Impact of oral nutritional supplements in post-discharge patients at nutritional risk following colorectal cancer surgery: A randomised clinical trial

Impact of adherence to oral nutritional supplements on nutrition status and muscle strength in patients with gastrointestinal cancer: A prospective observational longitudinal study

BACKGROUND

Given the lack of evidence regarding the effects of adherence to oral nutritional supplements (ONS) and the types of formulas used in clinical practice, we aimed to assess the impact of adherence to ONS and the high-protein formula on the nutrition status and muscle strength in patients with gastrointestinal cancer.

METHODS

This study evaluated newly diagnosed outpatients with esophageal, gastric, pancreatic, and colorectal cancer prescribed ONS. Nutrition status was assessed using the Patient-Generated Subjective Global Assessment (PG-SGA), and muscle strength was assessed using handgrip strength (HGS) dynamometry. ONS adherence was calculated as the ratio of self-reported intake to the prescribed amount and categorized as ≥80% or <80%.

RESULTS

A total of 54 patients were included. Most patients were ≥60 years of age (63%), were diagnosed with colorectal cancer (63%), were classified as stage III and IV (83%), and exhibited nutrition risk or malnutrition according to PG-SGA (89%). Patients with adherence ≥80% to ONS exhibited less weight loss and HGS reduction compared with patients with adherence <80% (P < 0.05). Although patients consuming a high-protein formula maintained HGS and those on a standard formula experienced a reduction, formula type did not predict HGS change in the multivariate analysis. ONS protein intake, adjusted for adherence, was a predictor of weight change (β: 0.09; 95% CI: 0.02-0.2; P = 0.011).

CONCLUSION

Patients with adherence ≥80% to ONS experienced less reduction in both weight and HGS, whereas those consuming a high-protein formula maintained HGS. Notably, ONS protein intake, adjusted for adherence, was an independent predictor of weight change.

Development and validation of a novel prognostic prediction system based on GLIM-defined malnutrition for colorectal cancer patients post-radical surgery

Background

Malnutrition often occurs in patients with colorectal cancer. This study aims to develop a predictive model based on GLIM criteria for patients with colorectal cancer who underwent radical surgery.

Methods

From December 2015 to May 2021, patients with colorectal cancer who underwent radical surgery at our center were recruited for this study. We prospectively collected data on GLIM-defined malnutrition and other clinicopathological characteristics. Using Cox regeneration, we developed a novel nomogram for prognostic prediction, which was validated and compared to traditional nutritional factors for predictive accuracy.

Results

Among the 983 patients enrolled in this study, malnutrition was identified in 233 (23.70%) patients. Multivariate analysis indicated that GLIM-defined malnutrition is the independent risk factor for overall survival (HR = 1.793, 95% CI = 1.390-2.313 for moderate malnutrition and HR = 3.485, 95% CI = 2.087-5.818 for severe malnutrition). The novel nomogram based on the GLIM criteria demonstrated a better performance than existing criteria, with AUC of 0.729, 0.703, and 0.683 for 1-year, 3-year, and 5-year OS, respectively, in the validation cohort. In addition, the risk score determined by this system exhibited significantly poorer short-term and long-term clinical outcomes in high-risk groups in both malnourished and well-nourished patients.

Conclusion

Combining handgrip strength, serum albumin level, and TNM stage would help improve the predictive effect of GLIM criteria for colorectal cancer patients post-radical surgery and benefit the individual prognostic prediction of colorectal cancer.

A rapid review of nutrition and exercise approaches to managing unintentional weight loss, muscle loss, and malnutrition in cancer

PURPOSE

This narrative review summarizes the evidence for nutrition, exercise, and multimodal interventions to maintain weight and muscle mass and prevent malnutrition from meta-analysis, systematic reviews, and randomized controlled trials published within the last 5 years, and in comparison to future research priority areas identified by international guidelines.

RECENT FINDINGS

Dietary counseling with oral nutrition support (ONS), escalated to enteral nutrition if weight loss continues, is the gold standard treatment approach to maintaining weight and preventing malnutrition. Recent ONS trials with dietary counseling show promising findings for weight maintenance, extending the literature to include studies in chemoradiotherapy, however, change in body composition is rarely evaluated. Emerging trials have evaluated the impact of isolated nutrients, amino acids, and their derivatives (ie, β-hydroxy β-methylbutyrate) on muscle mass albeit with mixed effects. There is insufficient evidence evaluating the effect of exercise interventions on unintentional weight loss, muscle mass, and malnutrition, however, our knowledge of the impact of multimodal nutrition and exercise interventions is advancing. Prehabilitation interventions may attenuate weight and muscle loss after surgery, particularly for patients having gastrointestinal and colorectal surgery. Multimodal trials that commence during treatment show mixed effects on weight and muscle mass when measured.

SUMMARY

This review highlights that the evidence for preventing unintentional weight loss and malnutrition from cancer treatment is strong within nutrition. Multimodal interventions are emerging as effective interventions to prevent unintentional weight loss. Promising interventions are demonstrating improvements in muscle mass, however further exploration through studies designed to determine the effect on muscle is required.

The Impact of Preoperative and Postoperative Nutritional Interventions on Treatment Outcomes and Quality of Life in Colorectal Cancer Patients-A Comprehensive Review

Colorectal cancer (CRC) is one of the most prevalent cancers worldwide, with high morbidity and mortality rates. Nutritional status has emerged as a significant factor influencing the prognosis and survival of CRC patients. This comprehensive literature review examines the role of nutritional support in improving treatment outcomes, including the efficacy of interventions, patient quality of life (QoL), and the modulation of inflammatory responses. The findings suggest that tailored nutritional interventions improve clinical outcomes, enhance QoL, and reduce treatment-related complications, particularly by attenuating inflammation. Furthermore, the review highlights the cost-effectiveness of nutritional strategies and identifies key methods to enhance patient compliance with dietary recommendations. In conclusion, integrating nutritional support into CRC treatment plans is crucial for optimizing clinical management and improving patient well-being.

Oral nutritional supplements improve clinical outcomes and are cost-effective for hospitalized patients in China

OBJECTIVE

This study assessed the therapeutic benefits and modeled the cost-effectiveness of oral nutritional supplements (ONS) in China.

METHODS

Data were collected from 27 152 adult inpatients between January 1, 2018, and December 31, 2020. Propensity score matching was used for balancing the baseline characteristics between the ONS group and non-ONS group. A decision-tree model was developed to assess the cost-effectiveness of ONS for patients with nutritional risk, and the incremental cost-effectiveness ratio was the metric to determine the most cost-effective strategy. One-way sensitivity and probabilistic sensitivity analyses were conducted to assess the model's stability. In addition, subgroup analysis was conducted based on clinical characteristics. Differences in clinical outcomes between the groups were compared using Student's t test, Mann-Whitney U test, or chi-square test.

RESULTS

The ONS group displayed significantly lower levels of prealbumin, albumin, hemoglobin, and BMI than the non-ONS group at admission. The incidence of malignant tumors, intestinal obstruction, and inflammatory bowel disease was significantly higher in the ONS group than the non-ONS group. The ONS group had a significantly higher effective rate than the non-ONS group (51.7% versus 50.3%, P < 0.05). Analysis of the decision-tree model revealed that the ONS group experienced an increase in cost of 19 850.96 yuan but achieved an additional 1.3406 effectiveness rate, resulting in an incremental cost-effectiveness ratio of 14 807.51, which fell below China's 2020 per capita gross domestic product of 71 965 yuan. Sensitivity analysis further confirmed the robustness of the model.

CONCLUSIONS

ONS are demonstrated a high rate of efficacy, although patients currently using ONS are typically in a severe disease state. In addition, ONS is cost-effective. We suggest that the reimbursement coverage of ONS be expanded to include in-hospital patients who are at high nutritional risk.

Feasibility of two levels of protein intake in patients with colorectal cancer: findings from the Protein Recommendation to Increase Muscle (PRIMe) randomized controlled pilot trial

BACKGROUND

Low muscle mass (MM) predicts unfavorable outcomes in cancer. Protein intake supports muscle health, but oncologic recommendations are not well characterized. The objectives of this study were to evaluate the feasibility of dietary change to attain 1.0 or 2.0 g/kg/day protein diets, and the preliminary potential to halt MM loss and functional decline in patients starting chemotherapy for stage II-IV colorectal cancer.

PATIENTS AND METHODS

Patients were randomized to the diets and provided individualized counseling. Assessments at baseline, 6 weeks, and 12 weeks included weighed 3-day food records, appendicular lean soft tissue index (ALSTI) by dual-energy X-ray absorptiometry to estimate MM, and physical function by the Short Physical Performance Battery (SPPB) test.

RESULTS

Fifty patients (mean ± standard deviation: age, 57 ± 11 years; body mass index, 27.3 ± 5.6 kg/m2; and protein intake, 1.1 ± 0.4 g/kg/day) were included at baseline. At week 12, protein intake reached 1.6 g/kg/day in the 2.0 g/kg/day group and 1.2 g/kg/day in the 1.0 g/kg/day group (P = 0.012), resulting in a group difference of 0.4 g/kg/day rather than 1.0 g/kg/day. Over one-half (59%) of patients in the 2.0 g/kg/day group maintained or gained MM compared with 44% of patients in the 1.0 g/kg/day group (P = 0.523). Percent change in ALSTI did not differ between groups [2.0 g/kg/day group (mean ± standard deviation): 0.5% ± 4.6%; 1.0 g/kg/day group: -0.4% ± 6.1%; P = 0.619]. No differences in physical function were observed between groups. However, actual protein intake and SPPB were positively associated (β = 0.37; 95% confidence interval 0.08-0.67; P = 0.014).

