact on a patient's nutrition status. Even more concerning is that the reverse is true as well: Poor and declining nutrition status can have profound impacts on cancer treatment and, therefore, on patient outcomes. In fact, malnutrition is such an important contributor to poor prognosis that data support the inclusion of nutrition screening as a formal component of survival prognostication for several tumor types.1,2

Individuals in cancer treatment may experience a broad spectrum of nutrition impact symptoms, such as anorexia, nausea, vomiting, pain, mouth soreness, taste and smell changes, lack of appetite, constipation, diarrhea, early satiety, anxiety, and depression. These symptoms impede oral intake and, depending on the type of cancer, may impact cancer patients well beyond what they envision. Some patients are at risk of weight loss and malnutrition, while others may struggle with weight gain. Obesity, often seen as a sign of "room to spare" in terms of weight loss, actually may increase malnutrition risk during cancer treatment.3,4 Furthermore, the varied nature of nutrition impact symptoms can contribute to a failure to meet nutrition needs during cancer treatment. From lack of appetite to taste changes, mucositis to fatigue, and everything in between, there's no such thing as a typical cancer patient anymore. Given these challenges, every cancer patient should receive an RD consultation—ideally with a person who has experience in oncology, such as a certified specialist in oncology nutrition (CSO).

Unfortunately, many patients don't have adequate access to an oncology-focused RD, or in many cases, any RD. This is why every dietitian must be well versed in the basics of cancer care. With an estimated 1.69 million new cancer cases expected to be diagnosed in 2016, and around 15.5 million cancer survivors presently in the United States, this is one of the fastest-growing chronic disease patient groups.5,6 Regardless of the area of specialization, every dietitian is likely to consult with a cancer patient at some point in his or her career.

Mind the Gap
Unlike previous generations, about 90% of cancer patients today receive treatment in outpatient cancer centers and clinics.7 This means individuals in active cancer care no longer are guaranteed to be screened for malnutrition, let alone treated for it. Inpatients must be screened for nutrition status within 24 hours of admittance into a hospital to meet standards set by The Joint Commission on Accreditation of Healthcare Organizations.8 Ambulatory nutrition care standards, however, are ambiguous, inconsistently applied, and lack an enforcement mechanism. Access to oncology nutrition care is left to the discretion of outpatient oncology treatment facilities or to individual health care providers. The result? Many individuals treated in outpatient cancer centers have no access to oncology nutrition services. This means the burden of providing cancer-specific nutrition care to affected individuals falls to all RDs in practice today.

What to Expect
Most people who have read about cancer are aware that cancer specialists and researchers don't consider cancer to be a single disease. The more we learn about it, the more we realize no two cancers are alike. This is certainly true between tumor types; breast cancer is very different from lung cancer, and these cancers are nothing like prostate or pancreatic cancers. It's also true even among patients with the same tumor type. There can be vast differences in how each tumor responds to treatment or what treatment may be best. When planning treatment, the oncologist may consider factors such as tumor genetics to be more important than the organ or tissue in which the cancer originated. Because cancer itself is such a heterogeneous collection of diseases, treatments also are quite variable. This, in turn, means nutrition impact symptoms also vary from person to person.

The costs of failing to detect and treat malnutrition are high for patients. A comprehensive review published in the Academy of Nutrition and Dietetics Evidence Analysis Library noted poor nutrition status is associated with increased morbidity, and that weight loss, malnutrition, sarcopenia, cachexia, and fatigue are associated with increased mortality.9 In addition, malnutrition decreases the likelihood of receiving the full course of treatment, reduces quality of life and functional status, increases the risk of unplanned and longer hospital admissions, contributes to more severe treatment side effects and dose-limiting toxicities, and boosts cancer recurrence risk.2,10-25

