CACHEXIA Nutritional

Management Present by:

Sajjad Moradi-MS StudentDepartment of Community Nutrition,

School of Nutritional Sciences and Dietetics, Tehran University of Medical

Sciences (TUMS), Tehran, Iran

Introduction

• Cachexia : Greek wordKakos : badHexis : condition

• CharacteristicsWeight lossLipolysisMuscle wastingAnorexiaChronic nauseaAstheniaAnemia Electrolyte and water abnormalities

Introduction • Diagnostic criteria for cachexia

• Unintentional weight loss (≥ 5%)• BMI

• < 20 in those aged < 65 yrs• < 22 in those aged ≥ 65 yrs

• Albumin < 3.5 g/dl• Low fat-free mass (lowest 10%)

CONDITION ASSOCIATED WITH CACHEXIA

CHRONIC INFLAMMATION

Pathogenesis

Glucose homeostasis• Increase gluconeogenesis →Muscle and fat

breakdown• Increase glycolysis from muscle and tumour• Increase lactate production• Elevation of cori cycle activity → 300 kcal/day of

energy loss• Insulin resistance• Increase counter regulatory hormone• Decrease muscle glucose uptake

Protein metabolism

• Increase muscle catabolism• Decrease muscle protein synthesis → Muscle

wasting : asthenia• Increase tumor protein synthesis• Increase liver protein synthesis → Acute phase

protein

Lipid metabolism• Increase lipolysis• Decrease lipogenesis• Profound loss of adipose tissue• Decrease lipoprotein lipase• Decrease clearance of triglyceride• Hypertriglyceridemia• Low LDL, HDL

Cachexia VS anorexia (starvation)

• Body composition Cachexia : loss of fat and skeletal muscle prior decrease food intakeAnorexia : loss of fat but small amount of muscle, after decrease food intake

• Weight lossCachexia : complex metabolic eventsAnorexia : simple nutritional deficiency

• Treatment Cachexia : multiple aspectAnorexia : treatable by protein-calorie supplementation

Metabolic Alteration Starvation Cancer CachexiaProtein turnover

Skeletal muscle catabolism

Nitrogen balance

Urinary nitrogen excretion

Decreased

Decreased

Negative

Decreased

Increased

Increased

Negative

Unchanged

Cachexia VS anorexia (starvation)

Role of Nutritional Management

• Improve the subjective quality of life• Enhance anti-tumor treatment effects • Reduce the adverse effects of anti-tumor therapies• Prevent & treat undernutrition

Nutrition screening• the process of identifying patients with characteristics

commonly associated with nutrition problems that may require comprehensive nutrition assessment

• 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

How should patients be identified for referral to the dietitian in order to

maximize nutritional intervention opportunities?

• Identify “at risk” patients in oncology wards and outpatient clinics using a nutrition screening tool such as the Malnutrition Screening Tool (MST)that has been validated for oncology patients.

Nutrition screening tools

• Malnutrition Screening Tool – Ferguson et al, 1999a, 1999b • Malnutrition Universal Screening Tool – British Association of Parenteral and Enteral Nutrition - Stratton et al, 2004 • Mini Nutrition Assessment-Short Form – Rubenstein et al, 2001 • Nutrition Risk Screening – Kondrup et al, 2003.

Nutrition screening tools problems

• Requiring specialized nutrition knowledge• Biochemical parameters that may not be

immediately available• Requiring complex calculations• Not being evaluated in terms of reliability or

validity

PRACTICE TIPS

• If a patient has been referred to the dietitian by other methods eg direct referral from medical oncologist, nutrition screening is unnecessary – proceed to nutrition assessment.

• Repeat nutrition screening during treatment at least fortnightly for patients initially screened at low risk.

Nutrition Assessment • Subjective global assessment (SGA)• Scored Patient Generated- Subjective

Global Assessment (PG-SGA) • Biochemistry Assessment • Anthropometric Assessment • Functional Assessment

Subjective global assessment (SGA)

• Nutritional status on the base is of a medical historyweight change, dietary intake change, presence of gastrointestinal

symptoms that have persisted for greater than two weeks, functional capacity, evidence of loss of subcutaneous fat, muscle wasting, oedema or ascites

SGA A: well nourished SGA B:moderately or suspected of being malnourished SGA C:severely malnourished

How should nutritional status be assessed?

• Use the scored Patient Generated - Subjective Global Assessment (PG-SGA) as the nutrition assessment tool in patients with cancer cachexia

Scored Patient Generated- Subjective Global Assessment

(PG-SGA) • An adaptation of SGA specifically developed for use in the

cancer population• Typical scores range from 0-47 with a higher score

reflecting a greater risk of malnutrition.• Objective parameters : % weight loss, body mass index• Measures of morbidity : survival, length of stay,

quality of life

Use the PG-SGA to identify barriers to food intake and facilitate optimal

symptom control• Dry mouth and/or swallowing problems -

modify texture as required and liaise with other allied health professional support e.g. speech pathology.

• The Cancer Councils in each state provide valuable patient resources describing the management of nutrition impact symptoms.

Use the PG-SGA to identify barriers to food intake and

facilitate optimal symptom control• Liaise with medical and support team and instigate appropriate medical and nutrition treatment

• Taste changes, early satiety, aversion to smells - use strategies to manage these

Nutrition Intervention

• Second stage • Diagnosis • Prognosis• Establishing goals

What are the goals of nutrition intervention for patients with

cancer cachexia?

• Weight stabilization is an appropriate goal for patients with cancer cachexia

• Longer survival and improved quality of life than those who continue to lose weight

What is the nutrition prescription to achieve these

goals? • Improving energy and

protein intake remains the first step in nutrition intervention for weight losing cancer patients • Eicosapentaenoic acid

(EPA)improving energy and protein

intake, body composition, performance status, quality of life

Nutrition Prescription • Prior to commencing nutrition

support, assess the patient for risk of refeeding syndrome

• Protein and Energy Requirements Energy intakes in excess of 120 kJ/kg/day protein intake in excess of 1.4 g/kg/day

Nutrition Prescription • Eicosapentaenoic acid (EPA)1.4 – 2 g EPA/day -at least four weeks to achieve

clinical benefit.• 8-11 capsules of fish oil (180 mg EPA/capsule)• 300 - 400 g oily fish• 310-445ml of a high protein energy supplement

enriched with EPA (0.45g EPA/100ml)

What are effective methods of implementation to ensure positive

outcomes? • Nutrition counselling assists cancer

patients to optimize their intake. • Regular nutrition intervention improves

clinical outcomes• High protein and energy supplements play

a valuable role in improving intake and do not simply take the place of usual meals.

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 protein intake is reduced due to taste changes emphasize good oral hygiene, encourage with alternative sources of protein – eggs, dairy, legumes and nuts, suggest marinating meats in juice or wine to disguise a bitter taste

Implementation of high protein, high energy dietary advice

• For patients with chewing and swallowing difficulties, ensure protein in adequate in texture modified diets minced meats, pureed meat/chicken/fish, poached eggs, mashed beans, peanut paste, lentil/bean soups • Encourage patients to consider high protein/energy supplements as an essential component of treatment.

Compliance issues with EPA to consider in implementation

• 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 oil and high protein energy supplements enriched with EPA – gradually increase dose.

Does nutrition intervention improve outcomes in patients

with cancer cachexia? • 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.

• 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.

Does nutrition intervention improve outcomes in patients

with cancer cachexia? • 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 was the outcome goal