CONCLUSION

Individualized nutrition counselling positively impacted protein intake. However, 2.0 g/kg/day was not attainable using our approach in this population, and group contamination occurred. Increased protein intake suggested positive effects on MM and physical function, highlighting the potential for nutrition to attenuate MM loss in patients with cancer. Nonetheless, muscle anabolism to any degree is clinically significant and beneficial to patients. Larger trials should explore the statistical significance and clinical relevance of protein interventions.

Compliance with oral nutritional supplements and its influencing factors in postoperative patients with digestive tract tumors: a cross-sectional study

BACKGROUND

Oral nutritional supplements are one of the preferred methods of nutritional support for postoperative patients. This study aims to investigate the current status of oral nutritional supplements compliance in postoperative patients with digestive tract tumors and its influencing factors.

METHODS

Convenience sampling was employed to select 242 patients who underwent surgery for digestive tract tumors at a tertiary hospital in Shanghai from October 2022 to July 2023 as the study subjects. Data following a normal distribution were analyzed using independent sample t-tests, ANOVA single-factor analysis, Pearson correlation analysis, and multiple linear regression analysis to determine the factors influencing compliance with oral nutritional supplements.

RESULTS

A total of 252 questionnaires were distributed, with 10 invalid questionnaires excluded, resulting in an effective questionnaire rate of 96.03%. The compliance score for oral nutritional supplements in postoperative patients with digestive tract tumors was (2.40 ± 1.45), General Self-efficacy Scale (GSES) score was (24.72 ± 4.86), Multidimensional Scale of Perceived Social Support Scale (MSPSS) score was (58.67 ± 11.09), and Belief about Medicines Questionnaire Scale (BMQ) score was (0.17 ± 2.78). Multiple linear regression analysis revealed that age, adverse reactions, educational level, self-efficacy, medication beliefs, and social support were factors influencing compliance with oral nutritional supplements in postoperative patients with digestive tract tumors (P < 0.05).

CONCLUSION

Our study revealed that the compliance to oral nutritional supplements among postoperative patients with digestive tract tumors was at a moderate level and was closely associated with age, educational level, adverse reactions to oral nutritional supplements, medication beliefs, social support, and self-efficacy. Nursing staff should conduct nursing assessments based on the specific circumstances of patients and their families, provide personalized health education management plans based on the patients' educational level, enhance patients' nutrition knowledge, improve patient self-efficacy, and enhance social support for patients, while further improving patient nutrition management.

The effects of oral nutritional supplements interventions on nutritional status in patients undergoing colorectal cancer surgery: A systematic review

BACKGROUND

The high incidence of malnutrition in patients undergoing colorectal cancer surgery can lead to unplanned weight loss, sarcopenia and reduced grip strength to the extent that it can seriously affect the prognosis of colorectal cancer patients.

OBJECTIVE

This study investigated the effect of oral nutritional supplements (ONS) on the prevalence of grip strength, unplanned weight loss and sarcopenia in patients undergoing colorectal cancer surgery.

METHODS

We systematically searched randomized controlled studies from CINAHL, PubMed, Embase, Cochrane and Web of Science and three Chinese databases (CNKI, Wan-Fang database, VIP database) from database creation to September 2023. The risk of bias in individual studies was assessed using the Cochrane Collaboration tool, and the certainty of evidence was assessed using the five GRADE criteria. Statistical analysis was performed using the RevMan 5.3 software, and information that could not be meta-analysed was reviewed in the form of a literature summary.

RESULTS

Eleven papers met the inclusion criteria with a combined sample size of 1070 cases, including 532 cases in the trial group and 538 cases in the control group. Four papers reported the effect of ONS on grip strength and included very low-quality evidence supporting no effect of ONS on grip strength. Ten studies reported the effect of ONS on body weight and body mass index (BMI) and included very low-quality evidence supporting a positive ONS on weight and BMI changes. Meta-analysis showed a significant reduction in weight loss (12-15 weeks) and BMI loss (12-15 weeks) in patients with colorectal cancer in the ONS group. The effect of ONS on the prevalence of sarcopenia after hospital discharge was reported in two studies, and meta-analysis showed a significant reduction in the prevalence of postoperative sarcopenia in colorectal cancer patients in the ONS group, but the quality of evidence was low.

CONCLUSIONS

This study showed that the use of ONS in patients undergoing surgery for colorectal cancer improved patient weight loss and BMI reduction and reduced the prevalence of postoperative sarcopenia but did not improve patient grip strength. The quality of evidence for inclusion in the article was low or very low, and further studies are needed to provide better evidence.

Postoperative nutrition in the setting of enhanced recovery programmes

Patients undergoing major surgery for gastrointestinal cancer are at high risk of developing or worsening malnutrition and sarcopenia. In malnourished patients, preoperative nutritional support may not be sufficient and so postoperative support is advised. This narrative review addresses several aspects of postoperative nutritional care in the setting of enhanced recovery programmes. Early oral feeding, therapeutic diet, oral nutritional supplements, immunonutrition, and probiotics are discussed. When postoperative intake is insufficient, nutritional support favouring the enteral route is recommended. Whether this approach should use a nasojejunal tube or jejunostomy is still a matter of debate. In the setting of enhanced recovery programmes with early discharge, nutritional follow-up and care should be continued beyond the short time in hospital. In enhanced recovery programmes, the main specific aspects of nutrition are patient education, early oral intake, and post-discharge care. The other aspects do not differ from conventional care.

Gut microbiome-metabolites axis: A friend or foe to colorectal cancer progression

An expanding corpus of research robustly substantiates the complex interrelation between gut microbiota and the onset, progression, and metastasis of colorectal cancer. Investigations in both animal models and human subjects have consistently underscored the role of gut bacteria in a variety of metabolic activities, driven by dietary intake. These activities include amino acid metabolism, carbohydrate fermentation, and the generation and regulation of bile acids. These metabolic derivatives, in turn, have been identified as significant contributors to the progression of colorectal cancer. This thorough review meticulously explores the dynamic interaction between gut bacteria and metabolites derived from the breakdown of amino acids, fatty acid metabolism, and bile acid synthesis. Notably, bile acids have been recognized for their potential carcinogenic properties, which may expedite tumor development. Extensive research has revealed a reciprocal influence of gut microbiota on the intricate spectrum of colorectal cancer pathologies. Furthermore, strategies to modulate gut microbiota, such as dietary modifications or probiotic supplementation, may offer promising avenues for both the prevention and adjunctive treatment of colorectal cancer. Nevertheless, additional research is imperative to corroborate these findings and enhance our comprehension of the underlying mechanisms in colorectal cancer development.

Prevalence and clinical outcomes of sarcopenia in patients with esophageal, gastric or colorectal cancers receiving preoperative neoadjuvant therapy: A meta-analysis

Objective

To investigate the prevalence of sarcopenia and its impact on clinical outcomes in patients with esophageal, gastric, or colorectal cancer (EC, GC, and CRC) receiving neoadjuvant therapy through Meta-analysis.

Methods

We searched the PubMed, Embase databases, and Cochrane Library for the prevalence of sarcopenia and its impact on clinical outcomes in EC, GC, or CRC patients treated with neoadjuvant therapy (NAT) from inception to November 2022. The primary endpoints were the prevalence of sarcopenia and overall survival in patients with EC, GC, or CRC treated with NAT. Secondary outcomes included recurrence-free survival, total postoperative complications, grade 3-4 chemotherapy toxicity, and 30-day mortality after surgery.

Results

Thirty-one retrospective studies with 3651 subjects were included. In a fixed-effects model, the prevalence of muscle loss was higher in patients with EC, GC, or CRC at 50% (95% CI ​= ​42% to 58%). The results of the multivariate analysis showed that preoperative patients with sarcopenia had a 1.91 times shorter overall survival (95% CI ​= ​1.61-2.27) and a 1.77 times shorter recurrence-free survival time (95% CI ​= ​1.33-2.35) than patients without sarcopenia, and that patients with sarcopenia had a higher risk of total postoperative complications than patients without sarcopenia OR ​= ​1.27 (95% CI ​= ​1.03-1.57). However, the two groups had no statistical difference in grade 3-4 chemotherapy toxicity (P ​= ​0.84) or 30-d postoperative mortality (P ​= ​0.88).

Conclusions

The prevalence of sarcopenia in patients with EC, GC, or CRC during NAT is high, and it is associated with poorer clinical outcomes. Clinicians should closely monitor the changes in patients' body composition and guide patients to carry out a reasonable diet and appropriate exercise to improve their poor prognosis and quality of life.

Systematic review registration

CRD42023387817.

Sarcopenia and Its Influencing Factors in Patients With Colorectal Cancer

Sarcopenia can lead to more postoperative complications and poorer prognosis in patients with colorectal cancer; however there is limited research exploring the incidence and influencing factors of different stages of sarcopenia in patients with colorectal cancer. We investigated 312 patients with colorectal cancer. Sarcopenia was determined by measuring muscle mass, grip strength, and gait speed. According to the European Working Group on Sarcopenia in Older People (EWGSOP) 2010, patients were classified into four groups: nonsarcopenia, presarcopenia, sarcopenia, and severe sarcopenia. The incidence of sarcopenia and severe sarcopenia was 10.3% and 8.7%, respectively. Multivariate logistic regression analysis showed that age, TNM stage smoking history, total protein, upper arm circumference, waist circumference, and Patient-Generated Subjective Global Assessment (PG-SGA) score were independently associated with sarcopenia at different stages. This study suggests that routine data should be used to provide targeted care during hospitalization for patients with colorectal cancer in order to reduce the incidence of sarcopenia and improve prognosis.

