Sensory preferences of supplemented food products among cancer patients: a systematic review

Effect of oral nutritional supplements on outcomes in children presenting with, or at risk of, faltering growth in clinical settings: A systematic review and meta-analysis

This systematic review summarises evidence regarding oral nutritional supplement (ONS) use in children with, or at risk of, faltering growth (FG). Ten randomised controlled trials (RCTs), compared changes in outcomes amongst children receiving ONS versus control were included. Overall, 1116 children (weighted mean (WM) age 5 years; n658 (59%) male) were recruited, of which 585 (52%) received ONS (WM intake contribution 412 kcal, 16.3 g protein, 395 ml) for 116 days (WM). ONS use was associated with significantly greater gains in weight (mean difference (MD) 0.4 kg, 95% CI [0.36, 0.44]) and height (MD 0.3 cm, 95% CI [0.03, 0.57]), likely related to improvements in nutritional intake. Mean compliance to prescribed dose was 98%. Data suggested an association between ONS use and reduced infections. Further research is warranted to establish ONS dosage and effects upon other outcomes. This review provides evidence to support use of ONS in the management of children with, or at risk of, FG.

[Evaluation of the organoleptic characteristics of an oral nutritional supplement designed specifically for the cancer patient]

INTRODUCTION

oral nutritional supplements (ONS) are nutritional therapies used to treat malnutrition in cancer patients, therefore, innovation in these treatments, from nutrients to sensory quality, is essential to ensure their consumption.

OBJECTIVES

to evaluate the organoleptic characteristic of different prototypes of oral nutritional supplements specifically designed for cancer patients.

METHOD

cross-sectional, randomized, double-blind pilot clinical study in patients with any type of cancer, with or without oncological treatment, who tasted five ONS prototypes with different flavors (brownie, tropical, pineapple, tomato and ham) and different sensory qualities in order to evaluate their organoleptic characteristics (color, smell, taste, residual taste, texture and density) through a specific questionnaire.

RESULTS

thirty patients aged 67.5 ± 11.2 years and body mass index (BMI) of 22.3 ± 3.52 kg/m2 were evaluated. The most prevalent tumors were head and neck (30 %), pancreas (20 %) and colon (17 %); 65 % of the patients had lost ≥ 10 % of their body weight in six months. The best rated supplements by the cancer population were those with brownie flavor (23.67 ± 3.91 points) and tropical (20.33 ± 3.37 points), while the least valued were tomato (16.33 ± 5.44 points) and ham flavor (13.97 ± 4.64 points).

CONCLUSIONS

cancer patients value the organoleptic characteristics of ONS with sweet flavors, such as brownie, and fruity flavors, such as tropical, much more positively. Less appreciated by these patients are those with a salty taste, such as ham and tomato flavor.

Recommending ultra-processed oral nutrition supplements for unintentional weight loss: Are there risks?

Oral nutrition supplements (ONS) are widely recommended for the management of unintentional weight loss in patient populations, long-term care residents, and community-dwelling older adults. Most marketed ONS are ultra-processed, with precision nutrition and aseptic composition, as well as convenience and availability, driving their selection. However, therapeutic effectiveness is mixed and the potential health risks of consuming ultra-processed ONS long-term in lieu of less-processed foods have received little attention. A diverse and balanced microbiota supporting immunity and wellness is maintained by a diet rich in plant-sourced foods. The implications of ultra-processed ONS displacing plant-sourced foods, and specifically the potential for undesirable impacts on the gut microbiota, require consideration. Most ONS are either devoid of fiber or are supplemented with isolated or purified fibers that may contribute to adverse gastrointestinal symptoms and appetite suppression. In contrast, the diversity of microbial-available, nondigestible carbohydrates, together with the array of phytochemicals found in plant-sourced foods, support microbial diversity and its resiliency. This review outlines the clinical dilemma of recommending commercial ultra-processed ONS vs nutritionally adequate (eg, high-energy/high-protein) foods and beverages that contribute to diet quality, maintenance of a diverse and stable gut microbiota composition, and support nutrition status and health. Ultra-processed ONS may fall short of expected health benefits, and overreliance may potentially contribute to the risk for patient and older adult populations because of the displacement of a variety of healthful foods.

Preferences of oral nutritional supplement therapy among postoperative patients with gastric cancer: Attributes development for a discrete choice experiment

Background

Adherence to oral nutritional supplement therapy among postoperative patients with gastric cancer is low. There is little knowledge about patients’ priorities and needs regarding oral nutritional supplement therapy. The discrete choice experiment is an innovative method used to elicit patients’ preferences. Good practice guidelines emphasize that the development of attributes and levels is a fundamentally important process.

Objective

To comprehensively describe the identification, refinement, and selection of attributes and levels for a discrete choice experiment.