Looks Can Be Deceiving
What's important for dietitians to note is that a patient's outward appearance can be deceiving. A patient who appears "overnourished" on a quick visual examination or falls into the obese BMI category may seem to be at lower risk of malnutrition than a slim person. However, the overweight patient may be at high risk of malnutrition, even though they seem to have excess nutritional stores. In fact, several studies have demonstrated that obesity itself may be a risk factor for more severe malnutrition.2,26-29 In other words, an overweight or obese patient who loses weight unintentionally during cancer treatment may have a higher risk of malnutrition-related poor outcomes compared with a normal-weight patient who loses weight. Data show that regardless of BMI, weight loss, low muscle mass index, and loss of lean body mass all predict poorer survival.2 Obesity offers no protection against malnutrition, and for this reason, it's vitally important to screen every patient for malnutrition and assess each person's current nutrition status. Without a proper malnutrition screening tool in place, individual practitioners' biases and prejudices regarding what malnutrition looks like can hinder timely and appropriate delivery of nutrition care to the oncology population.

Team Effort
Some patient populations, including individuals with head and neck, gastric, esophageal, advanced ovarian, small bowel, and pancreatic cancers, are likely to need more intensive nutrition intervention. This may include enteral nutrition support, enzyme replacement therapy, or total parenteral nutrition. In these cases, early intervention, and even prophylactic placement of feeding tubes may be considered. A detailed discussion of each of these modalities is beyond the scope of this article; however, RDs should be aware of these options and be ready to pursue them should the patient's nutrition status require them.

For many others, simple nutrition interventions will provide adequate support to prevent or limit malnutrition. It's vital to understand, however, that if symptoms are severe (eg, uncontrolled vomiting or diarrhea), dietitians must consult the medical care team. The best nutrition advice, support, and therapy will be useless if the patient is affected by severe symptoms and side effects. Failure to properly manage severe symptoms medically can lead to dehydration requiring IV fluids, bowel obstructions, fluid and electrolyte imbalances, and other serious events requiring hospitalization. Once severe symptoms are managed medically, remaining nutrition impact symptoms are more likely to respond to appropriate nutrition intervention.

Document Appropriately
To ensure optimal communication with the entire medical team, RDs should use appropriate malnutrition-related diagnostic language in chart notes, letters, and forms. Many facilities use standard Nutrition Care Process language to detail the nutrition-related diagnosis, and they practice the following problem, etiology, signs, and symptoms (PES) format:

• the nutrition diagnosis, or the nutrition problem, as related to (r/t);
• the etiology, or the cause of the nutrition problem/diagnosis, as evidenced by (AEB); and
• the signs and symptoms, or the data to support the nutrition diagnosis.

For example, a PES may look as follows: "Severe protein-energy malnutrition in the context of nasopharyngeal cancer, living alone, and lack of family support, r/t poor appetite, dysphagia, dysgeusia, and failure to meet nutrition needs, AEB 10 lb (5%) weight loss in two weeks, and estimated intake <50% of needs."

Key components in this PES statement include the degree (severe) and type (protein-energy) of malnutrition, the context in which the problems are occurring (complicating factors), the cause (r/t) of the malnutrition diagnosis (symptoms), and the data (AEB) to support that diagnosis.

Taking a few extra moments to provide a concise PES statement will help the entire team understand the scope of the problem and the rationale for nutrition intervention.

Symptom Management Specifics
Working with a health care team to ensure symptom management among patients also is important. Some of the following symptom management recommendations were created by Laura Elliott, MPH, RD, CSO, LD, who authored the book Oncology Nutrition for Clinical Practice,30 a primary reference regarding nutrition and cancer. This list isn't all-inclusive but is provided as an example of starting points for RDs unfamiliar with oncology care.

While some tips may seem self-evident, they're included because often they arise when working with cancer patients. "Take medications exactly as prescribed," seems obvious; however, many patients either don't understand how to take their symptom management medications or try to avoid taking them. For example, a patient may want to "take laxatives only if I need them," failing to understand that preventing medication-induced constipation is much easier than managing it once the problem arises. Many symptom management medications work optimally when taken prophylactically.

