Nutritional status of patients treated with radiotherapy as determined by subjective global assessment

Introduction to Nutrition and Cancer

By the beginning of the year 2021, the estimated number of new cancer cases worldwide was about 19.3 million and there were 10.0 million cancer-related deaths. Cancer is one of the deadliest diseases worldwide that can be attributed to genetic and environmental factors, including nutrition. The good nutrition concept focuses on the dietary requirements to sustain life. There is a substantial amount of evidence suggesting that a healthy diet can modulate cancer risk, particularly the risk of colorectal and breast cancers. Many studies have evaluated the correlation between our diet and the risk of cancer development, prevention, and treatment. The effect of diet on cancer development is likely to happen through intertwining mechanisms including inflammation and immune responses. For instance, a greater intake of red and processed meat along with low consumption of fruits and vegetables has been associated with increased levels of inflammatory biomarkers that are implicated in cancer development. On the other hand, the consumption of phytosterols, vitamins, and minerals, which exert antioxidant and anti-inflammatory roles have been linked to lower cancer risk, or even its occurrence prevention. In this book, we aim to summarize the current knowledge on the role of nutrition in cancer to provide the best scientific advice in this regard.

Quality assessment of PBM protocols for oral complications in head and neck cancer patients: part 2

PURPOSE

To investigate the role of photobiomodulation (PBM) in patients undergoing head and neck cancer (HNC) treatment. We focused on the consequences of the main complications, such as quality of life (QoL), analgesia, functional impairment, and nutritional status, as well as on the impact on survival/ recurrences, radiotherapy (RT) interruption, adherence, cost-effectiveness, safety, feasibility, and tolerability.

METHODS

An electronic search in PubMed and Scopus databases was performed. Full texts were carefully assessed, and data were assimilated into a tabular form for discussion and consensus among the expert panel.

RESULTS

A total of 22 papers were included. Overall, a beneficial effect of PBM was evidenced in the amelioration of QoL, nutritional status, the reduction of pain, and functional impairment. Preventive PBM may reduce the incidence and duration of RT interruptions, potentially contributing to improved cancer treatment outcomes. PBM treatments are safe and recommended for routine use, with the caveat of avoiding direct tumor exposures where feasible. However, it does not appear to impact cancer survivorship/recurrences directly. Despite additional clinical efforts involving routine PBM use, the individual and public health benefits will positively impact oncology care.

CONCLUSIONS

Quality of life, pain and functional impairment, nutritional status, and survival may be effectively improved with PBM. Given its established efficacy also in reducing RT interruptions and its safety, feasibility, and tolerability, PBM should be included in the field of supportive cancer care in HNC patients. Improved understanding of PBM mechanisms and precise dose parameters is enabling the generation of more robust, safe, and reproducible protocols; thus, it is imperative to support further clinical implementation as well as both applied and basic science research in this novel field.

Effect of Oral Nutritional Supplements on Patients with Esophageal Cancer During Radiotherapy

Background: This study investigated the effect of oral nutritional supplements (ONS) on patients with esophageal cancer during radiotherapy. Materials and Methods: Patients with esophageal cancer undergoing radiotherapy were randomly divided into nutritional intervention (NI) and routine treatment (RT) groups. All patients received one-on-one nutritional counseling and dietary advice, and patients in the NI group received ONS. Body mass index (BMI), a patient-generated subjective global assessment (PG-SGA), serum albumin (ALB), hemoglobin (Hb), white blood cell (WBC) count, prealbumin (PA), and platelets (PLTs) were recorded before and after radiotherapy in both the NI group and the RT group. Further, the adverse reactions during the treatment were evaluated. Results: In the NI group, the BMI after radiotherapy was significantly higher than that before radiotherapy, and the PG-SGA score after radiotherapy was significantly lower than that before radiotherapy (p < 0.05). In the RT group, the levels of BMI, Hb, ALB, PA, PLTs, and WBC after radiotherapy were significantly lower than those before radiotherapy, and the PG-SGA score was worse after radiotherapy (p < 0.05). After radiotherapy, the levels of BMI, Hb, ALB, and PA in the NI group were similar to those in the RT group (p > 0.05); whereas the levels of WBC and PLTs in the NI group were lower than those in the RT group (p < 0.05). During the treatment, the toxic reactions of radiation esophagitis, myelosuppression, nausea, and vomiting were decreased in the NI group compared with the RT group. Conclusions: ONS can reduce weight loss and improve the nutritional status of patients with esophageal cancer during radiotherapy.

