Evidence based statements.The evidence based statements are listed under headings based on the nutrition care process.
Access to Appropriate Care
How should patients be identified for referral to the dietitian dietitian /di·e·ti·tian/ (di?e-tish´in) one skilled in the use of diet in health and disease.
di·e·ti·tian or di·e·ti·cian
A person specializing in dietetics. in order to maximise nutritional intervention opportunities?
Evidence statement Level of evidence The Malnutrition Screening Tool (MST) is an Level III-3 (6) effective screening tool for identifying nutritional risk in cancer patients
How should nutritional status nutritional status,
n the assessment of the state of nourishment of a patient or subject. be assessed?
Evidence statement Level of evidence Subjective Global Assessment (SGA) is a valid method IV (7) of assessing nutritional status in patients with cancer cachexia The scored Patient-Generated Subjective Global III-3 (7,8) Assessment (PG-SGA) is a valid method of assessing nutritional status in patients with cancer cachexia Bioelectrical impedance analysis is not suitable for III-3 (9,10) body composition measurement in individual patients with cancer cachexia
Quality Nutrition Care
What are the goals of nutrition intervention for patients with cancer cachexia cancer cachexia Oncology A complex, multifactorial syndrome characterized by anorexia and/or unintended loss of appetite, accompanied by generalized host tissue wasting, skeletal muscle atrophy, immune dysfunction, and metabolic derangements. See Cachexia, Malnutrition. ?
Evidence statement Level of evidence Weight-losing patients with cancer cachexia who III-2 (11) stabilise their weight have greater quality of life and survival duration than those who continue to lose weight
What is the nutrition prescription to achieve these goals?
Evidence statement Level of evidence Energy and protein requirements for weight III-2 (11) stabilisation are approximately 120 kJ/kg/d and 1.4g protein/kg/d in patients with cancer cachexia receiving supportive care Energy and protein requirements for weight IV (7) stabilisation are approximately 120 kj/kg/d and 1.4g protein/kg/d in patients with cancer cachexia receiving chemotherapy Weight stable patients have higher energy intake than III-2 (11) weight losing patients in patients with cancer cachexia receiving supportive care Well-nourished patients with advanced cancer have IV (12) higher energy and protein intakes compared to malnourished patients with advanced cancer
Should EPA EPA eicosapentaenoic acid.
n.pr See acid, eicosapentaenoic.
n. be included in the prescription in patients with cancer cachexia?
Evidence statement Level of evidence The prescription of EPA improves outcomes in Level C (7,11,13-20) patients with cancer cachexia Body of evidence provides some support for recommendation but care should be taken in its application
What are effective methods of implementation to ensure positive outcomes?
Evidence statement Level of evidence Compliance with a nutrition prescription of 1.5 III-2 (20) cans/d of a high protein energy III-220 supplement [+ or -]EPA does not reduce total food intake in patients with cancer cachexia receiving supportive care Consumption of a high protein energy supplement IV (7) enriched with EPA does not reduce total food intake in patients with cancer cachexia receiving chemotherapy Frequent clinician contact (minimum fortnightly) III-3 (7,18) improves clinical outcomes in patients with cancer cachexia
Nutrition Monitoring and Evaluation
Measure and Evaluate Outcomes
Does nutrition intervention improve outcomes in patients with cancer cachexia?
Evidence statement Level of evidence Nutrition intervention improves outcomes Level C (7,11,13-20) in patients with cancer cachexia Body of evidence provides some support for recommendation but care should be taken in its application
A summary of recommendations for the nutritional management of cancer cacheia is presented in Table 1.
1 The AGREE collaboration. Appraisal of Guidelines for Research and Evaluation (AGREE) Instrument. London: St George's Hospital St George's Hospital, founded in 1733, is a teaching hospital in London, England. It has continuously trained medical students since that date. History
In 1716 Henry Hoare, William Wogan, Robert Witham and Patrick Cockburn decided to open the Westminster Public Infirmary Medical School, 2001. (Cited 12 Oct 2004.) Also available from URL URL
in full Uniform Resource Locator
Address of a resource on the Internet. The resource can be any type of file stored on a server, such as a Web page, a text file, a graphics file, or an application program. : http://www.agreecollaboration.org
2 National Health and Medical Research Council The National Health and Medical Research Council (NHMRC) is Australia's peak funding body for medical research, with a budget of nearly A$500M a year . The Council was established to develop and maintain health standards and is responsible for implementing the . A Guide to the Development, Implementation and Evaluation of Clinical Practice Guidelines clinical practice guidelines Clinical policies, practice guidelines, practice parameters, practice policies Medtalk Systematically developed statements to assist practitioner and Pt decisions about appropriate health care for specific clinical circumstances. See Psychology. . Canberra: Commonwealth of Australia Commonwealth of Australia: see Australia. , 1999. (Cited 9 Dec 2004.) Also available from URL: http://www.nhmrc.gov.au/publications/synopses/cp65syn.htm
3 National Health and Medical Research Council. NHMRC Additional Levels of Evidence and Grades for Recommendation for Developers of Guidelines. Pilot Program. Canberra: Commonwealth of Australia, 2005. (Cited 9 May 2005.) Also available from URL: http://www.nhmrc.gov.au/advice/consult.htm
4 Hakel-Smith N, Lewis NM. A standardized nutrition care process and language are essential components of conceptual model to guide and document nutrition care and patient outcomes. J Am Diet Assoc 2004; 104: 1878-84.
5 Splett PL. Cost Outcomes of Nutrition Intervention. Part 2. New York New York, state, United States
New York, Middle Atlantic state of the United States. It is bordered by Vermont, Massachusetts, Connecticut, and the Atlantic Ocean (E), New Jersey and Pennsylvania (S), Lakes Erie and Ontario and the Canadian province of : Mead Johnson and Company, 1996.
6 Ferguson ML, Bauer J, Gallagher B, Capra S, Christie DR, Mason BR. Validation of a malnutrition screening tool for patients receiving radiotherapy. Australas Radiol 1999; 43: 325-7.
7 Bauer J, Capra S. Intensive nutrition intervention improves outcomes in patients with cancer cachexia receiving chemotherapy--a pilot study. Support Care Cancer 2005; 13: 270-74.
8 Read JA, Crockett N, Volker DH et al. Nutritional assessment nutritional assessment Oncology The profiling of a Pt's current nutritional status and risk of malnutrition and cancer cachexia. See Cachexia, Malnutrition. in cancer--comparing the Mini-Nutritional Assessment (MNA MNA Monitored Natural Attenuation
MNA Massachusetts Nurses Association
MNA Michigan Nonprofit Association
MNA Mini-Nutritional Assessment
MNA Mission to North America (Presbyterian Church in America outreach) ) to the Scored Patient Generated Subjective Global Assessment (PGSGA). Nutr Cancer 2006; 53: 51-6.
9 Simons J, Schols A, Westerterp K, ten Velde G, Wouters E. The use of bioelectrical impedance analysis Bioelectrical impedance analysis (BIA) is a commonly used method for estimating body composition. Since the advent of the first commercially available devices in the mid-1980s the method has become popular owing to its ease of use, portability of the equipment and its relatively to predict total body water in patients with cancer cachexia. Am J Clin Nutr 1995; 61: 741-5.
10 Bauer J, Capra S, Davies PSW (Program Status Word) A hardware register that maintains the status of the program being executed. . Estimation of total body water from foot to foot bioelectrical impedance analysis in patients with cancer cachexia--agreement between prediction methods and deuterium oxide deuterium oxide
An isotopic form of water with composition D2O, isolated for use as a moderator in certain nuclear reactors.
same as heavy water
dilution. J Hum Nutr Diet 2005; 18: 295-300.
11 Davidson W, Ash S, Capra S, Bauer J. Weight stabilisation is associated with improved survival duration and quality of life in unresectable pancreatic cancer pancreatic cancer
Malignant tumour of the pancreas. Risk factors include smoking, a diet high in fat, exposure to certain industrial products, and diseases such as diabetes and chronic pancreatitis. Pancreatic cancer is more common in men. . Clin Nutr 2004; 23: 239-47.
12 Bruera E, Carraro S, Roca E, Cedaro L, Chacon R. Association between malnutrition and caloric caloric /ca·lo·ric/ (kah-lor´ik) pertaining to heat or to calories.
1. Of or relating to calories.
2. Of or relating to heat. intake, emesis emesis /em·e·sis/ (em´e-sis) vomiting.
n. pl. em·e·ses
The act or process of vomiting.
The medical term for vomiting. , psychological depression, glucose taste, and tumor tumor: see neoplasm. mass. Cancer Treat Rep 1984; 68: 873-6.
13 Fearon K, von Meyenfeldt M, Moses A et al. The effect of a protein and energy dense, n-3 fatty acid n-3 fatty acid n-3 polyunsaturated fatty acid, omega-3 fatty acid A family of long-chain polyunsaturated fatty acids, primarily eicosapentaenoic–C20:5 and docosahexanenoic acid–C22:6; ↑ dietary NFAs are cardioprotective and have a positive impact enriched oral supplement on loss of weight and lean tissue lean tissue
muscle tissue without fat. in cancer cachexia: a randomised Adj. 1. randomised - set up or distributed in a deliberately random way
irregular - contrary to rule or accepted order or general practice; "irregular hiring practices" double blind trial. Gut 2003; 52: 1479-86.
14 Wigmore SJ, Ross JA, Falconer Falconer
prison where former professor Farragut, who had killed his brother, witnesses the torments and chaos of the penal system. [Am. Lit.: Cheever Falconer in Weiss, 151]
See : Imprisonment JS et al. The effect of polyunsaturated fatty acids Noun 1. polyunsaturated fatty acid - an unsaturated fatty acid whose carbon chain has more than one double or triple valence bond per molecule; found chiefly in fish and corn and soybean oil and safflower oil on the progress of cachexia cachexia /ca·chex·ia/ (kah-kek´se-ah) a profound and marked state of constitutional disorder; general ill health and malnutrition. in patients with pancreatic cancer. Nutrition 1996; 12 (Suppl. 1): S27-30.
15 Persson C, Glimelius B, Ronnelid J, Nygren P. Impact of fish oil and melatonin melatonin: see pineal gland.
Hormone secreted by the pineal gland of most vertebrates. It appears to be important in regulating sleeping cycles; more is produced at night, and test subjects injected with it become sleepy. on cachexia in patients with advanced gastrointestinal cancer Gastrointestinal cancer refers to malignant conditions of the gastrointestinal tract, including the esophagus, stomach, liver, biliary system, pancreas, bowels, and anus.
16 Jatoi A, Rowland K, Loprinzi CL et al. An eicosapentaenoic acid eicosapentaenoic acid /ei·co·sa·pen·ta·eno·ic ac·id/ (EPA) (i-ko?sah-pen?tah-e-no´ik) an omega-3, polyunsaturated, 20-carbon fatty acid found almost exclusively in fish and marine animal oils. supplement versus megestrol acetate megestrol acetate
(mjes´trōl as´ versus both for patients with cancer-associated wasting: a North Central Cancer Treatment Group The North Central Cancer Treatment Group (NCCTG) is a national clinical research group sponsored by the National Cancer Institute. The NCCTG consists of a network of cancer specialists at community clinics, hospitals and medical centers in the United States, Canada and and National Cancer Institute of Canada collaborative effort. J Clin Oncol 2004; 22: 2469-76.
17 Bruera E, Strasser F, Palmer JL et al. Effect of fish oil on appetite and other symptoms in patients with advanced cancer and anorexia/cachexia: a double-blind, placebo-controlled study. J Clin Oncol 2003; 21: 129-34.
