The Effect of a Home Delivery Meal Service of Energy- and Protein-Rich Meals on Quality of Life in Malnourished Outpatients Suffering from Lung Cancer: A Randomized Controlled Trial

A theoretical explanation for how a nutrition counseling and medically tailored meal delivery program benefitted participants living with lung cancer

PURPOSE

The purpose of this study was to assess participants' perceptions and experiences while participating in a Food is Medicine medically tailored meal plus intensive nutrition counseling intervention to create a theoretical explanation about how the intervention worked.

METHODS

This interpretive qualitative study included the use of semi-structured interviews with active participants in a randomized controlled trial aimed at understanding how a medically tailored meal plus nutrition counseling intervention worked for vulnerable individuals with lung cancer treated at four cancer centers across the USA. During the 8-month long study, participants in the intervention arm were asked to be interviewed, which were recorded, transcribed verbatim, and analyzed using conventional content analysis with principles of grounded theory.

RESULTS

Twenty individuals participated. Data analysis resulted in a theoretical explanation of the intervention's mechanism of action. The explanatory process includes three linked and propositional categories leading to patient resilience: engaging in treatment, adjusting to diagnosis, and active coping. The medically tailored meals plus nutrition counseling engaged participants throughout treatment, which helped participants adjust to their diagnosis, leading to active coping through intentional self-care, behavior change, and improved quality of life.

CONCLUSIONS

These findings provide evidence that a Food is Medicine intervention may buffer some of the adversity related to the diagnosis of lung cancer and create a pathway for participants to experience post-traumatic growth, develop resilience, and change behaviors to actively cope with lung cancer. Medically tailored meals plus intensive nutrition counseling informed by motivational interviewing supported individuals' adjustment to their diagnosis and resulted in perceived positive behavior change.

Body weight and composition endpoints in cancer cachexia clinical trials: Systematic Review 4 of the cachexia endpoints series

Significant variation exists in the outcomes used in cancer cachexia trials, including measures of body composition, which are often selected as primary or secondary endpoints. To date, there has been no review of the most commonly selected measures or their potential sensitivity to detect changes resulting from the interventions being examined. The aim of this systematic review is to assess the frequency and diversity of body composition measures that have been used in cancer cachexia trials. MEDLINE, Embase and Cochrane Library databases were systematically searched between January 1990 and June 2021. Eligible trials examined adults (≥18 years) who had received an intervention aiming to treat or attenuate the effects of cancer cachexia for >14 days. Trials were also of a prospective controlled design and included body weight or at least one anthropometric, bioelectrical or radiological endpoint pertaining to body composition, irrespective of the modality of intervention (e.g., pharmacological, nutritional, physical exercise and behavioural) or comparator. Trials with a sample size of <40 patients were excluded. Data extraction used Covidence software, and reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidance. This review was prospectively registered (PROSPERO: CRD42022276710). A total of 84 clinical trials, comprising 13 016 patients, were eligible for inclusion. Non-small-cell lung cancer and pancreatic cancer were studied most frequently. The majority of trial interventions were pharmacological (52%) or nutritional (34%) in nature. The most frequently reported endpoints were assessments of body weight (68 trials, n = 11 561) followed by bioimpedance analysis (BIA)-based estimates (23 trials, n = 3140). Sixteen trials (n = 3052) included dual-energy X-ray absorptiometry (DEXA)-based endpoints, and computed tomography (CT) body composition was included in eight trials (n = 841). Discrepancies were evident when comparing the efficacy of interventions using BIA-based estimates of lean tissue mass against radiological assessment modalities. Body weight, BIA and DEXA-based endpoints have been most frequently used in cancer cachexia trials. Although the optimal endpoints cannot be determined from this review, body weight, alongside measurements from radiological body composition analysis, would seem appropriate. The choice of radiological modality is likely to be dependent on the trial setting, population and intervention in question. CT and magnetic resonance imaging, which have the ability to accurately discriminate tissue types, are likely to be more sensitive and provide greater detail. Endpoints are of particular importance when aligned with the intervention's mechanism of action and/or intended patient benefit.

SupporTive Care At Home Research (STAHR) for patients with advanced cancer: Protocol for a cluster non-randomized controlled trial

Advancements in the treatment and management of patients with cancer have extended their survival period. To honor such patients' desire to live in their own homes, home-based supportive care programs have become an important medical practice. This study aims to investigate the effects of a multidimensional and integrated home-based supportive care program on patients with advanced cancer. SupporTive Care At Home Research is a cluster non-randomized controlled trial for patients with advanced cancer. This study tests the effects of the home-based supportive care program we developed versus standard oncology care. The home-based supportive care program is based on a specialized home-based medical team approach that includes (1) initial assessment and education for patients and their family caregivers, (2) home visits by nurses, (3) biweekly regular check-ups/evaluation and management, (4) telephone communication via a daytime access line, and (5) monthly multidisciplinary team meetings. The primary outcome measure is unplanned hospitalization within 6 months following enrollment. Healthcare service use; quality of life; pain and symptom control; emotional status; satisfaction with services; end-of-life care; advance planning; family caregivers' quality of life, care burden, and preparedness for caregiving; and medical expenses will be surveyed. We plan to recruit a total of 396 patients with advanced cancer from six institutions. Patients recruited from three institutions will constitute the intervention group, whereas those recruited from the other three institutions will comprise the control group.

