Marian A.E. de van der Schueren

ESPEN guidelines on nutrition in cancer patients

Cancers are among the leading causes of morbidity and mortality worldwide, and the number of new cases is expected to rise significantly over the next decades. At the same time, all types of cancer treatment, such as surgery, radiation therapy, and pharmacological therapies are improving in sophistication, precision and in the power to target specific characteristics of individual cancers. Thus, while many cancers may still not be cured they may be converted to chronic diseases. All of these treatments, however, are impeded or precluded by the frequent development of malnutrition and metabolic derangements in cancer patients, induced by the tumor or by its treatment. These evidence-based guidelines were developed to translate current best evidence and expert opinion into recommendations for multi-disciplinary teams responsible for identification, prevention, and treatment of reversible elements of malnutrition in adult cancer patients. The guidelines were commissioned and financially supported by ESPEN and by the European Partnership for Action Against Cancer (EPAAC), an EU level initiative. Members of the guideline group were selected by ESPEN to include a range of professions and fields of expertise. We searched for meta-analyses, systematic reviews and comparative studies based on clinical questions according to the PICO format. The evidence was evaluated and merged to develop clinical recommendations using the GRADE method. Due to the deficits in the available evidence, relevant still open questions were listed and should be addressed by future studies. Malnutrition and a loss of muscle mass are frequent in cancer patients and have a negative effect on clinical outcome. They may be driven by inadequate food intake, decreased physical activity and catabolic metabolic derangements. To screen for, prevent, assess in detail, monitor and treat malnutrition standard operating procedures, responsibilities and a quality control process should be established at each institution involved in treating cancer patients. All cancer patients should be screened regularly for the risk or the presence of malnutrition. In all patients - with the exception of end of life care - energy and substrate requirements should be met by offering in a step-wise manner nutritional interventions from counseling to parenteral nutrition. However, benefits and risks of nutritional interventions have to be balanced with special consideration in patients with advanced disease. Nutritional care should always be accompanied by exercise training. To counter malnutrition in patients with advanced cancer there are few pharmacological agents and pharmaconutrients with only limited effects. Cancer survivors should engage in regular physical activity and adopt a prudent diet.

Common Ground? The Concordance of Sarcopenia and Frailty Definitions.

OBJECTIVES This study aimed to explore the concordance between definitions of sarcopenia and frailty in a clinically relevant population of geriatric outpatients. DESIGN Data were retrieved from a cross-sectional study. SETTING The study was performed in a geriatric outpatient clinic of a middle-sized teaching hospital. PARTICIPANTS The study included 299 geriatric outpatients (mean age 82.4, SD 7.1) who were consecutively referred to the outpatient clinic. MEASUREMENTS Prevalence rates and subsequent concordance evolving from 3 definitions of sarcopenia and 2 definitions of frailty were compared. Definitions of sarcopenia included the European Working Group on Sarcopenia in Older People (gait speed, handgrip strength, muscle mass), International Working Group on Sarcopenia (gait speed, muscle mass) and the definition by Janssen (muscle mass). Definitions of frailty included the Fried frailty phenotype (weight loss, exhaustion, physical inactivity, handgrip strength, walk time) and the definition of Rockwood (use of walking aid, activities of daily living, incontinence, and cognitive impairment). RESULTS Prevalence rates for sarcopenia varied between 17% and 22% and between 29% and 33% for frailty. There was little concordance in intraindividual prevalence rates of sarcopenia and frailty using different definitions. None of the outpatients was classified as having sarcopenia and frailty according to all applied definitions. Outpatients with sarcopenia were more likely to be frail than frail outpatients to be sarcopenic. CONCLUSION This study clearly indicates that sarcopenia and frailty are 2 separate conditions based on the current definitions. It is important to diagnose sarcopenia and frailty as separate entities, as each may require specific treatment.

Clinical and economic outcomes of nutrition interventions across the continuum of care

Optimal nutrition across the continuum of care plays a key role in the short‐ and long‐term clinical and economic outcomes of patients. Worldwide, an estimated one‐quarter to one‐half of patients admitted to hospitals each year are malnourished. Malnutrition can increase healthcare costs by delaying patient recovery and rehabilitation and increasing the risk of medical complications. Nutrition interventions have the potential to provide cost‐effective preventive care and treatment measures. However, limited data exist on the economics and impact evaluations of these interventions. In this report, nutrition and health system researchers, clinicians, economists, and policymakers discuss emerging global research on nutrition health economics, the role of nutrition interventions across the continuum of care, and how nutrition can affect healthcare costs in the context of hospital malnutrition.

The Association between Parameters of Malnutrition and Diagnostic Measures of Sarcopenia in Geriatric Outpatients.

