Preservation of macronutrient preferences in cancer anorexia

High prevalence of malnutrition and deranged relationship between energy demands and food intake in advanced non-small cell lung cancer

The relation between dietary intake and metabolic profile in non-small cell lung cancer (NSCLC) was evaluated. Patients with NSCLC were recruited and their caloric requirement and resting energy expenditure (REE) were calculated using the Harris-Benedict equation and Katch-McArdle formula respectively. Hypermetabolic state was defined as REE more than 10% above the basal metabolic rate (BMR). Body composition parameters were calculated by bioelectric impedance method. The 24-h dietary intake method and Malnutrition Universal Screening Tool assessed nutritional intake. One hundred and forty-eight subjects were included (87% males). Of these, 46.6% subjects were hypermetabolic and 31% cachexic, with lower calorie and protein intakes than recommended, although per cent of total energy derived from protein, fat and carbohydrates were similar. Hypermetabolic patients had lower BMI, though the per cent deficit in energy and protein consumption was similar. Cachexia was associated with lower BMR but not with deficit in energy or protein consumption. No correlation was seen between dietary intake and body composition parameters. The calorie and protein intake of NSCLC patients is lower than recommended. The discordance between elevated REE and dietary intake implies that the relationship between increased energy demands and food intake may be altered.

[Diagnostic value of selective anorexia in pathological weight loss]

PURPOSE

The diagnostic value of selective anorexia is debated. Some authors have suggested an association between meat aversion and cancer, but most do not use it as a diagnostic tool. We aimed to characterize anorexia of different diseases to search for an association between selective aversions and diagnostic groups.

METHODS

All the patients admitted to three departments of a teaching hospital were included consecutively for 22months if they had more than 10 % weight loss in less than one year. Patients were excluded if history taking was not reliable, or if they suffered from anorexia nervosa. We compiled diagnoses at discharge and validated them six months later. We used logistic regression to identify independent factors associated with selective anorexia.

RESULTS

Inclusion criteria were met in 106patients (female 44 %, median age 65years). Most frequent diagnoses were: cancer (36 %), infection (35 %), digestive diseases (19 %), non organic diseases (21 %). Recent selective anorexia was found in 46 % of the cases. It was significantly associated with female gender (P=0.002), marginally with young age (P=0.069) and long duration of weight loss (P=0.079). Opioid use at admission was negatively associated with selective anorexia (P=0.001). No specific diagnostic category was found to be associated.

CONCLUSION

Selective anorexia does not appear to be a useful symptom to investigate pathological weight loss. It behaves more like a non-specific reactivation by current disease of earlier latent personal food aversions.

Predicting survival in cancer patients: the role of cachexia and hormonal, nutritional and inflammatory markers

BACKGROUND

Cancer can lead to weight loss, anorexia, and poor nutritional status, which are associated with decreased survival in cancer patients.

METHODS

Male cancer patients (n = 136) were followed for a mean time of 4.5 years. Variables were obtained at baseline: cancer stage, albumin, hemoglobin, tumor necrosis factor alpha (TNF-α), interleukin (IL)-6, bioavailable testosterone, appetite questionnaire, and weight change from baseline to 18 months. Primary statistical tests included Kaplan-Meier survival analysis and Cox proportional hazard regression (PHREG).

RESULTS

Univariate PHREG showed that cancer stage, albumin, hemoglobin, TNF-α, IL-6, and weight change were each significantly associated with mortality risk (P < 0.05), but bioavailable testosterone was not. Multivariate PHREG analysis established that weight change and albumin were jointly statistically significant even after adjusting for stage.

CONCLUSION

In this sample of male oncology patients, cancer stage, serum albumin, and weight loss predicted survival. High levels of inflammatory markers and hemoglobin are associated with increased mortality, but do not significantly improve the ability to predict survival above and beyond cancer stage, albumin, and weight loss.

The energetics of wasting diseases

PURPOSE OF REVIEW

Unintentional weight loss or wasting continues to be a nutritional problem in the treatment of HIV/AIDS, cancer and many other diseases. Although wasting is a general sign of energy imbalance, the relative contribution of increased energy demands and decreased energy intake remains incompletely understood.