Prevention of Postoperative Malnutrition with Oral Nutritional Supplements in Patients Undergoing Gastrointestinal Surgery

Oral nutritional supplements (ONSs) offer support for the nutritional needs of surgical patients. However, their efficacy is contingent upon the nutrient composition, absorption efficiency, and postingestion tolerance. Our study included a cohort of 84 patients who underwent elective open surgery involving at least one intestine anastomosis. To mitigate the risk of malnutrition, 2 groups of 28 patients each received either a high-protein low-osmotic ONS (Group I) or a high-calorie high-osmotic ONS (Group II). A standard diet was used in the control group (Group III). The metabolic effects were evaluated by measuring body weight and relative change in body weight (Δkg) from 24 h (-1 day) presurgery to 28 days postprocedure. Subjective tolerance following ONS consumption on the second postoperative day was also assessed. Our findings showed that, across all groups, the average body weight decreased during the initial 2 weeks postsurgery, subsequently stabilizing or returning to baseline levels by the third and fourth week of observation. Patients receiving ONS demonstrated greater weight gain between days 14 and 28, with Group I exhibiting the highest rate of gain. Low-osmotic ONS displayed superior tolerance and elicited fewer patient complaints postconsumption. Postoperative hospitalization duration did not differ significantly among the nutritional strategies. In conclusion, early administration of ONS supplies essential nutrients and facilitates refeeding, thereby reducing the risk of malnutrition. Low-osmotic preparations are better tolerated and contribute more effectively to the restoration of preoperative body weight, despite their lower caloric content.

Multimodal prerehabilitation for elderly patients with sarcopenia in colorectal surgery

Sarcopenia, which is characterized by progressive and generalized loss of skeletal muscle mass and strength, has been well described to be associated with numerous poor postoperative outcomes, such as increased perioperative mortality, postoperative sepsis, prolonged length of stay, increased cost of care, decreased functional outcome, and poorer oncological outcomes in cancer surgery. Multimodal prehabilitation, as a concept that involves boosting and optimizing the preoperative condition of a patient prior to the upcoming stressors of a surgical procedure, has the purported benefits of reversing the effects of sarcopenia, shortening hospitalization, improving the rate of return to bowel activity, reducing the costs of hospitalization, and improving quality of life. This review aims to present the current literature surrounding the concept of sarcopenia, its implications pertaining to colorectal cancer and surgery, a summary of studied multimodal prehabilitation interventions, and potential future advances in the management of sarcopenia.

Is virtual nutritional counseling efficacious for cancer patients during the COVID-19 pandemic?

This study investigates the outcomes of virtual nutritional counseling (VNC) for oncology patients during the Covid-19 pandemic. Our study evaluated the nutritional status data of cancer patients at the baseline and after VNC. An oncology dietitian evaluated the patients by video calling each patient via WhatsApp and sent an individual nutrition diet plan and recommendations via e-mail. Patient-Generated Subjective Global Assessment (PG-SGA) was used as a screening and evaluation tool to assess nutritional status. A total of 157 patients with a mean age of 55.8 ± 14.7 (r = 19-89) were included in the study. Researchers detected at least one nutrition-related sign in 77.7% of patients. After the VNC and based on the final PG-SGA assessments, 62.2% of the patients whose baseline PG-SGA Score-B improved to Score-A, 12.5% with a baseline PG-SGA Score-C improved to Score-A and 54.2% with a baseline Score-C improved to a Score-B (χ2 = 55,000, P < 0.001). Based on the number of VNCs, the improvement in malnutrition status following two sessions and three or more sessions was found to be 17.6% and 35.7%, respectively (P < 0.001). Our results confirm that VNC can improve the nutritional status of cancer patients. Hence, nutritional counseling should be an integral part of oncological treatment.

The Best Supportive Care in Stage III Non-Small-Cell Lung Cancer

Lung cancer is a major cause of cancer deaths worldwide. Non-small-cell lung cancer (NSCLC) represents most lung cancer cases, and approximately one-third of patients present with stage III disease at diagnosis. As multiple treatment plans can be adopted for these patients depending on tumor size and nodal staging, stage III NSCLC management is challenging. Over the past decades, multidisciplinary teams (MDTs) have been implemented in healthcare services to coordinate actions among the different health care professionals involved in cancer care. The aim of this review was to discuss real-world evidence of the impact of MDTs on stage III NSCLC management, survival, and quality of life. Here, we performed a literature review to investigate the role of nutrition and navigational nursing in NSCLC care and the influence of MDTs in the choice of treatment plans, including immunotherapy consolidation, and in the management of chemotherapy and radiotherapy-related adverse events. We also performed a mapping review to identify gaps in the implementation of cancer care MDTs in healthcare services around the world.

High Protein Oral Nutritional Supplements Enable the Majority of Cancer Patients to Meet Protein Intake Recommendations during Systemic Anti-Cancer Treatment: A Randomised Controlled Parallel-Group Study

ESPEN guidelines recommend a minimum protein intake of 1.0 g/kg body weight (BW) per day to maintain or restore lean body mass in patients with cancer. During anti-cancer treatment, optimal protein intake is difficult to achieve. We investigated whether a high-protein, low-volume oral nutritional supplement (ONS) supports patients in meeting recommendations. A multi-centre, randomised, controlled, open-label, parallel-group study was carried out in nine hospitals (five countries) between January 2019 and July 2021 in colorectal and lung cancer patients undergoing first-line systemic treatment with chemo(radio-) or immunotherapy. Subjects were randomised (2:1) to receive Fortimel Compact Protein® or standard care. Protein intake was assessed with a 3-day food diary (primary outcome). BW was a secondary outcome. Due to challenges in recruitment, the study was terminated prematurely with 42 patients randomised (intervention group (IG) 28; control group (CG) 14). At T1 and T2, protein intake was statistically significantly higher in the IG compared to the CG (1.40 vs. 1.07 g/kg/day at T1, p = 0.008; 1.32 vs. 0.94 g/kg/day at T2, p = 0.002). At baseline, only 65% (IG) and 45% (CG) of patients met ESPEN minimum protein intake recommendations. However, at T1 and T2 in the IG, a higher proportion of patients met recommendations than in the CG (88% vs. 55% and 40%). No statistically significant difference between study groups was observed for BW. Mean compliance to the ONS was 73.4%. A high-protein, low-volume ONS consumed twice daily enables the majority of patients to reach minimal ESPEN protein recommendations.

Preoperative albumin-to-globulin ratio and prognostic nutritional index predict the prognosis of colorectal cancer: a retrospective study

The immunonutritional status has important effects on outcomes for cancer patients. Albumin-to-globulin ratio (AGR) and the prognostic nutrition index (PNI) are often used to assess the immunonutritional status of cancer patients. However, the clinical significance of these factors in colorectal cancer (CRC) remains unclear. We aimed to evaluate the clinical significance of the AGR and PNI in CRC. We reviewed the clinical data of 511 patients with CRC in two hospitals. Data from one institution was used as the training cohort. The optimal cutoff values for AGR and PNI in the training cohort were 1.4 and 48.65, respectively. Patients in both the low AGR and low PNI groups had poor overall survival (OS) and progression-free survival (PFS), while those in the low AGR-low PNI group had the lowest OS and PFS. Multivariate analysis revealed that preoperative AGR, preoperative PNI, gross type, and TNM stage were independent prognostic factors influencing OS in patients with CRC. Preoperative AGR, preoperative PNI, and TNM stage were independently associated with PFS in patients with CRC. According to the results of multivariate analysis in the training cohort, we developed the nomograms for OS and PFS and performed internal and external validation, which showed good prediction ability of the nomograms. In conclusion, preoperative AGR and PNI can be used as effective indicators to predict survival for patients with CRC. AGR and PNI may help develop effective adjuvant-therapy schedules.

Gastric Cancer with Sarcopenia: an Area Worth Focusing On

OPINION STATEMENT

Gastric cancer (GC) is the fifth most common cancer and the third leading cause of cancer death worldwide, which seriously endangers human health. A number of studies have shown that sarcopenia occurs more frequently in patients with gastric cancer than in the general population and can significantly affect the disease status and survival of patients, which is of great significance in predicting the prognosis of gastric cancer. Patients with gastric cancer may suffer sarcopenia no matter before or after surgery, and the pathogenesis is complex. Abnormal nutrient metabolism and reduced exercise are the leading causes. In addition, surgical treatment and chemotherapy for gastric cancer might participate in the physiological and pathological mechanism of sarcopenia. Generally speaking, exercise and nutritional therapy are the main prevention and treatment methods for sarcopenia. But more prospective evidence is needed to establish reasonable interventions, and other drug treatments are in their infancy. For the diagnostic criteria of sarcopenia, the cut-off values of the skeletal muscle mass index obtained from CT images vary widely and need to be standardized and unified. We also need to explore simple predictors to facilitate sarcopenia risk assessment. More research is needed to formulate more appropriate treatments for gastric cancer patients with sarcopenia.

Controlling Nutritional Status (CONUT) score as a prognostic marker for gastrointestinal stromal tumours

BACKGROUND

The Controlling Nutritional Status (CONUT) score, regarded as the effective indicator of patient nutrition, has been demonstrated to be related to prognosis of numerous tumours. Nevertheless, the significance of CONUT for gastrointestinal stromal tumour (GIST) remains unclear. This study intended to clarify the association between CONUT and the prognosis of GISTs.

METHODS

Three hundred and fifty-five patients with GISTs undergoing surgical resection at our center were retrospectively assessed. Receiver operating characteristic curve analysis was used to help determine the cut-off value of CONUT score. Relapse-free survival (RFS) and overall survival (OS) were assessed by Kaplan-Meier curve analysis. Prognostic factors for RFS and OS were examined by Cox proportional hazards models.