Appetite and dietary intake endpoints in cancer cachexia clinical trials: Systematic Review 2 of the cachexia endpoints series

There is no consensus on the optimal endpoint(s) in cancer cachexia trials. Endpoint variation is an obstacle when comparing interventions and their clinical value. The aim of this systematic review was to summarize and evaluate endpoints used to assess appetite and dietary intake in cancer cachexia clinical trials. A search for studies published from 1 January 1990 until 2 June 2021 was conducted using MEDLINE, Embase and Cochrane Central Register of Controlled Trials. Eligible studies examined cancer cachexia treatment versus a comparator in adults with assessments of appetite and/or dietary intake as study endpoints, a sample size ≥40 and an intervention lasting ≥14 days. Reporting was in line with PRISMA guidance, and a protocol was published in PROSPERO (2022 CRD42022276710). This review is part of a series of systematic reviews examining cachexia endpoints. Of the 5975 articles identified, 116 were eligible for the wider review series and 80 specifically examined endpoints of appetite (65 studies) and/or dietary intake (21 studies). Six trials assessed both appetite and dietary intake. Appetite was the primary outcome in 15 trials and dietary intake in 7 trials. Median sample size was 101 patients (range 40-628). Forty-nine studies included multiple primary tumour sites, while 31 studies involved single primary tumour sites (15 gastrointestinal, 7 lung, 7 head and neck and 2 female reproductive organs). The most frequently reported appetite endpoints were visual analogue scale (VAS) and numerical rating scale (NRS) (40%). The appetite item from the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ) C30/C15 PAL (38%) and the appetite question from North Central Cancer Treatment Group anorexia questionnaire (17%) were also frequently applied. Of the studies that assessed dietary intake, 13 (62%) used food records (prospective registrations) and 10 (48%) used retrospective methods (24-h recall or dietary history). For VAS/NRS, a mean change of 1.3 corresponded to Hedge's g of 0.5 and can be considered a moderate change. For food records, a mean change of 231 kcal/day or 11 g of protein/day corresponded to a moderate change. Choice of endpoint in cachexia trials will depend on factors pertinent to the trial to be conducted. Nevertheless, from trials assessed and available literature, NRS or EORTC QLQ C30/C15 PAL seems suitable for appetite assessments. Appetite and dietary intake endpoints are rarely used as primary outcomes in cancer cachexia. Dietary intake assessments were used mainly to monitor compliance and are not validated in cachexia populations. Given the importance to cachexia studies, dietary intake endpoints must be validated before they are used as endpoints in clinical trials.

How a Medically Tailored Meal Intervention with Intensive Nutrition Counseling Created Active Coping with Behavior Change for Vulnerable Patients with Lung Cancer

Purpose

The purpose of this study was to assess participants' perceptions and experiences while participating in a Food is Medicine medically tailored meal plus nutrition counseling intervention to create a theoretical explanation about how the intervention worked.

Methods

This interpretive qualitative study included the use of semi-structured interviews with active intervention participants. Purposeful sampling included vulnerable (uninsured, rural zip code residency, racial/ethnic minority, 65 years old, and/or low-income) individuals with lung cancer treated at four cancer centers across the United States. Interviews were recorded, transcribed verbatim, and analyzed using conventional content analysis with principles of grounded theory.

Results

Twenty individuals participated. Data analysis resulted in a theoretical explanation of the intervention's mechanism of action. The explanatory process includes 3 linked and propositional categories leading to patient resilience: engaging in treatment, adjusting to diagnosis, and active coping. The medically tailored meals plus intensive nutrition counseling engaged participants throughout treatment, which helped participants adjust to their diagnosis, leading to active coping through intentional self-care, behavior change, and improved quality of life.

Conclusions

These findings provide evidence that a food is medicine intervention may buffer some of the adversity related to the diagnosis of lung cancer and create a pathway for participants to experience post-traumatic growth, develop resilience, and change behaviors to actively cope with lung cancer. Medically tailored meals plus intensive nutrition counseling informed by motivational interviewing supported individuals' adjustment to their diagnosis and resulted in perceived positive behavior change.

Nutritional status and symptom burden in advanced non-small cell lung cancer: results of the dietetic assessment and intervention in lung cancer (DAIL) trial

INTRODUCTION

European Society for Clinical Nutrition and Metabolism guidelines recommend that patients with cancer should be screened for malnutrition at diagnosis. The dietetic assessment and intervention in lung cancer study investigated the nutritional status of patients with non-small cell lung cancer (NSCLC) and the need for dietetic intervention.