18 Moses AWG (American Wiring Gauge) A U.S. measurement standard of the diameter of non-ferrous wire, which includes copper and aluminum. In general, the thicker the wire, the greater the current-carrying capacity and the longer the distance it can span. , Slater C, Preston T, Barber MD, Fearon KCH KCH Kuching, Sarawak, Malaysia - Kuching (Airport Code)
KCH Keramchemie GmbH (Germany)
KCH Kentucky Children's Hospital (Lexington, KY) . Reduced total energy expenditure and physical activity in cachectic cachectic /ca·chec·tic/ (kah-kek´tik) pertaining to or characterized by cachexia.
Affected by or relating to cachexia. patients with pancreatic cancer can be modulated mod·u·late
v. mod·u·lat·ed, mod·u·lat·ing, mod·u·lates
1. To adjust or adapt to a certain proportion; regulate or temper.
2. by an energy and protein dense oral supplement enriched with n-3 fatty acids. Br J Cancer 2004; 90: 996-1002.
19 Gogos CA, Ginopoulos P, Salsa B, Apostolidou E, Zoumbos NC, Kalfarentzos F. Dietary omega-3 polyunsaturated fatty acids plus vitamin E vitamin E
Fat-soluble organic compound found principally in certain plant oils and leaves of green vegetables. Vitamin E acts as an antioxidant in body tissues and may prolong life by slowing oxidative destruction of membranes. restore immunodeficiency immunodeficiency
Defect in immunity that impairs the body's ability to resist infection. The immune system may fail to function for many reasons. Immune disorders caused by a genetic defect are usually evident early in life. and prolong survival for severely ill patients with generalized malignancy malignancy: see cancer. : a randomized ran·dom·ize
tr.v. ran·dom·ized, ran·dom·iz·ing, ran·dom·iz·es
To make random in arrangement, especially in order to control the variables in an experiment. control trial. Cancer 1998; 82: 395-402.
20 Bauer J, Capra S, Battistutta D, Davidson W, Ash S, on behalf of Cancer Cachexia Study Group. Compliance with nutrition prescription improves outcomes in patients with unresectable pancreatic cancer. Clin Nutr 2005; 24: 998-1004.
21 DeWys WD, Begg C, Lavin PT et al. Prognostic prog·nos·tic
1. Of, relating to, or useful in prognosis.
2. Of or relating to prediction; predictive.
1. A sign or symptom indicating the future course of a disease.
2. effect of weight loss prior to chemotherapy in cancer patients. Eastern Cooperative Oncology Group The Eastern Cooperative Oncology Group (ECOG) was established in 1955 as one of the first cooperative groups launched to perform multi-center cancer clinical trials. A cooperative group is a large network of researchers, physicians, and health care professionals at public and . Am J Med 1980; 69: 491-7.
22 Ollenschlager G, Thomas W, Konkol K, Diehl V, Roth E. Nutritional behaviour and quality of life during oncological polychemotherapy: results of a prospective study on the efficacy of oral nutrition therapy in patients with acute leukaemia. Eur J Clin Invest 1991; 22: 546-53.
23 Kern KA, Norton JA. Cancer cachexia. JPEN JPEN Joint Protection Enterprise Network
JPEN Journal of Parenteral & Enteral Nutrition J Parenter Enteral enteral /en·ter·al/ (en´ter'l) enteric.
1. Within or by way of the intestine, as distinguished from parenteral.
2. Enteric. Nutr 1988; 12: 286-98.
24 Shike M. Nutrition therapy for the cancer patient. Hematol Oncol Clin North Am 1996; 10: 221-34.
25 Grant M, Rivera L. Impact of dietary counselling on quality of life in head and neck patients undergoing radiation therapy. Qual Life Res 1994; 3: 77-8.
26 Ottery FD. Definition of standardized nutritional assessment and interventional pathways in oncology. Nutrition 1996; 12 (Suppl. 1): S15-19.
27 Nitenberg G, Raynard B. Nutritional support nutritional support,
n the supply of foods and liquids necessary to advance healing and support health. of the cancer patient: issues and dilemmas. Crit Rev Oncol Hematol 2000; 34: 137-68.
28 Palomares MR, Sayre JW, Shekar KC, Lillington LM, Chlebowski R. Gender influence of weight-loss pattern and survival of non-small cell lung carcinoma patients. Cancer 1996; 78: 2119-26.
29 Isenring E, Capra S, Bauer J. Nutrition intervention is beneficial in oncology outpatients receiving radiotherapy to the gastrointestinal, head or neck area. Br J Cancer 2004; 91: 447-52.
30 De Blaauw I, Deutz NEP NEP: see New Economic Policy. , Von Meyenfeldt MF. Metabolic changes in cancer cachexia--first of two parts. Clin Nutr 1997; 16: 169-76.
31 Chen HC, Leung SW, Wang CJ, Sun LM, Fang FM, Hsu JH. Effect of megestrol acetate and prepulsid on nutritional improvement in patients with head and neck cancers undergoing radiotherapy. Radiother Oncol 1997; 43: 75-9.
32 McQuellon RP, Moose Moose, river, Canada
Moose, river, c.50 mi (80 km) long, formed in central Ont., Canada, by the Mattagami and Missinaibi rivers. It flows NE to its confluence with the Abitibi River and into SW James Bay near Moosonee. DB, Russell GB et al. Supportive use of megestrol acetate (Megace) with head/neck and lung cancer lung cancer, cancer that originates in the tissues of the lungs. Lung cancer is the leading cause of cancer death in the United States in both men and women. Like other cancers, lung cancer occurs after repeated insults to the genetic material of the cell. patients receiving radiotherapy. Int J Radiat Oncol Biol Phys 2002; 52: 1180-85.
33 Simons JP, Schols AM, Hoefnagels JM, Westerterp KR, ten Velde GP, Wouters EF. Effects of medroxyprogesterone acetate med·rox·y·pro·ges·ter·one acetate
A progestin used to treat menstrual disorders and in hormone replacement therapy, often in combination with estrogen. on food intake, body composition, and resting energy expenditure in patients with advanced, nonhormone-sensitive cancer: a randomized, placebo-controlled trial. Cancer 1998; 82: 553-60.
34 Moldawer LL, Copeland EM. Proinflammatory cytokines Cytokines
Chemicals made by the cells that act on other cells to stimulate or inhibit their function. Cytokines that stimulate growth are called "growth factors. , nutritional support and the cachexia syndrome. Cancer 1997; 79: 1828-39.
35 Tisdale MJ. Inhibition of lipolysis lipolysis /li·pol·y·sis/ (li-pol´i-sis) the splitting up or decomposition of fat.lipolyt´ic
n. pl. li·pol·y·ses
The hydrolysis of lipids. and muscle protein degradation by EPA in cancer cachexia. Nutrition 1996; 12: 531-3.
36 Cohn SH, Gartenhaus W, Sawitsky A et al. Compartmental body composition of cancer patients with measurement of total body nitrogen, potassium and water. Metabolism 1981; 30: 222-9.
37 Ferguson M, Capra S. Nutrition screening practices in Australian hospitals. Nutr Dieta 1998; 55: 157-61.
38 Banks M. Nutrition screening and prevalence of malnutrition in an Australian public hospital: validation of a level one admission screen (Thesis). Brisbane: Queensland University of Technology, 1995.
39 Christensen KS, Gstundtner KM. Hospital-wide screening improves basis for nutrition intervention. J Am Diet Assoc 1985; 85: 704-6.
40 American Dietetic Association The American Dietetic Association (ADA) is the United States' largest organization of food and nutrition professionals, with nearly 65,000 members. Approximately 75 % of ADA's members are registered dietitians and about 4 % are dietetic technicians, registered. . Identifying patients at risk: ADA's definitions for nutrition screening and assessment. J Am Diet Assoc 1994; 94: 838-9.
41 Jones JM. The methodology of nutritional screening and assessment tools. J Hum Nutr Diet 2002; 15: 59-71.
42 Ferguson M, Bauer J, Banks M, Capra S. Development of a valid and reliable malnutrition screening tool for adult acute hospital patients. Nutrition 1999; 15: 458-64.
43 Stratton RJ, Hackston A, Longmore D et al. Malnutrition in hospital outpatients and inpatients: prevalence, concurrent validity concurrent validity,
n the degree to which results from one test agree with results from other, different tests. and ease of use of the 'malnutrition universal screening tool' ('MUST') for adults. Br J Nutr 2004; 92: 799-808.
44 Rubenstein LZ, Harker JO, Salva A, Guigoz Y, Vellas B. Screening for undernutrition Undernutrition
A type of malnutrition caused by inadequate food intake or the body's inability to make use of needed nutrients.
Mentioned in: Appetite-Enhancing Drugs
see malnutrition, starvation. in geriatric practice: developing the short-form mini-nutritional assessment (MNA-SF). J Gerontol A Biol Sci Med Sci 2001; 56: M366-72.
45 Kondrup J, Rasmussen HH, Hamberg O, Stanga Z, Ad Hoc For this purpose. Meaning "to this" in Latin, it refers to dealing with special situations as they occur rather than functions that are repeated on a regular basis. See ad hoc query and ad hoc mode. ESPEN ESPEN European Society for Clinical Nutrition and Metabolism Working Group. Nutritional risk screening (NRS NRS Nevada Revised Statutes
NRS National Runaway Switchboard (Chicago, IL)
NRS Natural Reserve System (University of California)
NRS National Readership Survey
NRS National Relay Service 2002): a new method based on an analysis of controlled clinical trials controlled clinical trial,
n a research strategy that calls for two samples: an experimental sample of patients receiving a pharmaceutical, and a second sample of control patients receiving a placebo. . Clin Nutr 2003; 22: 321-36.
46 Jeejeebhoy KN. Nutritional assessment. Nutrition 2000; 16: 585-90.
47 Gibson R. Principles of Nutritional Assessment. Oxford: Oxford University Press, 1990.
48 Detsky AS, McLaughlin JR, Baker JP et al. What is subjective global assessment of nutritional status? JPEN J Parenter Enteral Nutr 1987; 11: 8-13.
49 Ottery FD. Patient-Generated Subjective Global Assessment. In: McCallum PD, Polisena CG, eds. The Clinical Guide to Oncology Nutrition. Chicago: The American Dietetic Association, 2000; 11-23.
50 Ottery F, Bender F, Kasenic S. The design and implementation of a model of nutritional oncology clinic. Oncol Issues Suppl 2002; 17: 3-8.
51 Persson C, Sjoden PO, Glimelius B. The Swedish version of the patient-generated subjective global assessment of nutritional status: gastrointestinal vs urological cancers. Clin Nutr 1999; 18: 71-7.
52 Bauer J, Capra S, Ferguson M. Use of the scored patient--generated subjective global assessment as a nutrition assessment tool in patients with cancer. Eur J Clin Nutr 2002; 56: 779-85.
53 Isenring E, Bauer J, Capra S. The scored Patient-generated Subjective Global Assessment (PG-SGA) and its association with quality of life in ambulatory patients receiving radiotherapy, Eur J Clin Nutr 2003; 57: 305-9.
54 McCallum PD, Polisena CG, eds. The Clinical Guide to Oncology Nutrition. Chicago: The American Dietetic Association, 2000.
55 Evans WK, Nixon DW, Daly JM et al. A randomized study of oral nutritional support versus ad lib An earlier sound card from Ad Lib, Inc., Quebec City, that, for a while, was the de facto standard for synthesized background music for computer games. It was a precursor to the MIDI standard. nutritional intake during chemotherapy for advanced colorectal and non small cell lung cancer Lung Cancer, Small Cell Definition
Small cell lung cancer is a disease in which the cells of the lung tissues grow uncontrollably and form tumors.
Lung cancer is divided into two main types: small cell and non-small cell. . J Clin Oncol 1987; 5: 113-24.