RESULTS

A total of 355 patients were enrolled in this study. Areas under the curve (AUC) were 0.638 for CONUT score, and the cut-off value of CONUT was shown to be three. Kaplan-Meier curve analysis showed that high CONUT score was linked to poorer RFS and OS. Univariate and multivariate analyses ultimately revealed that CONUT was a risk factor for RFS and OS, independent of demographics and clinicopathological tumour characteristics.

CONCLUSIONS

CONUT score was an effective and novel predictor for prognosis of GIST patients treated with surgery, indicating its potential as a prognostic marker in the overall management.

Monitoring the effect of perioperative nutritional care on body composition and functional status in patients with carcinoma of gastrointestinal and hepatobiliary system and pancreas

BACKGROUND

The significance of nutritional care in the management of cancer, particularly in the surgical treatment of abdominal cancer, is increasingly acknowledged. Body composition analysis, such as the Bioelectric impedance assay (BIA), and functional tests, e.g., handgrip strength, are used when assessing nutritional status alongside general and nutritional history, clinical examination, and laboratory tests. The primary approach in nutritional care is individually adjusted nutritional counselling and the use of medical nutrition, especially oral nutritional supplements. The aim of the study was to investigate the effects of perioperative nutritional care on body composition and functional status in patients with carcinoma of the gastrointestinal tract, hepatobiliary system, and pancreas.

PATIENTS AND METHODS

47 patients were included, 27 received preoperative and postoperative nutritional counselling and oral nutritional supplements (Group 1), while 20, due to surgical or organisational reasons, received nutritional care only postoperatively (Group 2). The effect of nutritional therapy was measured with bioimpedance body composition and handgrip measurements.

RESULTS

Group 2 had a higher average Nutritional Risk Screening (NRS) 2002 score upon enrolment (3 vs. 2 points); however, there was no difference when malnutrition was assessed using Global Leadership in Malnutrition (GLIM) criteria. There was a relative increase in lean body mass and fat-free mass index (FFMI) 7 days after surgery in group 1 (+4,2% vs. -2,1% in group 2). There was no difference in handgrip strength.

CONCLUSIONS

Our results indicate that combined preoperative and postoperative nutritional care is superior to only postoperative nutritional care. It seems to prevent statistically significant lean mass loss 7 days after surgery but not after 14 days or 4 weeks.

A quality control circle process to improve enteral nutrition feeding support in discharged patients with colorectal cancer

Correct usage and maintenance of the enteral nutrition feeding pump system is always a challenge in nutrition support for patients with colorectal cancer (CRC). However, there are few studies on the sustained accuracy improvement of the enteral nutrition feeding system in discharged CRC patients. Here, we established a seven-month quality control circle (QCC) activity with the theme of improving the performance of home enteral feeding pumps (EFP) and examined the effect of QCC activity on the nutritional state and quality of life in discharged CRC patients. We enrolled 100 discharged CRC patients treated with home enteral nutrition from Zhejiang Cancer Hospital between March 2020 and December 2021. The patients were randomly split into two research groups: one participated in the QCC activity (n = 50) and the other did not (n = 50). QCC analysis indicated that the top 3 causes of EFP inaccurate usage are the simple and boring contents of training, various types of pumps, no examination rules, and lack of management. Furthermore, both intra- and inter-group comparisons showed that QCC significantly improved the patients' pass rate of nutrition pump operation from 52 to 70% after 1-month of activity, which gradually improved and got the highest (90%) after 3 months (p < 0.05). Interestingly, the established QCC activity significantly increased the patient-generated subjective global assessment (PG-SGA) and Barthel index (BI) scores, body fat mass (BFM) and superior longitudinal muscle (SLM) by intra- and inter-group comparisons. In this study, we clarified the main causes of inaccurate EFP usage and established a QCC process to improve the pass rate of EFP usage. It finally leads to the improvement of nutritional state and quality of life in CRC patients.

The effect of post-discharge oral nutritional supplements on outcomes after gastrointestinal surgery: A systematic review and meta-analysis

BACKGROUND

Malnutrition is a risk-factor for adverse postoperative outcomes. This systematic review and meta-analysis evaluated the impact of post-discharge oral nutritional supplements (ONS) on outcomes in patients undergoing gastrointestinal surgery.

METHODS

The Medline and Embase databases were searched for randomised clinical trials in patients undergoing gastrointestinal surgery who had received ONS for at least two weeks after discharge from hospital. The primary endpoint was weight change. Secondary endpoints included quality of life, total lymphocyte count, total serum protein and serum albumin. Analysis was performed using RevMan5.4 software.

RESULTS

Fourteen studies with 2480 participants (1249 ONS/1231 controls) were included. Pooling of results revealed that a reduction in postoperative weight loss in patients taking ONS, when compared with control: overall weighted mean difference (WMD) -1.69 kg, 95% CI -2.98 to -0.41, P = 0.01. Serum albumin concentration was increased in the ONS group: WMD = 1.06 g/L, 95% CI 0.04 to 2.07, P = 0.04. Haemoglobin was also increased: WMD = 2.91 g/L, 95% CI 0.58 to 5.25, P = 0.01. Total serum protein, total lymphocyte count, total cholesterol and quality of life did not differ between the groups. Patient compliance was relatively poor across the studies and there was variability in the composition of ONS, volume consumed and surgical procedures performed.

CONCLUSIONS

There was a reduction in postoperative weight loss and an improvement in some biochemical parameters in patients receiving ONS after gastrointestinal surgery. Future RCTs with more consistent methodologies are needed to investigate the efficacy of ONS after discharge from hospital following gastrointestinal surgery.

Nutrition as prevention for improved cancer health outcomes: a systematic literature review

BACKGROUND

Among adults with cancer, malnutrition is associated with decreased treatment completion, more treatment harms and use of health care, and worse short-term survival. To inform the National Institutes of Health Pathways to Prevention workshop, "Nutrition as Prevention for Improved Cancer Health Outcomes," this systematic review examined the evidence for the effectiveness of providing nutrition interventions before or during cancer therapy to improve outcomes of cancer treatment.

METHODS

We identified randomized controlled trials enrolling at least 50 participants published from 2000 through July 2022. We provide a detailed evidence map for included studies and grouped studies by broad intervention and cancer types. We conducted risk of bias (RoB) and qualitative descriptions of outcomes for intervention and cancer types with a larger volume of literature.

RESULTS

From 9798 unique references, 206 randomized controlled trials from 219 publications met the inclusion criteria. Studies primarily focused on nonvitamin or mineral dietary supplements, nutrition support, and route or timing of inpatient nutrition interventions for gastrointestinal or head and neck cancers. Most studies evaluated changes in body weight or composition, adverse events from cancer treatment, length of hospital stay, or quality of life. Few studies were conducted within the United States. Among intervention and cancer types with a high volume of literature (n = 114), 49% (n = 56) were assessed as high RoB. Higher-quality studies (low or medium RoB) reported mixed results on the effect of nutrition interventions across cancer and treatment-related outcomes.

CONCLUSIONS

Methodological limitations of nutrition intervention studies surrounding cancer treatment impair translation of findings into clinical practice or guidelines.

Clinical usefulness of the Patient-Generated Subjective Global Assessment and modified Glasgow Prognostic Score in decision making concerning the indication of enteral nutritional therapy in patients with incurable cancer receiving palliative care

OBJECTIVES

This study aimed to identify the clinical usefulness of assessing nutritional status using validated tools for the indication of enteral nutrition for patients with incurable cancer in palliative care.

METHODS

In this prospective cohort study, patients were assessed for nutritional risk using the Patient-Generated Subjective Global Assessment and for cancer cachexia (CC) using the modified Glasgow Prognostic Score upon enrollment and after ∼30 d. The outcome was stable or improved Karnofsky Performance Status. Logistic regression models were used, providing the odds ratio (OR) and 95% confidence interval (CI).

RESULTS

A total of 180 patients participated. The only nutritional status parameter that was associated with function was CC. The less severe the CC, the more likely Karnofsky Performance Status was to remain stable or improve over 30 d (non-cachectic: OR = 1.95; 95% CI, 1.01-3.47; malnourished: OR = 1.06; 95% CI, 1.01-1.42). Furthermore, white skin color (OR = 1.79; 95% CI, 1.04-2.47), higher educational level (OR = 1.39; 95% CI, 1.13-2.78), and inadequate calorie intake (OR = 1.96; 95% CI, 1.02-2.81) were also associated with the outcome.

CONCLUSIONS

Using the modified Glasgow Prognostic Score to identify the existence and severity of CC, which is associated with function, has the potential to help clinical decision making concerning the indication of enteral nutrition in patients with incurable cancer receiving palliative care.

Development and validation of a cancer cachexia risk score for digestive tract cancer patients before abdominal surgery

BACKGROUND

Cancer cachexia is prevalent in digestive tract cancer patients and has significant impacts on prognosis; it is vital to identify individuals who are at risk of cancer cachexia to allow for appropriate evaluation and treatment. This study evaluated whether digestive tract cancer patients with a risk of cancer cachexia and who had a risk of adverse survival could be identified before abdominal surgery.

METHODS

This large-scale cohort study involved patients who underwent abdominal surgery between January 2015 and December 2020 to treat digestive tract cancer. Participants were allocated to the development cohort, the validation cohort, or the application cohort. Univariate and multivariate analyses of the development cohort were performed to detect distinct risk variables for cancer cachexia to create a cancer cachexia risk score. The performance of the risk score across all the three cohorts was assessed through calculating the area under the receiver operating characteristic curve (AUC), as well as calibration and decision curves. We tested how well the score predicted survival outcomes in the application cohort.