METHODS

In this observational cohort pilot study, patients with stage 3b and 4 NSCLC were assessed prior to starting first line systemic anticancer therapy (SACT) with a range of measurements and questionnaires. We report the outcomes related to the Patient Generated Subjective Global Assessment tool (PG-SGA), RESULTS: 96 patients were consented between April 2017 and August 2019. The PG-SGA identified that 78% of patients required specialist nutritional advice; with 52% patients having a critical need for dietetic input and symptom management. Results were dominated by symptom scores. As a screening test, one or more symptoms or recent weight loss history had a sensitivity of 88% (95% CI 78.44% to 94.36%) and specificity of 95.24% (95% CI 76.18% to 99.88%) for need for dietetic intervention.

CONCLUSION

A large proportion of patients with NSCLC have a high symptom burden and are at risk of malnutrition prior to starting SACT and would benefit from dietetic review. It is imperative that oncologists and healthcare professionals discuss weight loss history and symptoms with lung cancer patients to correct nutritional deficiencies and resolve symptoms prior to starting treatment.

Physical function endpoints in cancer cachexia clinical trials: Systematic Review 1 of the cachexia endpoints series

In cancer cachexia trials, measures of physical function are commonly used as endpoints. For drug trials to obtain regulatory approval, efficacy in physical function endpoints may be needed alongside other measures. However, it is not clear which physical function endpoints should be used. The aim of this systematic review was to assess the frequency and diversity of physical function endpoints in cancer cachexia trials. Following a comprehensive electronic literature search of MEDLINE, Embase and Cochrane (1990-2021), records were retrieved. Eligible trials met the following criteria: adults (≥18 years), controlled design, more than 40 participants, use of a cachexia intervention for more than 14 days and use of a physical function endpoint. Physical function measures were classified as an objective measure (hand grip strength [HGS], stair climb power [SCP], timed up and go [TUG] test, 6-min walking test [6MWT] and short physical performance battery [SPPB]), clinician assessment of function (Karnofsky Performance Status [KPS] or Eastern Cooperative Oncology Group-Performance Status [ECOG-PS]) or patient-reported outcomes (physical function subscale of the European Organisation for the Research and Treatment of Cancer Quality of Life Questionnaires [EORTC QLQ-C30 or C15]). Data extraction was performed using Covidence and followed PRISMA guidance (PROSPERO registration: CRD42022276710). A total of 5975 potential studies were examined and 71 were eligible. Pharmacological interventions were assessed in 38 trials (54%). Of these, 11 (29%, n = 1184) examined megestrol and 5 (13%, n = 1928) examined anamorelin; nutritional interventions were assessed in 21 trials (30%); and exercise-based interventions were assessed in 6 trials (8%). The remaining six trials (8%) assessed multimodal interventions. Among the objective measures of physical function (assessed as primary or secondary endpoints), HGS was most commonly examined (33 trials, n = 5081) and demonstrated a statistically significant finding in 12 (36%) trials (n = 2091). The 6MWT was assessed in 12 trials (n = 1074) and was statistically significant in 4 (33%) trials (n = 403), whereas SCP, TUG and SPPB were each assessed in 3 trials. KPS was more commonly assessed than the newer ECOG-PS (16 vs. 9 trials), and patient-reported EORTC QLQ-C30 physical function was reported in 25 trials. HGS is the most commonly used physical function endpoint in cancer cachexia clinical trials. However, heterogeneity in study design, populations, intervention and endpoint selection make it difficult to comment on the optimal endpoint and how to measure this. We offer several recommendations/considerations to improve the design of future clinical trials in cancer cachexia.

Food Access Support Technology (FAST): a Centralized City-Wide Platform for Rapid Response to Food Insecurity

BACKGROUND

Food access for patients remains a critical need for health systems to address given varying resource availability and inefficient coordination among health and food services.

AIM

Develop and evaluate the Food Access Support Technology (FAST), a centralized digital platform for food access that pairs health systems with food and delivery community-based organizations (CBOs).

SETTING AND PARTICIPANTS

Two health systems, 12 food partners, and 2 delivery partners in Philadelphia, PA.

PROGRAM DESCRIPTION

Using FAST, referrers can post requests for food delivery on recipients' behalf, which are reviewed and claimed by eligible CBOs that can prepare food boxes for delivery to people's homes.

PROGRAM EVALUATION

Between March 2021 and July 2022, FAST received 364 requests, representing 207 food insecure households in 51 postal codes. The platform facilitated the completion of 258 (70.9%) requests, with a median completion time of 5 (IQR 0-7) days and a median of only 1.5 days (IQR 0-5) for requests marked "urgent." Qualitative interviews with FAST end-users endorsed the usability of the FAST platform and its effectiveness in facilitating resource-sharing between partners.