56 Wigmore SJ, Plester CE, Ross JA, Fearon KC. Contribution of anorexia and hypermetabolism to weight loss in anicteric patients with pancreatic cancer. Br J Surg 1997; 84: 196-7.
57 Falconer JS, Fearon KC, Plester CE, Ross JA, Carter DC. Cytokines, the acute-phase response, and resting energy expenditure in cachectic patients with pancreatic cancer. Ann Surg 1994; 219: 325-31.
58 Heymsfield S, Wang Z, Visser M, Gallagher D, Pierson R. Techniques used in the measurement of body composition: an overview with emphasis on bioelectrical impedance analysis. Am J Clin Nutr 1996; 64 (Suppl.): S478-84.
59 Simons J, Schols A, Westerterp K, ten Velde G, Wouters E. Bioelectrical impedance analysis to assess changes in total body water in patients with cancer. Clin Nutr 1999; 18: 35-9.
60 McMillan DC, Watson WS, Preston T, McArdle CS. Lean body mass changes in cancer patients with weight loss. Clin Nutr 2000; 19: 403-6.
61 Isenring E, Bauer J, Davies P, Capra S. Evaluation of foot-to-foot bioelectrical impedance bioelectrical impedance (bīˈ·ō·ē·lekˑ·trik im·pēˈ·d in oncology outpatients receiving radiotherapy to the head and neck areas. Eur J Clin Nutr 2004; 58: 46-51.
62 Bauer J, Capra S, Davies PSW, Ash S, Davidson W. Estimation of total body water from bioelectrical impedance analysis in subjects with pancreatic pancreatic /pan·cre·at·ic/ (pan?kre-at´ik) pertaining to the pancreas.
pertaining to the pancreas. See also pancreatitis, diabetes mellitus, cystic pancreatic duct. cancer--agreement between three methods of prediction. J Hum Nutr Diet 2002; 15: 185-8.
63 Aaronson NK, Ahmedzai S, Bergman B et al. The European Organisation for Research and Treatment of Cancer QLQ-C30: a quality of life instrument for use in international clinical trials in oncology. J Natl Cancer Inst 1993; 85: 365-76.
64 Cella DF, Tulsky DS, Gray C. The Functional Assessment of Cancer Therapy scale: development and validation of the general measure. J Clin Oncol 1993; 11: 570-79.
65 Ware JE, Sherbourne CD. The MOS (1) (Metal Oxide Semiconductor) See MOSFET.
(2) (Mean Opinion Score) The quality of a digitized voice line. It is a subjective measurement that is derived entirely by people listening to the calls and scoring the results from 36-item short-form health survey (SF-36): conceptual framework For the concept in aesthetics and art criticism, see .
A conceptual framework is used in research to outline possible courses of action or to present a preferred approach to a system analysis project. and item selection. Med Care 1992; 30: 473-83.
66 Capra S, Bauer J, Davidson W, Ash S. Nutritional therapy for cancer-induced weight loss. Nutr Clin Pract 2002; 17: 210-13.
67 ASPEN Board of Directors and The Clinical Guidelines Task Force. Guidelines for the use of parenteral parenteral /pa·ren·ter·al/ (pah-ren´ter-al) not through the alimentary canal, but rather by injection through some other route, as subcutaneous, intramuscular, etc.
1. and enteral nutrition Enteral nutrition
Nourishment given through a tube or stoma directly into the small intestine, thus bypassing the upper digestive tract.
Mentioned in: Electrolyte Supplements, Enterostomy, Necrotizing Enterocolitis
in adult and pediatric patients pediatric patient Child, see there . JPEN J Parenter Enteral Nutr 2002; 26 (1 Suppl.): lSA-138SA.
68 Andreyev HJ, Norman AR, Oates J, Cunningham D. Why do patients with weight loss have a worse outcome when undergoing chemotherapy for gastrointestinal malignancies? Eur J Cancer 1998; 34: 503-9.
69 Ross PJ, Ashley S For use as a person's name, see .
Ashley may refer to: Places
70 Dietitians Association of Australia. Dietitians Association of Australia position paper. Nutrition priorities in palliative care palliative care (paˑ·lē·ā·tiv kerˑ),
n an approach to health care that is concerned primarily with attending to physical and emotional comfort rather of oncology patients. Nutr Dieta 1994; 51: 92-3.
71 Jatoin A, Daly BD, Hughes VA, Dallal GE, Kehayias J, Roubenoff R. Do patients with nonmetastatic non-small cell lung cancer Lung Cancer, Non-Small Cell Definition
Non-small cell lung cancer (NSCLC) is a disease in which the cells of the lung tissues grow uncontrollably and form tumors.
There are two kinds of lung cancers, primary and secondary. demonstrate altered resting energy expenditure? Ann Thorac Surg 2001; 72: 348-51.
72 Staal-van den Brekel AJ, Schols AM, Dentener MA, ten Velde GP, Buurman WA, Wouters EF. Metabolism in patients with small cell lung carcinoma compared with patients with non-small cell lung carcinoma and healthy controls. Thorax thorax, body division found in certain animals. In humans and other mammals it lies between the neck and abdomen and is also called the chest. The skeletal frame of the thorax is formed by the sternum (breastbone) and ribs in front and the dorsal vertebrae in back. 1997; 52: 338-41.
73 Reeves MM. Estimating patients' energy requirements: cancer as a case study (PhD Thesis). Queensland University of Technology, 2004.
74 Meyer BJ, Mann NJ, Lewis JL, Milligan GC, Sinclair AJ, Howe PR. Dietary intakes and food sources of omega-6 and omega-3 polyunsaturated fatty acids. Lipids 2003; 38: 391-8.
75 Endres S, Ghorbani R, Kelley VE et al. The effect of dietary supplementation with n-3 polyunsaturated fatty acids or the synthesis of interleukin-1 and tumor necrosis factor tumor necrosis factor
n. Abbr. TNF
A protein that is produced in the presence of an endotoxin, especially by monocytes and macrophages, is able to attack and destroy tumor cells, and exacerbates chronic inflammatory diseases. by mononuclear mononuclear /mono·nu·cle·ar/ (-noo´kle-er)
1. having but one nucleus.
2. a cell having a single nucleus, especially a monocyte of the blood or tissues.
adj. cells. N Engl J Med 1989; 320: 265-71.
76 Tisdale MJ, Beck SA. Inhibition of tumour-induced lipolysis in vitro in vitro /in vi·tro/ (in ve´tro) [L.] within a glass; observable in a test tube; in an artificial environment.
In an artificial environment outside a living organism. and cachexia and tumour growth in vivo in vivo /in vi·vo/ (ve´vo) [L.] within the living body.
Within a living organism.
in vivo adv. by eicosapentaenoic acid. Biochem Pharmacol 1991; 41: 103-7.
77 Caughey GE, Mantzioris E, Gibson RA, Cleland LG, James MJ. The effect on human tumor necrosis factor [alpha] and interleukin interleukin
Any of a class of naturally occurring proteins important in regulation of lymphocyte function. Several known types are recognized as crucial constituents of the body's immune system (see immunity). IB production of diets enriched in n-3 fatty acids from vegetable oil or fish oil. Am J Clin Nutr 1996; 63: 116-22.
78 Burns CP, Halabi S, Clamon GH et al. Phase 1 clinical study of fish oil fatty acid fatty acid, any of the organic carboxylic acids present in fats and oils as esters of glycerol. Molecular weights of fatty acids vary over a wide range. The carbon skeleton of any fatty acid is unbranched. Some fatty acids are saturated, i.e. capsules for patients with cancer cachexia: cancer and leukemia group B Cancer and Leukemia Group B (CALGB) is a cancer research cooperative group in the United States.
CALGB research is focused on seven major disease areas: leukemia, lymphoma, breast cancer, lung cancer, gastrointestinal malignancies, genito-urinary malignancies, and melanoma. study 9473. Clin Cancer Res 1999; 5: 3942-7.
79 Barber MD, Ross JA, Voss AC, Tisdale MJ, Fearon KC. The effect of an oral nutritional supplement enriched with fish oil on weight-loss in patients with pancreatic cancer. Br J Cancer 1999; 81: 80-86.
80 Wigmore SJ, Barber MD, Ross JA, Tisdale MJ, Fearon KCH. Effect of oral eicosapentaenoic acid on weight loss in patients with pancreatic cancer. Nutr Cancer 2000; 36: 177-84.
81 National Health and Medical Research Council. Draft Executive Summary of Nutrient Reference Values ref·er·ence values
A set of laboratory test values obtained from an individual or from a group in a defined state of health. for Australia and New Zealand New Zealand (zē`lənd), island country (2005 est. pop. 4,035,000), 104,454 sq mi (270,534 sq km), in the S Pacific Ocean, over 1,000 mi (1,600 km) SE of Australia. The capital is Wellington; the largest city and leading port is Auckland. , Including Recommended Dietary Intakes. Canberra, Australia: Commonwealth Department of Health and Ageing Health and Ageing is a research programme set up by the Geneva Association, also known as the International Association for the Study of Insurance Economics. The Geneva Association Research Programme on Health and Ageing seeks to bring together facts, figures and analyses ; New Zealand: Ministry for Health, December 2004.
82 Food and Drug Administration. Agency Response Letter GRAS GRAS - A public domain graph-oriented database system for software engineering applications from RWTH Aachen. Notice No. GRN GRN Green
GRN Green (Political) Party
GRN Global Recycling Network
GRN Gulf Restoration Network (New Orleans, LA)
GRN Goods Received Note
GRN Global Reference Network (GPS) 000105. Xxxx: United States Food and Drug Administration United States Food and Drug Administration (FDA),
n.pr a unit of the Public Health Service created to protect the health of the nation against impure and unsafe foods, drugs, and cosmetics. , 2002. (Cited 16 May 2005.) Also available from URL: http://www.cfsan.fda.gov/~rdb/opa-g105.html
83 Scientific Advisory Committee on Nutrition. Advice on Fish Consumption: Benefits and Risks. London: Stationery Office, 2004. (Cited 30 Nov 2005.) Also available from URL: http://www.food.gov.uk/multimedia/pdfs/fishreport200401.pdf
84 Food Standards Australia New Zealand Food Standards Australia New Zealand (FSANZ, formally ANZFA) is the governmental body responsible for developing food standards for Australia and New Zealand.
FSANZ develops food standards after consulting with other government agencies and stakeholders. . Mercury in Fish. 2004. (Cited 16 May 2005.) Also available from URL: http://www.foodstandards.gov.au/mediareleasespublications/factsheets/factsheets2004/mercuryinfishfurther2394.cfm
85 Begbie S, Kerestes Z, Bell D. Patterns of alternative medicine use by cancer patients. Med J Aust 1996; 165: 545-8.
86 Miller M, Boyer M, Burstow P et al. The use of unproven methods of treatment by cancer patients: frequency, expectations, cost. Support Care Cancer 1998; 6: 337-47.
87 MacLennan A, Wilson D, Taylor A. The escalating cost and prevalence of alternative medicine. Prev Med 2002; 35: 166-73.
88 The Cancer Council Australia. Position Statement. Complimentary and Alternative Therapies. Australia: The Cancer Council, 2005.
89 Arnold C, Richter MP. The effect of oral nutritional supplements Nutritional Supplements Definition
Nutritional supplements include vitamins, minerals, herbs, meal supplements, sports nutrition products, natural food supplements, and other related products used to boost the nutritional content of the diet. on head and neck cancer. Int J Radiat Oncol Biol Phys 1989; 16: 1595-9.
90 McCarthy D, Weihofen D. The effect of nutritional supplements on food intake in patients undergoing radiotherapy. Oncol Nurs Forum 1999; 26: 897-900.