RESULTS

A total of 16 264 patients (median 64 years of age; 65.9% male) were included, with 8743 in the development cohort, 5828 in the validation cohort, and 1693 in the application cohort. Seven variables were identified as independent predictive factors and were included in the cancer cachexia risk score: cancer site, cancer stage, time from symptom onset to hospitalization, appetite loss, body mass index, skeletal muscle index, and neutrophil-lymphocyte ratio. The risk score predicting cancer cachexia owns a good discrimination, with the mean AUC of 0.760 (P < 0.001) in the development cohort, 0.743 (P < 0.001) in the validation cohort, and 0.751 (P < 0.001) in the application cohort, respectively, and had an excellent calibration (all P > 0.05). The decision curve analysis revealed net benefits of the risk score across a range of risk thresholds in the three cohorts. In the application cohort, compared with the high-risk group, the low-risk group experienced significantly longer overall survival [hazard ratio (HR) 2.887, P < 0.001] as well as relapse-free survival (HR 1.482, P = 0.01).

CONCLUSIONS

The cancer cachexia risk score constructed and validated demonstrated good performance in identifying those digestive tract cancer patients before abdominal surgery at a higher risk of cancer cachexia and unfavourable survival. This risk score can help clinicians to enhance their capabilities to screen for cancer cachexia, assess patient prognosis, and strengthen early decision-making on targeted approaches to attune cancer cachexia for digestive tract cancer patients before abdominal surgery.

Nutrition education with or without oral nutrition supplements has contrasting effects on nutrition status in older adults: A randomized controlled study

BACKGROUND

Oral nutrition supplements (ONSs) play an important role in the management of malnutrition. This aim of study was to examine whether a comprehensive intervention, combining ONSs, family-centered health education, and nutrition and medical consultations, could improve the nutrition and health status of malnourished older adults living in community dwellings.

METHODS

A randomized controlled trial was conducted from October 2017 to May 2018 in Shanghai. All participants were screened using the Mini Nutritional Assessment-Short Form (MNA-SF). Participants with MNA-SF scores ≤11 and age ≥65 were selected. Participants with potential nutrition risk were randomized into two groups: intervention group (n = 101) were prescribed ONSs (400 kcal/day) and family-centered nutrition education (once every 2 weeks) and control group (n = 100) received only family-centered nutrition education. Anthropometric measurements, including weight and height, and nutrition and functional scales, including MNA-SF, grip strength, and activities of daily living scores, were collected at the beginning of the study and 12 weeks later.

RESULTS

Of the 201 study participants, 182 completed the study (mean age, 75.48 ± 7.47 years). After 12 weeks, nutrient intake improvements in the intervention group (+370.6 ± 432.6 kcal/day, +17.6 ± 24.1 g/day) exceeded that of the control group (-67.5 ± 378.2 kcal/day, -0.9 ± 16.7 g/day). In addition, improvements in weight, body mass index, and handgrip strength were significantly higher in the intervention vs control group (P < .05).

CONCLUSION

Comprehensive nutrition interventions improved nutrition status in malnourished older people living in community dwellings. Use of ONSs may be a good strategy to improve nutrition status and strength in community-dwelling older adults.

Oncology-Led Early Identification of Nutritional Risk: A Pragmatic, Evidence-Based Protocol (PRONTO)

Nutritional issues, including malnutrition, low muscle mass, sarcopenia (i.e., low muscle mass and strength), and cachexia (i.e., weight loss characterized by a continuous decline in skeletal muscle mass, with or without fat loss), are commonly experienced by patients with cancer at all stages of disease. Cancer cachexia may be associated with poor nutritional status and can compromise a patient's ability to tolerate antineoplastic therapy, increase the likelihood of post-surgical complications, and impact long-term outcomes including survival, quality of life, and function. One of the primary nutritional problems these patients experience is malnutrition, of which muscle depletion represents a clinically relevant feature. There have been recent calls for nutritional screening, assessment, treatment, and monitoring as a consistent component of care for all patients diagnosed with cancer. To achieve this, there is a need for a standardized approach to enable oncologists to identify patients commencing and undergoing antineoplastic therapy who are or who may be at risk of malnutrition and/or muscle depletion. This approach should not replace existing tools used in the dietitian's role, but rather give the oncologist a simple nutritional protocol for optimization of the patient care pathway where this is needed. Given the considerable time constraints in day-to-day oncology practice, any such approach must be simple and quick to implement so that oncologists can flag individual patients for further evaluation and follow-up with appropriate members of the multidisciplinary care team. To enable the rapid and routine identification of patients with or at risk of malnutrition and/or muscle depletion, an expert panel of nutrition specialists and practicing oncologists developed the PROtocol for NuTritional risk in Oncology (PRONTO). The protocol enables the rapid identification of patients with or at risk of malnutrition and/or muscle depletion and provides guidance on next steps. The protocol is adaptable to multiple settings and countries, which makes implementation feasible by oncologists and may optimize patient outcomes. We advise the use of this protocol in countries/clinical scenarios where a specialized approach to nutrition assessment and care is not available.

Body mass index-based predictions and personalized clinical strategies for colorectal cancer in the context of PPPM

Currently colorectal cancer (CRC) is the third most prevalent cancer worldwide. Body mass index (BMI) is frequently used in CRC screening and risk assessment to quantitatively evaluate weight. However, the impact of BMI on clinical strategies for CRC has received little attention. Within the framework of the predictive, preventive, and personalized medicine (3PM/PPPM), we hypothesized that BMI stratification would affect the primary, secondary, and tertiary care options for CRC and we conducted a critical evidence-based review. BMI dynamically influences CRC outcomes, which helps avoiding adverse treatment effects. The outcome of surgical and radiation treatment is adversely affected by overweight (BMI ≥ 30) or underweight (BMI < 20). A number of interventions, such as enhanced recovery after surgery and robotic surgery, can be applied to CRC at all levels of BMI. BMI-controlling modalities such as exercise, diet control, nutritional therapy, and medications may be potentially beneficial for patients with CRC. Patients with overweight are advised to lose weight through diet, medication, and physical activity while patients suffering of underweight require more focus on nutrition. BMI assists patients with CRC in better managing their weight, which decreases the incidence of adverse prognostic events during treatment. BMI is accessible, noninvasive, and highly predictive of clinical outcomes in CRC. The cost-benefit of the PPPM paradigm in developing countries can be advanced, and the clinical benefit for patients can be improved with the promotion of BMI-based clinical strategy models for CRC.

Identification and management of cancer cachexia in patients: Assessment of healthcare providers' knowledge and practice gaps

BACKGROUND

Cancer cachexia negatively impacts patient outcomes, quality of life and survival. Identification and management of cancer cachexia remains challenging to healthcare professionals (HCPs). The aim of this assessment was to identify current gaps in HCPs' knowledge and practice for identifying and managing adults with cancer-related cachexia. Results may guide development of new educational programmes to close identified gaps and improve outcomes of cancer patients.

METHODS

An international assessment was conducted using a mixed-methods approach including focus group interviews with subject matter experts and an electronic survey of practising HCP. The assessment was led by the Society on Sarcopenia, Cachexia and Wasting Disorders (SCWD) and was supported by in-country collaborating organizations.

RESULTS

A quantitative survey of 58 multiple-choice questions was completed by physicians, nurses dietitians and other oncology HCP (N = 2375). Of all respondents, 23.7% lacked confidence in their ability to provide care for patients with cancer cachexia. Patients with gastrointestinal, head and neck, pulmonary cancers and leukaemia/lymphoma were reported as those at highest risk for cachexia. Only 29.1% of respondents recognized a key criterion of cancer cachexia as >5% weight loss from baseline, but many (14.4%) did not utilize a standardized definition of cancer cachexia. Despite this, most clinicians (>84%) were able to identify causes of weight loss-reduced oral intake, progressive disease, side effects of therapy and disease-related inflammation. Of all respondents, 52.7% indicated newly diagnosed patients with cancer should be screened for weight loss. In practice, 61.9% reported that patient weight was systematically tracked over time, but only 1125 (47.4%) reported they weigh their cancer patients at each visit. Treatment of cachexia focused on increasing the patient's nutritional intake by oral nutritional supplements (64.2%), energy and protein fortified foods (60.3%) and counselling by a dietitian (57.1%). Whereas many respondents (37.3%) considered cachexia inevitable, most (79.2%) believed that an interprofessional team approach could improve care and that use of standardized tools is critical.

CONCLUSIONS

Findings from this international assessment highlight the challenges associated with the care of patients with cancer cachexia, opportunities for interventions to improve patient outcomes and areas of variance in care that would benefit from further analysis.

Acute Sarcopenia after Elective and Emergency Surgery

Sarcopenia is an increasingly recognised condition of loss of muscle mass and function. The European Working Group on Sarcopenia in Older People 2 (EWSOP2) updated their definition in 2018, emphasising the importance of low muscle strength in diagnosis. Acute sarcopenia has been arbitrarily defined as sarcopenia lasting less than 6 months. This review highlights the pathophysiology involved in muscle wasting following surgery, focussing on hormonal factors, inflammation, microRNAs, and oxidative stress. Biomarkers such as GDF-15, IGF-1 and various microRNAs may predict post-surgical muscle loss. The impact of existing sarcopenia on various types of surgery and incident muscle wasting following surgery is also described. The gaps in research found include the need for longitudinal studies looking in changes in muscle strength and quantity following surgery. Further work is needed to examine if biomarkers are replicated in other surgery to consolidate existing theories on the pathophysiology of muscle wasting.

Extending the benefit of nutrition intervention beyond the operative setting

PURPOSE OF REVIEW

To provide an update of the recent evidence on the potential of perioperative nutritional interventions to benefit adult patients undergoing head and neck and digestive procedures.