Dietitians shouldn't advise patients on medication use, as this is beyond scope of practice, but simply asking the patient about which medications have been prescribed and why can alert RDs to medication adherence issues. A referral back to the medical team for additional medication education may be critical for ensuring optimal symptom management. Here's how RDs can counsel patients during cancer treatment to help them manage common symptoms.

Nausea
• Eat five to six small meals and snacks per day.
• Stick to low-odor, bland foods, such as oatmeal, rice or rice porridge, cream of wheat, scrambled eggs, yogurt, dry cereal, toast, plain noodles/pasta, plain chicken, potatoes, and sweet potatoes.
• Drink liquids, smoothies, or oral nutrition supplements in a covered "to go" mug to limit exposure to food odors.
• Sit up or keep the head of the bed raised for at least one hour after eating.
• Separate liquids and solid foods by 15 to 30 minutes; take additional fluids between meals and snacks.
• Drink adequate fluids throughout the day by sipping small amounts frequently; avoid large fluid volumes.
• Sip ginger tea or suck on ginger candies.
• Consult with the medical team to address medical issues such as delayed gastric emptying or excessive acid production.
• Consider acupuncture, a proven way to reduce chemotherapy-related nausea.

Poor Appetite, Early Satiety, and Anorexia
• Eat by the clock rather than wait for hunger cues.
• Keep easy, handy foods available; try crackers, oatmeal, yogurt, cold cooked chicken, precooked hard-boiled eggs for quick availability, smoothies, and oral nutrition supplements.
• Eat immediately if appetite returns, as it may last only a few minutes.
• Reduce stress at meal times. For example, don't talk finances when you're trying to eat.
• Take the pressure off of eating by finding nonfood-related ways to socialize.
• Keep nonperishable snacks in a purse, briefcase, backpack, or bag.
• Engage in light physical activity to stimulate appetite.
• Manage pain, nausea, constipation, depression, anxiety, and other issues that may interfere with eating; refer to the medical team, support groups, or therapy as appropriate.

Constipation
• Take bowel-management medications exactly as prescribed.
• Drink adequate amounts of fluids; aim for pale yellow/straw-colored urine (unless darker color is caused by medication).
• Try warm beverages, such as coffee in the morning (if caffeine isn't being limited due to treatment) and tea (caffeinated, such as black or green tea, if allowed, or noncaffeinated or herbal) during the day.
• If not on a prescribed low-residue or low-fiber diet for preexisting gastrointestinal issues, gradually increase fiber up to 25 to 35 g daily. Use fiber products or supplements if needed, but drink adequate amounts of fluids; fiber (particularly fiber supplements) without fluids worsens constipation.
• Advise patients to contact their health care team if they have no bowel movement for three days; this can signal a serious problem, such as a bowel obstruction.

Diarrhea
• Take antidiarrheal medications exactly as prescribed.
• Drink adequate amounts of fluids to avoid dehydration, but avoid sugary beverages (soda, juice, punch), which can worsen diarrhea.
• Take fluids throughout the day by sipping small amounts frequently; avoid large fluid volumes.
• Focus on soluble fiber, the type of fiber in "sticky" foods such as oats and oatmeal, bananas, mashed potatoes, natural applesauce (no added sugar), well-cooked and mashed lentils, pears (without the skin), barley, and white rice.
• Avoid caffeine and alcohol.
• Eat small, frequent meals to avoid overloading the gastrointestinal tract.
• Avoid sugar alcohols (sorbitol, xylitol, and other "-ols," found in sugarless gum and candy).
• Try eliminating dairy; some patients develop lactose intolerance (usually temporarily) during treatment.

