Christine Baldwin

Oral Nutritional Interventions in Malnourished Patients With Cancer: A Systematic Review and Meta-Analysis

BACKGROUND International guidelines on the nutritional management of patients with cancer recommend intervention with dietary advice and/or oral nutritional supplements in patients who are malnourished or those judged to be at nutritional risk, but the evidence base for these recommendations is lacking. We examined the effect of oral nutritional interventions in this population on nutritional and clinical outcomes and quality of life (QOL). METHODS Electronic searches of several databases including MEDLINE, EMBASE, and CINAHL (from the first record to February 2010) were searched to identify randomized controlled trials of patients with cancer who were malnourished or considered to be at risk of malnutrition and receiving oral nutritional support compared with routine care. We performed a meta-analysis using a fixed effect model, or random effects models when statistically significant heterogeneity was present, to calculate relative risk (mortality) or mean difference (weight, energy intake, and QOL) with 95% confidence intervals (CIs). Heterogeneity was determined by using the χ(2) test and the I(2) statistic. All statistical tests were two-sided. RESULTS Thirteen studies were identified and included 1414 participants. The quality of the studies varied, and there was considerable clinical and statistical heterogeneity. Nutritional intervention was associated with statistically significant improvements in weight and energy intake compared with routine care (mean difference in weight = 1.86 kg, 95% CI = 0.25 to 3.47, P = .02; and mean difference in energy intake = 432 kcal/d, 95% CI = 172 to 693, P = .001). However, after removing the main sources of heterogeneity, there was no statistically significant difference in weight gain or energy intake. Nutritional intervention had a beneficial effect on some aspects of QOL (emotional functioning, dyspnea, loss of appetite, and global QOL) but had no effect on mortality (relative risk = 1.06, 95% CI = 0.92 to 1.22, P = .43; I(2) = 0%; P(heterogeneity) = .56). CONCLUSION Oral nutritional interventions are effective at increasing nutritional intake and improving some aspects of QOL in patients with cancer who are malnourished or are at nutritional risk but do not appear to improve mortality.

Symptoms and weight loss in patients with gastrointestinal and lung cancer at presentation

IntroductionWeight loss is an independent prognostic factor for decreased survival in cancer patients. The effectiveness of treatment is impaired in patients with weight loss. The aetiology of this weight loss is complex and poorly characterised. Decreased calorie intake may be important. The reasons for decreased intake are unknown.Aims and methodsTo determine in adult patients with cancer, who had not started chemotherapy or radiotherapy, the prevalence of symptoms which carry a risk to nutritional status and how these relate to weight loss, tumour burden and primary tumour site. New patients referred for treatment of any form of gastrointestinal (GI) cancer, non-small cell lung cancer or lung mesothelioma completed a validated questionnaire recording symptoms contributing to weight loss (Patient-generated Subjective Global Assessment—PG-SGA). In a subset of patients without metastatic disease, computed tomography scans were assessed to determine tumour burden.ResultsBetween August and October 2004, 122 patients with GI and 29 with lung cancers were recruited. There were 48% of GI and 28% of lung cancer patients who had lost weight. Sixty-two percent of the patients had one or more symptoms at presentation. The frequency of symptoms varied according to the site of disease. The most common symptom at all tumour sites was loss of appetite (38%). There was a weak but significant correlation between the number of symptoms and amount of weight loss (r=0.347). Patients reporting a reduced food intake had more symptoms than patients who had not lost weight. Tumour burden did not correlate with weight loss.ConclusionThe symptoms in cancer patients occur across different types of primary tumours, may affect food intake and have a part in causing weight loss. More information on the role of symptom management in improving nutritional status is needed.

The views and practice of oncologists towards nutritional support in patients receiving chemotherapy

Malnutrition in patients with cancer is common and an adverse prognostic indicator. A questionnaire answered by 357 (72%) UK specialist oncological trainees suggests that they lack the ability to identify factors that place patients at risk from malnutrition. Major barriers to effective nutritional practice included lack of guidelines, knowledge and time.

