Nutritional management is important for patients with cancer cachexia. The goals of nutrition intervention are weight stabilization and improved quality of life and survival. Nutrition screening using a validated tool can identify patients in need of comprehensive assessment using the PG-SGA. A nutrition prescription including increased protein, energy, and eicosapentaenoic acid (EPA) can improve intake and attenuate weight loss. Regular nutrition counseling and high protein supplements are effective for implementation. Outcomes like intake and weight loss can be positively impacted, though effects on quality of life and survival require longer-term studies.

1. CACHEXIA
Nutritional Management
Present by:
Sajjad Moradi-MS Student
Department of Community Nutrition, School of
Nutritional Sciences and Dietetics, Tehran Univer
sity of Medical Sciences (TUMS), Tehran, Iran

2. Introduction
• Cachexia : Greek word
Kakos : bad
Hexis : condition
• Characteristics
Weight loss
Lipolysis
Muscle wasting
Anorexia
Chronic nausea
Asthenia
Anemia
Electrolyte and water abnormalities

3. 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%)

5. CONDITION ASSOCIATED WITH
CACHEXIA
CHRONIC INFLAMMATIONCHRONIC INFLAMMATION

7. Pathogenesis

9. 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

10. Protein metabolism
• Increase muscle catabolism
• Decrease muscle protein synthesis → Muscle wasting : asthenia
• Increase tumor protein synthesis
• Increase liver protein synthesis → Acute phase protein

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

12. Cachexia VS anorexia (starvation)
• Body composition
Cachexia : loss of fat and skeletal muscle prior decrease food intake
Anorexia : loss of fat but small amount of muscle, after decrease food intake
• Weight loss
Cachexia : complex metabolic events
Anorexia : simple nutritional deficiency
• Treatment
Cachexia : multiple aspect
Anorexia : treatable by protein-calorie supplementation

13. Metabolic Alteration Starvation Cancer Cachexia
Protein turnover
Skeletal muscle catabolism
Nitrogen balance
Urinary nitrogen excretion
Decreased
Decreased
Negative
Decreased
Increased
Increased
Negative
Unchanged
Cachexia VS anorexia (starvation)

14. 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

16. 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

17. 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 su
ch as the Malnutrition Screening Tool (MST)that has
been validated for oncology patients.

18. 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.

19. 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

20. 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.

21. Nutrition Assessment
• Subjective global assessment (SGA)
• Scored Patient Generated- Subjective Global Assessment
(PG-SGA)
• Biochemistry Assessment
• Anthropometric Assessment
• Functional Assessment

22. Subjective global assessment (SGA)
• Nutritional status on the base is of a medical history
weight 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

23. How should nutritional status be assessed?
• Use the scored Patient Generated - Subjective
Global Assessment (PG-SGA) as the nutrition a
ssessment tool in patients with cancer cachexi
a

24. 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

25. 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.

26. 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

28. Nutrition Intervention
• Second stage
• Diagnosis
• Prognosis
• Establishing goals

29. 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

31. 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 patie
nts
• Eicosapentaenoic acid (EPA)
improving energy and protein intake,
body composition, performance
status, quality of life

32. 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

33. 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)

34. 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.

35. 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

36. Implementation of high protein, high
energy dietary advice
• For patients with chewing and swallowing difficulties,
ensure protein in adequate in texture modified diets minced m
eats, 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.

37. 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.

38. 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.

39. 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