91 Ovesen L, Allingstrup L, Hannibal J, Mortensen EL, Hansen OP. Effect of dietary counseling on food intake, body weight, response rate, survival, and quality of life in cancer patients undergoing chemotherapy: a prospective, randomized study. J Clin Oncol 1993; 11: 2043-9.
92 Ravasco P, Monteiro-Grillo I, Vidal PM, Camilo ME. Dietary counseling improves patient outcomes: a prospective, randomized, controlled trial controlled trial Clinical research A clinical study in which one group of participants receives an experimental drug while the other receives either a placebo or an approved–'gold standard' therapy. See Blinding, Double-blinded. in colorectal cancer colorectal cancer
Malignant tumour of the large intestine (colon) or rectum. Risk factors include age (after age 50), family history of colorectal cancer, chronic inflammatory bowel diseases, benign polyps, physical inactivity, and a diet high in fat. patients undergoing radiotherapy. J Clin Oncol 2005; 23: 1431-8.
93 Gillbreath J, Inman-Felton AE, Johnson EQ, Robinson G, Smith KG, eds. Medical Nutrition Therapy Across the Continuum of Care--Client Protocols, 2nd edn. Chicago: The American Dietetic Association, 1998.
94 National Health and Medical Research Council. How to Use the Evidence: Assessment and Application of Scientific Evidence. Canberra: Commonwealth of Australia, 2000. (Cited 9 Dec 2004.) Also available from URL: http://www.nhmrc.gov.au/publications/synopses/cp65syn.htm
APPENDIX I: BACKGROUND TO EVIDENCE STATEMENTS AND TIPS
The majority of cancer patients experience weight loss as their disease progresses and in general, weight loss is a major prognostic indicator of poor survival and impaired response to cancer treatment. (21) The incidence of malnutrition amongst patients with cancer has been estimated at between 40% and 80%. (22,23) The prevalence of malnutrition depends on the tumour type, location, stage and treatment. (24) The consequences of malnutrition may include an increased risk of complications, decreased response and tolerance to treatment, a lower quality of life, reduced survival and higher health-care costs. (25-27) Cancer cachexia has been implicated im·pli·cate
tr.v. im·pli·cat·ed, im·pli·cat·ing, im·pli·cates
1. To involve or connect intimately or incriminatingly: evidence that implicates others in the plot.
2. in the deaths of 30-50% of all cancer patients, as many die from the wasting associated with the condition. (28)
The causes of weight loss in patients with cancer are multifactorial multifactorial /mul·ti·fac·to·ri·al/ (mul?te-fak-tor´e-al)
1. of or pertaining to, or arising through the action of many factors.
2. and may be due to symptoms reducing intake, treatment related or mechanical obstruction, or cachexia. Symptoms such as anorexia, depression, anxiety, fatigue, early satiety satiety
being in a state of satiation; in experimental animals used with reference to eating and drinking.
located in the ventromedial hypothalamic nucleus. and pain can result in a decreased appetite and food intake. Cancer treatment may result in weight loss, for example surgery (malabsorption malabsorption /mal·ab·sorp·tion/ (mal?ab-sorp´shun) impaired intestinal absorption of nutrients.
Defective or inadequate absorption of nutrients from the intestinal tract. ), radiotherapy (nausea, pain, diarrhoea, mucositis), and chemotherapy (nausea, vomiting vomiting, ejection of food and other matter from the stomach through the mouth, often preceded by nausea. The process is initiated by stimulation of the vomiting center of the brain by nerve impulses from the gastrointestinal tract or other part of the body. , diarrhoea, mucositis). Weight loss may be due to mechanical obstruction caused by the cancer itself, such as obstruction of the oesophagus oe·soph·a·gus
Variant of esophagus.
oesophagus British spelling for esophagus, see there causing swallowing problems and reduced intake. Appropriate nutrition support nutrition support,
n intravenous nutrition or orally modified for-mulas necessitated by inability to consume a general diet; administered to malnourished individuals who cannot consume food in its original form. provided during radiotherapy can help to overcome some of the nutrition impact symptoms and help patients to maintain weight compared with standard practice where patients continued to lose weight during radiotherapy treatment. (29) However if the weight loss is due to cachexia, it may not be reversible because host intermediary metabolism (carbohydrate, protein and lipid metabolism Lipid metabolism
The assimilation of dietary lipids and the synthesis and degradation of lipids; this article is restricted to mammals.
The principal dietary fat is triglyceride. ) is abnormal, limiting the success of nutrition intervention. (30)
Numerous drug therapies (e.g. megestrol, steroids) have been trialled in patients with cancer cachexia to stimulate appetite or attenuate To reduce the force or severity; to lessen a relationship or connection between two objects.
In Criminal Procedure, the relationship between an illegal search and a confession may be sufficiently attenuated as to remove the confession from the protection afforded by the metabolic changes. Several trials with synthetic progesterone progesterone (prōjĕs`tərōn'), female sex hormone that induces secretory changes in the lining of the uterus essential for successful implantation of a fertilized egg. agents have demonstrated a beneficial influence on weight, however, this is largely due to an increase in fat mass. (31-33) Evaluation of pharmacotherapies is beyond the scope of these guidelines.
The term cancer cachexia is derived from the Greek words kakos and hexis meaning poor condition. Cachexia has been defined as a syndrome characterised by the progressive loss of lean tissue and body fat, and losses are often in excess to that explained by the associated anorexia. There are often additional metabolic derangements, including anaemia anaemia
see anemia. , acute phase protein Acute-phase proteins are a class of proteins whose plasma concentrations increase (positive acute phase proteins) or decrease (negative acute phase proteins) in response to inflammation. This response is called the acute-phase reaction (also called acute phase response). response and alterations in plasma lipid profile lipid profile,
n a series of tests used to gauge a person's risk for coro-nary heart conditions. Blood levels examined in a lipid profile include those for total cholesterol, LDL- and HDL-cholesterol, and triglycerides. . (34) The development of cachexia is common in people with solid tumours such as pancreatic, lung, gastric and colorectal cancer.
Weight loss in cancer cachexia is different from the weight loss of starvation or anorexia. This is due to accelerated loss of skeletal muscle in relation to adipose tissue adipose tissue (ăd`əpōs'): see connective tissue.
or fatty tissue
Connective tissue consisting mainly of fat cells, specialized to synthesize and contain large globules of fat, within a , presence of pro-inflammatory cytokines and prolonged acute phase protein response (APPR APPR Approve
APPR Annual Professional Performance Review
APPR Asociación de Psicología de Puerto Rico (Association of Psychologists of Puerto Rico)
APPR Army Package Power Reactor
APPR Approach/Approach Mode ) that contributes to increased resting energy expenditure and weight loss. (35) Patients with cancer cachexia experience anorexia, early satiety, weakness, muscle wasting, fatigue, anaemia and severe weight loss. In starvation more than three-quarters of the weight lost is from body fat and only a small amount from muscle. In cancer cachexia, weight loss arises equally from loss of muscle and fat. (36)
There are no definitive methods for diagnosis of cancer cachexia. Clinical signs of anorexia, muscle wasting and weight loss of [greater than or equal to] 5% over 6 months in patients diagnosed with cancer would be expected but clinical judgement is required. Weight loss due to mechanical obstruction, treatment or side-effects, which would be expected to resolve once the obstruction is bypassed/removed or treatment ceased should not be classified as cachexia. These patients still require nutrition intervention but the focus of these guidelines is on cancer cachexia.
The patient target group encompasses any adult patient with cancer fulfilling the diagnostic criteria for cachexia.
Appropriate Access to Care
In Australia, hospital inpatients are generally seen by dietitians as a result of referrals by medical or nursing staff. (37) Studies have found the prevalence of malnutrition to be similar between those patients who were referred to a dietitian by medical staff and those who were not referred. (38,39) It is recommended that in addition to referrals by medical staff, nutrition screening be performed on admission to hospital or in the outpatient setting during the planning stages of commencing anticancer therapies.
Nutrition screening is the process of identifying patients with characteristics commonly associated with nutrition problems that may require comprehensive nutrition assessment (American Dietetic Association (ADA Ada, city, United States
Ada (ā`ə), city (1990 pop. 15,820), seat of Pontotoc co., S central Okla.; inc. 1904. It is a large cattle market and the center of a rich oil and ranch area. ). (40) The purpose of nutrition screening is to quickly identify clients who are malnourished mal·nour·ished
Affected by improper nutrition or an insufficient diet. or at risk of becoming malnourished who would benefit from nutrition support and prioritise resources to those clients who most need nutrition support. According to according to
1. As stated or indicated by; on the authority of: according to historians.
2. In keeping with: according to instructions.
3. the ADA, (40) an effective nutrition screening tool should be:
* Simple, quick, reliable, valid and inexpensive
* Easily administered with minimal nutritional expertise
* Applicable to most patients and designed to incorporate only routine data and tests available on admission
Many nutrition screening tools have been developed to identify clients at risk of malnutrition in the acute care setting and the community Problems identified with numerous published nutrition screening tools include requiring specialised nutrition knowledge, bio-chemical parameters that may not be immediately available, requiring complex calculations or not being evaluated in terms of reliability or validity. (37,41) A number of reliable and valid nutrition screening tools have been recently published:
* Malnutrition Screening Tool (6,42)
* Malnutrition Universal Screening Tool (43)
* Mini Nutrition Assessment-Short Form (44)
* Nutrition Risk Screening (45)
When selecting an appropriate nutrition screening tool, it is imperative that the tool has been validated in the client population in which it is to be applied. The Malnutrition Screening Tool (MST See micro systems technology. ) is a valid screening tool for identifying nutrition risk in patients with cancer (Appendix II) (6,42) No studies have been identified that report nutrition screening in patients with cancer cachexia.
How should patients be identified for referral to the dietitian in order to maximise nutritional intervention opportunities?
Evidence statement Level of evidence The Malnutrition Screening Tool (MST) is an effective Level III-3 (6) screening tool for identifying nutritional risk in patients with cancer
Identify 'at risk' patients in oncology wards and outpatient clinics using a nutrition screening tool such as the Malnutrition Screening Tool that has been validated for oncology patients
1 Nutrition assistants, administration or nursing staff may implement the MST.
2 The MST can be incorporated into admission forms or patient information sheets.
3 Repeat nutrition screening during treatment at least fortnightly fort·night·ly
Happening or appearing once in or every two weeks.
Once in a fortnight.
n. pl. fort·night·lies
A publication issued once every two weeks. for patients initially screened at low risk.
4 If a patient has been referred to the dietitian by other methods, e.g. direct referral from medical oncologist medical oncologist Oncology An oncologist who diagnoses and treats cancer with chemotherapy, hormones, biologicals, or immunologic agents; the MO becomes a cancer Pt's de facto primary care giver, and coordinates treatment provided by other specialists. , nutrition screening is unnecessary--proceed to nutrition assessment.
Nutrition assessment is a comprehensive approach to defining nutritional status using medical, nutrition and medication histories, physical examination, anthropometric measurements anthropometric measurements (anˈ·thrō·p and laboratory data. (40) Nutrition assessment parameters may be affected by non-nutritional factors resulting in poor sensitivity and specificity. (46) No single parameter is sufficiently sensitive and specific to determine nutritional status and a combination of parameters should be used. (47) Several nutrition assessment tools have been published which use a combination of parameters.
Subjective global assessment
Subjective global assessment (SGA SGA
small for gestational age
A term used to describe newborns who are below the 10th percentile in height or weight for their estimated gestational age. ) determines nutritional status on the basis of a medical history (weight change, dietary intake change, presence of gastrointestinal symptoms that have persisted for greater than two weeks, functional capacity) and physical assessment (evidence of loss of subcutaneous fat Subcutaneous fat is found just beneath the skin as opposed to visceral fat which is found in the peritoneal cavity. Subcutaneous fat can be measured using body fat calipers giving a rough estimate of total body adiposity. , muscle wasting, oedema oedema
see edema. or ascites Ascites Definition
Ascites is an abnormal accumulation of fluid in the abdomen.