DISCUSSION

Our findings suggest that centralized platforms can address household food insecurity by (1) streamlining partnerships between health systems and CBOs for food delivery and (2) facilitating the real-time coordination of resources among CBOs.

Diet as a Factor Supporting Lung Cancer Treatment-A Systematic Review

The purpose of this study was to summarize the evidence from epidemiological studies concerning associations between diet and the effectiveness of treatment for lung cancer. For this review, a literature search has been conducted in the EMBASE and PubMed databases, including papers published between 1977 and June 2022. The term "lung cancer" was used in conjunction with "diet". Footnotes from the selected papers were also analyzed. The present study is in line with the recommendations included in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The review included studies involving adults, including randomized controlled trials (RCTs) and cohort and observational studies. In total, 863 papers were found, with duplicates excluded. Ultimately, 20 papers were reviewed. The present systematic review indicates that vitamin A, ascorbic acid (vitamin C), vitamin E, selenium, and zinc-as antioxidants-can strengthen the body's antioxidant barrier. Furthermore, preoperative immunonutrition may not only improve perioperative nutritional status following induction chemoradiotherapy in lung cancer surgery patients but also reduce the severity of postoperative complications. Similarly, a protein supply may exert a beneficial effect on human health by increasing average body weight and muscle mass. Omega-3 fatty acid content in the diet and the consumption of their main source, fish, may have some regulatory effect on inflammation in patients with lung cancer treated with chemotherapy and radiotherapy. In addition, n-3 fatty acids inhibit tumor cell proliferation and may reduce the toxicity of chemotherapy. Increased energy and protein intake are strongly associated with improved quality of life, functional outcomes, hand grip strength, symptoms, and performance in patients with lung cancer. The use of a supportive diet should be the standard of care, alongside pharmaceutical therapy, in treatment for patients with lung cancer.

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

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

Cancer, Phase Angle and Sarcopenia: The Role of Diet in Connection with Lung Cancer Prognosis

Lung cancer is the most common cause of cancer death and is associated with malnutrition and sarcopenia. The detection of sarcopenia and conduction of simple body composition measurements, such as the phase angle (PhA) deriving from bioelectrical impedance analysis (BIA), can help to early identify, monitor, prevent and treat malnutrition. The present review aims to clarify the relationship between PhA and sarcopenia with the pathophysiology, clinical outcomes, and therapeutic aspects of lung cancer. PhA and sarcopenia are connected to lung cancer prognosis through various mechanisms including inflammation and oxidative stress, although more research is needed to identify the critical thresholds for increased mortality risk. Moreover, emphasis is given on the role of dietary interventions (oral nutritional supplementation, and dietary counseling) to manage sarcopenia and related variables in patients with lung cancer. Oral nutritional supplements and/or those containing n - 3 polyunsaturated fatty acids may have a positive effect on physical strength measures and muscle mass if administered at the beginning of chemotherapy. Data on sole dietary counseling or multimodal interventions are less promising so far. In the future, sophisticated body composition phenotypes deriving from the described methods along with artificial intelligence techniques could be used to design personalized nutrition interventions and timely treat these patients.

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.

ESPEN guideline on hospital nutrition

In hospitals through Europe and worldwide, the practices regarding hospital diets are very heterogeneous. Hospital diets are rarely prescribed by physicians, and sometimes the choices of diets are based on arbitrary reasons. Often prescriptions are made independently from the evaluation of nutritional status, and without taking into account the nutritional status. Therapeutic diets (low salt, gluten-free, texture and consistency modified, …) are associated with decreased energy delivery (i.e. underfeeding) and increased risk of malnutrition. The European Society for Clinical Nutrition and Metabolism (ESPEN) proposes here evidence-based recommendations regarding the organization of food catering, the prescriptions and indications of diets, as well as monitoring of food intake at hospital, rehabilitation center, and nursing home, all of these by taking into account the patient perspectives. We propose a systematic approach to adapt the hospital food to the nutritional status and potential food allergy or intolerances. Particular conditions such as patients with dysphagia, older patients, gastrointestinal diseases, abdominal surgery, diabetes, and obesity, are discussed to guide the practitioner toward the best evidence based therapy. The terminology of the different useful diets is defined. The general objectives are to increase the awareness of physicians, dietitians, nurses, kitchen managers, and stakeholders towards the pivotal role of hospital food in hospital care, to contribute to patient safety within nutritional care, to improve coverage of nutritional needs by hospital food, and reduce the risk of malnutrition and its related complications.

Fortified Snack Preferences among Patients with Cancer

Fortified snacks can increase nutrient intake among patients with cancer. The aim of this study was to identify snack foods preferred as potential vehicles for fortification and how experienced symptoms influence preferences.

A study-specific survey among 150 patients identified snack foods for fortification, influence of symptom presence, desired nutrients and characteristics of a fortified snack, and perception of oral nutritional supplements.