Subjective Global Assessment of Nutritional Status in Head and Neck Cancer Patients Treated with Radiotherapy - A Prospective Observational Study from North East India

Head and neck cancer (HNC) patients undergoing curative radiotherapy (RT) are at risk of malnutrition due to disease process as well as effects of therapy. Identifying the nutritional status of these patients at the earliest, helps to introduce adequate and timely interventions that can improve compliance and outcomes of treatment. Various tools for nutritional assessment in cancer patients have been proposed. In this prospective observational study we used the Subjective Global Assessment (SGA) questionnaire in a cohort of HNC patients receiving definitive RT at a regional cancer center of North East India. Recording of data was done at baseline, at two weekly intervals during treatment, at end of radiotherapy (EORT) and at follow-up upto 6 months. We observed that despite proper nutrition counseling, our patients suffered from malnutrition throughout their course of RT, which was at its peak by EORT but gradually improved over six months of follow-up. Pain on eating and swallowing were the most debilitating symptoms which caused significant decline of nutrient intake, body fat and muscle mass among patients together with deteriorating SGA ratings. Our results will hopefully help us design better strategies for nutrition management while delivering curative (chemo)radiotherapy for HNC patients of this region- which has one of the highest incidences of HNC in the world.

Association Between Fat Mass to Lean Body Mass Ratio and All-Cause Mortality Among Middle-Aged and Elderly Cancer Patients Without Obesity: A Multi-Center Observational Study in China

Objective

We aimed to investigate the association between fat mass to lean body mass ratio (RFL), percentage of body fat (PBF), and fat mass (FM) with mortality among middle-aged and elderly cancer patients without obesity.

Methods

This prospective hospital-based cohort study comprised 3,201 patients with stage I to IV cancer aged 40 years or above (mean age: 58 years for female patients and 61 years for male patients; mean length of follow-up was 1.67 years; the maximal follow-up length was 6.42 years). FM and PBF were measured by bioelectrical impedance analysis (BIA). Cox proportional hazard models were used, and adjusted hazard ratios (HRs) were estimated.

Results

We revealed a significant association between RFL and all-cause mortality among men aged ≥60 years after adjusting for confounders. Compared with those in the lowest tertile of RFL, elderly men in the medium and highest tertile had a 35 and 34% lower hazard of death from any cause, respectively. After additionally adjusted for C-reaction protein (CRP), HRs of medium and high tertile of RFL became short of statistical significance [medium tertile: adjusted HRs (95% CI) = 0.74 (0.46, 1.20); highest tertile: adjusted HRs (95% CI) = 0.84 (0.53, 1.33)]. Among elderly women, RFL was significantly related to all-cause mortality only when the additional adjustment for CRP [medium tertile: adjusted HRs (95% CI) = 2.08 (1.08, 4.01); highest tertile: adjusted HRs (95% CI) = 0.90 (0.45, 1.81)]. No significant association between RFL and all-cause mortality was observed among female participants or male participants aged less than 60 years.

Conclusion

Our findings showed a significant non-linear association between RFL and all-cause mortality, which was observed only in elderly men, and might be attenuated by their inflammation state.

Predictive value of postoperative serum prealbumin levels for early detection of anastomotic leak after esophagectomy: A retrospective study

The impact of serum prealbumin in patients with esophageal carcinoma after undergoing esophagectomy remains unclear, we speculated that serum prealbumin is associated with anastomotic leak (AL) after surgery, low serum prealbumin level may lead to AL. The aim of the study was to evaluate the relationship between serum prealbumin levels and AL after esophagectomy, to explore the value of serum prealbumin as an early predictor of AL after esophagectomy.Between January 2014 and December 2018, 255 patients were enrolled in this study, their basic characteristics and perioperative serum prealbumin levels were retrospectively analyzed. Statistical analysis by t test, nonparametric test and logistic regression were used to analyze data for patients with and without AL. Based on a receiver operator characteristic curve, a cut-off value for serum prealbumin levels as a predictor of AL was determined.Among the 255 patients, 18 patients were diagnosed with AL. The overall AL rate was 7.0% (18/255) including 12 cases of intrathoracic AL and 6 cases of cervical AL. By univariate analysis, we identified postoperative serum prealbumin level as a risk factor for AL (P < .001). Multivariate analysis also demonstrated postoperative serum prealbumin level (P = .028) to be an independent risk factor for AL. The best cut-off value of postoperative serum prealbumin level was 131 mg/L for predicting AL, with 83.3% sensitivity and 72.2% specificity.Postoperative serum prealbumin level was significantly associated with AL. it may help the early prediction of postoperative AL.