RECENT FINDINGS

Perioperative nutrition within multimodal prehabilitation programs improve postoperative outcomes. Perioperative fasting time can be reduced with beverages containing carbohydrate alone or blended with a nitrogenous source such as whey protein; this approach seems to be safe and improve outcome. The choice of protein-containing formula, as well as diet composition to be recommended early during the postoperative refeeding, can be optimized to reduce complications. Sarcopenia is an important risk factor for surgical patients, as such, prehabilitation along with preoperative nutrition is strongly advised. Perioperative supplementation with β-hydroxy β-methylbutyrate to mitigate sarcopenia requires further investigation. Although perioperative nutritional interventions reduce healthcare costs, recent data suggest it has been scarcely prescribed.

SUMMARY

Nutritional intervention is key in multimodal programs of enhanced recovery after surgery to ensure better outcomes. Perioperative fasting should be shortened, and include clear fluids containing carbohydrates and protein, especially in the early postoperative period. Multimodal prehabilitation is key to mitigate sarcopenia. Action to improve knowledge on the cost-effectiveness of nutritional interventions in the perioperative setting are needed.

A Digital Smartphone-Based Self-administered Tool (R+ Dietitian) for Nutritional Risk Screening and Dietary Assessment in Hospitalized Patients With Cancer: Evaluation and Diagnostic Accuracy Study

BACKGROUND

Malnutrition is a common and severe problem in patients with cancer that directly increases the incidence of complications and significantly deteriorates quality of life. Nutritional risk screening and dietary assessment are critical because they are the basis for providing personalized nutritional support. No digital smartphone-based self-administered tool for nutritional risk screening and dietary assessment among hospitalized patients with cancer has been developed and evaluated.

OBJECTIVE

This study aims to develop a digital smartphone-based self-administered mini program for nutritional risk screening and dietary assessment for hospitalized patients with cancer and to evaluate the validity of the mini program.

METHODS

We have developed the R+ Dietitian mini program, which consists of 3 parts: (1) collection of basic information of patients, (2) nutritional risk screening, and (3) dietary energy and protein assessment. The face-to-face paper-based Nutritional Risk Screening (NRS-2002), the Patient-Generated Subjective Global Assessment Short Form (PG-SGA-SF), and 3 days of 24-hour dietary recall (3d-24HRs) questionnaires were administered according to standard procedure by 2 trained dietitians as the reference methods. Sensitivity, specificity, positive predictive value, negative predictive value, κ value, and correlation coefficients (CCs) of nutritional risk screened in R+ Dietitian against the reference methods, as well as the difference and CCs of estimated dietary energy and protein intakes between R+ Dietitian and 3d-24HRs were calculated to evaluate the validity of R+ Dietitian.

RESULTS

A total of 244 hospitalized patients with cancer were recruited to evaluate the validity of R+ Dietitian. The NRS-2002 and PG-SGA-SF tools in R+ Dietitian showed high accuracy, sensitivity, and specificity (77.5%, 81.0%, and 76.7% and 69.3%, 84.5%, and 64.5%, respectively), and fair agreement (κ=0.42 and 0.37, respectively; CC 0.62 and 0.56, respectively) with the NRS-2002 and PG-SGA-SF tools administered by dietitians. The estimated intakes of dietary energy and protein were significantly higher (P<.001 for both) in R+ Dietitian (mean difference of energy intake: 144.2 kcal, SD 454.8; median difference of protein intake: 10.7 g, IQR 9.5-39.8), and showed fair agreement (CC 0.59 and 0.47, respectively), compared with 3d-24HRs performed by dietitians.

CONCLUSIONS

The identified nutritional risk and assessment of dietary intakes of energy and protein in R+ Dietitian displayed a fair agreement with the screening and assessment conducted by dietitians. R+ Dietitian has the potential to be a tool for nutritional risk screening and dietary intake assessment among hospitalized patients with cancer.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR1900026324; https://www.chictr.org.cn/showprojen.aspx?proj=41528.

Prognostic significance of postoperative loss of skeletal muscle mass in patients underwent coronary artery bypass grafting

Background

Increasing life expectancy of coronary artery bypass grafting (CABG) remains to be the major concern of cardiac surgeons. However, few studies have investigated the effect of postoperative skeletal muscle index (SMI) loss on prognosis. This study aims to evaluate the prognostic role of postoperative SMI loss ≥ 5% after CABG, in order to develop a novel nomogram to predict overall survival (OS).

Methods

Patients underwent CABG via midline sternotomy from December 2015 to March 2021 were recruited in this study. Preoperative and postoperative 3 months chest computed tomography (CT) images were compared to assess changes in SMI at T12 level. Based on this, patients were classified into the presence or absence of SMI loss ≥ 5%. The association between postoperative SMI loss ≥ 5% and OS was then analyzed by the Kaplan-Meier curves and Cox model. A novel nomogram incorporating independent clinical prognostic variables was also developed.

Results

The study enrolled 506 patients receiving CABG, of whom 98 patients experienced T12 SMI loss ≥ 5% and had a significantly worse OS (P < 0.0001). Multivariate regression analysis showed that T12 SMI per cent change (%T12 SMI-change) was an independent prognostic factor for OS (HR = 0.809, 95% CI = 0.749–0.874). The nomogram incorporating %T12 SMI-change with other variables was accurate for predicting OS. Besides, we also found that postoperative oral nutritional supplement (ONS) can rescue T12 SMI loss.

Conclusion

Postoperative SMI loss can predict survival outcome after CABG. The nomogram incorporating changes in SMI provides a superior performance than existing systems.

High protein diet in digestive cancers

PURPOSE OF REVIEW

Recent advances in the nutritional management of patients with digestive cancers suggest that modulation of protein intake may significantly contribute to achieve nutritional and clinical benefits. By reviewing the available evidence, a quantitatively and qualitatively optimal protein intake could be derived.

RECENT FINDINGS

High protein diets (i.e., 1-1.5 g/kg body weight/day) appear key to maintain the adequate nutritional status, and may also contribute to achieve clinical benefits. This target appears particularly relevant in patients with digestive cancers at risk or already malnourished, or in older patients. During active cancer treatments, protein intake should be closer to the upper limit of the recommended intake. Also, high protein intake should be maintained beyond the periods of catabolic crisis associated with active treatments. In contrast with general reasoning, animal proteins should represent the majority of the recommended intake. Based on the available evidence, the intake of no specific amino acid can be strongly recommended to enhance anabolic potentials or the immune modulating effects of high protein diets.

SUMMARY

High protein intake, mostly based on animal proteins, should be recommended to patients with digestive cancers. However, this target should be translated into clinical prescription after considering the clinical and metabolic needs of the patients. The quest for the optimal protein intake of patients with cancer at different time points of their clinical journey is still open.

Does Home Oral Nutritional Support Improve Nutritional Status and Quality of Life following Colorectal Cancer Surgery?

Oral nutritional support (ONS) is a form of supportive intervention in patients' diet in response to insufficient oral intake, malabsorption, or functional insufficient food intake during the disease process. This study aimed to evaluate the nutritional status, morbidity, re-admissions, functional status, QoL of patients who had undergone elective colorectal cancer surgery and initiated home ONS. A total of 144 patients who had undergone colorectal cancer surgery and given home ONS were analyzed with regard to demographics, diagnosis, weight-BMI changes, re-admissions, morbidity, daily caloric and protein intake, functional status (Barthel index) and QoL (The Satisfaction with Life Scale-SWLS). The mean age was 65,6 ± 12,8 with a Female/Male ratio of 53/91. The mean BMI increased from 25.71 ± 3.81 to 28,35 ± 4,53 (p < 0.0001). Re-admission was significantly higher in patients who had received 600 kcal (55.8%) than those who received 900 kcal (40.2%) (p = 0.007). Furthermore, adaptation to chemotherapy (p = 0.02) and the Bartel index scores (p = 0.001) were significantly worse in patients who received 600 kcal compared to patients who received 900 kcal; however, the complication rate (p = 0.84), adaptation to radiotherapy (p = 0.68) and the QoL scores (p = 0.35) were not significantly different. Home ONS improved the BMI in all patients. In addition, ONS resulted in good outcomes with regard to adaptation to chemotherapy and the functional status in the treatments of patients with colorectal cancer.

Clinical and economic value of oral nutrition supplements in patients with cancer: a position paper from the Survivorship Care and Nutritional Support Working Group of Alliance Against Cancer

Malnutrition is a common clinical and public health problem that can frequently affect patients in hospital and community settings. In particular, cancer-related malnutrition results from a combination of metabolic dysregulation and anorexia, caused both by the tumor itself and by its treatment. Patients with head-neck cancer, or with gastroesophageal, pancreatic, lung, and colorectal cancer, are particularly at risk of developing malnutrition, with a prevalence varying between 30 and 50% depending on tumor location and anti-cancer treatment complications. Prevention and adequate management of malnutrition is now considered an essential key point of therapeutic pathways of patients with cancer, with the aim to enhance their quality of life, reduce complications, and improve clinical outcomes. Oral nutritional supplements (ONS) are part of the nutritional therapy and represent an effective tool to address cancer-related malnutrition, as supported by growing literature data. However, patients' access to ONS - which is regulated by different national and regional policies in terms of reimbursement - is quite heterogeneous. This narrative review aims to summarize the current knowledge about the role of ONS in terms of cost-effectiveness in the management of actively treated patients with cancer, following surgery and/or radiotherapy/chemotherapy treatment and to present the position on this issue of the Alliance Against Cancer, the Italian National Oncology Network, coming up from a focused virtual roundtable of the Survivorship Care and Nutritional Support Working Group.

