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• To recognise the nutrition impact symptoms that people with cancer may experience
• To consider the interventions you could implement in your practice to manage nutrition-related issues and improve quality of life
• To contribute towards revalidation as part of your 35 hours of CPD (UK readers)
• To contribute towards your professional development and local registration renewal requirements (non-UK readers)
Cancer and its associated treatments can result in a range of adverse symptoms which can affect a person’s ability to consume, digest and absorb food and fluids. These are collectively referred to as nutrition impact symptoms, and they can occur singularly or in combination at any stage of the cancer journey. If left unmanaged, nutrition impact symptoms can result in diminished nutritional intake, leading to malnutrition, cachexia and sarcopenia, which can result in suboptimal cancer treatment outcomes and reduced quality of life. Therefore, early recognition and management or alleviation of nutrition impact symptoms is crucial. This article explores nutrition impact symptoms and the dietary modifications that can be used to manage or alleviate these symptoms. It also discusses the role of the nurse in nutrition screening and assessment and in providing nutritional support interventions.
Cancer Nursing Practice. doi: 10.7748/cnp.2023.e1830
Peer reviewThis article has been subject to external double-blind peer review and checked for plagiarism using automated software
Correspondencemalnutritionpathway@franklincoms.co.uk
Conflict of interestNone declared
Holdoway A, Donald M, Hodge A (2023) Supporting people with cancer to manage nutrition throughout the cancer journey. Cancer Nursing Practice. doi: 10.7748/cnp.2023.e1830
Published online: 25 January 2023
This article aims to enhance nurses’ awareness and understanding of nutrition impact symptoms and the dietary modifications that can be used to manage or alleviate these symptoms, and to examine the role of the nurse in providing nutrition support to people with cancer. After reading this article and completing the time out activities you should be able to:
• Understand the terms malnutrition, cachexia and sarcopenia and recognise the negative effects of these conditions.
• Identify nutrition impact symptoms and their association with various cancer treatments.
• Understand the importance of integrating nutrition screening and assessment into patient care pathways.
• Advise patients about first-line dietary modifications to alleviate or manage nutrition impact symptoms.
• Identify and refer patients who may require a detailed dietetic assessment.
• Signpost patients and families to credible sources of information on nutrition.
Nutrition-related issues are highly prevalent among people with all types of cancer and can be experienced at any point in the cancer journey, including well beyond the treatment phase (Sullivan et al 2021). These issues can arise from the cancer itself, cancer treatment or comorbidities, and are collectively referred to as nutrition impact symptoms (Amano et al 2019). Failure to address these complex and burdensome symptoms through dietary advice and nutrition support can have an adverse effect on patients’ responses to treatment, ability to function, day-to-day living, quality of life and survival (Arends et al 2017, Su et al 2019). Conversely, dietary modifications to manage or alleviate nutrition impact symptoms – combined with personalised exercise and psychological and behaviour change programmes – can support patients to improve their nutritional status and cardiorespiratory fitness, reduce the risk of post-treatment complications, reduce the length of hospital stay and enhance recovery (Macmillan Cancer Support 2019).
Patients’ nutrition status and experience of nutrition impact symptoms can change at different points in their cancer journey, so there is a need to consider this aspect of care throughout the cancer pathway. As nurses have a central role in providing holistic care, they are in an optimal position to initiate and undertake regular nutrition screening and assessment, identify nutrition impact symptoms, offer patients advice and implement first-line dietary interventions to alleviate or manage these symptoms. Nurses can also refer patients to dietitians for a comprehensive nutrition assessment and additional nutrition support.
• Nutrition impact symptoms can arise from cancer itself, cancer treatment or comorbidities
• For people with cancer, weight and muscle loss can be extreme and may lead to the development of disease-related malnutrition, cachexia and sarcopenia
• The provision of optimal nutritional care relies on: early nutritional screening; assessment of nutrition-related issues; and the use of multimodal nutrition therapies
• Nurses can initiate and undertake regular nutrition screening and assessment, identify nutrition impact symptoms, offer patients advice and implement first-line dietary interventions to alleviate or manage these symptoms
For people with cancer, weight and muscle loss can be extreme and may lead to the development of disease-related malnutrition, cachexia and sarcopenia (Box 1). There is considerable overlap between malnutrition, cachexia and sarcopenia which, if left untreated, can result in suboptimal patient outcomes and increased mortality (Arends et al 2017).