Radiation Necrosis with Proton Therapy in a Patient with Aarskog-Scott Syndrome and Medulloblastoma

Purpose

Medulloblastoma is known to be associated with multiple cancer-predisposition syndromes. In this article, we explore a possible association among a patient's Aarskog-Scott syndrome, development of medulloblastoma, and subsequent brainstem radiation necrosis.

Case Presentation

A 5-year-old male with Aarskog-Scott syndrome initially presented to his pediatrician with morning emesis, gait instability, and truncal weakness. He was ultimately found to have a posterior fossa tumor with pathology consistent with group 3 medulloblastoma. After receiving a gross total resection and standard proton beam radiation therapy with concurrent vincristine, he was noted to develop brainstem radiation necrosis, for which he underwent therapy with high-dose dexamethasone, bevacizumab, and hyperbaric oxygen therapy with radiographic improvement and clinical stabilization.

Conclusion

Based on several possible pathologic correlates in the FDG1 pathway, there exists a potential association between this patient's Aarskog-Scott syndrome and medulloblastoma, which needs to be investigated further. In patients with underlying, rare genetic syndromes, further caution should be taken when evaluating chemotherapy and radiation dosimetry planning.

Nutritional Deficiencies in Radiotherapy-Treated Head and Neck Cancer Patients

Nutritional deficiencies (malnutrition, cachexia, sarcopenia, and unfavorable changes in the body composition) developing as a side effect of radiotherapy (RT) currently represents a significant but still inaccurately studied clinical problem in cancer patients. The incidence of malnutrition observed in head and neck cancer (HNC) patients in oncological radiology departments can reach 80%. The presence of malnutrition, sarcopenia, and cachexia is associated with an unfavorable prognosis of the disease, higher mortality, and deterioration of the quality of life. Therefore, it is necessary to identify patients with a high risk of both metabolic syndromes. However, the number of studies investigating potential predictive markers for the mentioned purposes is still significantly limited. This literature review summarizes the incidence of nutritional deficiencies in HNC patients prior to therapy and after the commencement of RT, and presents recent perspectives for the prediction of unfavorable nutritional changes developing as a result of applied RT.

Impact of cervical cancer on the sexual and physical health of women diagnosed with cervical cancer in Ghana: A qualitative phenomenological study

INTRODUCTION

Although cervical cancer is preventable, it is a major gynecological disorder among women currently. More than 500,000 new cases of cervical cancer are being diagnosed across the globe, with one woman dying of cervical cancer every 2 min. In addition, about half of cervical cancer survivors have challenges with their sexual function. Despite these findings, literature regarding the sexual function of women with cervical cancer is scanty. The study aims to assess cervical cancer's impact on the sexual and physical health of women diagnosed with cervical cancer in Ghana.

METHODS

The researchers of this study employed a qualitative approach with phenomenological design. A purposive sampling technique was used to select 30 participants engaged in face-to-face in-depth interviews that were audio-recorded. The content of the transcripts was analyzed using content analysis.

RESULTS

This study revealed that cervical cancer patients experienced low libido due to the cervical cancer symptoms and the side effects of chemotherapy. This low libido made them divert their sexual gratification from the vagina to other centers of the body. Findings further revealed that some participants showed apathy toward their partners' sexual feelings. Some physical problems experienced by the participants were also unraveled.

CONCLUSION

Cervical cancer affects all aspects of a woman's health, including sexual function and physical well-being. Therefore, there is the need for more to help address challenges faced by cervical cancer women about their sexual and physical health.