Role of nutritional intervention in patients treated with radiotherapy for pelvic malignancy

Up to 12 000 patients with gynaecological, urological and rectal cancer undergo radical pelvic radiotherapy annually in the UK. More than 70% develop acute inflammatory changes causing gastrointestinal symptoms during treatment because healthy bowel tissue is encompassed in the radiation field. In total, 50% go on to develop chronic bowel symptoms, which affect quality of life due to permanent changes in the small and large intestine. Nutritional intervention may influence acute and chronic bowel symptoms but the validity of the advice given to patients is not clear. To assess the incidence and significance of malnutrition and to examine the efficacy of therapeutic nutritional interventions used to manage gastrointestinal side effects in patients undergoing pelvic radiotherapy and those with chronic bowel side effects after treatment, a critical review of relevant original studies on human subjects was carried out using a specific set of mesh terms in MEDLINE and EMBASE databases and the Cochrane Library in September 2003. Full texts of all relevant articles were collected and reference lists were checked. Sources of grey literature including conference abstracts and web-based information were also reviewed. A total of 36 papers published in peer-reviewed journals between 1966 and 2003 were identified. In all, 14 randomised controlled trials, 12 prospective cohorts, four retrospective, two qualitative, one validation, one pilot study and two case reports were obtained. These included 2646 patients. Eight articles including three conference abstracts and web-based information were found. None of the studies was definitive because of weakness in methodology. No studies could be combined because the interventions and the end points were different. There is no evidence base for the use of nutritional interventions to prevent or manage bowel symptoms attributable to radiotherapy. Low-fat diets, probiotic supplementation and elemental diet merit further investigation.

A review of the evidence for the impact of improving nutritional care on nutritional and clinical outcomes and cost.

BACKGROUND The association between malnutrition and poor clinical outcome is well-established, yet most research has focussed on the role of artificial nutritional support in its management. More recently, emphasis has been placed on the provision of adequate nutritional care, including nutritional screening and the routine provision of food and drink. The aim of this literature review is to establish the evidence for the efficacy of interventions that might result in improvements in nutritional and clinical outcomes and costs. METHODS A structured literature review was conducted investigating the role of nutritional care interventions in adults, and their effects on nutritional and clinical outcomes and costs, in all healthcare settings. Ten databases were searched electronically using keywords relating to nutritional care, patient outcomes and healthcare costs. High quality trials were included where available. RESULTS Two hundred and ninety-seven papers were identified and reviewed. Of these, only two randomised, controlled trials and six other trials were identified that addressed the major issues. A further 99 addressed some aspects of the provision of nutritional care, although very few formally evaluated nutritional or clinical outcomes and costs. CONCLUSIONS This review reveals a serious lack of evidence to support interventions designed to improve nutritional care, in particular with reference to their effects on nutritional and clinical outcomes and costs. The review suggests that screening alone may be insufficient to achieve beneficial effects and thus more research is required to determine the most cost-effective interventions in each part of the nutritional care pathway, in a variety of healthcare settings and across all age ranges, to impact upon nutritional and clinical outcomes.

Simple nutritional intervention in patients with advanced cancers of the gastrointestinal tract, non-small cell lung cancers or mesothelioma and weight loss receiving chemotherapy: a randomised controlled trial

BACKGROUND Weight loss in patients with cancer is common and associated with a poorer survival and quality of life. Benefits from nutritional interventions are unclear. The present study assessed the effect of dietary advice and/or oral nutritional supplements on survival, nutritional endpoints and quality of life in patients with weight loss receiving palliative chemotherapy for gastrointestinal and non-small cell lung cancers or mesothelioma. METHODS Participants were randomly assigned to receive no intervention, dietary advice, a nutritional supplement or dietary advice plus supplement before the start of chemotherapy. Patients were followed for 1 year. Survival, nutritional status and quality of life were assessed. RESULTS In total, 256 men and 102 women (median age, 66 years; range 24-88 years) with gastrointestinal (n = 277) and lung (n = 81) cancers were recruited. Median (range) follow-up was 6 (0-49) months. One-year survival was 38.6% (95% confidence interval 33.3-43.9). No differences in survival, weight or quality of life between groups were seen. Patients surviving beyond 26 weeks experienced significant weight gain from baseline to 12 weeks, although this was independent of nutritional intervention. CONCLUSIONS Simple nutritional interventions did not improve clinical or nutritional outcomes or quality of life. Weight gain predicted a longer survival but occurred independently of nutritional intervention.

Dietary counselling with or without oral nutritional supplements in the management of malnourished patients: a systematic review and meta-analysis of randomised controlled trials.

