Sandra Capra

Use of the scored Patient-Generated Subjective Global Assessment (PG-SGA) as a nutrition assessment tool in patients with cancer

Objective: To evaluate the use of the scored Patient-Generated Subjective Global Assessment (PG-SGA) as a nutrition assessment tool in patients with cancer.Design: An observational study assessing the nutritional status of patients with cancer.Setting: Oncology ward of a private tertiary Australian hospital.Subjects: Seventy-one cancer patients aged 18–92 y.Intervention: Scored PG-SGA questionnaire, comparison of scored PG-SGA with subjective global assessment (SGA), sensitivity, specificity.Results: Some 24% (17) of 71 patients were well nourished, 59% (42) of patients were moderately or suspected of being malnourished and 17% (12) of patients were severely malnourished according to subjective global assessment (SGA). The PG-SGA score had a sensitivity of 98% and a specificity of 82% at predicting SGA classification. There was a significant difference in the median PG-SGA scores for each of the SGA classifications (P<0.001), with the severely malnourished patients having the highest scores. Re-admission within 30 days of discharge was significantly different between SGA groups (P=0.037). The mortality rate within 30 days of discharge was not significantly different between SGA groups (P=0.305). The median length of stay of well nourished patients (SGA A) was significantly lower than that of the malnourished (SGA B+C) patients (P=0.024).Conclusion: The scored PG-SGA is an easy to use nutrition assessment tool that allows quick identification and prioritisation of malnutrition in hospitalised patients with cancer.Sponsors: The Wesley Research Institute.

Development of a valid and reliable malnutrition screening tool for adult acute hospital patients.

Nutrition screening identifies individuals who are malnourished or at risk of becoming malnourished and who may benefit from nutrition support. The aim of this study was to develop a simple, reliable and valid malnutrition screening tool that could be used at hospital admission to identify adult acute patients at risk of malnutrition. The sample population included 408 patients admitted to an Australian hospital, excluding pediatric, maternity, and psychiatric patients. The ability of various nutrition screening questions to predict subjective global assessment (SGA) were examined in contingency tables. The combination of nutrition screening questions with the highest sensitivity and specificity at predicting SGA was termed the malnutrition screening tool (MST), and consisted of two questions regarding appetite and recent unintentional weight loss. Subjects who were at risk of malnutrition according to the MST had significantly lower mean values for the objective nutrition parameters (except immunologic parameters) and longer length of stays than subjects who were not at risk of malnutrition. Therefore convergent and predictive validity of the MST was established. The interrater reliability of the malnutrition screening tool was high (93-97%). The MST is a simple, quick, valid, and reliable tool which can be used to identify patients at risk of malnutrition.

Nutrition intervention is beneficial in oncology outpatients receiving radiotherapy to the gastrointestinal or head and neck area.

Malnutrition occurs frequently in patients with cancer of the gastrointestinal (GI) or head and neck area and can lead to negative outcomes. The aim of this study is to determine the impact of early and intensive nutrition intervention (NI) on body weight, body composition, nutritional status, global quality of life (QoL) and physical function compared to usual practice in oncology outpatients receiving radiotherapy to the GI or head and neck area. Outpatients commencing at least 20 fractions of radiotherapy to the GI or head and neck area were randomised to receive intensive, individualised nutrition counselling by a dietitian using a standard protocol and oral supplements if required, or the usual practice of the centre (general advice and nutrition booklet). Outcome parameters were measured at baseline and 4, 8 and 12 weeks after commencing radiotherapy using valid and reliable tools. A total of 60 patients (51M : 9F; mean age 61.9±14.0 years) were randomised to receive either NI (n=29) or usual care (UC) (n=31). The NI group had statistically smaller deteriorations in weight (P<0.001), nutritional status (P=0.020) and global QoL (P=0.009) compared with those receiving UC. Clinically, but not statistically significant differences in fat-free mass were observed between the groups (P=0.195). Early and intensive NI appears beneficial in terms of minimising weight loss, deterioration in nutritional status, global QoL and physical function in oncology outpatients receiving radiotherapy to the GI or head and neck area. Weight maintenance in this population leads to beneficial outcomes and suggests that this, rather than weight gain, may be a more appropriate aim of NI.