Methods

A mixed-methods approach, consisting of three consecutive steps: a literature review, in-depth interviews, and focus groups. First, the literature review allowed quick identification of attributes and levels. Then, 15 in-depth interviews were conducted to gather a rich description of the experience of patients taking oral nutritional supplements after gastrectomy and to verify and enrich the attributes and levels list. Finally, four focus group participants discussed the wording of the attributes and levels and reduced the number of attributes to manageable numbers through voting ranking methods.

Results

Following the literature review and qualitative data collection, eight attributes were finally generated, each with two to three levels. The following attributes were included: 1) information provider; 2) health guidance approach; 3) adverse reactions; 4) flavor; 5) follow-up method; 6) follow-up frequency; 7) psychological support; 8) cost. These attributes covered the important attributes of nutritional preparations and health guidance included in ONS therapy that were relevant to patients.

Conclusions

This study’s mixed-methods approach has been found highly suitable to identify, refine and select attributes and levels for a discrete choice experiment. The three methods have pros and cons, and they complement each other, especially the analysis of qualitative data led to a deeper and broader understanding of attributes and levels.

'Between foods and medicines': A qualitative interview study of patient experiences of the meaning and usage of oral nutritional supplements

The aim of this study was to deepen the understanding of what oral nutritional supplements mean to patients and how this meaning connects to supplement usage, by exploring patient experiences of such supplements. Qualitative interviews were conducted in June 2019-March 2020 with ten patients with malnutrition or at nutritional risk, prescribed oral nutritional supplements by dietitians. Data were thematically analysed using systematic text condensation. Two final categories were identified: 'Oral nutritional supplements are a one-dimensional remedy' and 'Everyday oral nutritional supplement usage is regulated autonomously'. The patients described the meaning of oral nutritional supplements as nutrition. While the supplements could compensate for nutrients not eaten or be part of a helpful compensation strategy, they could not lessen the burden of altered eating. Supplement usage was described as dependent on the acceptance of taste and the priority given to nutrition in everyday life. Usage was greater when nutrients were perceived as needed, such as when striving for higher bodyweight or disease recovery. Usage was lower when a patient's own goals were not increased nutrient intake or bodyweight or when other activities were perceived as more important. Patient experiences indicated that oral nutritional supplements could serve as a remedy for malnutrition, but not for a situation of altered eating. Supplement usage was described as being regulated autonomously based on patient views on the importance of nutrition. Those views were diverse, highlighting the importance of supplement prescribers discussing treatment goals with each patient. A deeper understanding of the meaning of oral nutritional supplements and reasons for their usage from a patient perspective is crucial in order for healthcare to provide appropriate, effective nutrition therapy for malnutrition.

Acceptance of oat-based beverages tailored for patients with cancer

Oat-based beverages are a nutritious product with the potential to support increased nutrient intake of patients with cancer. The aim of this research was to evaluate the sensory acceptance of oat-based beverages and perceptions of oats among patients with cancer as future vehicles for nutrient delivery. In study 1, three flavors of oat-beverages were well accepted without significant difference in liking among flavors or serving temperature, or between patients with cancer and healthy participants. Patients with cancer more frequently rated the beverages as too sweet compared to healthy participants; flavor intensity was just about right for all participants. In the second study, one of two formulations fortified with protein and fish oil was not different in liking compared to the unfortified chocolate product. Patients associated oat food products with specific oat-based food products and oat health benefits in a free-word association task in the third study. Together, sensory acceptance and the perceived health benefits of oats indicate the potential for oats to be incorporated in fortified and unfortified products tailored for patients with cancer. PRACTICAL APPLICATION: The three studies presented here to assess the sensory acceptance of oat-based beverages and perceptions of oats among patients with cancer demonstrate that oats can be incorporated in fortified and unfortified products tailored for patients with cancer. Inadequate nutrition is highly prevalent among oncology patients and there is a lack of available products targeted to improve their nutritional intake. These findings can support product developers and sensory scientists in the development and evaluation of food products acceptable to this population.

Taste alterations and oral discomfort in patients receiving chemotherapy

PURPOSE

Taste alterations (TA) and oral discomfort in cancer patients are neglected side effects of the disease and treatments. They contribute to poor appetite, decrease food intake and affect quality of life, leading to adverse outcomes such as malnutrition and depression. The study aimed to explore TAs in relation to other oral conditions causing discomfort in cancer patients. Additionally, the correlation between patients' acidity of saliva and experienced TAs and oral discomfort was evaluated.

METHODS

A case study including 100 patients diagnosed with cancer receiving chemotherapy or immunotherapy. Data were collected using two questionnaire forms: the Chemotherapy-induced Taste Alteration Scale (CiTAS) and an additional information questionnaire. Saliva samples were collected for each patient and measured with a pocket pH meter. Data were analysed using descriptive statistics, and comparisons were performed using the Kruskal-Wallis H test, Mann-Whitney U test and Fisher's exact test.