Dietary counselling and oral nutritional supplements (ONS) are recommended for managing malnutrition. A recent systematic review demonstrated (in separate analyses) that dietary counselling and dietary counselling with ONS improved energy intake, weight and some indices of body composition, although there was considerable heterogeneity. The present analysis aimed to examine the effects on mortality and nutritional indices of dietary counselling given with or without ONS and to explore the heterogeneity in the meta-analyses aiming to characterise the groups most likely to benefit from these interventions. A systematic review and meta-analysis was performed using Cochrane methodology. Twenty-six studies were included in the analysis: 12 comparing dietary counselling with usual care and 14 comparing dietary counselling and ONS if required with usual care (2123 participants). Quality of studies varied. Dietary counselling given with or without ONS had no effect on mortality [relative risk (fixed) = 1.12; 95% confidence interval = 0.86-1.46] but was associated with significant but heterogeneous benefits to weight [mean difference (random) = 1.7 kg; 95% confidence interval = 0.86-2.55], energy intake and some aspects of body composition. Subgroup analyses taking into account clinical background, age, nutritional status, type and length of intervention failed to reveal any differences in mortality, weight change and energy intake between groups. There were insufficient data on functional outcomes to explore these findings. Dietary counselling given with or without ONS is effective at increasing nutritional intake and weight but adequately-powered studies in similar patient populations and standardised for factors that might account for variations in response are required.

The effectiveness of nutritional interventions in malnutrition and cachexia

Cancer is a common diagnosis and leading cause of death worldwide. Amounts of weight loss vary but it is associated with considerable morbidity, poorer quality of life and reduced survival. Nutritional intervention has the potential to maximise response to treatment and improve functioning and quality of life. The aim of this paper was to review the evidence for oral nutritional interventions in the management of weight loss in patients with cancer. Comparison of studies of nutritional support interventions in people with cancer is complicated by variations in understanding of what constitutes a compromised nutritional status. There are similarities and differences between definitions of both malnutrition and cachexia and studies of oral nutritional interventions have failed to use standard criteria at study inclusion contributing to heterogeneity amongst studies. Meta-analysis of randomised controlled trials has suggested limited evidence of benefit to nutritional and clinical outcomes but some improvements to aspects of quality of life. The presence of cachexia in patients with cancer might explain the limited efficacy of simple oral nutritional interventions, which lack a component designed to address metabolic abnormalities associated with cachexia. Novel strategies combining nutritional support with therapeutic agents designed to down-regulate the metabolic aberrations have failed to demonstrate consistent benefits and the results of multimodal treatments combining several interventions are awaited. There is a need for intervention studies recruiting patients early in the disease course, which underlines the need for definitions which predict poor outcome and hence allow early recognition of vulnerable patients.

Clinical trial: normal diet vs. partial replacement with oral E028 formula for the prevention of gastrointestinal toxicity in cancer patients undergoing pelvic radiotherapy

Background  Acute gastrointestinal symptoms affect 90% of patients during pelvic radiotherapy. Elemental diet is protective in animal models. A nonrandomized study suggested benefit from a partial elemental diet. A pilot study suggested that radiotherapy patients only tolerate oral elemental diet comprising one‐third of total calories for 3 weeks.

Nutritional intervention as part of functional rehabilitation in older people with reduced functional ability: a systematic review and meta-analysis of randomised controlled studies

BACKGROUND Nutritional intervention is increasingly recognised as having an important role in functional rehabilitation for older people. Nonetheless, a greater understanding of the functional benefit of nutritional interventions is needed. METHODS A systematic review and meta-analysis examined randomised controlled trials (RCTs) published between 2007 and 2014 with the aim of determining whether nutritional intervention combined with rehabilitation benefited older people with reduced functional ability. Six electronic databases were searched. RCTs including people aged 65 years and older with reduced physical, social and/or cognitive function were included. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed, and gradepro computer software (http://gradepro.org) was used for the quality assessment of critical and important outcomes. Included studies considered to be clinical homogenous were combined in a meta-analysis. RESULTS Of the 788 studies screened, five were identified for inclusion. Nutritional intervention given with functional rehabilitation improved energy and protein intake, although it failed to provide any improvement in final body weight, hand-grip strength or muscle strength. There was no difference between groups in the critical outcomes; balance, cognition, activities of daily living and mortality at long-term follow-up. Nutritional intervention given with functional rehabilitation was associated with an increased likelihood of both mortality (odds ratio = 1.77; 95% confidence interval = 1.13-2.76) and hospitalisation (odds ratio = 2.29; 95% confidence interval = 1.10-4.79) during the intervention. Meta-analysis of the baseline data showed that, overall, the intervention cohort had a lower body weight and cognition. CONCLUSIONS This meta-analysis highlights concerns regarding the quality of the randomisation of participants at baseline. Future high-quality research is essential to establish whether older people with loss of functional abilities can benefit from nutritional intervention.