Rapidly developing (acute) ascites can occur as a complication of trauma, perforated ulcer, appendicitis, or inflammation of the colon or other ). The features are combined subjectively into an overall or global assessment where patients are rated as being well nourished nour·ish
tr.v. nour·ished, nour·ish·ing, nour·ish·es
1. To provide with food or other substances necessary for life and growth; feed.
2. (SGA A), moderately or suspected of being malnourished (SGA B) or severely malnourished (SGA C). (48)
Scored Patient-Generated Subjective Global Assessment
The scored Patient-Generated Subjective Global Assessment (PG-SGA) is an adaptation of SGA specifically developed for use in the cancer population (Appendix III). (49) It contains additional questions regarding short-term weight loss, a more extensive range of nutrition impact symptoms and for each component of the PG-SGA, points (0-4) are awarded depending on the impact on nutritional status. Typical scores range from 0 to 47 with a higher score reflecting a greater risk of malnutrition. The PG-SGA score has been correlated with a number of objective parameters (% weight loss, body mass index (BMI BMI body mass index.
body mass index
Body mass index (BMI)
A measurement that has replaced weight as the preferred determinant of obesity. )), measures of morbidity (survival, length of stay, quality of life), has a high degree of interrater reproducibility and high sensitivity and specificity when compared with other validated nutritional assessment tools. (8,26,50-53) A change in score of approximately nine points is required to move one global rating category. (53) The PG-SGA score may be more sensitive than the global rating to demonstrate improvement or deterioration in nutritional status. (52) The scored PG-SGA has been recommended as the nutrition assessment tool for patients with cancer by the Oncology Nutrition Dietetic dietetic /di·e·tet·ic/ (di?ah-tet´ik) pertaining to diet or proper food.
1. Of or relating to diet.
2. practice group of the American Dietetic Association. (54) In patients with cancer cachexia, two studies report nutritional status based on the global categorisation and the PG-SGA score. (7,8)
Biochemistry may be influenced by disease and treatment and therefore it is important to use clinical judgement when interpreting values. For example, serum albumin serum albumin
See seralbumin. may be low due to the acute phase protein response. However, serum albumin has been shown to be an independent prognostic variable A variable that a GCM predicts by integration of a physical equation, typically vorticity, divergence, temperature, surface pressure, and water vapor concentration. for survival in patients with cancer. (55) Patients with raised serum C-reactive protein C-Reactive Protein Definition
C-reactive protein (CRP) is a protein produced by the liver and found in the blood.
C-reactive protein is not normally found in the blood of healthy people. levels have lower energy intake than those with normal levels (56) and there is some evidence that resting energy expenditure may be increased in these patients. (57)
The study of human body measurement for use in anthropological classification and comparison.
A variety of techniques are available to measure body composition such as Dual Energy X-ray Absortiometry (DEXA DEXA,
n.pr See dual-energy x-ray absorptiometry. ), anthropometric measurements (e.g. triceps triceps, any muscle having three heads, or points of attachment, but especially the triceps brachii at the back of the upper arm. One head originates on the shoulder blade and two on the upper-arm bone, or humerus. skinfold skinfold /skin·fold/ (skin´fold) the layer of skin and subcutaneous fat raised by pinching the skin and letting the underlying muscle fall back to the bone; used to estimate the percentage of body fat. thickness (TSF TSF Text Services Framework
TSF TOE Security Functions
TSF Télégraphie Sans Fil (French: former term for radio)
TSF Twelve Step Facilitation (counseling intervention) ); corrected arm muscle area (CAMA (Central Automatic Message Accounting) See AMA. )), deuterium deuterium (dtēr`ēəm), isotope of hydrogen with mass no. 2. The deuterium nucleus, called a deuteron, contains one proton and one neutron. and bioelectrical impedance analysis (BIA BIA
Bureau of Indian Affairs ). DEXA and deuterium are expensive methods that are impractical in the clinical setting but may be of use in research studies. Serial anthropometric measurements may be useful to monitor change however, accredited accredited
recognition by an appropriate authority that the performance of a particular institution has satisfied a prestated set of criteria.
cattle herds which have achieved a low level of reactors to, e.g. training in anthropometry anthropometry (ănthrəpŏm`ətrē), technique of measuring the human body in terms of dimensions, proportions, and ratios such as those provided by the cephalic index. is recommended. BIA measures tissue conductivity conductivity /con·duc·tiv·i·ty/ (kon?duk-tiv´i-te) the capacity of a body to transmit a flow of electricity or heat; the conductance per unit area of the body.
1. and can be used to assess total body water (TBW TBW Total Body Water
TBW Total Body Weight
TBW To Be Written
TBW Tambov (Russia)
TBW To Be Watched
TBW Talking Book World
TBW The Business Workshop (India)
TBW Time-Bandwidth Product ) from which fat free mass (FFM FFM Frankfurt Am Main
FFM Fat-Free Mass (muscle)
FFM Female Female Male
FFM Full Face Mask (diving)
FFM Final Fantasy Movie
FFM Fundus Flavimaculatus
FFM Frequent Flyer Mile(s) ) can be calculated. It is important that a BIA prediction equation is used that has been validated in the population under study. (58) Studies examining the validation of BIA in cancer patients are limited (9,10,59-62) and no equation has been developed or validated in patients with cancer cachexia. At a group level, these equations are suitable to predict TBW in patients with cancer cachexia but for an individual, they are unsuitable for use. (10)
Tools used to assess functional status include Karnofsky Performance Status and Eastern Cooperative Oncology Group (ECOG ECOG Eastern Cooperative Oncology Group ). A variety of tools have been developed and validated to measure quality of life such as the European Organisation for Research and Treatment of Cancer (EORTC EORTC European Organization for Research and Treatment of Cancer ) QLQ-C30, (63) Functional Assessment of Cancer Therapy (FACT) (64) and the Short Form Health Survey (SF 36). (65) In patients with cancer, the PG-SGA score has been shown to be associated with quality of life (EORTC-QLQC30), and therefore can be used to predict the direction and magnitude of change in quality of life. (53)
How should nutritional status be assessed?
Evidence statement Level of evidence Subjective Global Assessment (SGA) is a valid method IV (7) of assessing nutritional status in patients with cancer cachexia The scored Patient-Generated Subjective Global III-3 (7,8) Assessment (PG-SGA) is a valid method of assessing nutritional status in patients with cancer cachexia Bioelectrical impedance analysis is not suitable for III-3 (9,10) body composition measurement in individual patients with cancer cachexia
Use the scored Patient Generated--Subjective Global Assessment. (PG-SGA) as the nutrition assessment tool in patients with cancer cachexia.
A summary of nutrition assessment practice tips are contained in Table 2.
Quality Nutrition Care
Nutrition intervention is the second stage of the clinical judgements made in the nutrition care process. The key aspects of intervention are establishing the goals of treatment, determining the nutrition prescription and the implementation of the nutrition care. The success or otherwise of nutrition intervention depends equally on these components. (66)
Having identified the nutrition problem by assessing and interpreting the evidence and data collected about the patient, a judgement about the goals of treatment must be made. Established goals provide the criteria to be measured in the outcome evaluation step, where effectiveness of the nutrition intervention is evaluated. (4)
When discussing nutrition intervention options with patients and carers, it is important to present realistic potential outcomes. The goals and outcomes of nutrition intervention will be dependent on patient's diagnosis and prognosis. If goal requirements cannot be achieved with oral intake, alternative means of nutrition support should be considered. Refer to guidelines for the use of parenteral and enteral nutrition in adult and paediatric Adj. 1. paediatric - of or relating to the medical care of children; "pediatric dentist"
pediatric patients from the American Society of Parenteral and Enteral Nutrition. (67)
Traditionally, treatment has focused on weight gain as the goal of nutrition intervention. Some studies have failed to show a positive effect of nutrition intervention when weight gain was the outcome. (16,17,55) Other studies using weight stabilisation as an outcome of nutrition intervention have shown positive effects. Weight losing patients with advanced gastrointestinal and non-small cell lung cancer whose weight stabilises have a longer survival and improved quality of life than those who continue to lose weight. (11,68,69) Weight stabilisation is an appropriate goal for weight losing cancer patients provided that life expectancy Life Expectancy
1. The age until which a person is expected to live.
2. The remaining number of years an individual is expected to live, based on IRS issued life expectancy tables. is at least two months. (11)
Continue to reassess stage of treatment and disease, and whether any change to palliative care status. Determine level of support from the patients General Practitioner general practitioner
n. Abbr. GP
A physician whose practice consists of providing ongoing care covering a variety of medical problems in patients of all ages, often including referral to appropriate specialists. , carer carer
a person who looks after someone who is ill or old, often a relative: the group offers support for the carers of those with dementia
carer n → and palliative care team. When a patient is having palliative treatment palliative treatment
Treatment to alleviate symptoms without curing the disease.
A type treatment that does not provide a cure, but eases the symptoms.
Mentioned in: Laparoscopy or palliative palliative /pal·li·a·tive/ (pal´e-a?tiv) affording relief; also, a drug that so acts.
Relieving or soothing the symptoms of a disease or disorder without effecting a cure. supportive care supportive care,
n medical and other interventions that attempt to support and make comfortable rather than to cure. at end stage of disease, intensity of dietary intervention may need to be adapted. Liaise with patient/family/carers and medical team to determine level of intervention required. Unnecessary dietary restrictions can be relaxed (e.g. cholesterol lowering modifications). Discuss treatment with patient for indication of satisfaction with intensity of care.
If end stage, the dietitian may advocate for patient with carer or family to reduce intensity of dietary treatment. The desired outcomes are maximising patient comfort and maintaining quality of life. In many cases this may mean a patient will not meet full nutrition requirements, for example if tube feeding tube feeding,
n a method for supplying liquid nutrition through a tube that passes through the nasal passages and into the stomach. This method is utilized when ingesting food through the oral cavity is inadvisable or painful due to surgery or injury. is refused or supplement drinks are not liked. Each case should be assessed individually and with full discussion with the team to determine new goals of care. Patients in the final weeks of life are unlikely to be able to maintain their lean body mass. Any weight gain that does occur at this time is likely to be due to fluid retention. For comfort measures refer to DAA DAA - Distributed Application Architecture: under design by Hewlett-Packard and Sun. A distributed object management environment that will allow applications to be developed independent of operating system, network or windowing system. paper: Nutrition priorities in palliative care of oncology patients. (70)
What are the goals of nutrition intervention for patients with cancer cachexia?
Evidence statement Level of evidence Weight-losing patients with cancer cachexia who III-2 (11) stabilise their weight have greater quality of life and survival duration than those who continue to lose weight
Weight stabilisation is an appropriate goal for patients with cancer cachexia
Nutrition intervention goals should be individualised Adj. 1. individualised - made for or directed or adjusted to a particular individual; "personalized luggage"; "personalized advice"
individualized, personalised, personalized taking into consideration prognosis, psychosocial psychosocial /psy·cho·so·cial/ (si?ko-so´shul) pertaining to or involving both psychic and social aspects.
Involving aspects of both social and psychological behavior. issues and the patient's wishes (Table 3).
* Protein and energy requirements
Measurement of energy expenditure via indirect calorimetry calorimetry (kăl'ərĭm`ətrē), measurement of heat and the determination of heat capacity is the most accurate method for determining individuals' energy requirements. Energy expenditure of patients with cancer has been shown to vary greatly. (71-73) Treatment and disease stage may alter metabolic requirements over time. Energy intakes in excess of 120 kJ/kg/day have been needed for weight maintenance in some studies of patients with cancer. (7,11,22) Protein intake is often reduced as the result of taste alterations, poor appetite and fatigue. Protein requirements for advanced cancer patients have not been elucidated. However protein intake in excess of 1.4 g/kg/day have been required for weight maintenance in some studies of cancer patients. (7,11)
* Eicosapentaenoic acid
A novel approach to the nutrition intervention in patients with cancer cachexia has been the prescription of pharmacological Pharmacological
Referring to therapy that relies on drugs.