Toxicities Caused by Head and Neck Cancer Treatments and Their Influence on the Development of Malnutrition: Review of the Literature

Malnutrition poses a significant problem for oncology patients, resulting in fatalities within this population. Patients with head and neck cancer (HNC) are at high risk, with up to 90% developing malnutrition. Common treatments used for HNC can often lead to adverse side effects, including oral health conditions, gastrointestinal upsets, and several metabolic changes. Consequently, treatments can cause inadequate nutritional intake, resulting in a reduction in energy consumption, and alterations in energy utilization, contributing to the development of malnutrition. Furthermore, the presence of these treatment toxicities, and the related malnutrition can lead to reduced quality of life, weight loss, and psychological distress. There are interventions available (nutritional, medicinal, and physical therapies) that have demonstrated potential effectiveness in reducing the severity of symptomatic toxicities, reducing the risk of malnutrition, and improving survival outcomes of patients with HNC. Based on the findings of this review, there is an urgent need for the implementation or continuation of multi-disciplinary strategies, as well as updated and improved guidelines to assist in the prevention and treatment of malnutrition caused by treatment-related toxicities in patients with HNC.

AA genotype of PLIN1 13041A>G as an unfavourable predictive factor of malnutrition associated with fat mass loss in locally advanced head and neck cancer male patients treated with radiotherapy

Introduction

Malnutrition is a frequently diagnosed condition in head and neck cancer (HNC) patients after radiation therapy (RTH). Malnutrition causes adipose tissue dysfunction associated with intensified lipolysis and disruption of the activity of mechanisms that protect adipose tissue against this process, which include the protective function of perilipin.

Material and methods

The purpose of this study was the evaluation of the predictive value of 13041A>G PLIN1 polymorphism in the development of malnutrition related to adipose tissue loss in a group of 80 patients with locally advanced HNC treated by means of radical radiation therapy.

Results

After the completion of RTH, men with AA genotype had significantly lower fat mass (FM compared to men with G haplotype; FM: 13.84 ± 6.36 kg and 19.06 ± 6.30 kg (p = 0.009). In consequence of RTH, the AA genotype carriers lost an average of 37.01% adipose tissue mass and patients with GA and GG genotypes lost 12.82 and 0.31% (p = 0.035), respectively. AA genotype was also associated with higher chance of ≥ 10%, ≥ 20% and ≥ 30% FM loss in the course of RTH (OR = 13.78; 5.78; 2.28).

Conclusions

The evaluation of such molecular factors as SNP 13041A>G may have higher predictive value in the development of malnutrition associated with severe loss of fat mass than the subjective scales, e.g., SGA and NRS-2002. The presence of AA genotype on men with HNC before RTH may facilitate earlier nutritional intervention and supportive treatment aimed at limiting or preventing body mass and fat mass loss during the applied treatment.

Electronic supplementary material

The online version of this article (10.1007/s00520-020-05675-8) contains supplementary material, which is available to authorized users.

Factors influencing non-adherence to radiotherapy: a retrospective audit of 1,548 patients from a tertiary cancer centre

Purpose:

To determine the frequency, factors and reasons of patient non-adherence to radiotherapy (RT) in a tertiary cancer centre.

Background:

Inadvertent treatment interruptions often lead to prolongation of planned treatment time. In the case of RT with a curative intent, prolongation of planned treatment has been associated with inferior clinical outcomes. Delay or prolongation of treatment is associated with a relative risk of local recurrence by up to 2% per day for specific malignancies. Thus, it is critical to understand key factors that influence non-adherence to RT.

Methods and Materials:

A retrospective observation audit was conducted comprising patients treated with radical, adjuvant or palliative RT at our centre from January 2018 to December 2018. Non-adherence was defined as premature permanent termination of planned treatment by the patient without recommendation or consultation from the treating clinician. All data were collected and analysed (retrospectively) with the help of Statistical Package for the Social Sciences (SPSS) version 22.

Results:

A total of 1,548 patients were included in the study of which 105 (6·7%) were non-adherent to planned RT. Of the total 105 patients, 44 (42%) were elderly (60 years and above). Treatment non-adherence was predominant in males (male:female = 1·85:1). More than 90% of non-adherent patients had stage III and IV cancer. A total of 77 patients (74%) out of 105 were more than 50 km away from our centre. A total of 66 (63%) out of 105 patients had completed more than 2 weeks of radiation (40% of planned RT) and then defaulted for radiation due to acute toxicities.

Conclusion:

Treatment adherence is a major factor in determining successful outcomes among cancer patients treated with RT. This study reveals several factors that contribute to non-adherence to treatment.

