Effects of nutritional counselling on anthropometric measures in adult patients with cancer undergoing treatment and their perception and satisfaction level: a comprehensive systematic review

BACKGROUND

Patients with cancer undergoing treatment often develop malnutrition. Malnutrition can lead to multiple complications. In view of the potential complications, it is important for the patients to maintain good nutritional status. One method to maintain a good nutritional status is to provide frequent nutritional support such as nutritional counselling. The effectiveness of nutritional counselling is commonly indicated by anthropometric measures. Other than anthropometric measures, the value of patients' perception and satisfaction levels towards nutritional counselling are important as well.

OBJECTIVES

The objectives of this systematic review were: (1) to examine the effect of nutritional counselling based on anthropometric measures in adult patients with cancer undergoing treatment, and (2) to determine patients' perceptions and satisfaction levels towards nutritional counselling.

INCLUSION CRITERIA

Types of participants This review considered adult patients with cancer aged 18 years or over. Patients were at various stages of the disease. Patients were undergoing treatment.Types of intervention This review considered all types of nutritional counselling given to patients with cancer.Types of outcomes The outcome of interest were anthropometric measures, patients' subjective perceptions and patients' satisfaction level.Types of studies This review considered studies that examined the effectiveness of nutritional counselling on anthropometric measures in adult patients with cancer undergoing treatment, as well as their perception and satisfaction levels towards nutritional counselling.

SEARCH STRATEGY

A comprehensive search strategy was developed using all identified MeSH headings and key words for quantitative and qualitative studies.

METHODOLOGICAL QUALITY

Both quantitative and qualitative papers selected for review for methodological validity were assessed by two independent reviewers prior to inclusion in the review. The review was then carried out using the standardised critical appraisal instruments.

DATA COLLECTION/EXTRACTION

Following the critical appraisal, data were extracted from the included study using data extraction tools developed by JBI.A total of 11 articles were included in this systematic review, 6 were randomised controlled trials, 3 were comparable cohort studies and 2 qualitative studies.

DATA ANALYSIS

Narrative summary was presented for the quantitative studies as statistical pooling was not possible. For qualitative studies, findings were presented in meta-synthesis form.

RESULTS

From the presented quantitative studies, some patients with cancer were clinically benefited from the effect of nutritional counselling through the improvement or minimisation of the deterioration of body weight and fat free mass at particular time or chemotherapy cycle. Overall, patients were satisfied with the nutritional counselling they received. Patients feel that the ability to eat is important however, patients with cancer developed eating inability as a result of disease process and treatment side effects From the qualitative findings, most participants expressed that counseling was beneficial but highlighted the need for understanding of the individual food preferences when giving nutritional counselling.

CONCLUSIONS

Lastly, from the quantitative finding, no absolute conclusion can be drawn on the effect of nutritional counselling on anthropometric measures. The findings of patients' perceptions and satisfaction levels towards nutritional counselling can provide an improved framework to help health care professionals in implement better nutritional counselling session.

IMPLICATIONS FOR PRACTICE -

The quantitative findings support the use of individualized and intensive nutritional counselling for patients with cancer to improve body weight and fat free mass measurement. Patient satisfaction with nutritional counselling should be conducted regularly in the clinical area. The qualitative findings highlight the need for minimising eating inability related to treatment side effects and disease process. Furthermore, the qualitative findings indicated the need for more individualized nutritional counselling in the clinical area, taking into account individual dietary differences, concerns, and needs.

IMPLICATIONS FOR RESEARCH -

There is a need for further research to assess the effectiveness of nutritional counselling based on anthropometric measures, patients' perception and satisfaction.

Cancer wasting and quality of life react to early individualized nutritional counselling!

To devise a meaningful nutritional therapy in cancer, a greater understanding of nutritional dimensions as well as patients' expectations and disease impact is essential. We have shown that nutritional deterioration in patients with gastrointestinal and head and neck cancer was multifactorial and mainly determined by the tumour burden and location. In a larger cohort, stage and location were yet again the major determinants of patients' quality of life (QoL), despite the fact that nutritional deterioration combined with intake deficits were functionally more relevant than cancer stage. Based on this framework, the potential role of integrated oral nutritional support on outcomes was investigated. In a pilot study using individualized nutritional counselling on a heterogeneous patient population, the achieved improvement of nutritional intake was proportional to a better QoL. The role of early nutritional support was further analysed in a prospective randomized controlled trial in head and neck cancer patients stratified by stage undergoing radiotherapy. Pre-defined outcomes were: nutritional status and intake, morbidity and QoL, at the end and 3 months after radiotherapy. Nutritional interventions, only given during radiotherapy, consisted of three randomization arms: (1) individualized nutritional counselling vs. (2) ad libitum diet+high protein supplements vs. (3) ad libitum diet. Nutritional interventions 1 and 2 positively influenced outcomes during radiotherapy; however, 3 months after its completion individualized nutritional counselling was the single method capable of sustaining a significant impact on patients' outcomes. The early provision of the appropriate mixture of foods and textures using regular foods may modulate outcomes in cancer patients.