Mouth Sores
• Use mouth rinses exactly as prescribed.
• Eat soft, bland foods, such as soups, cooked cereals, oatmeal, pasta without tomato sauce (acidic foods irritate the mouth), egg noodles, or scrambled eggs.
• Try smoothies, oral nutrition supplements, puddings, yogurt, and casseroles.
• Avoid irritating spices and flavorings (chili, horseradish, or anything hot, spicy, or peppery).
• Avoid alcohol and tobacco.
• Avoid acidic foods, citrus, tomato products, and pickled and vinegar-preserved items.
• Ask about pain management options if mouth sores are preventing the patient from eating.
• Try foods that are lukewarm instead of hot (thoroughly cooked, then cooled, for food safety).
• Try cold foods, such as frozen grapes, watermelon, or melon balls. (Don't recommend this if the patient is advised to avoid cold—some chemotherapy medications cause severe cold sensitivity.)
• Avoid rough, dry foods such as crackers, toast, and raw vegetables.
• Use a blender or food processor to mix foods for easier eating.

Dysphagia (Pain/Difficulty Swallowing)
• If receiving radiation therapy to the head or neck, pay special attention to difficulty swallowing. This can indicate a serious problem and may increase aspiration risk; refer for evaluation by a speech language therapist, as needed.
• Sit up straight and use good posture when eating (slouching can worsen aspiration risk).
• Limit talking and distractions while eating; these may increase choking risk.
• Eat moist foods of a similar texture so you end up with one cohesive "bolus"; avoid combining liquids with hard solids, which increases risk of choking or aspiration.
• Try low-acid smoothies. Blenderize fruits such as melons, bananas, and peaches with yogurt, milk, or tofu.

Taste and Smell Changes
• Foods have little to no taste: Try fruit marinades for meats; use lemon, herbs, and spices (if no mouth sores are present).
• Foods have "off" taste: Try fruity and salty flavors; flavor water with lemon or cucumber.
• Bitter or metallic tastes: Try spices and seasonings, such as fresh basil and oregano, or rosemary and thyme; try fruit marinades for meats; use plastic or bamboo utensils to eat.
• Foods too salty, bitter, or acidic: Try sweet flavors, and use low-sodium products; do not cook with salt.
• Meats taste bitter or "off": Try fruit marinades or sweet/sour sauces; try nonmeat protein sources such as nuts and nut butters, eggs, tofu, and beans.
• Consider zinc: Short-term, high-dose zinc supplementation may improve taste, but do not do this without consulting the health care team.
• Refer as needed: Presence of a mouth infection or thrush will affect sense of taste; prompt antibiotic or antifungal treatment is required to resolve.
Weight Loss
• Focus on high-calorie, high-protein food options, such as smoothies with a scoop of protein powder, oral nutrition supplements, foods with extra olive oil added for calories, nuts and nut butters, casseroles, and stews.
• Avoid or limit no-calorie beverages such as tea, coffee, diet soda, diet juice drinks, or other drinks.
• Address all other symptoms with the medical care team and with a dietitian. Symptoms should be well managed to reduce weight loss.

Weight Gain
• Consider factors contributing to overeating, such as eating because of stress, boredom, anxiety, and for comfort; consider support groups and therapy options to cope more effectively.
• Try to get regular, moderate physical activity every day. Walking and light resistance training are options for most people.
• Avoid liquid calories, which aren't as satisfying as solid foods.
• Focus on a healthful, plant-based diet centered on vegetables, fruits, legumes (beans, peas, lentils), nuts and seeds, and whole grains.
• Other health care providers should refer patients to a dietitian or healthful-eating weight management program (allow no restrictive diets or crash dieting). As the RD, ensuring that this referral process is in place is imperative to reaching the patient population coping with unintended weight gain.
• Focus on health, not weight; regular physical activity and a healthful diet will improve health regardless of whether the patient loses weight.