Objectives Diagnostic criteria for sarcopenia include measures of muscle mass, muscle strength and physical performance. Consensus on the definition of sarcopenia has not been reached yet. To improve insight into the most clinically valid definition of sarcopenia, this study aimed to compare the association between parameters of malnutrition, as a risk factor in sarcopenia, and diagnostic measures of sarcopenia in geriatric outpatients. Material and Methods This study is based on data from a cross-sectional study conducted in a geriatric outpatient clinic including 185 geriatric outpatients (mean age 82 years). Parameters of malnutrition included risk of malnutrition (assessed by the Short Nutritional Assessment Questionnaire), loss of appetite, unintentional weight loss and underweight (body mass index <22 kg/m2). Diagnostic measures of sarcopenia included relative muscle mass (lean mass and appendicular lean mass [ALM] as percentages), absolute muscle mass (total lean mass and ALM/height2), handgrip strength and walking speed. All diagnostic measures of sarcopenia were standardized. Associations between parameters of malnutrition (independent variables) and diagnostic measures of sarcopenia (dependent variables) were analysed using multivariate linear regression models adjusted for age, body mass, fat mass and height in separate models. Results None of the parameters of malnutrition was consistently associated with diagnostic measures of sarcopenia. The strongest associations were found for both relative and absolute muscle mass; less stronger associations were found for muscle strength and physical performance. Underweight (p = <0.001) and unintentional weight loss (p = 0.031) were most strongly associated with higher lean mass percentage after adjusting for age. Loss of appetite (p = 0.003) and underweight (p = 0.021) were most strongly associated with lower total lean mass after adjusting for age and fat mass. Conclusion Parameters of malnutrition relate differently to diagnostic measures of sarcopenia in geriatric outpatients. The association between parameters of malnutrition and diagnostic measures of sarcopenia was strongest for both relative and absolute muscle mass, while less strong associations were found with muscle strength and physical performance.

Identifying the Barriers and Enablers to Nutrition Care in Head and Neck and Esophageal Cancers An International Qualitative Study

BACKGROUND The goal of this work was to identify barriers and enablers to the implementation of nutrition care in head and neck and esophageal (HNE) cancers and to prioritize barriers to help improve the nutrition care process. MATERIALS AND METHODS This study used a multimethod qualitative study design (including semistructured interviews, focus group). Interviews (n = 29) were conducted at 5 European sites providing care and treatment to patients with HNE cancers. A focus group (n = 21) reviewed and corroborated interview findings and identified priorities for nutrition care. Participants were healthcare providers and researchers with direct experience in the field of HNE cancer. RESULTS Five themes with accompanying barriers and enablers were identified related to nutrition care: (1) evidence for the benefit of nutrition interventions, (2) implementation of nutrition care processes (assessment, intervention, and follow-up), (3) characteristics of healthcare providers, (4) site factors, and (5) patient characteristics. Focus group discussions identified 2 priorities that must be acted on to improve nutrition care: (1) improve the evidence base and (2) develop standardized nutrition care pathways. CONCLUSION Themes related to nutrition care in HNE cancers were similar between sites, but barriers and enablers differed. Interview and focus group participants agreed the following actions will result in improvements in nutrition care: (1) enhance the evidence base to test the benefit of nutrition interventions, with a focus on resolving specific controversies regarding nutrition therapy, and (2) establish a minimum data set with a goal to create standardized nutrition care pathways where roles and responsibilities for care are clearly defined.

The influence of different muscle mass measurements on the diagnosis of cancer cachexia

Progressive loss of muscle mass is a major characteristic of cancer cachexia. Consensus definitions for cachexia provide different options to measure muscle mass. This study describes the effect of different methods to determine muscle mass on the diagnosis of cancer cachexia. In addition, the association of cachexia with other features of cachexia, quality of life, and survival was explored.

Malnutrition and Risk of Structural Brain Changes Seen on Magnetic Resonance Imaging in Older Adults

To study the associations between protein energy malnutrition, micronutrient malnutrition, brain atrophy, and cerebrovascular lesions.