• Disease-related malnutrition – deficiency of energy, protein and other nutrients causing adverse effects on the body (shape, size and composition), the way it functions and clinical outcomes
• Cachexia – involuntary weight loss characterised by anorexia, loss of adipose tissue and skeletal muscle mass
• Sarcopenia – progressive and generalised loss of skeletal muscle mass and function, resulting in reduced physical performance that can contribute to frailty, prolonged disability, risk of falls, suboptimal quality of life and death
It is estimated that 40-80% of people with cancer will be malnourished during the course of the disease (Ravasco 2019). Identification and treatment are vital because patients who develop disease-related malnutrition, cachexia or sarcopenia are likely to have a suboptimal response to treatment, including surgery, be at increased risk of treatment-related toxicity and require prolonged treatment, and may experience lower levels of activity, reduced quality of life and a suboptimal prognosis (Arends et al 2017). There are also implications for healthcare services in terms of increased demand on services and cost of care (van Vugt et al 2017). Table 1 outlines the negative effects associated with malnutrition, cachexia and sarcopenia in people with cancer.
(Adapted from Donald and Holdoway 2022)
Suboptimal nutritional status and nutrition impact symptoms may result from the local effects of, or metabolic response to, cancer and/or to cancer treatments (Shaw 2011). Nutrition impact symptoms can be singular or many and varied, general or specific to the tumour site and short or long term. These symptoms may be apparent at initial presentation, providing an opportunity for the patient to be offered nutritional advice at diagnosis, or absent initially but develop, worsen or change as treatment progresses, and may persist beyond treatment. Table 2 lists nutrition impact symptoms associated with cancer treatments.
(Adapted from Shaw 2011, Oncology Nursing Society 2020)
As nutritional status varies from person to person, and throughout the cancer journey, provision of optimal nutritional care relies on three main steps (Arends et al 2017, Muscaritoli et al 2021):
• Early nutritional screening.
• Assessment of nutrition-related issues, for example nutrition impact symptoms and nutritional intake; functional measures, for example hand-grip strength; and physiological measures, for example weight loss and body mass index (BMI).
• Use of multimodal nutrition therapies with individualised plans, focused on optimising nutritional intake and physical activity. Multimodal nutrition therapies are methods used by the multidisciplinary team (MDT) to improve patients’ nutritional intake and status based on each individual’s needs and goals as identified during a nutritional assessment. Such therapies may include dietary advice, dietary counselling, food modification, oral nutritional supplements, enteral or parenteral nutrition.
Regular nutrition screening should be undertaken using a validated screening tool, such as the Malnutrition Universal Screening Tool (Elia 2003), the Mini Nutrition Assessment (Guigoz et al 2002) or the Malnutrition Screening Tool (Ferguson et al 1999), which has been validated in chemotherapy and radiotherapy settings (Reber et al 2021).
Unintentional weight loss, impaired appetite and reduced food intake are key indicators of risk of malnutrition; therefore, questions about nutritional issues and nutrition impact symptoms (Table 2), alongside sequential measures for weight and BMI, should form part of patients’ review appointments. Patients identified as at risk of malnutrition should be further assessed, offered treatment and monitored to evaluate improvement, deterioration and the need for further action, including dietetic referral (National Institute for Health and Care Excellence 2017).
Around three quarters of adults aged 45-74 years in England are overweight or obese (House of Commons Library 2022), so it is important to identify unexplained weight loss and/or impaired nutritional intake in people with a high BMI. Excess body weight at any point in the cancer journey does not guarantee protection from disease-related malnutrition (Kobylińska et al 2022).