Unresolved issues in perioperative nutrition: A narrative review

Surgical patients are at an increased risk of negative outcomes if they are malnourished or at risk of malnutrition preoperatively. Optimisation of nutritional status should be a focus throughout the perioperative continuum to promote improved surgical outcomes. Enhanced Recovery after Surgery (ERAS) protocols are increasingly applied in the surgical setting but are not yet widespread. This narrative review focused on areas of perioperative nutrition that are perceived as controversial or are lacking in agreement. A search for available literature was conducted on 1 March 2022 and relevant high-quality articles published since 2015 were considered for inclusion. Most malnutrition screening tools are not specific to the surgical population except for the Perioperative Nutrition Screen (PONS) although more large-scale initiatives are needed to improve the prevalence of preoperative nutrition screening. Poor muscle health is common in patients with malnutrition and further exacerbates negative health outcomes indicating that prevention, detection and treatment is of high importance in this population. Although a lack of consensus remains for who should receive preoperative nutritional therapy, evidence suggests a positive impact on muscle health. Additionally, postoperative nutritional support benefits surgical outcomes, with some patients requiring enteral and/or parenteral feeding routes and showing benefit from immunonutrition. The importance of nutrition extends beyond the time in hospital and should remain a priority post-discharge. The impact of individual or personalised nutrition based on select patient characteristics remains to be further investigated. Overall, the importance of perioperative nutrition is evident in the literature despite select ongoing areas of contention.

Nutritional Treatment of Patients with Colorectal Cancer

Colorectal cancer is one of the most common cancers in Europe and the world. Cancer treatments have side effects and cause significant deterioration of the patient’s nutritional status. Patient malnutrition may worsen the health condition and prevent the deliberate effects of the therapy. The aim of this review was to describe the available data about clinical nutrition in colorectal cancer patients. A large proportion of colorectal cancer patients suffer from malnutrition, which negatively affects the survival prognosis, quality of life, and oncological therapy. Therefore, monitoring nutritional status during the treatment is essential and can be used to arrange proper nutritional therapy to enhance patient responses, prevent side effects, and shorten recovery time. The principles of nutrition during anticancer therapy should mainly consider light and low-fat foods, the exclusion of lactose and gluten-containing foods in certain cases, or the introduction of special dietary products such as oral nutrition supplements and it should be tailored to patients’ individual needs.

Effects of β-hydroxy β-methylbutyrate (HMB) supplementation on muscle mass, function, and other outcomes in patients with cancer: a systematic review

Low muscle mass is prevalent among patients with cancer and a predictor of adverse clinical outcomes. To counteract muscle loss, β-hydroxy β-methylbutyrate (HMB) supplementation has been proposed as a potential therapy for older adults and various diseases states. This systematic review aimed to investigate the effects and safety of HMB supplementation in relation to muscle mass and function and other clinical outcomes in patients with cancer. A systematic search of MEDLINE, CINAHL, Embase, Cochrane Central Register of Controlled Trials, Scopus, ProQuest, and grey literature for reports published from inception to December 2021 was conducted. Included studies provided supplements containing any dose of HMB to adult patients with active cancer. A synthesis without meta-analysis was conducted using a vote-counting approach based solely on the direction of the effect (i.e. regardless of statistical significance). Risk of bias was assessed for each outcome domain, and evidence from higher-quality studies (i.e. those with either low or moderate risk of bias) was examined. Safety was evaluated using both lower-quality and higher-quality studies. Fifteen studies were included, in which six were randomized controlled trials in patients with various cancer types and treatments. Studies prescribed HMB combined with amino acids (73.3%), HMB in oral nutritional supplements (20.0%), or both supplement types (6.7%); Ca-HMB doses of 3.0 g/day were provided in 80.0% of the studies. Four studies had high risk of bias across all outcome domains. Considering the higher-quality studies, evidence of a beneficial effect of HMB supplementation was found in four of four studies for muscle mass, two of two for muscle function, three of three for hospitalization, and five of seven for survival. In contrast, no beneficial effects of HMB on quality of life or body weight was found in two of four and three of five studies, respectively. A limited number of higher-quality studies evaluating the impact of HMB on cancer therapy-related toxicity, inflammation, and tumour response were observed. No serious adverse effects directly related to the nutrition intervention were reported. Although limited, current evidence suggests that HMB supplementation has a beneficial effect on muscle mass and function in patients with cancer. Well-designed trials are needed to further explore the clinical benefit of HMB supplementation in this patient population.

Effect of Home Enteral Nutritional Support Compared With Normal Oral Diet in Postoperative Subjects With Upper Gastrointestinal Cancer Resection: A Meta-Analysis

Introduction

We performed a meta-analysis to evaluate the influence of a home enteral nutritional support compared with a normal oral diet in postoperative subjects with upper gastrointestinal cancer resection.

Methods

A systematic literature search up to December 2021 was done and 23 studies included 3,010 subjects with upper gastrointestinal cancer resection at the start of the study; 1,556 of them were given home enteral nutritional support and 1,454 were normal oral diet. We calculated the odds ratio (OR) and mean difference (MD) with 95% CIs to evaluate the influence of home enteral nutritional support compared with a normal oral diet in postoperative subjects with upper gastrointestinal cancer resection by the dichotomous or continuous methods with a random or fixed-influence model.

Results

Home enteral nutritional support had significantly higher quality of life (MD, 2.08; 95% CI, 1.50–2.67, p &lt; 0.001), better body weight change (MD, 1.87; 95% CI, 1.31–2.43, p &lt; 0.001), higher albumin (MD, 1.27; 95% CI, 0.72–1.82, p &lt; 0.001), and higher pre-albumin (MD, 30.79; 95% CI, 7.29–54.29, p = 0.01) compared to the normal oral diet in subjects with upper gastrointestinal cancer resection. However, home enteral nutritional support had no significant impact on the hemoglobin (MD, 4.64; 95% CI, −4.17 to 13.46, p = 0.30), and complications (OR, 1.03; 95% CI, 0.76–1.40, p = 0.83) compared to the normal oral diet in subjects with upper gastrointestinal cancer resection.

Conclusions

Home enteral nutritional support had a significantly higher quality of life, better body weight change, higher albumin, and higher pre-albumin, and had no significant impact on the hemoglobin and complications compared to the normal oral diet in subjects with upper gastrointestinal cancer resection. Further studies are required.

Relationship Between Nutritional Status and Clinical Outcome in Patients With Gastrointestinal Stromal Tumor After Surgical Resection

Background

Currently, gastrointestinal stromal tumors (GIST) are the most common mesenchymal tumors in the gastrointestinal tract, and surgical resection is the main treatment. Malnutrition after gastrointestinal surgery is not uncommon, which may have adverse effects on postoperative recovery and prognosis. However, the nutritional status of GIST patients after surgical resection and its impact on clinical outcomes have received less attention. Therefore, the aim of this study was to dynamically evaluate the nutritional status of GIST patients undergoing surgical resection, and to analyze the correlation between nutritional status and clinical outcomes.

Methods

We retrospectively analyzed the clinical data of GIST patients who underwent surgical resection in the Fourth Hospital of Hebei Medical University from January 2016 to January 2020. Nutritional risk screening 2002 (NRS2002) and Patient-Generated Subjective Global Assessment (PG-SGA) were used to assess the nutritional status of all patients at admission and discharge, and the correlation between nutritional risk and clinical outcomes was analyzed.

Results

A total of 413 GIST patients were included in this study, among which 114 patients had malnutrition risk at admission (NRS2002 score ≥ 3), and 65 patients had malnutrition (PG-SGA score ≥ 4). The malnutrition risk rate (27.60 vs. 46.73%, p &lt; 0.001) and malnutrition incidence (15.73 vs. 37.29%, p &lt; 0.001) at admission were lower than those at discharge. Compared with the laboratory results at admission, the albumin, prealbumin, and total protein of the patients at discharge were significantly lower (all p &lt; 0.05). And there was a negative correlation between PG-SGA and clinical outcome (all p &lt; 0.05).

Conclusion

The nutritional status of GIST patients after surgical resection at discharge was worse than that at admission, and malnutrition is an important risk factor leading to poor clinical outcomes.

Postoperative Loss of Skeletal Muscle Mass Predicts Poor Survival After Gastric Cancer Surgery

Background

Skeletal muscle mass deterioration is common in gastric cancer (GC) patients and is linked to poor prognosis. However, information regarding the effect of skeletal muscle mass changes in the postoperative period is scarce. This study was to investigate the link between postoperative loss of skeletal muscle mass and survival following GC surgery.

Methods

Patients who underwent GC surgery between January 2015 and December 2016 were recruited into the study. Computed tomography at L3 vertebral level was used to examine skeletal muscle index prior to surgery and about 6 months after surgery. Skeletal muscle index changes were categorized as presence or absence of ≥5% loss. Overall survival (OS) and disease-free survival (DFS) were analyzed, and Cox proportional hazard models used to identify their predictors.

Results

The study comprised of 318 gastric cancer patients of which 63.5% were male. The group's mean age was 58.14 ± 10.77 years. Sixty-five patients experienced postoperative skeletal muscle index loss ≥5% and had poorer OS (P = 0.004) and DFS (P = 0.020). We find that postoperative skeletal muscle index loss ≥ 5% predicts OS [hazard ratio (HR): 2.769, 95% confidence interval (CI): 1.865–4.111; P < 0.001] and DFS (HR: 2.533, 95% CI: 1.753–3.659; P < 0.001).

Conclusions

Loss of skeletal muscle mass postoperatively is linked to poor survival following GC surgery. Further studies are needed to determine whether stabilizing or enhancing skeletal muscle mass after surgery improves survival.