Nutritional Risk Screening and Assessment

Malnutrition is an independent risk factor that negatively influences patients’ clinical outcomes, quality of life, body function, and autonomy. Early identification of patients at risk of malnutrition or who are malnourished is crucial in order to start a timely and adequate nutritional support. Nutritional risk screening, a simple and rapid first-line tool to detect patients at risk of malnutrition, should be performed systematically in patients at hospital admission. Patients with nutritional risk should subsequently undergo a more detailed nutritional assessment to identify and quantify specific nutritional problems. Such an assessment includes subjective and objective parameters such as medical history, current and past dietary intake (including energy and protein balance), physical examination and anthropometric measurements, functional and mental assessment, quality of life, medications, and laboratory values. Nutritional care plans should be developed in a multidisciplinary approach, and implemented to maintain and improve patients’ nutritional condition. Standardized nutritional management including systematic risk screening and assessment may also contribute to reduced healthcare costs. Adequate and timely implementation of nutritional support has been linked with favorable outcomes such as a decrease in length of hospital stay, reduced mortality, and reductions in the rate of severe complications, as well as improvements in quality of life and functional status. The aim of this review article is to provide a comprehensive overview of nutritional screening and assessment methods that can contribute to an effective and well-structured nutritional management (process cascade) of hospitalized patients.

Combined Chemoradiotherapy-induced Weight Loss Decreases Survival in Locally Advanced Non-small Cell Lung Cancer Patients

BACKGROUND/AIM

The aim of the study was to investigate the prognostic impact and predictors of weight loss during definitive radiotherapy in non-small cell lung cancer (NSCLC) patients.

PATIENTS AND METHODS

A total of 125 NSCLC patients (2003-2016) who had received definitive radiotherapy were included in the study. Multivariate analyses were performed to estimate prognostic values. Predictors for weight loss were analyzed.

RESULTS

The median survival of patients with weight loss (>5%) during radiotherapy and for those without any significant weight loss was 15.6 and 33 months, respectively (p=0.015). Non-intensity modulated radiotherapy (IMRT) technique was the only factor associated with weight loss (p=0.039). Weight loss was a poor prognostic factor for overall survival (OS) (hazard ratio [HR] 2.072, p=0.018), and IMRT was a favorable prognostic factor (HR=0.192, p=0.029).

CONCLUSION

During definitive radiotherapy, weight loss of >5% resulted in decreased OS rate in locally advanced NSCLC. IMRT might increase OS rate by minimizing weight loss.

Nutritional status, the development and persistence of malnutrition and dietary intake in oesophago-gastric cancer: a longitudinal cohort study

BACKGROUND

Patients with oesophago-gastric (OG) cancer may be at risk of malnutrition, troublesome gastrointestinal symptoms (GI) and reduced dietary intake in view of the tumour location and multimodality curative treatment approach. Longitudinal research is lacking. The present study aimed to assess (i) nutritional status and how it evolved over the first year; (ii) the association between nutritional status scores and GI symptom scores; and (iii) the nutrient and food group intake pattern.

METHODS

This was a prospective, observational study of patients with an OG lesion planned for radical treatment, with assessment at diagnosis, 3 months and 12 months after the start of treatment. Nutritional assessment was performed using the Patient-Generated Subjective Global Assessment, GI symptoms measured using the modified Gastrointestinal Symptom Rating Scale and dietary intake assessed using a semi-quantitative food frequency approach.

RESULTS

Eighty patients (61 males, 19 females; aged 46-89 years) were recruited. At baseline, 3 (n = 68) and 12 months (n = 57), 61%, 62% and 60%, respectively, were moderately/severely malnourished. Higher symptom burden was associated with poorer nutritional status at baseline (r = 0.55, P < 0.001), 3 months (r = 0.51, P < 0.001) and 12 months (r = 0.42, P = 0.001). At each respective time point, 37%, 38% and 42% were meeting their estimated average requirement for energy. No change in mean (SD) intake of energy, fibre, nutrient and food groups was observed over time.

CONCLUSIONS

Patients with OG cancer have progressive weight loss, with malnutrition present over the majority of the 12-month study period. Optimising nutritional status and symptom management throughout the treatment pathway should be a clinical priority.