RECENT FINDINGS

Until the development of the method using doubly labeled water for measuring total energy expenditure, it was difficult to obtain unbiased estimates of total energy expenditure, particularly in clinical populations. Although costly, this technique provides greater insight in the energy requirements of clinical populations and the relative contributions of energy expenditure, energy intake and disease to wasting diseases. Although data are available in only a small portion of wasting diseases, the data suggest that even in the presence of increased demands for resting metabolic rate, total energy expenditure is often reduced because of decreased physical activity.

SUMMARY

Wasting is often the result of endocrine disorders accompanying the disease process itself. This, coupled with reduced energy intake, is often the primary contributor to wasting.

Nonexercise activity thermogenesis (NEAT): environment and biology

Nonexercise activity thermogenesis (NEAT) is the energy expended for everything that is not sleeping, eating, or sports-like exercise. It includes the energy expended walking to work, typing, performing yard work, undertaking agricultural tasks, and fidgeting. NEAT can be measured by one of two approaches. The first is to measure or estimate total NEAT. Here, total daily energy expenditure is measured, and from it "basal metabolic rate-plus-thermic effect of food" is subtracted. The second is the factoral approach, whereby the components of NEAT are quantified, and total NEAT is calculated by summing these components. The amount of NEAT that humans perform represents the product of the amount and types of physical activities and the thermogenic cost of each activity. The factors that impact a human's NEAT are readily divisible into environmental factors, such as occupation or dwelling within a "concrete jungle," and biological factors such as weight, gender, and body composition. The combined impact of these factors explains the substantial variance in human NEAT. The variability in NEAT might be viewed as random, but human and animal data contradict this. It appears that changes in NEAT subtly accompany experimentally induced changes in energy balance and are important in the physiology of weight change. Inadequate modulation of NEAT plus a sedentary lifestyle may thus be important in obesity. It then becomes intriguing to dissect mechanistic studies that delineate how NEAT is regulated into neural, peripheral, and humoral factors. A scheme is described in this review in which NEAT corresponds to a carefully regulated "tank" of physical activity that is crucial for weight control.

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

OBJECTIVE

We examined nutritional issues, assessment, and intervention strategies for patients with cancer.

METHODS

Reviews of practice guidelines and published reports were used to identify nutritional issues and strategies that can benefit patients with cancer.

RESULTS

Assessment tools such as the Patient-Generated Subjective Global Assessment are useful in terms of identifying patients with nutrition issues and guiding intervention. However, quality of life and other measures should also be considered. There is a need for early and ongoing nutrition interventions.

CONCLUSIONS

Encourage patients to try a new food or supplement on days when they are not receiving chemotherapy or radiation therapy because it may result in better tolerance. Screen patients to determine their nutritional status. Closely monitor changes in weight, food intake, and symptoms such as nausea and vomiting. Refer to a registered dietitian for a complete nutrition assessment and individualized counseling.

Dietary intake and resting energy expenditure in relation to weight loss in unselected cancer patients

Weight loss and anorexia are frequent findings in advanced cancer. The progressive wasting could be attributed to changes in dietary intake and/or energy expenditure mediated by metabolic alterations. In this study, we analyzed dietary intake in generalized malignant disease of solid tumor type in relation to resting energy expenditure (REE) and reported weight loss. In a group of 297 unselected cancer patients from a university hospital outpatient clinic, dietary intake of energy and macronutrients from a 4-day food record, REE by indirect calorimetry, height, weight and weight loss were recorded. Protein intake was validated against 24 hr urine nitrogen in a subgroup (n = 53), and no indication of systematic misreporting was found. Mean daily dietary intake was below maintenance requirements, 26 +/- 10 kcal/kg. Weight loss of more than 10% was present in 43% of patients and elevated REE (>110% of predicted) in 48%. Dietary intake did not differ between normo- and hypermetabolic patients, nor was tumour type or gender related to energy and protein intake. Weight loss could not be accounted for by diminished dietary intake since energy intake in absolute amounts was not different and intake per kilogram body weight was higher in weight-losing patients compared to weight-stable patients. Dietary macronutrient composition did not differ from the general population. Dietary intake of energy and protein was decreased, but dietary macronutrient composition did not appear to be changed. Weight loss and hypermetabolism were frequent and not compensated for by an increase in spontaneous food intake. Our results indicate that an expected up-regulation of dietary intake in response to elevated energy expenditure is frequently lost in cancer patients. This may be the explanation behind cancer cachexia rather than a primary decrease in appetite.