RESULTS

The prevalence of reported TAs was 93%. Patient age, oral discomfort and swallowing difficulty were found to be significant factors for experienced TAs (p < 0.05). No correlation between patients' acidity of saliva and reported TAs and oral discomfort was found.

CONCLUSION

CiTAS proved to be a convenient tool to collect information about TAs in cancer patients. Using the CiTAS tool, a high prevalence (93%) of reported TAs in cancer patients receiving chemo- or immunotherapy was found. CiTAS provides a fast and cheap recognition of symptoms and causes of TAs that can be addressed.

Sensory perceptions of survivors of cancer and their caregivers upon blinded evaluation of produce from two different sources

PURPOSE

Evidence documents the role of modifiable lifestyle behaviors in optimizing physical and mental health outcomes for survivors of cancer. Fruit and vegetable consumption is one such behavior, and understanding survivor sensory perceptions of produce can inform interventions aimed at improving dietary patterns. The objective of this study was to assess the sensory perceptions of survivors of cancer and their caregivers when asked to evaluate garden-harvested and grocery-purchased produce.

METHODS

Participants enrolled in a garden-based biobehavioral intervention and their caregivers (n=32) were invited to participate in a sensory evaluation of four produce types: tangerine cherry tomatoes, green cabbage, green beans, and green bell peppers. Samples were coded and distributed in a random fashion, and participants completed validated sensory surveys (preference, liking/acceptability, and discrimination) for each type of produce.

RESULTS

Upon initial blinded evaluation, a significant preference for grocery-purchased produce was noted for green cabbage, green beans, and green bell peppers but not tomatoes (all p<0.05). After self-labeling, however, participants reported a preference for perceived garden-harvested produce (all p≤0.001) even when incorrectly labeled. Liking/acceptability scores were significantly higher among self-labeled garden-harvested versus self-labeled grocery-purchased for all types of produce (all p≤0.001). These data reveal survivors of cancer and their caregivers perceive garden-harvested produce as superior to grocery-purchased, though were unable to accurately identify the two sources based upon sensory factors such as taste, smell, and texture alone when blinded for three of the four types of produce.

CONCLUSION

Findings indicate future interventions should address perceptions of produce to facilitate improvements in consumption in these vulnerable individuals.

Flavor alterations in cancer treatment: Extrinsic factors as a means of augmentation

Flavor, comprising taste, smell and somatosensory inputs, is commonly altered in patients undergoing chemotherapy resulting in malnutrition leading to cachexia. A narrative review considered taste and smell alterations associated with malignancies treated using chemotherapy and the various interventions proffered to lessen alterations. Many of the currently used interventions directed towards enhancing intrinsic factors of food appeared ineffective in encouraging intake of adequate nutrition to ward off complications of malnutrition. Counselling is used in some cases with positive results. The use of extrinsic influences commensurate with the principles of food behavior and gastronomy are considered as a means of providing purpose to patients to accommodate flavor loss which when integrated with counseling and appropriate intrinsic factors are potentially a means of curtailing malnutrition and enhancing the psychological status of the patient. The close association between the cephalic phase responses (CPRs) and the control of eating and digestive behaviors is multifaceted, and when the influences of taste and smell are diminished, other contributing factors guiding CPRs may compensate a deficit. The need for the application of a consistent lexicon is essential when describing taste and smell alterations.

Self-reported taste and smell alterations and the liking of oral nutritional supplements with sensory-adapted flavors in cancer patients receiving systemic antitumor treatment

PURPOSE

Taste and smell alterations (TAs and SAs) are often reported by patients with cancer receiving systemic antitumor therapy and can negatively impact food intake and quality of life. This study aimed to examine the occurrence of TAs and SAs and investigate the impact of TAs on overall liking of oral nutritional supplements (ONS) with warming and cooling sensations.

METHODS

Patients receiving systemic antitumor therapy completed a questionnaire on sensory alterations and evaluated overall liking of 5 prototype flavors of Nutridrink® Compact Protein (hot tropical ginger (HTG), hot mango (HM), cool red fruits (CRF), cool lemon (CL), and neutral (N)) on a 10-point scale via a sip test. Differences between patients with and without TAs were investigated using permutation analysis.

RESULTS

Fifty patients with various cancer types and treatments were included. Thirty patients (60%) reported TAs and 13 (26%) experienced SAs. Three flavors were rated highly with a liking score > 6 (CRF 6.8 ± 1.7; N 6.5 ± 1.9; HTG 6.0 ± 2.0). Larger variation in ONS liking scores was observed in patients with TAs with or without SAs (4.5-6.9 and 4.6-7.2, respectively) vs. patients without TAs (5.9-6.5). TAs were associated with increased liking of CRF (Δ = + 0.9) and N (Δ = + 1.0) flavors.