Practice Realities
These strategies for managing select symptoms and side effects of cancer and its treatment only scratch the surface. Ideally, every patient affected by cancer should have access to an RD specializing in oncology nutrition. This nutrition professional is well-positioned to tackle more acute nutrition issues, including malabsorption, vitamin and mineral deficiencies, weight loss or gain, and appropriate use of enteral and parenteral nutrition. Until the day comes when all cancer patients are working with oncology dietitians, RDs who don't specialize in oncology may find themselves to be the ones who serve as the resource for keeping a cancer patient on treatment, out of the hospital, and on their way to a healthier, and hopefully cancer-free, future.

— Suzanne Dixon, MPH, MS, RDN, is a dietitian and epidemiologist best known as the creator of an award-winning cancer nutrition website. She has received numerous awards from the Academy of Nutrition and Dietetics, and has authored journal articles, textbook chapters, and consumer health publications. She runs her own consulting business in Portland, Oregon.


References
1. Gu W, Zhang G, Sun L, et al. Nutritional screening is strongly associated with overall survival in patients treated with targeted agents for metastatic renal cell carcinoma. J Cachexia Sarcopenia Muscle. 2015;6(3):222-230.

2. Martin L, Birdsell L, Macdonald N, et al. Cancer cachexia in the age of obesity: skeletal muscle depletion is a powerful prognostic factor, independent of body mass index. J Clin Oncol. 2013;31(12):1539-1547.

3. Gioulbasanis I, Martin L, Baracos VE, Thézénas S, Koinis F, Senesse P. Nutritional assessment in overweight and obese patients with metastatic cancer: does it make sense? Ann Oncol. 2015;26(1):217-221.

4. Anandavadivelan P, Brismar TB, Nilsson M, Johar AM, Martin L. Sarcopenic obesity: a probable risk factor for dose limiting toxicity during neo-adjuvant chemotherapy in oesophageal cancer patients. Clin Nutr. 2016;35(3):724-730.

5. American Cancer Society. Cancer facts & figures 2016. http://www.cancer.org/acs/groups/content/@research/documents/document/acspc-047079.pdf. Published 2016. Accessed July 25, 2016.

6. Simon S. ACS report: number of US cancer survivors expected to exceed 20 million by 2026. American Cancer Society website. http://www.cancer.org/cancer/news/news/report-number-of-cancer-survivors-continues-to-grow. Published June 2, 2016.

7. Halpern MT, Yabroff KR. Prevalence of outpatient cancer treatment in the United States: estimates from the Medical Panel Expenditures Survey (MEPS). Cancer Invest. 2008;26(6):647-651.

8. Nutritional and functional screening — requirement. The Joint Commission website. https://www.jointcommission.org/standards_information/jcfaqdetails.aspx?StandardsFaqId=872&ProgramId=46. Accessed April 25, 2015.

9. Academy of Nutrition and Dietetics. Oncology (ONC) guideline (2007). http://andevidencelibrary.com/topic.cfm?cat=2819. Accessed August 25, 2015.

10. Ravasco P, Monteiro-Grillo I, Vidal PM, Camilo ME. Dietary counseling improves patient outcomes: a prospective, randomized, controlled trial in colorectal cancer patients undergoing radiotherapy. J Clin Oncol. 2005;23(7):1431-1438.

11. Ravasco P, Monteiro-Grillo I, Camilo M. Individualized nutrition intervention is of major benefit to colorectal cancer patients: long-term follow-up of a randomized controlled trial of nutritional therapy. Am J Clin Nutr. 2012;96(6):1346-1353.

12. Isenring EA, Capra S, Bauer JD. Nutrition intervention is beneficial in oncology outpatients receiving radiotherapy to the gastrointestinal or head and neck area. Br J Cancer. 2004;91(3):447-452.

13. Rock CL. Dietary counseling is beneficial for the patient with cancer. J Clin Oncol. 2005;23(7):1348-1349.

14. Halfdanarson TR, Thordardottir E, West CP, Jatoi A. Does dietary counseling improve quality of life in cancer patients? A systematic review and meta-analysis. J Support Oncol. 2008;6(5):234-237.