Effects of Perioperative Oral Nutrition Supplementation in Malaysian Patients Undergoing Elective Surgery for Breast and Colorectal Cancers-A Randomised Controlled Trial

This study aimed to investigate the effectiveness of preoperative and an extended 90-days postoperative use of ONS among patients undergoing elective surgery for breast and colorectal cancers. Ninety-one patients were randomised into (i) Group SS received ONS up to 14 days preoperatively and postoperatively up to discharge, (ii) Group SS-E received ONS up to 14 days preoperatively, postoperatively up to discharge and for an extended 90-days after discharge and (iii) Group DS received ONS postoperatively up to discharge. Preoperatively, SS had significantly higher body weight (66.1 ± 15.3 kg vs. 62.5 ± 12.0 kg, p = 0.010) and BMI (26.8 ± 6.8 kg/m2 vs. 26.1 ± 6.7 kg/m2, p = 0.022) than DS when adjusted for baseline values. Postoperatively, SS-E had significantly higher handgrip strength (26 ± 9 kgF vs. 24 ± 6 kgF, p = 0.044) than DS at 90-days post-discharge after adjusted for preoperative values. At 90-days post-discharge, the proportions of patients in SS with albumin < 35 g/d, CAR ≥ 0.1, mPINI ≥ 0.4, mGPS score 1 or 2 were significantly reduced while in SS-E, the reduction in proportions of patients with high hsCRP and mPINI ≥ 0.4 was significant compared to upon discharge. Preoperative ONS had modest benefits in attenuating weight loss whilst postoperative supplementation up to 90-days post-discharge improved handgrip strength and inflammatory prognostic markers.

Total Parenteral Nutrition Treatment Improves the Nutrition Status of Gynecological Cancer Patients by Improving Serum Albumin Level

Background

Malnutrition is often observed in gynecological cancer patients, however its prevalence in these patients remains largely unexplored. Total parenteral nutrition (TPN) is a nutritional intervention method that has controversial treatment outcome on gynecological cancer patients. The present retrospective study is designed to evaluate the nutrition status and TPN treatment outcome on patients diagnosed with endometrial, cervical or ovarian malignant tumors.

Methods

Medical records of a total of 263 patients treated at the First Hospital of Shanxi Medical University, China were included. Nutrition status was assessed by patient-generated subjective global assessment (PG-SGA). Patients were grouped based on nutrition status, cancer type or treatment strategy for clinical characteristic comparison. Multivariable logistic regression analysis was used to identify predictors for malnutrition status and hospital stay duration.

Results

Presence of endometrial and cervical cancer, body weight before nutritional intervention and serum albumin level (P < 0.001 for all) were found to be significant predictors for malnutrition status in gynecological cancer patients. In the malnourished patients, those who were treated with TPN had significantly lower serum albumin levels before and after treatment (P < 0.001) and PG-SGA scores after treatment. Also, TPN treatment could significantly increase the serum albumin levels in these patients after 1 week. In addition, shorter hospitalization period was needed for TPN-treated endometrial (P = 0.019) and ovarian (P < 0.001) patients. Moreover, serum albumin levels (P < 0.001), use of TPN treatment (P = 0.025) and nutrition status (P = 0.010) were identified to be independent predictors for hospital stay duration.

Conclusion

Our results suggest that malnutrition is a significant clinical manifestation in gynecological cancer patients who may benefit from TPN treatment for reduced hospitalization and improved serum albumin levels.

Dietary advice with or without oral nutritional supplements for disease-related malnutrition in adults

BACKGROUND

Disease-related malnutrition has been reported in 10% to 55% of people in hospital and the community and is associated with significant health and social-care costs. Dietary advice (DA) encouraging consumption of energy- and nutrient-rich foods rather than oral nutritional supplements (ONS) may be an initial treatment.

OBJECTIVES

To examine evidence that DA with/without ONS in adults with disease-related malnutrition improves survival, weight, anthropometry and quality of life (QoL).

SEARCH METHODS

We identified relevant publications from comprehensive electronic database searches and handsearching. Last search: 01 March 2021.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of DA with/without ONS in adults with disease-related malnutrition in any healthcare setting compared with no advice, ONS or DA alone.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed study eligibility, risk of bias, extracted data and graded evidence.

MAIN RESULTS

We included 94, mostly parallel, RCTs (102 comparisons; 10,284 adults) across many conditions possibly explaining the high heterogeneity.  Participants were mostly older people in hospital, residential care and the community, with limited reporting on their sex. Studies lasted from one month to 6.5 years.  DA versus no advice - 24 RCTs (3523 participants) Most outcomes had low-certainty evidence. There may be little or no effect on mortality after three months, RR 0.87 (95% confidence interval (CI) 0.26 to 2.96), or at later time points. We had no three-month data, but advice may make little or no difference to hospitalisations, or days in hospital after four to six months and up to 12 months. A similar effect was seen for complications at up to three months, MD 0.00 (95% CI -0.32 to 0.32) and between four and six months. Advice may improve weight after three months, MD 0.97 kg (95% CI 0.06 to 1.87) continuing at four to six months and up to 12 months; and may result in a greater gain in fat-free mass (FFM) after 12 months, but not earlier. It may also improve global QoL at up to three months, MD 3.30 (95% CI 1.47 to 5.13), but not later. DA versus ONS - 12 RCTs (852 participants) All outcomes had low-certainty evidence. There may be little or no effect on mortality after three months, RR 0.66 (95% CI 0.34 to 1.26), or at later time points. Either intervention may make little or no difference to hospitalisations at three months, RR 0.36 (95% CI 0.04 to 3.24), but ONS may reduce hospitalisations up to six months. There was little or no difference between groups in weight change at three months, MD -0.14 kg (95% CI -2.01 to 1.74), or between four to six months. Advice (one study) may lead to better global QoL scores but only after 12 months. No study reported days in hospital, complications or FFM. DA versus DA plus ONS - 22 RCTs (1286 participants) Most outcomes had low-certainty evidence. There may be little or no effect on mortality after three months, RR 0.92 (95% CI 0.47 to 1.80) or at later time points. At three months advice may lead to fewer hospitalisations, RR 1.70 (95% CI 1.04 to 2.77), but not at up to six months. There may be little or no effect on length of hospital stay at up to three months, MD -1.07 (95% CI -4.10 to 1.97). At three months DA plus ONS may lead to fewer complications, RR 0.75 (95% CI o.56 to 0.99); greater weight gain, MD 1.15 kg (95% CI 0.42 to 1.87); and better global QoL scores, MD 0.33 (95% CI 0.09 to 0.57), but this was not seen at other time points. There was no effect on FFM at three months. DA plus ONS if required versus no advice or ONS - 31 RCTs (3308 participants) Evidence was moderate- to low-certainty. There may be little or no effect on mortality at three months, RR 0.82 (95% CI 0.58 to 1.16) or at later time points. Similarly, little or no effect on hospitalisations at three months, RR 0.83 (95% CI 0.59 to 1.15), at four to six months and up to 12 months; on days in hospital at three months, MD -0.12 (95% CI -2.48 to 2.25) or for complications at any time point. At three months, advice plus ONS probably improve weight, MD 1.25 kg (95% CI 0.73 to 1.76) and may improve FFM, 0.82 (95% CI 0.35 to 1.29), but these effects were not seen later. There may be little or no effect of either intervention on global QoL scores at three months, but advice plus ONS may improve scores at up to 12 months. DA plus ONS versus no advice or ONS - 13 RCTs (1315 participants) Evidence was low- to very low-certainty. There may be little or no effect on mortality after three months, RR 0.91 (95% CI 0.55 to 1.52) or at later time points. No study reported hospitalisations and there may be little or no effect on days in hospital after three months, MD -1.81 (95% CI -3.65 to 0.04) or six months. Advice plus ONS may lead to fewer complications up to three months, MD 0.42 (95% CI 0.20 to 0.89) (one study). Interventions may make little or no difference to weight at three months, MD 1.08 kg (95% CI -0.17 to 2.33); however, advice plus ONS may improve weight at four to six months and up to 12 months. Interventions may make little or no difference in FFM or global QoL scores at any time point.

AUTHORS' CONCLUSIONS

We found no evidence of an effect of any intervention on mortality. There may be weight gain with DA and with DA plus ONS in the short term, but the benefits of DA when compared with ONS are uncertain. The size and direction of effect and the length of intervention and follow-up required for benefits to emerge were inconsistent for all other outcomes.  There were too few data for many outcomes to allow meaningful conclusions. Studies focusing on both patient-centred and healthcare outcomes are needed to address the questions in this review.

Examining guidelines and new evidence in oncology nutrition: a position paper on gaps and opportunities in multimodal approaches to improve patient care

Malnutrition, muscle loss, and cachexia are prevalent in cancer and remain key challenges in oncology today. These conditions are frequently underrecognized and undertreated and have devastating consequences for patients. Early nutrition screening/assessment and intervention are associated with improved patient outcomes. As a multifaceted disease, cancer requires multimodal care that integrates supportive interventions, specifically nutrition and exercise, to improve nutrient intake, muscle mass, physical functioning, quality of life, and treatment outcomes. An integrated team of healthcare providers that incorporates societies' recommendations into clinical practice can help achieve the best possible outcomes. A multidisciplinary panel of experts in oncology, nutrition, exercise, and medicine participated in a 2-day virtual roundtable in October 2020 to discuss gaps and opportunities in oncology nutrition, alone and in combination with exercise, relative to current evidence and international societies' recommendations. The panel recommended five principles to optimize clinical oncology practice: (1) position oncology nutrition at the center of multidisciplinary care; (2) partner with colleagues and administrators to integrate a nutrition care process into the multidisciplinary cancer care approach; (3) screen all patients for malnutrition risk at diagnosis and regularly throughout treatment; (4) combine exercise and nutrition interventions before (e.g., prehabilitation), during, and after treatment as oncology standard of care to optimize nutrition status and muscle mass; and (5) incorporate a patient-centered approach into multidisciplinary care.