Patients had mainly breast, gastrointestinal, lung, and colorectal tumors. Soup, yogurt, cheese, fruit juice, egg products, and protein bars were identified as suitable fortified snacks by >60% of subjects. Desired characteristics for snacks included nutritious, flavorful, convenient, ready to eat, easy to chew, and easy to swallow. Vitamins, minerals, and protein were the nutrients of interest. Three clusters of symptoms were identified that predicted patients' desired characteristics of fortified snacks and satisfaction with food-related life. Patients in High and Moderate symptom clusters were more likely to have reduced food intake and higher consumption of oral nutritional supplements.

Preferences for fortified snacks and their characteristics are influenced by symptom presence. The results of this study provide insight to guide the development of fortified snacks for patients with cancer.

Normal reference intervals of prognostic nutritional index in healthy adults: A large multi-center observational study from Western China

Background

It has been widely reported that the prognostic nutritional index (PNI) played a pivotal role in nutritional assessment of surgical patients and tumor prognosis. In order to improve the accuracy of evaluation in Western China, we established reference intervals (RIs) of PNI in healthy controls.

Methods

A retrospective cohort study on healthy ethnic Han adults (18–79 years) was conducted to explore the influences of age, gender, study centers, and instruments on PNI and to establish RIs. The data came from a healthy routine examination center database and laboratory information system (LIS) of four centers in Western China, and there were 200 persons selected randomly for verification of RIs.

Results

Five thousand eight hundred and thirty‐nine healthy candidates were enrolled. PNI showed a marked gender dependence, and males had significantly higher PNI than females across all ages (p < 0.01). We found that PNI is significantly different between age groups (p < 0.01), the value of PNI tended to decrease with age increasing. There is also an obvious influence of centers and instruments on PNI (p < 0.01).

Conclusions

We established reference intervals of PNI in healthy Han Chinese population in Western China and validated successfully. Further established RIs will lead to better standardizations of PNI for clinical applications.

Effects of Home-Delivered Meals on Older People's Protein Intake, Physical Performance, and Health-Related Quality of Life: The Power Meals Randomized Controlled Trial

This trial examined the effectiveness of an 8-week home meal service on protein and other nutrient intake, physical performance (PP) and health related quality of life (HRQoL) among older people living at home (≥65 years; home care clients, caregivers and care recipients). Participants were randomized into three groups; (1) protein-rich meal, snack, and bread (INT1), (2) regular meal (INT2) and (3) control group. Nutrient intake was assessed with 3-day food diaries, PP with Short Physical Performance Battery (SBBP) and HRQoL with 15 dimensional Health-related quality of life instrument. Total of 67 (59.7% women, mean age 78.2 years) participants (n = 22 INT1, n = 24 INT2, n = 21 CG) completed the trial. At baseline, mean protein intake was 0.92 (SD 0.32) g/kg adjusted body weight (aBW)/d. At 8 weeks, protein-rich home meal service in INT1 increased protein intake (+ 0.11 (95%CI -0.01 to 0.21) g/kg aBW/d, 9.4 (95%CI 1.0 to 17.8) g/d) compared to other groups. It also increased calcium intake (+169.9 (95%CI 26 to 314) mg/d) and improved results in Sit-to-Stand Test (-4.8 (95%CI -6.8 to -2.7) sec) in INT1 compared to CG. Both home meal services increased saturated fat intake (INT1; 4.6 (95%CI 1.0-8.2) g/d, INT2;7.8 (95%CI 1.9 to 13.7)g/d) and decreased salt intake (INT1;-2330.9 (95%CI -2998 to -1664) mg/d, INT2; -2371.9 (95%CI -3399 to -1345) mg/d) compared to CG. There was no effect on overall HRQoL.

A culinary twist of a two-course meals-on-wheels menu in a cluster-randomized controlled trial influencing health-related quality of life in nursing home residents

BACKGROUND AND AIMS

Meals-on-wheels in nursing homes are sensory diminished because of the packaging and reheating of the food, which creates less appetite stimulation and an impaired meal experience for nursing home residents. This background is crucial since nursing home residents are a frail and often malnourished group that is physiologically affected by sensory, physical and mental alterations. The study aimed to increase health-related quality of life in nursing home residents receiving meals-on-wheels using an intervention menu with favourite meals that added a culinary twist and were sensory improved by chefs.

METHODS

A double-blinded cluster-randomized controlled trial with two arms, one group receives an intervention menu, and the other group receives a non-optimized menu. The intervention menu included popular meals-on-wheels (a main meal for dinner and a starter/dessert before or after dinner with culinary improvements). The participants received the same meals without culinary improvements in the control group. Health-related quality of life (EQ5D3L) was the primary outcome of the study. Secondary outcomes were mental and nutritional status and muscle strength. The measurements were assessed at a baseline and end visit (12 weeks after baseline visit).