Subjective indicators of malnutrition risk are shown in Box 2.
• Thin or very thin appearance
• Loose fitting clothing and/or jewellery
• History of recent unplanned weight loss
• Change in appetite, for example eating smaller amounts of food
• Eating or swallowing difficulties (dysphagia)
• Dry mouth and/or dull eyes
• Low mood
• Dry skin and/or, skin becoming looser and breaking more easily
• Changes in nail structure – bumps and lines
• Altered bowel habit
• Sleeping or resting a lot of the day
• Reduced functional ability
(Adapted from Duerksen et al 2021)
Patients identified as at risk of malnutrition, and those with nutrition impact symptoms, require a detailed nutrition assessment. Various nutrition assessment tools have been validated for use in oncology by non-nutrition experts (Thompson et al 2017, Ravasco 2019) and include assessment of dietary intake, nutrition impact symptoms, weight and weight loss over time (Arends et al 2017). Examples of such tools are the Subjective Global Assessment (Canadian Malnutrition Taskforce 2022) and the Patient-Generated Subjective Global Assessment (Pt-Global 2014), which includes a self-evaluation component for food intake and functional activity.
Preserving muscle is also an important goal in improving patient outcomes, such as response to treatment and quality of life (Muscaritoli et al 2021). In hospitals, sophisticated methods to assess body composition – including muscle mass – may be available; for example, computed tomography scans and bioelectrical impedance analysis, which estimates body composition – particularly body fat and muscle mass. Where these methods are not available, the following functional measures can be used to indicate loss of muscle mass and strength and guide treatment decisions:
• 30-second chair stand (Centers for Disease Control and Prevention 2017) – to test leg strength and endurance.
• NIH Toolbox (2020) 4-Meter Walk Gait Speed Test and 2-Minute Walk Endurance Test Walking Course – to measure functional ability.
• SARC-F (strength, assistance with walking, rising from a chair, climbing stairs and falls) test (Malmstrom and Morley 2013) – to identify sarcopenia.
• Measurement of hand-grip strength using a handheld dynamometer – to indicate muscle strength in the hands and forearms.
Nutrition support can be provided via oral, enteral (tube feeding) or parenteral (intravenous) routes. Timely nutrition support can prevent and/or manage malnutrition, cachexia and sarcopenia, improve cancer treatment efficacy, alleviate or manage nutrition impact symptoms and improve patients’ quality of life (Gandy 2019). Nutrition support may need to be commenced at diagnosis, during prehabilitation or treatment, or at any other point throughout patient’s cancer journey.
Dietary counselling, with or without oral nutritional supplements, has been shown to be effective in improving nutritional intake in people with cancer and preventing deterioration in nutritional status to preserve function during treatment and beyond (Ravasco 2019). In-depth dietary counselling is usually provided by a dietitian, but nurses can provide first-line advice on managing nutrition impact symptoms and adapting diets to fit with individuals’ circumstances to support self-care. They can also signpost patients to credible nutrition resources and identify the need for referral to a dietitian for expert advice.
Effective dietary counselling should be individualised and consider patients’ (Arends 2017, Ravasco 2019):
• Usual and current diet.
• Nutrition impact symptoms (Table 2).
• Past medical history and presence of medical conditions other than cancer that may affect dietary intake.
• Cooking abilities, access to food and food poverty.
• Psychological, cultural, religious and social status that may influence food choices.
All individuals require a balanced diet that includes foods from all food groups and consumption of sufficient calories and protein to maintain a steady weight. The calorie requirements of people with cancer are similar to those of healthy individuals; however, due to increased catabolism, muscle loss and the nutritional demands of the cancer tumour or treatment, protein requirements for people with cancer are higher than those of the general population (Muscaritoli et al 2021). For people who are overweight, losing weight is not recommended during cancer treatment, but nurses can advise that they should avoid gaining excess weight.
Table 3 outlines first-line management of nutrition impact symptoms. The further resources section at the end of this article provides information that nurses can use to enhance their delivery of nutritional care, support patients with nutrition and signpost patients and carers to.