The causes and consequences of cancer-associated malnutrition

Cancer-associated malnutrition can result from local effects of a tumour, the host response to the tumour and anticancer therapies. Although cancer patients often have reduced food intake (due to systemic effects of the disease, local tumour effects, psychological effects or adverse effects of treatment), alterations in nutrient metabolism and resting energy expenditure (REE) may also contribute to nutritional status. Several agents produced by the tumour directly, or systemically in response to the tumour, such as pro-inflammatory cytokines and hormones, have been implicated in the pathogenesis of malnutrition and cachexia. The consequences of malnutrition include impairment of immune functions, performance status, muscle function, and quality of life. In addition, responses to chemotherapy are decreased, chemotherapy-induced toxicity and complications are more frequent and severe, and survival times are shortened. Depression, fatigue and malaise also significantly impact on patient well-being. In addition, cancer-related malnutrition is associated with significant healthcare-related costs. Nutritional support, addressing the specific needs of this patient group, is required to help improve prognosis, and reduce the consequences of cancer-associated nutritional decline.

Understanding cachexia and excessive weight loss in cancer

Cachexia, a wasting condition often seen in advanced cancer, is often confused with anorexia but they are two separate conditions. It is evident that cachexia frequently leads to anorexia but anorexia alone cannot cause cachexia. The cachexia syndrome is weight loss with a specific cause--the action of cytokines, chemical messengers that are produced both by the body in response to the tumour and by the tumour to ensure its growth and spread. Treatment of cachexia is very difficult. Drugs to improve appetite have little effect, however, supplementing the diet with fish oils and vitamin E seems to be beneficial. Increasing a patient's level of exercise, even if bed-bound, does seem to have a positive effect and helps to synthesize skeletal muscle protein and delay the ravages of cachexia. Increasing exercise also has a positive effect on fatigue levels, a side-effect of cachexia.

Nutritional support strategies for malnourished cancer patients

A large body of evidence exists, which demonstrates the importance of nutritional support in cancer. The nutritional needs of patients with cancer may differ from those of the healthy population due to hypermetabolism, impaired organ function, increased nutrient losses and therapy-related malnutrition. Patients with cancer often have increased requirements for both macro- and micronutrients due to long periods of undernutrition prior to diagnosis. The aim of nutritional support should be the prevention or reversal of malnutrition, and this should be initiated as early as possible to improve outcomes. Oral supplementation is a simple, non-invasive method of increasing the nutrient intake of those patients who are unable to meet nutritional requirements, despite dietary counselling. Enteral tube feeding is indicated for patients who are unable to meet their nutritional needs by oral intake alone, and has been shown to improve clinical outcomes. Novel approaches in oral supplementation include the use of eicosapentaenoic acid (EPA), a compound under investigation for its role in preventing and treating cancer-associated malnutrition. Individual studies suggest that EPA attenuates cancer-associated wasting and improves immune function. In addition, it has been shown to have anti-tumour effects and improve clinical outcomes. However, results are not consistent for all patient groups and further research is required.

Cancer-associated malnutrition

Malnutrition is a common problem among patients with cancer, affecting up to 85% of patients with certain cancers (e.g. pancreas). In severe cases, malnutrition can progress to cachexia, a specific form of malnutrition characterised by loss of lean body mass, muscle wasting, and impaired immune, physical and mental function. Cancer cachexia is also associated with poor response to therapy, increased susceptibility to treatment-related adverse events, as well as poor outcome and quality of life. Cancer cachexia is a complex, multifactorial syndrome, which is thought to result from the actions of both host- and tumour-derived factors, including cytokines involved in a systemic inflammatory response to the tumour. Early intervention with nutritional supplementation has been shown to halt malnutrition, and may improve outcome in some patients. However, increasing nutritional intake is insufficient to prevent the development of cachexia, reflecting the complex pathogenesis of this condition. Nutritional supplements containing anti-inflammatory agents, for example the polyunsaturated fatty acid (PUFA) eicosapentanoic acid (EPA), have been shown to be more beneficial to malnourished patients than nutritional supplementation alone. EPA has been shown to interfere with multiple mechanisms implicated in the pathogenesis of cancer cachexia, and in clinical studies, has been associated with reversal of cachexia and improved survival.

Does Perioperative Immunonutrition Reduce Postoperative Complications in Patients with Gastrointestinal Cancer Undergoing Operations?

Perioperative immune modulation using specialized enteral diets containing specific immunonutrients may improve postoperative outcomes in critically ill patients compared with standard formulas. A study from Italy involving 305 patents with histologically confirmed cancer of the gastrointestinal tract undergoing major elective surgery and preoperative weight loss < 10% demonstrated that a specialized preoperative oral formula enriched with arginine, omega-3 fatty acids, and RNA for 5 days before surgery with no nutritional support postoperatively (preoperative group) was as effective as pre- and postoperative administration of the same enriched formula (perioperative group) in decreasing the incidence of postoperative infections and length of hospital stay. Both pre- and perioperative immunonutritional strategies were superior to the conventional approach (no artificial nutrition perioperatively).