RESULTS

Fifty-two nursing home residents were included in the study (There are 20 in the intervention group and 32 in the control group). Following the principle of intention-to-treat, a significant decreasing effect (p-value 0.026) was found between the groups on health-related quality of life. The treated group experienced the largest decrease from the baseline to the end visit. The intervention group had a significant decrease in the second item on Satisfaction With Food-related Life (SWFL2) (I am very pleased with my food). No changes were found either within or between the groups, on the rest of the measured parameters.

CONCLUSIONS

Nursing home residents are a target group experiencing natural aggravation, why the health-related quality of life might be difficult to improve using a culinary meal intervention. The decreasing effect of Satisfaction With Food-related Life found in the intervention group could be related to these older adults being too unfamiliar with the culinary twist added to the intervention menu. The study was registered on ClinTrials.gov (Identifier NCT03133364).

Food, Nutrition, Physical Activity and Microbiota: Which Impact on Lung Cancer?

Lung cancer still represents the leading cause of cancer-related death, globally. Likewise, malnutrition and inactivity represent a major risk for loss of functional pulmonary capacities influencing overall lung cancer severity. Therefore, the adhesion to an appropriate health lifestyle is crucial in the management of lung cancer patients despite the subtype of cancer. This review aims to summarize the available knowledge about dietary approaches as well as physical activity as the major factors that decrease the risk towards lung cancer, and improve the response to therapies. We discuss the most significant dietary schemes positively associated to body composition and prognosis of lung cancer and the main molecular processes regulated by specific diet schemes, functional foods and physical activity, i.e., inflammation and oxidative stress. Finally, we report evidence demonstrating that dysbiosis of lung and/or gut microbiome, as well as their interconnection (the gut–lung axis), are strictly related to dietary patterns and regular physical activity playing a key role in lung cancer formation and progression, opening to the avenue of modulating the microbiome as coadjuvant therapy. Altogether, the evidence reported in this review highlights the necessity to consider non-pharmacological interventions (nutrition and physical activity) as effective adjunctive strategies in the management of lung cancer.

Lessons learned from a randomized controlled trial on a home delivered meal service in advanced cancer patients undergoing chemotherapy: a pilot study

BACKGROUND

Performing a randomized controlled trial (RCT) in the field of nutrition is challenging and success highly depends on understanding the factors that influence recruitment and dropout of participants. Our aim was to assess the feasibility of a RCT that evaluated a home delivered meal service in advanced cancer patients while receiving chemotherapy.

METHODS

This pilot RCT aimed to enroll 20 participants who were randomized into the home delivered meal service group or usual care group. Study procedures took place before chemotherapy (T0), 3 weeks after T0 (T1), 6 weeks after T0 (T2) and 3 months after T2 (T3). All information regarding recruitment, dropout and study procedures was recorded. Patient satisfaction was assessed by in-depth interviews.

RESULTS

Over 7 months, 20 of 41 approached patients (49%) were included, followed by a dropout rate of 35%. At baseline, hand grip strength (n = 8/16), the Short Physical Performance Battery (n = 12/16) and nutritional intake (n = 8/16) had the highest rate of missing values. Study procedures were not experienced as burdensome and planning of these procedures in line with fixed hospital appointments contributed to this low burden. Keeping the symptom diary was mentioned as being burdensome.

CONCLUSIONS

It is feasible to conduct a RCT on a home delivered meal service in advanced cancer patients during chemotherapy, although recruitment is challenging. Close contact of patients with recruiting personnel is essential to sustain motivation. To increase compliance with the study protocol it is important to carefully instruct participants on how to complete questionnaires and to emphasize to use these in the communication with their practitioners.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03382171 .

Optimising patient fitness: strategies to reduce the effects of cancer cachexia in patients with advanced lung cancer

PURPOSE OF REVIEW

Outcomes for patients with advanced lung cancer have traditionally been very poor. This patient group are often comorbid, less fit and experience multiple symptoms. This review discusses strategies for minimizing the impact of cachexia on patients with advanced lung cancer. This is timely, as in recent years there has been a rapid increase in available systemic therapy options, with the potential of long-term survival for some patients.

RECENT FINDINGS

The review discusses current strategies in combating cachexia, including: symptom control, systemic therapy for cancer and for cachexia, nutritional interventions and exercise interventions. It discusses current clinical trials, combining interventions and the paradigm of prehabilitation.

SUMMARY

It is likely that the optimal way of minimizing the impact of cachexia in advanced lung cancer is through a combination of early interventions including symptom management.

Nutritional Support in Lung Cancer Patients: The State of the Art

Lung cancer (LC) represents the most commonly diagnosed neoplasm worldwide for both sexes and is the leading cause of cancer mortality. Malnutrition is a comorbidity frequently found in neoplastic patients, but it remains often underestimated and thus undertreated. In this review, we aimed to investigate the incidence of malnutrition among LC patients according to different screening and assessment tools, to evaluate the impact of weight loss and body composition on survival, and to analyze the efficacy of different nutritional interventions in this setting. Although malnutrition, weight loss, and body composition changes can affect survival and other clinical outcomes in LC patients, the role of nutritional interventions is not yet strongly proven, and further studies are recommended. Nevertheless, screening, assessing, and eventually treating malnutrition in LC patients are strongly recommended, according to the most recent nutritional intervention guidelines for oncology patients.