The scored Patient-generated Subjective Global Assessment (PG-SGA) and its association with quality of life in ambulatory patients receiving radiotherapy

Objective: To evaluate the scored Patient-generated Subjective Global Assessment (PG-SGA) tool as an outcome measure in clinical nutrition practice and determine its association with quality of life (QoL).Design: A prospective 4 week study assessing the nutritional status and QoL of ambulatory patients receiving radiation therapy to the head, neck, rectal or abdominal area.Setting: Australian radiation oncology facilities.Subjects: Sixty cancer patients aged 24–85 y.Interventions: Scored PG-SGA questionnaire, subjective global assessment (SGA), QoL (EORTC QLQ-C30 version 3).Results: According to SGA, 65.0% (39) of subjects were well-nourished, 28.3% (17) moderately or suspected of being malnourished and 6.7% (4) severely malnourished. PG-SGA score and global QoL were correlated (r=−0.66, P<0.001) at baseline. There was a decrease in nutritional status according to PG-SGA score (P<0.001) and SGA (P<0.001); and a decrease in global QoL (P<0.001) after 4 weeks of radiotherapy. There was a linear trend for change in PG-SGA score (P<0.001) and change in global QoL (P=0.003) between those patients who improved (5%) maintained (56.7%) or deteriorated (33.3%) in nutritional status according to SGA. There was a correlation between change in PG-SGA score and change in QoL after 4 weeks of radiotherapy (r=−0.55, P<0.001). Regression analysis determined that 26% of the variation of change in QoL was explained by change in PG-SGA (P=0.001).Conclusion: The scored PG-SGA is a nutrition assessment tool that identifies malnutrition in ambulatory oncology patients receiving radiotherapy and can be used to predict the magnitude of change in QoL.Sponsors: The Wesley Research Institute.

Cancer: Impact of nutrition intervention outcome-nutrition issues for patients

OBJECTIVE We examined nutritional issues, assessment, and intervention strategies for patients with cancer. METHODS Reviews of practice guidelines and published reports were used to identify nutritional issues and strategies that can benefit patients with cancer. RESULTS Assessment tools such as the Patient-Generated Subjective Global Assessment are useful in terms of identifying patients with nutrition issues and guiding intervention. However, quality of life and other measures should also be considered. There is a need for early and ongoing nutrition interventions. CONCLUSIONS Encourage patients to try a new food or supplement on days when they are not receiving chemotherapy or radiation therapy because it may result in better tolerance. Screen patients to determine their nutritional status. Closely monitor changes in weight, food intake, and symptoms such as nausea and vomiting. Refer to a registered dietitian for a complete nutrition assessment and individualized counseling.

Effect of intensive dietetic interventions on weight and glycaemic control in overweight men with Type II diabetes: a randomised trial

OBJECTIVE: To investigate the effectiveness of intensive innovative methods for implementing dietary prescriptions on weight management and glycaemic control in overweight men with Type II diabetes.DESIGN: A randomised clinical trial with a 12-week intervention period — three isocaloric dietary intervention groups (intermittent energy restriction, pre-portioned meals and self-selected meals) each with weekly dietitian contact — and a follow-up visit after 18 months.SUBJECTS: A total of 51 men with Type II diabetes (mean age 54 y, mean body mass index (BMI) 31.7 kg/m2).MEASUREMENTS: Weight, body composition, waist circumference, glycaemic control (HbA1c) and blood lipids.RESULTS: For all subjects, intensive diet therapy over the 12-week intervention period resulted in a mean reduction in energy intake of 2360±2780 kJ/day (564±665 kcal/day) and significant reductions in weight (6.4±4.6 kg), waist circumference (8.1±4.6 cm), percent body fat (1.9±1.5%), HbA1c (1.0±1.4%) and triglyceride levels (0.3±0.6 mmol/l) compared to baseline levels. Intervention group did not affect clinical outcomes, with the exception of percent body fat. A total of 27 (52.9%) subjects attended the 18-month follow-up visit. At this visit, none of the improvements in clinical parameters was maintained, with all parameters returning to preintervention levels.CONCLUSIONS: A dietary prescription of 6000–7000 kJ/day (1400–1700 kcal/day) was effective in achieving a 6% weight loss and improving glycaemic control. The method of implementation made no difference to the outcomes between groups at 12 weeks or 18 months. Thus, we propose that it was the intensive weekly contact with a health professional in combination with moderate energy restriction that facilitated the successful short-term results seen.

Association between eating frequency, weight and health

There is speculation amongst health professionals, the media, and the public regarding eating frequency (EF) and its impact on weight and health. Nutritional weight-loss and -maintenance interventions of longer than 1 weeks duration were reviewed for associations between EF and weight and health. Of the 176 studies identified, 25 relevant studies matched the criteria and only 10 of these were weight-loss interventions. Generally, sample sizes were small, interventions were short-term, and a wide array of definitions was used to define an eating occasion. Several key outcomes such as physical activity, adherence to assigned EF, and hunger were often not measured. The limited evidence available suggests there is no association between EF and weight or health in either weight-loss or -maintenance interventions, with a possible inverse association between EF and lipids in weight-maintenance interventions. Longer term, larger studies that include important weight and health outcomes are needed.