Mentioned in: Pain Management
pertaining to pharmacology. doses of eicosapentaenoic acid (EPA), an omega-3 polyunsaturated fat Noun 1. polyunsaturated fat - a class of fats having long carbon chains with many double bonds unsaturated with hydrogen atoms; used in some margarines; supposedly associated with low blood cholesterol . The major dietary sources of EPA in Australia are marine oils, seafood, meat and eggs with the average Australian intake at 0.056 g per day. (74) Studies in both animals and humans have indicated that EPA supplementation reduces production of pro-inflammatory cytokines such as interleukin-6, interleukin-1 and tumour necrosis factor Noun 1. tumour necrosis factor - a proinflammatory cytokine that is produced by white blood cells (monocytes and macrophages); has an antineoplastic effect but causes inflammation (as in rheumatoid arthritis)
TNF, tumor necrosis factor and in cultured cancer cell lines increases cell death rate. (14,75-77) Appendix IV summarises studies in relation to EPA supplementation (EPA capsules and oral nutrition supplements) in patients with cancer.
The results of studies of supplementation with EPA either in the form of capsules or high protein energy supplements enriched with EPA, are inconsistent. Although positive changes have been demonstrated in outcomes (improving energy and protein intake, body composition, performance status, quality of life) in patients with cancer cachexia receiving high protein energy supplements enriched with EPA in open trials (Level IV studies), in general these results have not been confirmed in randomised trials (Level II studies). Issues such as compliance with the prescription, (13) duration of intervention, (17) appropriate end points (16) and the treatment group (supportive care/chemotherapy/mixed therapy) are important to consider when evaluating study outcomes. A common weakness of the four randomised controlled trials investigating EPA is the limited discussion of dietetic involvement. Therefore whether or not patients received dietary counselling, the recommendations and frequency of contact were not documented and could also limit the efficacy of EPA or fish oil. Further studies in different patient groups with cancer are required.
A Cochrane review of the role of EPA in cancer cachexia was scheduled for release in 2005. The guideline steering committee steer·ing committee
A committee that sets agendas and schedules of business, as for a legislative body or other assemblage.
Noun produced evidence based statements regarding EPA and outcomes (Appendix V). The body of evidence in relation to EPA and cancer cachexia was assessed using NHMRC additional levels of evidence and grades for recommendations for developers of guidelines--Pilot Program 2005. (3)
Potential risks EPA
The draft Nutrient Reference Values for Australia and New Zealand recommend acceptable macronutrient macronutrient /mac·ro·nu·tri·ent/ (-noo´tre-ent) an essential nutrient required in relatively large amounts, such as carbohydrates, fats, proteins, or water; sometimes certain minerals are included, such as calcium, chloride, or sodium. distribution ranges to reduce chronic disease whilst still ensuring adequate micronutrient mi·cro·nu·tri·ent
A substance, such as a vitamin or mineral, that is essential in minute amounts for the proper growth and metabolism of a living organism. status. (81) The lower to upper ends of the recommended intake range for omega 3 fats (DHA DHA docosahexaenoic acid.
n.pr See acid, docosahexaenoic. : EPA : DPA DPA - Data Protection Act ) are 190 mg/day to 610 mg/day for men and 90 mg/day to 430 mg/day for women, where the upper end of the range is based on 90th percentile percentile,
n the number in a frequency distribution below which a certain percentage of fees will fall. E.g., the ninetieth percentile is the number that divides the distribution of fees into the lower 90% and the upper 10%, or that fee level of current intake. (81) The United States Food and Drug Administration has concluded that fish oil concentrate is Generally Recognised As Safe (GRAS) provided that combined intake of EPA and DHA from all added sources does not exceed 3 g/person/day. (82) Cancer patients consuming 6 g EPA/d have reported no adverse effects on platelet counts Platelet Count Definition
A platelet count is a diagnostic test that determines the number of platelets in the patient's blood. Platelets, which are also called thrombocytes, are small disk-shaped blood cells produced in the bone marrow and involved in . (80) No studies, however, have been conducted specifically on EPA in cancer patients who are using anticoagulants Anticoagulants
Drugs that suppress, delay, or prevent blood clots. Anticoagulants are used to treat embolisms.
Mentioned in: Embolism, Heart Valve Replacement . It is therefore advisable to exercise caution with the use of EPA supplements in cancer patients on anticoagulant therapies anticoagulant therapy Hematology The use of anticoagulants to prevent intravascular clot formation, or dissolve clots that have already formed Indications DVT/thrombophlebitis, CAD, TIA/stroke, dysrhythmia, prosthetic heart valve, cancer Monitoring Serial such as warfarin warfarin (wôr`fərĭn), anticoagulant used to treat blood clots. In large doses it causes bleeding. Warfarin, mixed with bait, is used in rodent control.
Anticoagulant drug, marketed as Coumadin. . Use in such situations should be with the knowledge and approval of the patient's doctor. Large dose of fish oil can cause gastrointestinal side-effects. (14,19) Cod liver Cod´ liv`er
n. 1. The liver of the common cod and allied species.
an oil obtained from the liver of the codfish, and used extensively in medicine as a means of supplying the body with fat in cases of malnutrition. and halibut halibut: see flatfish.
Any of various flatfishes, especially the Atlantic and Pacific halibuts (genus Hippoglossus, family Pleuronectidae), both of which have eyes and colour on the right side. liver oil are not suitable sources of EPA as the doses required could provide excess levels of Vitamin A vitamin A
also called retinol
Fat-soluble alcohol, most abundant in fatty fish and especially in fish-liver oils. It is not found in plants, but many vegetables and fruits contain beta-carotene (see . Dioxin dioxin
Aromatic compound, any of a group of contaminants produced in making herbicides (e.g., Agent Orange), disinfectants, and other agents. Their basic chemical structure consists of two benzene rings connected by a pair of oxygen atoms; when substituents on the rings are and dioxin like polychlorinated biphenyls polychlorinated biphenyls, (pol´ēklôr´nā´tid bīfē´n are environmental contaminates that accumulate in lipid. Fish oils are potentially a significant source, so fish oil supplements are purified to meet European commission European Commission, branch of the governing body of the European Union (EU) invested with executive and some legislative powers. Located in Brussels, Belgium, it was founded in 1967 when the three treaty organizations comprising what was then the European Community maximum standards for dioxin. (83) The main concerns with these toxins relate to long-term accumulation, as well as the effect on the foetus or breastfed infant. High short-term intakes in adults are unlikely to significantly increase total body burden. (83) Fish oil products and supplements are not a major source of dietary mercury and no recommendation has been made to restrict consumption because of mercury. (83,84)
Complimentary and alternative therapy
Australian studies have shown that between 22% and 52% of patients with cancer use complimentary or alternative therapy with up to $2.3 billion spent in 2000. (85-87) Evaluation of complimentary or alternative therapy is beyond the scope of these guidelines--refer to The Cancer Council Australia's 2005 Position Statement on Complementary & Alternative Therapies. (88)
What is the nutrition prescription to achieve these goals?
Should ercosapentaenoic acid be included in the prescription?
Evidence statement Level of evidence Energy and protein requirements for weight III-2 (11) stabilisation are approximately 120 kJ/kg/d and 1.4 g protein/kg/d in patients with cancer cachexia receiving supportive care Energy and protein requirements for weight IV (7) stablisation are approximately 120 kJ/kg/d and 1.4 g protein/kg/d in patients with cancer cachexia receiving chemotherapy Weight stable patients have higher energy III-2 (11) intake than weight losing patients in patients with cancer cachexia receiving supportive care Well-nourished patients with advanced cancer IV (12) have higher energy and protein intakes compared to malnourished patients with advanced cancer The prescription of EPA improves outcomes in Level C (7,11,13-20) patients with cancer cachexia Body of evidence provides some support for recommendation but care should be taken in its application
1 Improving energy and protein intake remains the first step in nutrition intervention for weight losing cancer patients
2 If indirect calorimetry is unavailable, aim for an energy intake of approximately 120 kJ/kg/day.
3 Aim for a protein intake of approximately 1.4 g/kg/day
4 EPA can be considered as a component of nutrition intervention in cancer cachexia but patients should first be assessed for suboptimal Suboptimal
A solution is called suboptimal if a part of the solution has been optimized without regards to the overall objective. symptom control or inadequate intake. If using EPA, aim for an intake of 1.4-2 g EPA/day which needs to be consumed for at least four weeks to achieve clinical benefit.
1 An individuals energy requirements are best determined by measurement of energy expenditure (e.g. indirect calorimetry), however, in practice this is rarely available. Due to high variation in energy expenditure, use clinical judgement with respect to energy requirements taking into consideration age, treatment and treatment goals. Regular monitoring of intake and weight will determine whether energy needs are being met.
2 Prior to commencing nutrition support, assess the patient for risk of refeeding syndrome Refeeding syndrome is a syndrome consisting of metabolic disturbances that occur as a result of reinstitution of nutrition to patients who are starved or severely malnourished. Renourishment is the process of avoiding refeeding syndrome. .
3 EPA: Potential sources include dietary intake, capsules or a high protein energy supplement enriched with EPA. To achieve 1.4-2 g EPA/day patients need to consume at least 8-11 capsules of fish oil (180 mg EPA/capsule), 300-400 g oily fish Oily fish, oil-rich fish or pelagic fish are those fish which have oils throughout the fillet and in the belly cavity around the gut, rather than only in the liver like white fish. , 310-445 mL of a high protein energy supplement enriched with EPA (0.45 g EPA/100 mL) or combination of these.
The implementation of dietetic care involves counselling of the patient and/or carers to maximise food intake and facilitation Facilitation
The process of providing a market for a security. Normally, this refers to bids and offers made for large blocks of securities, such as those traded by institutions. of optimal symptom control. Counselling, especially in conjunction with high protein energy supplements, has been shown to increase intake and attenuate weight loss in a range of cancer patients. (22,29,89-92) A concern expressed by many patients is that consumption of high protein energy supplements may reduce their meal intake. In patients with cancer, high protein energy supplements have been shown to increase intake without negatively impacting on spontaneous food intake. (7,20,90) Prognosis, economic circumstances and client preferences need to be considered in decisions regarding supplement usage.
Nutrition counselling is effective both during phases of active treatment (chemotherapy and radiotherapy) and supportive care. Recommended time for initial consultation is 45-60 minutes and review consultation 15-30 minutes. (93) Recent studies in patients with cancer have demonstrated effective clinical outcomes with weekly to fortnightly dietetic intervention. (7,13,18,29,91,92) Dietetic practice regarding the implementation of medical nutrition therapy in clients with cancer, however, varies considerably, often depending on resources available. Further research regarding innovative methods of nutrition implementation such as telephone counselling is required.
What are effective methods of implementation to ensure positive outcomes?
Evidence statement Level of evidence Compliance with a nutrition prescription of 1.5 cans/ III-2 (20) d of a high protein energy supplement [+ or -] EPA does not reduce total food intake in patients with cancer cachexia receiving supportive care Consumption of a high protein energy supplement IV (7) enriched with EPA does not reduce total food intake in patients with cancer cachexia receiving chemotherapy Frequent clinician contact (minimum fortnightly) III-3 (7,18) improves clinical outcomes in patients with cancer cachexia
1 Nutrition counselling assists cancer patients to optimise their intake.
2 High protein and energy supplements play a valuable role in improving intake and do not simply take the place of usual meals.