Skeletal muscle analyses: agreement between non-contrast and contrast CT scan measurements of skeletal muscle area and mean muscle attenuation

Low skeletal muscle area (SMA) and muscle radiation attenuation (MRA) have been associated with poor prognosis in various patient populations. Both non‐contrast and contrast CT scans are used to determine SMA and MRA. The effect of the use of a contrast agent on SMA and MRA is unknown. Therefore, we investigated agreement between these two scan options. SMA and MRA of 41 healthy individuals were analysed on a paired non‐contrast and contrast single CT scan, and agreement between paired scan results was assessed with use of Bland–Altman plots, intraclass correlation coefficients (ICCs), standard error of measurements (SEM) and smallest detectable differences at a 95% confidence level (SDD95). Analyses were stratified by tube voltage. Difference in SMA between non‐contrast and contrast scans made with a different tube voltage was 7·0 ± 7·5 cm2; for scans made with the same tube voltage this was 2·3 ± 1·7 cm2. Agreement was excellent for both methods: ICC: 0·952, SEM: 7·2 cm2, SDD95: 19·9 cm2 and ICC: 0·997, SEM: 2·0 cm2, SDD95: 5·6 cm2, respectively. MRA of scans made with a different tube voltage differed 1·3 ± 11·3 HU, and agreement was poor (ICC: 0·207, SEM: 7·9 HU, SDD95: 21·8 HU). For scans made with the same tube voltage the difference was 6·7 ± 3·2 HU, and agreement was good (ICC: 0·682, SEM: 5·3 HU, SDD95: 14·6 HU). In conclusion, SMA and MRA can be slightly influenced by the use of contrast agent. To minimise measurement error, image acquisition parameters of the scans should be similar.

Effect of Early Individualized Dietary Counseling on Weight Loss, Complications, and Length of Hospital Stay in Patients With Head and Neck Cancer: A Comparative Study.

Patients with head and neck cancer (HNC) are at risk for undernutrition. Dietary counseling during treatment has positive effects on nutritional status and quality of life, however, the effects of dietary counseling started before initiation of treatment are currently unknown. Therefore we assessed the effect of early individualized dietary counseling (DC) on weight loss, major complications, and length of hospital stay (LOS) in patients with HNC. Ninety-five newly diagnosed HNC patients with (risk of) undernutrition receiving DC were compared to 95 matched HNC patients receiving usual nutritional care (UC). Difference in weight change over time was analyzed by generalized estimating equations (GEE). Differences in complications and LOS were studied by Pearson chi-squared and students t-tests. Weight change between diagnosis and end of treatment was −6.0 ± 6.9% (DC) and −5.4 ± 5.7% (UC; GEE: −0.4kg, 95% confidence interval: −1.2 to 0.5; P = 0.44). Less DC patients experienced overall postoperative complications (44%/70%, P = 0.04). No effect on major postoperative or (chemo)radiotherapy complications or LOS was found. This study showed a lower prevalence of overall postoperative complications in HNC patients receiving DC but could not demonstrate an effect on weight loss, other complications, and LOS.

Plasma Ghrelin Levels Are Associated with Anorexia but Not Cachexia in Patients with NSCLC

Background and Aims: The ghrelin receptor is one of the new therapeutic targets in the cancer anorexia-cachexia syndrome. Previous studies revealed that plasma ghrelin levels were high in patients with anorexia nervosa and low in obese subjects. We studied to what extent ghrelin levels are related with anorexia and cachexia in patients with cancer. Materials and Methods: Fasted ghrelin levels were determined as well as anorexia and cachexia in patients with stage III/IV non-small cell lung cancer before chemotherapy. Total plasma ghrelin was measured by radioimmunoassay. Anorexia was measured with the FAACT-A/CS questionnaire (cut-off value ≤ 37). Cachexia was determined as >5% weight loss (WL) in 6 months or >2% WL in 6 months in combination with low BMI or low muscle mass. The Kruskal-Wallis test was performed to assess differences in plasma ghrelin levels between four groups: patients with (+) or without (−) anorexia (A) or cachexia (C). Multiple regression analyses were performed to assess differences in plasma ghrelin levels between patients C+ and C− and patients with A+ and A− (adjusted for age and sex). Results: Forty patients with stage III (33%) or stage IV (68%) were recruited, of which 50% was male. Mean age was 59.6 ± 10.3 years. Sixteen patients had no anorexia or cachexia (A−C−), seven patients had both anorexia and cachexia (A+C+), ten patients had anorexia without cachexia (A+C−) and seven patients had cachexia without anorexia (A−C+). The levels of total plasma ghrelin were significantly different between the four groups of patients with or without anorexia or cachexia (p = 0.032): the A+C− patients had significantly higher ghrelin levels [median (IQR): 1,754 (1,404–2,142) compared to the A−C+ patients 1,026 (952–1,357), p = 0.003]. A+ patients had significantly higher ghrelin levels compared A− patients (C+ and C− combined, β: 304, p = 0.020). Plasma ghrelin levels were not significantly different in C+ patients compared to C− patients (A+ and A− combined, β: −99, p = 0.450). Conclusions: Patients with anorexia had significantly higher ghrelin levels compared to patients without anorexia. We therefore hypothesize that patients with cancer anorexia might benefit from treatment with a ghrelin receptor agonist to prevent WL and deterioration in physical functioning.