15. Lee H, Cho YS, Jung S, Kim H. Effect of nutritional risk at admission on the length of hospital stay and mortality in gastrointestinal cancer patients. Clin Nutr Res. 2013;2(1):12-18.

16. Silver HJ, de Campos Graf Guimaraes C, Pedruzzi P, et al. Predictors of functional decline in locally advanced head and neck cancer patients from south Brazil. Head Neck. 2010;32(9):1217-1225.

17. Andreyev HJ, Norman AR, Oates J, Cunningham D. Why do patients with weight loss have a worse outcome when undergoing chemotherapy for gastrointestinal malignancies? Eur J Cancer. 1998;34(4):503-509.

18. Lis CG, Gupta D, Lammersfeld CA, Markman M, Vashi PG. Role of nutritional status in predicting quality of life outcomes in cancer — a systematic review of the epidemiological literature. Nutr J. 2012;11:27.

19. Gupta D, Vashi PG, Lammersfeld CA, Braun DP. Role of nutritional status in predicting the length of stay in cancer: a systematic review of the epidemiological literature. Ann Nutr Metab. 2011;59(2-4):96-106.

20. Laky B, Janda M, Kondalsamy-Chennakesavan S, Cleghorn G, Obermair A. Pretreatment malnutrition and quality of life — association with prolonged length of hospital stay among patients with gynecological cancer: a cohort study. BMC Cancer. 2010;10:232.

21. Malietzis G, Aziz O, Bagnall NM, Johns N, Fearon KC, Jenkins JT. The role of body composition evaluation by computerized tomography in determining colorectal cancer treatment outcomes: a systematic review. Eur J Surg Oncol. 2015;41(2):186-196.

22. Barret M, Antoun S, Dalban C, et al. Sarcopenia is linked to treatment toxicity in patients with metastatic colorectal cancer. Nutr Cancer. 2014;66(4):583-589.

23. Antoun S, Borget I, Lanoy E. Impact of sarcopenia on the prognosis and treatment toxicities in patients diagnosed with cancer. Curr Opin Support Palliat Care. 2013;7(4):383-389.

24. Antoun S, Baracos VE, Birdsell L, Escudier B, Sawyer MB. Low body mass index and sarcopenia associated with dose-limiting toxicity of sorafenib in patients with renal cell carcinoma. Ann Oncol. 2010;21(8):1594-1598.

25. Prado CM, Baracos VE, McCargar LJ, et al. Sarcopenia as a determinant of chemotherapy toxicity and time to tumor progression in metastatic breast cancer patients receiving capecitabine treatment. Clin Cancer Res. 2009;15(8):2920-2926.

26. Dalal S, Hui D, Bidaut L, et al. Relationships among body mass index, longitudinal body composition alterations, and survival in patients with locally advanced pancreatic cancer receiving chemoradiation: a pilot study. J Pain Symptom Manage. 2012;44(2):181-191.

27. Baracos VE, Reiman T, Mourtzakis M, Gioulbasanis I, Antoun S. Body composition in patients with non-small cell lung cancer: a contemporary view of cancer cachexia with the use of computed tomography image analysis. Am J Clin Nutr. 2010;91(4):1133S-1337S.

28. Tan BH, Birdsell LA, Martin L, Baracos VE, Fearon KC. Sarcopenia in an overweight or obese patient is an adverse prognostic factor in pancreatic cancer. Clin Cancer Res. 2009;15(22):6973-6979.

29. Prado CM, Lieffers JR, McCargar LJ, et al. Prevalence and clinical implications of sarcopenic obesity in patients with solid tumours of the respiratory and gastrointestinal tracts: a population-based study. Lancet Oncol. 2008;9(7):629-635.

30. Elliott L. Symptom management of cancer therapies. In: Leser M, Ledesma N, Bergerson S, Trujillo E. eds. Oncology Nutrition for Clinical Practice. Oncology Nutrition Dietetic Practice Group of the Academy of Nutrition and Dietetics; 2013:115-121.

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