Effect of a Preoperative Home-Delivered, Protein-Rich Meal Service to Improve Protein Intake in Surgical Patients: A Randomized Controlled Trial

BACKGROUND

The preoperative period likely provides an important opportunity to improve postoperative recovery, as suggested by the finding that low nutrition status is a predictor of increased postoperative complications and longer length of stay (LOS). It was investigated whether a home-delivered, protein-rich meal service improves protein intake relative to requirements within 3 weeks prior to surgery compared to usual care (UC).

METHODS

This randomized controlled trial included adults (n = 126) with planned surgery performed at the orthopedics, urology, gynecology, or general surgery departments. The intervention group received 6 protein-rich dishes per day for 3 weeks, and the control group sustained their usual diet. Dietary intake, nutrition status, hand grip strength, physical performance, and quality of life were assessed at baseline and after 3 weeks. Patient satisfaction was reported after 3 weeks, and data on complications and LOS were reported 30 days after surgery.

RESULTS

Protein intake relative to requirements significantly improved by 16%, and energy intake relative to requirements increased by 19% for the meal service, as compared with UC. The intervention group experienced significantly less stress with preparing meals and were more satisfied with the presentation of the meals than the control group. No significant effects of the intervention were detected on other secondary outcomes.

CONCLUSION

The home-delivered, protein-rich meal service was successfully implemented before surgery and improved protein and energy intake relative to requirements within 3 weeks while patient satisfaction maintained. The preoperative period serves as a window of opportunity to prepare patients before hospitalization.

Dietetic assessment and intervention in lung cancer

PURPOSE OF REVIEW

Systemic therapy for lung cancer is increasing in intensity and duration. European nutrition guidelines suggest screening for weight loss and malnutrition, however acknowledges there is a lack of evidence. We discuss current data round this issue and identify opportunities for further research.

RECENT FINDINGS

International guidelines now exist to aid the definition of weight loss in cancer, including cachexia, sarcopenia and malnutrition. These allow consistent definition of overlapping, but distinct clinical syndromes. Nutritional status can be assessed in a range of ways including questionnaires, functional assessments, blood markers, physical activity, weight and BMI. Weight loss is commonly associated with a proinflammatory state. Future treatment is likely to be a combination of dietetic support and pharmacological treatment of cachexia.

SUMMARY

There is a paucity of data on dietetic intervention. It is potentially quick, inexpensive and patient specific, using a holistic approach to aid patients who are malnourished or at risk of malnutrition. Lung cancer-related weight loss is common, further strategies are needed to effectively assess and intervene. Dietetic intervention has the potential to improve patients' quality of life and outcomes.

Health economic benefits from optimized meal services to older adults-a literature-based synthesis

Malnutrition among older adults causes health problems and economic costs. Prevention of malnutrition through meal service can reduce such costs. This study estimates potential health economic benefits to be generated through meal service to home-dwelling older adults. The study contains three components: (1) systems analysis describing the relationship between meal service, nutritional status, health risk, and health-related costs, focusing on older adults, (2) a series of literature reviews to quantify the identified elements in each stage-subject combination: (i) meal service impact on nutrition status of older adults, (ii) associations between nutrition status and health risks, (iii) health care resource needs associated with these health risks, and (3) a model synthesis of literature findings to estimate the expected economic benefit of improved health status derived from meal service enrollment, using Denmark as an example. Expected economic benefits in terms of saved direct and indirect health care costs and improved quality-of-life was estimated at an amount of €307 per year per individual enrolled, of which direct health care cost savings constituted €75, while value of improved quality-of-life and reduced mortality constituted the rest. The average health economic benefit from enrolling older adults into meal service is likely to decrease with the number of subscribers. Findings like these are important to take into consideration, when making policy decisions regarding size of the meal service capacity, although it should be noted that the presented estimates are based on a number of assumptions of which some are subject to uncertainty.

Nutritional status and interventions for patients with cancer - A systematic review

BACKGROUND

Malnourishment is commonly seen in ageing, cancer and many chronic conditions, and is associated with poorer prognosis.

AIM

We set out to collect all currently available evidence on the association between nutritional status assessed with a validated screening tool and prognosis or course of treatment in older patients with cancer, and on the benefit of nutritional interventions in improving these outcomes.

METHODS

A systematic search in MEDLINE and EMBASE.