3 Regular nutrition intervention improves clinical outcomes
1 Implementation of high protein, high energy dietary advice:
* Discuss good sources of protein in the diet--meat, fish and poultry, and encourage with at least one serve a day If vegan/vegetarian ensure adequate alternative sources of protein.
* If protein intake is reduced due to taste changes emphasise good oral hygiene Oral Hygiene Definition
Oral hygiene is the practice of keeping the mouth clean and healthy by brushing and flossing to prevent tooth decay and gum disease. , encourage with alternative sources of protein--eggs, dairy, legumes Legumes
A family of plants that bear edible seeds in pods, including beans and peas.
Mentioned in: Cholesterol, High
legumes (l and nuts, suggest marinating meats in juice or wine to disguise a bitter taste;
* For patients with chewing and swallowing difficulties, ensure protein is adequate in texture modified diets, e.g. minced meats Minced meat may refer to:
tr.v. poached, poach·ing, poach·es
To cook in a boiling or simmering liquid: Poach the fish in wine. eggs, mashed beans, peanut paste, lentil/bean soups;
* Encourage patients to consider high protein/energy supplements as an essential component of treatment.
* Assess need for alternative nutrition support if oral intake inadequate and liaise with medical team regarding options available and discuss with patient.
2 Compliance issues with EPA to consider in implementation:
* Decreased appetite and nutrition impact symptoms [right arrow] difficult to consume adequate quantities of fish, capsules or supplements;
* Capsules--number required, large size, side-effects (burping, fishy fish·y
adj. fish·i·er, fish·i·est
1. Resembling or suggestive of fish, as in taste or odor.
2. Cold or expressionless: a fishy stare.
3. aftertaste aftertaste /af·ter·taste/ (-tast?) a taste continuing after the substance producing it has been removed.
n. , tolerance);
* High protein energy nutrition supplements enriched with EPA--ensure adequate quantity consumed each day, consider taste, consider cost;
* Need to develop gastrointestinal tolerance to fish orl and high protein energy supplements enriched with EPA--gradually increase dose.
3 Use the PG-SGA to identify barriers to food intake and facilitate optimal symptom control:
* Nausea, constipation, vomiting, diarrhoea, mouth sores, pain--liaise with medical and support team and instigate To incite, stimulate, or induce into action; goad into an unlawful or bad action, such as a crime.
The term instigate is used synonymously with abet, which is the intentional encouragement or aid of another individual in committing a crime. appropriate medical and nutrition treatment;
* Taste changes, early satiety, aversion a·ver·sion
1. A fixed, intense dislike; repugnance, as of crowds.
2. A feeling of extreme repugnance accompanied by avoidance or rejection. to smells--use strategies to manage these;
* Dry mouth and/or swallowing problems--modify texture as required and liaise with other allied health professional support, e.g. speech pathology speech pathology
The science concerned with the diagnosis and treatment of functional and organic speech defects and disorders. Also called speech-language pathology. .
* The Cancer Councils in each state provide valuable patient resources describing the management of nutrition impact symptoms.
4 If patient is using complimentary or alternative therapies, provide appropriate information.
Nutrition Monitoring and Evaluation
Measure and Evaluate Outcomes--Intermediate and Clinical/Cost/Patient
Nutrition intervention may lead to a variety of outcomes. Intermediate outcomes include changes in dietary intake, symptoms, biochemistry, anthropometric measures or nutrition status. These changes will then impact upon and result in clinical, cost and patient outcomes. This includes morbidity and mortality Morbidity and Mortality can refer to:
n.pl the epidemiologic investigations designed to test a hypothesized cause and effect relation by modifying the supposed causal factor(s) in the study population. in patients with cancer. To date, in cancer cachexia, intervention studies have focused on using fish oil or EPA supplements in management of outcomes. Weight stabilisation may improve length and quality of life in patients with cancer cachexia. (11) The body of evidence has been evaluated using the NHMRC additional levels of evidence and grades for recommendations for developers of guidelines--Pilot Program 2005. (3) The evidence based statement in relation to outcomes of nutrition intervention is below.
Does nutrition intervention improve outcomes in patients with cancer cachexia?
Evidence statement Level of evidence Nutrition intervention improves outcomes Level C (7,11,13-20) in patients with cancer cachexia Body of evidence provides some support for recommendation but care should be taken in its application.
1 A range of outcomes can be measured in patients with cancer cachexia including protein and energy intake, appetite, weight, lean body mass, functional status, quality of life and survival.
2 Consumption of high protein energy supplement enriched with EPA over a period of at least 8 weeks improves intake, total energy expenditure and physical activity level and attenuates weight loss in patients with cancer cachexia.
3 There is conflicting evidence about whether EPA supplementation can improve quality of life, appetite, lean body mass, and survival. This may be due to studies not being conducted for long enough (at least 4 weeks) or because improvement rather than attenuation Loss of signal power in a transmission.
The reduction in level of a transmitted quantity as a function of a parameter, usually distance. It is applied mainly to acoustic or electromagnetic waves and is expressed as the ratio of power densities. was the outcome goal.
APPENDIX II: THE MALNUTRITION SCREENING TOOL[c]
Have you lost weight recently without trying?
If no 0 If unsure 2 If yes, how much weight (kg) have you lost? 0.5-5.0 1 >5.0-10.0 2 >10.0-15.0 3 >15.0 4 Unsure 2
Have you been eating poorly because of a decreased appetite?
No 0 Yes 1 If score 0 or 1 not at risk of malnutrition score [greater than or equal to]2 at risk of malnutrition
Reprinted from Ferguson M, Bauer J, Banks M, Capra S. Development of a valid and reliable malnutrition screening tool for adult acute hospital patients. Nutrition 1999; 15: 458-64. Copyright (1999), with permission from Elsevier.
APPENDIX III: THE PATIENT GENERATED SUBJECTIVE GLOBAL ASSESSMENT (PG-SGA)
Scored Patient-Generated Subjective Global Assessment (PG-SGA)
History (Boxes 1-4 are designed to be completed by the patient.)
Worksheets for PG-SGA Scoring
Boxes 1-4 of the PG-SGA are designed to be completed by the patient. The PG-SGA numerical score is determined using 1) the parenthetical points noted in boxes 1-4 and 2) the worksheets below for items not marked with parenthetical points. Scores for boxes 1 and 3 are additive with each box and scores for boxes 2 and 4 are based on the highest scored item checked off by the patient.
APPENDIX IV: SUMMARY OF STUDIES OF ROLE OF EICOSAPENTAENOIC ACID IN PATIENTS WITH CANCER CACHEXIA
Level of Author Year evidence and Patient cancer Country study design type and number Method Wigmore et Level IV 18 weight losing Dose escalation al. (14) Observational pancreatic escalation 1996 study 12 wks cancer patients study to 16 g UK fish oil/d max (Max-EPA) Gogos et al. (19) Level II 64 patients with 18 g fish oil 1998 RCT mixed solid (Max-EPA-- Greece tumour types 3.06 g EPA + 2.07 g DHA) or placebo daily Burns et al. (78) Level IV 22 weight losing Dose escalation 1999 Observational cancer patients study of fish USA study oil Barber et al. (79) Level IV 20 weight losing High protein, 1999 Observational pancreatic energy UK study 7 wks cancer patients supplement with 2.18 g EPA Wigmore et Level IV 26 weight losing Dose escalation al. (80) Observational pancreatic study of fish 2000 study 12 wks cancer patients oil to 6 g/d UK EPA (95% pure) Fearon et al. (13) Level II RCT 8 200 weight losing Randomised to 2003 wks untreated high protein Multinational pancreatic and energy cancer patients supplement [+ or -] EPA Bruera et al. (17) Level II RCT 2 60 cachectic Randomised to 2003 wks cancer patients fish oil USA capsules or placebo (mean dose EPA 1.8 g) Jatoi et al. (16) Level II RCT 3 421 weight losing Randomised to 2004 mths cancer patients EPA sup v meg USA ace + control v meg ace + EPA sup Moses et al. (18) Level II RCT 8 24 weight losing Randomised to 2004 wks pancreatic high protein UK cancer patients and energy supplement [+ or -] EPA for 8 wks Doubly labelled water to assess PAL. Davidson et Level III-2 107 pts wt losing High protein al. (11) Post hoc (>1 kg) or wt and energy 2004 analysis RCT stable untreated supplement Australia 8 wks pancreatic [+ or -] EPA cancer patients Bauer & Capra (7) Level IV 8 weight losing High protein 2005 Observational pancreatic and and energy Australia study 8 wks non-small cell supplement lung cancer pts [+ or -] EPA receiving chemotherapy Persson et Level II RCT 8 24 weight losing Randomised to al. (15) wks untreated fish oil 2005 advanced (4.9 g EPA) Sweden gastrointestinal or Melatonin cancer pts (18 mg/d) 4 wks, both treatments additional 4 wks Bauer et al. (20) Level III-2 200 untreated Compliance (C) 2005 Post hoc pancreatic with 1.5 Australia analysis RCT cancer patients cans/d high 8 wks protein and energy supplement [+ or -] EPA compared to non-compliant (NC) Author Year Country Results Comment Wigmore et Energy intake--N Demonstrated al. (14) Protein intake--NA attenuation of 1996 Weight--[down arrow] 2.9 kg/mth weight loss in UK prestudy, [up arrow] 0.3 kg/mth cancer cachexia 3 mths LBM--NA Functional capacity--NA Quality of life--NA Survivall--NA Other--patients tolerated median of 12 Max-EPA daily (2.2 g EPA + 1.4 g DHA). No serious toxicity--25% steatorrhoea, some taste aberrations or transient diarrhoea Changes in weight accompanied by a temporary sig [down arrow] APPR and stabilisation REE Gogos et al. (19) Energy intake--NA Demonstrated high 1998 Protein intake--NA doses of omega Greece Weight--ns improvement 3 PUFA given LBM--NA with Functional capacity--[up arrow] antioxidant KPS after 40 d in malnourished supplementation patients receiving fish oil --prolonged only survival in Quality of life--NA patients with Survival--doubled in patients cancer-- receiving fish oil only [up arrow] KPS Other--no effect of fish oil on in malnourished albumin or transferrin cancer patients No toxicity of fish oil except for mild abdominal discomfort and transient diarrhoea Burns et al. (78) Energy intake--NA Demonstrated 1999 Protein intake--NA maximum USA Weight--NA tolerated dose LBM--NA EPA Functional capacity--NA Quality of life--NA Survival--NA Other--maximum tolerated dose 0.3 g/kg/d fish oil = 21 x 1 g capsules/d containing 7.9 g EPA + 5.2 g DHA for a 70 kg male. Dose limiting toxicity was gastrointestinal--diarrhoea. Barber et al. (79) Energy intake--[up arrow] 372 First study to 1999 kcals demonstrate UK Protein intake--NA positive Weight--[down arrow] 3.2 kg/mth outcomes prestudy; [up arrow] 1 kg 3 (weight gain, wks, [up arrow] 2.5 kg 7 wks LBM, KPS, LBM--[up arrow] LBM 1 kg 3 wks; energy) with a [up arrow] 1.9 kg 7 wks combination of Functional capacity--KPS EPA and [up arrow] 10 3 wks; [up arrow] protein/energy 10 7 wks Quality of life--NA Survival--NA Other--median consumption supplement 1.9 cans/d Wigmore et Energy intake--NA Confirmed al. (80) Protein intake--NA previous 2000 Weight--[down arrow] 2 kg/mth studies that UK prestudy; [up arrow] 0.5 kg/mth doses of EPA to 4 wks; 6 g well 16 patients weight stable or tolerated gained weight 12 wks Confirmed EPA was LBM--NA the active Functional capacity--NA ingredient in Quality of life--NA fish oil Survival--NA capsules Other--no change