(Adapted from Donald and Holdoway 2022)
Patients with complex or persistent nutrition impact symptoms or nutritional needs, and/or those who require textural changes to foods, should be referred to a dietitian or another member of the MDT, such as speech and language therapist. These patients may include those who (Ravasco 2019):
• Are following special diets for another medical condition, for example heart disease or diabetes mellitus.
• Have a high-output colostomy or ileostomy.
• Have not responded to first-line nutrition treatment.
• Require clinically assisted nutrition support, for example enteral or parenteral nutrition.
Reflecting on the patient in Time out 2, what dietary advice could you give them to alleviate or manage their nutrition impact symptoms? How could you ensure this advice is person-centred? Consider cultural, psychological, religious and social issues
Oral nutritional supplements are liquids, semi-solids or powders that provide macronutrients and micronutrients, and they are used for people whose nutritional requirements cannot be met through oral diet alone (British Association for Parenteral and Enteral Nutrition 2016). Evidence shows that oral nutritional supplements can effectively improve nutrition-related outcomes when used in conjunction with dietary counselling (Arends et al 2017). Initiation of oral nutritional supplements, alongside dietary counselling, may be required early in the cancer treatment pathway to prevent weight loss and irreversible deterioration in nutritional status (Muscaratoli et al 2021). Nutritional intervention using oral nutritional supplements can increase calorie and protein intake and reduce weight loss in people with cancer (Gandy 2019, Richards et al 2020) and improve the quality of life of those who are malnourished (Ferrer et al 2019). They have also been shown to be cost-effective in the management of malnutrition (Elia 2015).
Oral nutritional supplements enhance rather than replace normal diet and are often consumed between meals via sipping, spilt into manageable portions of approximately 40mL-60mL, or incorporated into everyday foods. Dietitians will often guide the use of specific oral nutritional supplements tailored to individuals’ needs; however, nurses can support patients and dietitian colleagues by identifying and assessing:
• Patients’ preference for type and flavour of oral nutritional supplements, for example milk or juice based, sweet or savoury.
• The format that may be most suitable for a patient and their clinical circumstances. For example:
• Low-volume oral nutritional supplements may aid adherence (Gandy 2019) and may be better tolerated by patients who cannot consume large volumes.
• High-protein oral nutritional supplements may be appropriate for patients with high protein requirements.
• Oral nutritional supplements containing anti-catabolic and anti-inflammatory ingredients (targeted essential amino acids or omega-3 fatty acids). These are designed to increase synthesis of muscle protein, stimulate appetite and reduce body wasting in people with cancer (Arends et al 2017).
• The appropriateness of powdered forms of oral nutritional supplements. The patient or carer will require a fridge and the ability to purchase fresh milk, storage space for milk and boxes of powder and the ability to make up the powdered supplement and adhere to safe handling practice. For some patients a ready-made supplement may be more appropriate (Mulholland et al 2019).
Nurses can also ensure that clear and realistic goals are set, for example: to prevent further weight loss; to monitor tolerance, adherence and progress; to identify and assess potential ongoing nutrition impact symptoms; to reinforce the importance of following the prescription instructions; and to liaise with dietitians and the MDT to jointly manage patients’ nutrition impact symptoms. Further advice for nurses on managing malnutrition with oral nutritional supplements is available at: www.malnutritionpathway.co.uk/library/ons.pdf, while ideas for patients and carers on using oral nutritional supplements can be found at: www.malnutritionpathway.co.uk/library/pleaflet_red.pdf
If oral nutrition is inadequate to manage patients’ requirements, despite interventions such as dietary counselling and/or oral nutritional supplements, enteral nutrition may be indicated (de Las Peñas et al 2019). Parenteral nutrition may be considered for patients receiving cancer therapy who have had >7 days of inadequate calorie intake, and where dietary counselling, oral nutritional supplements or enteral nutrition are contraindicated or likely to be ineffective due to impaired gastrointestinal function (de Las Peñas et al 2019). Patients receiving enteral or parenteral nutrition should be under the care of a dietitian, nutrition nurse and nutrition support team.