A randomised control trial comparing lifestyle groups, individual counselling and written information in the management of weight and health outcomes over 12 months

Objective:To investigate the effect of an 8-week group-based cognitive behaviour therapy lifestyle intervention with monthly follow-up to 6 months and further follow up at 12 months on change in weight and other weight-related variables, change in physical activity and change in health and well being compared to individualised dietetic treatment or giving an information booklet only (BO).Design:A randomised controlled trial of two intervention groups, a group-based cognitive behaviour therapy lifestyle intervention, Fat Booters Incorporated – (FBI) and individualised dietetic treatment (IDT) and control group receiving an information booklet only (BO). The intervention groups involved weekly contact for 8 weeks with monthly follow-up to 6 months and further follow-up at 12 months, conducted in real practice setting.Subjects:A total of 176 adults with body mass index (BMI)>27 kg/m2, mean (±s.d.) age 48±13 years, mean BMI 34±5.5 kg/m2.Main outcome measures:Weight, percent body fat, waist circumference, physical activity, health status, self-efficacy and satisfaction with life were measured at baseline, 3, 6 and 12 months.Results:A statistically significant difference between groups was observed for weight change over time (P=0.05). The change in weight (mean±s.e.) for the FBI group was significantly greater than the BO group at 3 and 12 months (−2.8±0.7 compared to −1.0±0.6 kg, P<0.05 and −2.9±0.9 compared to +0.5±0.9 kg, P<0.005, respectively). Change in weight in the IDT group did not differ from the FBI group at any time point. For all groups, waist circumference was significantly less than baseline at all time points (P<0.001). Significant differences in self-efficacy were observed over time (P=0.02), with both intervention groups having greater self-efficacy than the BO group. Significant drop-outs occurred over time for all three groups.Conclusions:A cognitive behaviour-based lifestyle intervention was more effective than providing an information booklet alone and as effective as intensive individualised dietetic intervention in weight loss and improvements in self-efficacy.

Clinical accuracy of the MedGem indirect calorimeter for measuring resting energy expenditure in cancer patients.

ObjectiveTo compare, in patients with cancer and in healthy subjects, measured resting energy expenditure (REE) from traditional indirect calorimetry to a new portable device (MedGem™) and predicted REE.DesignCross-sectional clinical validation study.SettingPrivate radiation oncology centre, Brisbane, Australia.SubjectsCancer patients (n=18) and healthy subjects (n=17) aged 37–86 y, with body mass indices ranging from 18 to 42 kg/m2.InterventionsOxygen consumption (VO2) and REE were measured by VMax229 (VM) and MedGem (MG) indirect calorimeters in random order after a 12-h fast and 30-min rest. REE was also calculated from the MG without adjustment for nitrogen excretion (MGN) and estimated from Harris–Benedict prediction equations. Data were analysed using the Bland and Altman approach, based on a clinically acceptable difference between methods of 5%.ResultsThe mean bias (MGN–VM) was 10% and limits of agreement were –42 to 21% for cancer patients; mean bias −5% with limits of −45 to 35% for healthy subjects. Less than half of the cancer patients (n=7, 46.7%) and only a third (n=5, 33.3%) of healthy subjects had measured REE by MGN within clinically acceptable limits of VM. Predicted REE showed a mean bias (HB–VM) of −5% for cancer patients and 4% for healthy subjects, with limits of agreement of −30 to 20% and −27 to 34%, respectively.ConclusionsLimits of agreement for the MG and Harris Benedict equations compared to traditional indirect calorimetry were similar but wide, indicating poor clinical accuracy for determining the REE of individual cancer patients and healthy subjects.

Barriers to nutritional intake in patients with acute hip fracture: time to treat malnutrition as a disease and food as a medicine?

Inadequate energy and protein intake leads to malnutrition; a clinical disease not without consequence post acute hip fracture. Data detailing malnutrition prevalence, incidence, and intake adequacy varies widely in this patient population. The limited success of reported interventional strategies may result from poorly defined diagnostic criteria, failure to address root causes of inadequate intake, or errors associated with selection bias. This pragmatic study used a sequential, explanatory mixed methods design to identify malnutrition aetiology, prevalence, incidence, intake adequacy, and barriers to intake in a representative sample of 44 acute hip fracture patients (73% female; mean age, 81.7 ± 10.8 years). On admission, malnutrition prevalence was 52.2%. Energy and protein requirements were only met twice in 58 weighed 24 h food records. Mean daily patient energy intake was 2957 kJ (50.9 ± 36.1 kJ·kg(-1)) and mean protein intake was 22.8 g (0.6 ± 0.46 g·kg(-1)). This contributed to a further in-patient malnutrition incidence of 11%. Barriers to intake included patient perceptions that malnutrition and (or) inadequate intake were not a problem, as well as patient and clinician perceptions that treatment for malnutrition was not a priority. Malnutrition needs to be treated as a disease not without consequence, and food should be considered as a medicine after acute hip fracture.