in total body water, MAMC, TSF APPR stable. EPA supplement well tolerated--some patients had nausea and/steatorrhoea Fearon et al. (13) Energy intake--[up arrow] 224 Both E and C 2003 kcal E v 68 kcal C, ns; Sig supplements Multinational [up arrow] E baseline to 8 wks attenuated only weight loss. Protein intake--[up arrow] 15 g E [up arrow] LBM v 6 g C, ns; Sig [up arrow] E in E only. baseline to 8 wks only Non-compliance Weight-- -0.37 kg E v -0.25 kg C, with protocol ns; Sig change baseline to 8 in both groups wks E & C; Wt [up arrow] High dropout rate correlated with intake cans E due to death only LBM--[up arrow] 0.27 E v 0.12 kg C, ns; [up arrow] LBM correlated intake cans E only Functional capacity--NA Quality of life--Global E v C, ns; Post hoc analysis [up arrow] QoL and [up arrow] wt E only Survival--142 d E v 128 d C, ns Other Bruera et al. (17) Energy intake--[up arrow] 51 No effect of fish 2003 kcals E v [down arrow] 57 C oil on outcomes USA kcals ns but only 2 wks Protein intake--NA of treatment Weight--[up arrow] 0.03 kg E v Non-compliance [down arrow] 0.89 kg C ns with protocol LBM--NA in both groups Functional capacity--KPS 10% controls [up arrow] 10.0 E v high EPA levels [down arrow] 6.9 C ns High dropout Quality of life--NA rate due to Survival--NA intolerance of Other--appetite, tiredness, fish oil nausea, well being ns Jatoi et al. (16) Energy intake--NA No better effect 2004 Protein intake--NA of EPA USA Weight--[up arrow] 10%: EPA 6% v supplement Meg + c 18% v Meg + EPA 11% Ns compared to EPA v Meg + c P = 0.004 megace on Any [up arrow]: EPA 37% Meg 39% outcome Outcome Meg + EPA 45% ns of 10% weight LBM--NA gain in cancer Functional capacity--NA patients Quality of life--ns unrealistic Survival--ns Other--appetite [up arrow] EPA 63 Meg 69 Meg + epa 66 Moses et al. (18) Energy intake--E 474 kcals v C First study to 2004 166 kcals ns; Baseline change E demonstrate UK P < 0.05 only improvement in Protein intake--Sig [up arrow] E functional 27 g v C 4 g outcomes with a Weight--E 0.0 kg v C [down arrow] combination of 0.2 kg ns EPA and LBM--E 0.3 kg v C 0.6 kg ns protein/energy Functional capacity--TEE and PAL ns; [up arrow] PAL baseline--8 wks E only Quality of life--NA Survival--NA Other Davidson et Energy intake--WL 107 kJ/kg/d v Demonstrated that al. (11) WS125 P < 0.001 weight 2004 Protein intake--NA maintenance Australia Weight--NA suitable goal LBM--NA for patents Functional capacity--ns with cancer Quality of life--WS 55 v WL 47.1 cachexia and is P = 0.037 associated with Survival--WS 259 d v WL 164 P = [up arrow] 0.019 survival and Other QoL Bauer & Capra (7) Energy intake--[up arrow] 36 kJ/ Demonstrated 2005 kg/d improvement in Australia Protein intake--[up arrow] 0.3 g/ outcomes kg/d (dietary Weight--[up arrow] 2.3 kg intake, QoL, clinically sig KPS) in LBM--[up arrow] 4.4 kg clinically cachectic sig patients Functional capacity--KPS receiving [up arrow] 10 chemotherapy Quality of life--[up arrow] 16.7 and combination Survival--NA of EPA/protein/ Other--[up arrow] nutritional energy Small status PG-SGA score 9 number patients No change in meal protein or energy intake over 8 wks Persson et Energy intake--[down arrow] 65 Weight al. (15) kcal 4 wks, [down arrow] 196 8 stablisation 2005 wks FO; Sweden MLT [up arrow] 187 kcal 4 wks, [up arrow] 19 kcal 8 wks (no stats provided) Protein intake--NA Weight--38% stable or gain FO; 27% MLT; 63% FO and MLT LBM--NA Functional capacity--KPS stable FO and MLT; ns between groups Quality of life--stable FO and MLT, ns between groups Survival--ns Other--no biochemical/cytokine changes; [up arrow] plasma EPA levels Bauer et al. (20) Energy intake--30.3 C v 23.0 NC Compliance with 2005 kcal/kg/d prescription Australia Protein intake--1.26 C v 0.90 NC 1.5 cans/d g/kg/d supplement no Weight--1.7 kg difference (P = effect on meal 0.052) intake LBM--44.1 v 43.6 kg ns Functional capacity--NA Quality of Life--56.8 v 52.4 ns Survival--NA Other--no change in meal protein or energy intake over 8 wks C = control product; E = experimental product; KPS = Karnofsky Performance Status; LBM = lean body mass; NA = Not assessed; ns = not significant; PAL = physical activity level; QoL = quality of life.
APPENDIX V: EVIDENCE BASED STATEMENTS IN RELATION TO EPA AND OUTCOMES IN CANCER CACHEXIA
Level of Evidence statement evidence Intermediate outcomes Consumption of a high protein energy supplement enriched II (13) with EPA for 8 weeks increases protein and energy intake (meals + supplements). Consumption of a standard high protein energy supplement for 8 weeks increases protein and trends towards increasing energy intake in patients with cancer cachexia compared with baseline Consumption of a high protein energy supplement [+ or -] II (13) EPA for 8 weeks attenuates loss of weight and lean body mass in patients with cancer cachexia receiving supportive care Supplementation with EPA capsules or fish oil for at III-3 (14,15) least 4 weeks attenuates weight loss in patients with cancer cachexia receiving supportive care Consumption of a high protein energy supplement enriched IV (7) with EPA for 8 weeks protein and energy intake and attenuates loss of weight and lean body mass in patients with cancer cachexia receiving chemotherapy A higher intake of a high protein energy supplement III-2 (13) enriched with EPA is associated with increases in body weight and LBM in patients with cancer cachexia receiving supportive care Consumption of a high protein energy supplement enriched II (16) with EPA [+ or -] megestrol acetate (median 12 weeks) does not improve weight ([greater than or equal to]10% baseline) or appetite better than megesterol acetate alone in patients with cancer cachexia receiving supportive care/chemotherapy/radiotherapy. Supplementation with fish oil for 2 weeks does not II (17) improve appetite, energy intake, weight, or fat-free mass compared with placebo in patients with cancer cachexia receiving supportive care/chemotherapy. Clinical/cost/patient outcomes Consumption of a high protein energy supplement enriched II (18) with EPA improves total energy expenditure and physical activity level in patients with cancer cachexia receiving supportive care Supplementation with fish oil for at least 4 weeks III-2 (19) improves performance status in malnourished patients with cancer cachexia receiving supportive care Supplementation with fish oil for at least 4 weeks II (19) improves survival in patients with cancer cachexia receiving supportive care Supplementation with fish oil for 2 weeks does not II (17) improve physical function compared with placebo in patients with cancer cachexia receiving supportive care/ chemotherapy Consumption of a high protein energy supplement enriched II (16) with EPA used alone or in combination with megestrol acetate (median 12 weeks) does not improve quality of life or survival in patients with cancer cachexia receiving supportive care/chemotherapy/radiotherapy Consumption of a high protein energy supplement [+ or -] II (13) EPA for 8 weeks does not improve quality of life or survival in patients with cancer cachexia receiving supportive care Weight-losing patients with cancer cachexia who stabilise III-2 (11) their weight have greater quality of life and survival duration than those who continue to lose weight Weight gain in patients consuming a high protein energy III-2 (13) supplement enriched with EPA is associated with improvements in quality of life in patients with cancer cachexia receiving supportive care Consumption of a high protein energy supplement enriched IV (7) with EPA for 8 weeks improves nutritional status, performance status and quality of life in patients with cancer cachexia receiving chemotherapy Table 1 Summary of recommendations for the nutritional management of cancer cachexia Point of referral Anorexia, weight loss [greater than or equal to]5% in 6 months and MST [greater than or equal to]2 Time for consultation 45-60 minutes initially, 15-30 minutes follow-up Biochemistry and clinical Albumin, blood glucose (for persons with diabetes), Hb, CRP medications including supplements Nutrition assessment Weight, PG-SGA, protein/energy intake assessment Nutrition intervention Prescription Promote high protein (>1.4 g/kg/day) and energy (>120 g/kg/day) intake [+ or -]EPA (1.4-2.0 g/day) Implementation Counselling [+ or -] supplements, symptom management, meal planning and modification, self monitoring Support Liaise with medical and palliative care team, carers and family Monitoring Weight, PG-SGA, protein/energy intake minimum fortnightly Frequency of monitoring will vary as treatment goals change towards end stage. Table 2 Recommended nutrition assessment parameters for patients with cancer cachexia Nutrition PG-SGA: Record both the global rating (SGA-A well assessment nourished, SGA-B moderately malnourished, SGA-C tool severely malnourished) and the PG-SGA score (1-47), which need to be determined independently. The diagnosis of malnutrition is based on the global rating. Nutrition impact symptoms are a major component of the PG-SGA score. Some clients with cancer may have a high score due to presence of multiple nutrition impact symptoms yet still be well nourished. The score is more sensitive than the global rating to demonstrate improvement or deterioration in nutritional status and hence can be used when the global rating has not changed. The lower the PG-SGA score, the better the clients nutritional status. Anthropometry Record height, body weight, body mass index (BMI) Due to the prevalence of overweight and obesity, clients with cachexia may have a BMI >25 kg/[m.sup.2] yet still be moderately or severely malnourished due to weight loss, reduced intake, functional capacity presence of nutrition impact symptoms, etc. Determine lean body mass if technology available-- deuterium, DEXA, bioelectrical impedance (BIA)--group level only Record anthropometric measurements--TSF, CAMA Dietary intake Assess dietary intake, especially energy and protein, quantitatively Determine use of vitamin/mineral supplements and complementary medicines Assess dietary restrictions and beliefs, texture of diet and other barriers to food intake, hydration Symptoms/ GI symptoms (nausea, vomiting, constipation, diarrhoea, side-effects steatorrhoea, early satiety) Appetite and taste changes Presence of pain Mood change Functional Determine functional status and level of fatigue, using status and PG-SGA, Karnofsky Performance Scale or Eastern quality of Co-operative Oncology Group. life PG-SGA score can be used as surrogate measure of quality of life Biochemistry Determine: Serum albumin C reactive protein Haemoglobin Blood glucose Medications Review medications and note if patients is taking analgesics, enzymes, laxatives, antiemetics, alternative therapies Table 3 Goals of nutrition intervention for patients with cancer cachexia Measure Goal PG-SGA Reduce or maintain PG-SGA score Anthropometry: Stabilise weight and lean body mass * Weight * Skin folds, CAMA (if accredited in measuring skin folds) * DEXA, deuterium (if available) Dietary intake Achieve appropriate current energy and protein intake Symptoms or side-effects identified Minimise symptoms which impact in the PG-SGA on nutritional intake and status Karnofsky Performance Scale or ECOG Improve or maintain functional status score PG-SGA as surrogate measure of Improve or maintain quality of quality of life life Biochemistry Use to interpret current clinical condition * Serum albumin * C reactive protein * Haemoglobin * Blood glucose Medications Ensure symptoms are being medically managed Other * Assess need for texture modification Ensure appropriate nutrition of diet or alternative nutrition support is provided support * Assess social situation and need for Meet energy and protein education of carers/family/other requirements social support, e.g. Meals-on-Wheels