Care should be taken to ensure that nutrition support is not withdrawn when it is still of benefit. For example, in the authors’ experience, nutritional support such as tube feeding is sometimes stopped as soon as the person is able to eat and drink; however, if their food intake is slow to increase or insufficient to meet their nutritional requirements, it may need to be continued to support oral intake.
Preparing people for treatment by supporting their psychological well-being, physical fitness and nutrition is a central component of modern cancer care. Addressing nutritional concerns before treatment can support patients to better tolerate treatment and can reduce side effects (Macmillan Cancer Support 2019). A fact sheet on prehabilitation is available at: www.malnutritionpathway.co.uk/library/prehabilitation.pdf
Evidence is emerging in cancer care of the beneficial effects of physical activity, combined with optimal nutrition, on muscle strength, health-related quality of life, self-esteem and reduction in fatigue and anxiety (Muscaritoli et al 2021). Patients should be encouraged to be active every day to support physical and mental health and advised that any activity is better than none, with even ten minutes exercise at a time adding up throughout the day and week (Macmillan Cancer Support 2019, Muscaratoli et al 2021).
Patients’ appetite can be very poor and weight loss is inevitable in the later stages of cancer. In the last weeks of life, there should be an emphasis on supporting patients to eat food they enjoy and supporting families to accept what may be an inevitable deterioration in food intake, while managing nutrition impact symptoms to maintain the person’s quality of life. Explaining how factors produced by the cancer can impair appetite and increase the likelihood of weight loss and muscle wasting can help to alleviate patients’ and carers’ anxiety (Cooper et al 2015).
As a patient approaches the end of life, oral nutritional supplements and nutrition support may be continued if they provide comfort and to maintain skin integrity and if the patient has expressed a desire to continue with them. Nutritional support interventions should be closely monitored to ensure they do not cause unnecessary distress or exacerbate symptoms such as nausea or increased secretions.
A summary guide to nutritional support is shown in Box 3.
• Undertake nutritional screening at diagnosis and subsequent clinic appointments using a validated local or national screening tool
• Perform regular assessment to identify nutrition impact symptoms
• Offer patient relevant nutrition advice and information and/or refer to other members of the multidisciplinary team as appropriate
• Make an immediate referral to the dietitian for patients at high risk of malnutrition
• Encourage effective mouth care
• Consider oral nutritional supplements early in the cancer pathway to prevent deterioration in nutritional status
• Provide ongoing nutrition monitoring and review
• Adjust intervention as required to maximise nutritional intake, seeking advice from/referral to dietitian/nutrition team where necessary
• Ensure monitoring – including patient self-monitoring – beyond cancer treatment to prevent diet-related issues, unintentional weight loss and muscle loss
(Adapted from Donald and Holdoway 2022)
People with cancer are at risk of developing nutrition impact symptoms, which can lead to malnutrition, cachexia and sarcopenia, potentially resulting in suboptimal response to treatment, increased risk of treatment-related toxicity, prolonged treatment and reduced quality of life. The use of validated screening tools and assessments can assist in identifying patients at risk of malnutrition and those with nutrition impact symptoms throughout the cancer journey. Nurses can offer patients nutrition advice and initiate first-line dietary strategies to alleviate or manage nutrition impact symptoms and improve patients’ nutritional status. Nurses can also work with dietitians to support and monitor patients on oral nutritional supplements.
Identify how supporting people with cancer to manage nutrition applies to your practice and the requirements of your regulatory body
Now that you have completed the article, reflect on your practice in this area and consider writing a reflective account. Go to: rcni.com/reflective-account
Malnutrition Pathway – Managing Adult Nutrition
Macmillan Cancer Support – Eating problems and cancer
Cancer Research UK – Tips for diet problems
Cancer Research UK – Mouth care
www.cancerresearchuk.org/about-cancer/coping/physically/mouth-problems/mouth-care
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