Nutritional managment of cachexia

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  • 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

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  • Introduction Cachexia : Greek word

    Kakos : badHexis : conditionCharacteristics

    Weight lossLipolysisMuscle wastingAnorexiaChronic nauseaAstheniaAnemia Electrolyte and water abnormalities

  • Introduction Diagnostic criteria for cachexiaUnintentional weight loss ( 5%)BMI< 20 in those aged < 65 yrs< 22 in those aged 65 yrsAlbumin < 3.5 g/dlLow fat-free mass (lowest 10%)

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  • CONDITION ASSOCIATED WITH CACHEXIA

    CHRONIC INFLAMMATION

  • Pathogenesis

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  • Glucose homeostasisIncrease gluconeogenesis Muscle and fat breakdownIncrease glycolysis from muscle and tumourIncrease lactate productionElevation of cori cycle activity 300 kcal/day of energy lossInsulin resistanceIncrease counter regulatory hormoneDecrease muscle glucose uptake

  • Protein metabolismIncrease muscle catabolismDecrease muscle protein synthesis Muscle wasting : astheniaIncrease tumor protein synthesisIncrease liver protein synthesis Acute phase protein

  • Lipid metabolismIncrease lipolysisDecrease lipogenesisProfound loss of adipose tissueDecrease lipoprotein lipaseDecrease clearance of triglycerideHypertriglyceridemiaLow 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 intakeWeight lossCachexia : complex metabolic eventsAnorexia : simple nutritional deficiencyTreatment Cachexia : multiple aspectAnorexia : treatable by protein-calorie supplementation

  • Cachexia VS anorexia (starvation)

    Metabolic AlterationStarvationCancer CachexiaProtein turnover

    Skeletal muscle catabolism

    Nitrogen balance

    Urinary nitrogen excretionDecreased

    Decreased

    Negative

    DecreasedIncreased

    Increased

    Negative

    Unchanged

  • Role of Nutritional Management

    Improve the subjective quality of lifeEnhance anti-tumor treatment effects Reduce the adverse effects of anti-tumor therapiesPrevent & treat undernutrition

  • Nutrition screeningthe 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 problemsRequiring specialized nutrition knowledgeBiochemical parameters that may not be immediately availableRequiring complex calculationsNot being evaluated in terms of reliability or validity

  • PRACTICE TIPSIf 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 ascitesSGA 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 populationTypical 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 controlDry 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 InterventionSecond stage Diagnosis PrognosisEstablishing goals

  • What are the goals of nutrition intervention for patients with cancer cachexia? Weight stabilization is an appropriate goal for patients with cancer cachexiaLonger 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 syndromeProtein 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 fish310-445ml 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 outcomesHigh 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 adviceDiscuss 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 implementationHigh 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

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