Subjective Global Assessment (SGA) Score Could Be a Predictive Factor for Radiation Pneumonitis in Lung Cancer Patients With Normal Pulmonary Function Treated by Intensity-Modulated Radiation Therapy and Concurrent Chemotherapy

INTRODUCTION

To investigate the relationship between malnutrition and the severity of radiation pneumonitis (RP) in patients with lung cancer with normal baseline pulmonary function and lungs' V20 < 35% treated by intensity-modulated radiation therapy (IMRT) and concurrent chemotherapy.

MATERIALS AND METHODS

A total of 150 patients with lung cancer who received definitive IMRT (≥ 60 Gy) and concurrent chemotherapy were enrolled. In the condition of normal baseline pulmonary function and strict constraints of the irradiation dose to normal lung tissues, we recorded Eastern Cooperative Oncology Group score; concurrent chemotherapy; clinical stage; the level of albumin (ALB), hemoglobin, and C-reactive protein; Subjective Global Assessment (SGA) scores; radiation esophagitis grade; V20 of lungs; and mean lung dose. These factors were correlated with RP using univariate and multivariate regression analyses.

RESULTS

Of 150 patients, 12 patients (8.0%) developed Grade 3 to 5 RP, 37 (24.6%) patients developed grade 3 to 5 esophageal toxicity. In univariate analysis, ALB level (P = .002), radiation esophagitis (P < .001), and SGA score (P < .001) were significantly associated with RP. Multivariate analysis revealed that SGA (P < .001) was the independent predictor of RP.

CONCLUSIONS

SGA could be a predictor for RP in patients with lung cancer treated with definitive IMRT and concurrent chemotherapy.

Severe weight loss during preoperative chemoradiotherapy compromises survival outcome for patients with locally advanced rectal cancer

Purpose

In addition to tumor factors, poor nutritional status before and during anti-tumor treatment might compromise prognosis in several types of cancer. This study was done to determine the impact of weight loss during preoperative chemoradiotherapy (CRT) on the survival outcome of patients with locally advanced rectal cancer (LARC).

Methods

The retrospective study examined consecutive patients with LARC who underwent preoperative CRT followed by radical resection in a single institute, between 2003 and 2013. Correlation of proportional body mass index (BMI) change after preoperative CRT and patient’s demographics, tumor characteristics, treatment parameters, CRT-related toxicity, disease-free survival (DFS) and overall survival (OS) were investigated.

Results

A total of 364 patients were enrolled, and BMI loss was found in 243 patients (66.2 %) after preoperative CRT. Severe weight loss (SWL) was defined as BMI loss ≥7 %. Thirty-nine (10.7 %) cases were enrolled in SWL cohort and found to have higher incidence of diarrhea (P = 0.033), renal disorder (P = 0.033) and grade 3–4 radiation proctitis (P = 0.041). Although no significant difference was found in 3-year DFS, patients in SWL cohort showed significantly worse 3-year OS rate (71.8 vs 88.0 %, P = 0.030) than the others. In univariate analysis, BMI loss ≥7 %, completed dose of preoperative chemotherapy, pathologic T and N stages were correlated with OS (all P < 0.05). In multivariable analysis, BMI loss ≥7 % (HR 1.984; 95 % CI 1.061–3.709; P = 0.032) remained the independent prognostic factor for OS.

Conclusions

Our results demonstrate that SWL during preoperative CRT indeed compromises survival outcome in patients with LARC. Routine nutritional monitoring and nutritional support during preoperative CRT are suggested as the integral part of the multidisciplinary approach for these patients.

Long-term effects of varying consumption of ω3 fatty acids in ear, nose and throat cancer patients: assessment 1 year after radiotherapy

A prospective 1-year follow-up study in ear, nose, and throat (ENT) cancer patients was carried out one year after radiotherapy to assess the effect of varying consumption of ω3 fatty acid according to whether they consumed more or less than the 50th percentile of ω3 fatty acids. Clinical, analytical, inflammatory (CRP and IL-6), and oxidative variables (TAC, GPx, GST, and SOD) were evaluated. The study comprised 31 patients (87.1% men), with a mean age of 61.3 ± 9.1 years. Hematological variables showed significant differences in the patients with a lower consumption of ω3 fatty acids. A lower mortality and longer survival were found in the group with ω3 fatty acid consumption ≥50th percentile but the differences were not significant. No significant difference was reached in toxicity, inflammation, and oxidative stress markers. The group with ω3 fatty acid consumption <50th percentile significantly experienced more hematological and immune changes.