CONCLUSIONS

TAs and SAs are common in patients with cancer undergoing systemic antitumor therapy. Patients with TAs were more discriminant in liking of ONS flavors compared to patients without TAs, and sensory-adapted flavors appeared to be appreciated. The presence of TAs should be considered when developing or selecting ONS for patients with cancer.

TRIAL REGISTRATION

Registration at ClinicalTrials.gov (NCT03525236) on 26 April 2018.

Nutrition and gastroenterological support in end of life care

Malnutrition and the broad spectrum of cancer cachexia frequently occur in patients with malignant disease of all tumour stages and impact on survival and quality of life of patients. Structured screening for the risk of malnutrition with validated tools and nutritional assessment are the prerequisite for adequate nutritional support in cancer patients. In patients receiving tumour directed therapy, the patients diet should meet the requirements to give optimal support, while later on comfort feeding is part of symptom focused palliation. The basis of nutritional support in a malnourished patient is nutritional counselling, and nutritional support can be offered within a step-up approach meeting the patient's needs. A combination of nutritional support with interventions targeting metabolic changes and physical exercise is suggested to treat cancer cachexia.

Oral Nutritional Supplementation in Cancer Patients Who Were Receiving Chemo/Chemoradiation Therapy: A Multicenter, Randomized Phase II Study

Introduction: Oral nutritional supplementation (ONS) in cancer patients is justified by the low food intake caused by several factors. However, ONS can be affected by adverse events (AEs) correlated to treatment. This study aimed to compare the safety and efficacy of ONS (whey protein isolated, leucin, zinc-IMMAX®) during oncologic treatment.Methods: Patients in chemo/chemoradiotherapy were randomly assigned to receive IMMAX®+nutritional counseling (NC) according to daily requirements (S arm) or NC alone (C arm) for 4 weeks. Body weight (BW), %fat-free mass (%FFM) and nutrition intake were assessed before and after. In S arm, calories from IMMAX met the energy requirements. AEs were classified according to CTC-AE-NCI.Results: Eighty-five patients were included (51 females). After 4 weeks, the median of caloric intake, BW and %FFM were not statistically different in C arm. In S arm, median ONS intake was 81 g/332 kcal/day, protein intake was higher (pre: 66.75 ± 31.57 g; post: 88.57 ± 35.11 g; p < 0.01) and calories as well (pre: 1,549 ± 596 kcal; post: 1,756 ± 614 kcal; p = 0.02). The most common treatment related AEs were anemia, nausea/vomiting, not different between the arms. AEs supplement related were constipation and diarrhea (2 patients/4.6% each).Conclusion: IMMAX was safe, well tolerated, it did not interfere with oncologic treatment and provided significant amount of protein intake in this patient population, with few related AEs.

Oral Nutritional Supplementation Following Upper Gastrointestinal Cancer Surgery: A Prospective Analysis Exploring Potential Barriers to Compliance

Objective: Malnutrition is common in patients who underwent upper gastrointestinal cancer surgery. Our goal was to explore postoperative compliance with oral nutritional supplementation and define barriers to consumption in patients with esophageal, gastroesophageal junction, and gastric cancer.Methods: Participants were prospectively recruited from September 2015 to November 2018. Preoperative nutritional status was assessed using the Patient Generated Subjective Global Assessment. Malnourished patients and patients at risk for malnutrition were offered oral nutritional supplementation at the time of hospital discharge. Compliance was evaluated 1 month after hospital discharge.Results: A total of 78 patients were analyzed. Mean patient age was 62.8 ± 10.7 years and 83.3% were males. Εsophagectomy and gastrectomy were performed in 60.3% and 39.7% of the patients respectively. Twenty-eight (35.9%) participants reported consuming all prescribed supplements, whereas 50 (64.1%) patients were noncompliant with their prescribed oral nutritional supplementation regimen. The main barriers to oral nutritional supplementation compliance were bloating (compliant vs. noncompliant patients: 17.9% vs. 58%, p < 0.001), early satiety (compliant vs. noncompliant patients: 25% vs. 52.32%, p < 0.001), flavor or texture dislike (compliant vs. noncompliant patients: 7.1% vs. 34%, p < 0.001), and diarrhea (compliant vs. noncompliant patients: 10.7% vs. 24%, p < 0.001). No other statistically significant differences were identified between the two groups.Conclusions: Postoperative compliance to oral nutritional supplementation is low in patients who underwent upper gastrointestinal cancer surgery. Patient education and support as well as providing a range of oral nutrition supplement flavors, texture, and compositions may be useful in increasing adherence to oral nutritional supplementation regimens.