RESULTS

We included 71 studies on the association between nutritional status and outcome in (older) patients with cancer and 17 studies on the benefit of nutritional interventions in improving outcomes in this patient population. There is a significant association between nutritional status and increased intermediate- and long-term mortality (hazard ratio 1.87 (95% confidence interval 1.62-2.17). Those with poorer nutritional status were less likely to complete oncologic treatment according to plan and had higher health care consumption. Benefit of dietary interventions was limited although dietary counselling may lead to improved quality of life while nutritional support may lead to a decrease in post-operative complication rates.

CONCLUSION

Nutritional status is associated with poorer survival, decreased treatment completion and higher health care consumption and nutritional interventions are only able to negate these negatives outcome to a very limited degree.

The Role of Malnutrition and Muscle Wasting in Advanced Lung Cancer

PURPOSE OF REVIEW

Malnutrition, cancer cachexia, and sarcopenia often co-occur in patients with advanced cancer and are associated with poorer response to chemotherapy and reduced survival. Here, we evaluate the current literature regarding the role of nutrition and these associated conditions in patients with advanced lung cancer.

RECENT FINDINGS

While rates of malnutrition are high, nutritional intervention studies have generally been limited by small sample sizes. Novel strategies such as home-based meal delivery may have promise. While no therapy is approved for cancer cachexia, ghrelin agonists and other targeted therapies have yielded promising data in clinical trials. Recent data also suggest that obesity may improve immunotherapy responsiveness. Malnutrition and associated muscle wasting are clearly negative prognostic markers in advanced lung cancer. Patients with malnutrition should be urgently referred for dietary counseling and guidelines for nutritional support should be followed. Optimal treatment of these syndromes will likely include nutrition and anti-cachexia interventions used in combination.

Efficacy of Cereal-based Oral Nutrition Supplement on Nutritional Status, Inflammatory Cytokine Secretion and Quality of Life in Cancer Patients Under Cancer Therapy

A rapid increase in cancer incidence accompanied by aging population requires evidence-based supportive cancer care practices. Cancer therapies often accompany adverse events which induce malnutrition and declined quality of life. We conducted an 8-week non-randomized clinical trial to evaluate efficacy of cereal-based oral nutritional supplement (ONS) intervention on nutritional status, quality of life and inflammatory responses in cancer patients undergoing cancer therapy with 5% < weight loss. The study included 34 pateints (24 in control group, 10 in intervention group) with 15 drop-outs. ONS used in this intervention contained 0.5% arabinoxylan-rich fermented rice bran powder and 5.5% black rice powder as active ingredients in a regular cereal-based formula. Results showed that ONS intervention for 8 weeks did not show significant improvement in blood biomarkers of nutritional status or patient-generated subjective global assessment scores. However, 8-week of intervention showed reduced interleukin (IL)-6 and IL-1β secretion in lipopolysaccharide-stimulated peripheral blood mononuclear cells while IL-12p70 level was increased. For health-related quality of life (HRQoL) indices, emotional functioning and fatigue symptoms were improved after 4 weeks only in the intervention group although no difference was found at week 8. These results suggest that ONS intervention may improve chronic inflammatory status and HRQoL indices (at week 4) in cancer patients receiving treatments.

Cancer and older adult patient care

Cancer occurs most frequently in patients aged 65 and older. With the increasing age of the world's population, there will be a significant increase in cancer diagnoses in older adults. Aging imposes a wide variety of physiological responses, comorbidities, and ailments, but older patients are less represented in clinical studies. Specific needs of older patients with cancer often go under-recognized and consequently unmet. In this review, common diagnoses that can affect the outcomes of this population, including frailty, malnutrition, and delirium, are discussed. Areas that need further research to improve the care of geriatric cancer patients, particularly in the hospital settings, are also identified.

Effective elements of home-delivered meal services to improve energy and protein intake: A systematic review

Home-delivered meal services are an example of a nutritional intervention in the home setting developed to enhance dietary intake and contribute to the independence of especially older adults. There is a lack of evidence about the contribution of specific elements of any home-delivered meal service on the improved outcomes. Therefore, a systematic review was performed to evaluate which elements of home-delivered meal services are effective to improve energy and protein intake, nutritional status, functional outcomes and satisfaction in adults. Pubmed, Embase and Web of Science databases were searched for studies assessing energy and protein intake, nutritional or functional status, or satisfaction of these services. The quality of the studies was assessed using the Quality Criteria Checklist for Primary Research. Of 138 studies meeting the search criteria, 19 were included, none of which met the criteria to be rated as high quality. These studies show that various elements of home-delivered meal services such as Meals on Wheels providing protein-enriched bread or snacks in addition to meals or providing meals and snacks for whole days can improve outcomes such as energy and protein intake and satisfaction. A distinction can be made between services focusing on supporting homebound, essentially healthy, older adults and services aiming at the optimal, nutritional, transmural care for patients at risk for malnutrition. This review shows that various elements of these meal services can improve key outcomes. Following the rising interest and importance of these interventions, there is an urgent need to optimize such services to improve nutritional care at home regarding the increasingly limited time frame of admission in hospitals.