Malnutrition presents a serious risk to cancer patients, impairing quality of life and therapeutic response to treatment (i.e. chemotherapy) which leads to poorer prognosis. Using valid tools to actively and frequently conduct nutritional screening and assessments is the vital first step for timely initiation of appropriate nutritional and exercise intervention to prevent muscle wasting.^1,2

Cachexia and Dysregulated Energy Metabolism

Cachexia a wasting syndrome characterised by the loss of skeletal muscle mass and fat that leads to weakness and progressive functional impairment.³ Cachexia differs from sarcopenia in that it is a product of illness not advancing age.^4,5

Cachexia is common in cancer patients. The interplay of reduced nutrient intake from anorexia and malnutrition, metabolic dysfunction and increased energy requirements perpetuate cachexia. The disease process involves a variety of inflammatory cytokines in cancer cells, alterations in protein and lipid metabolism, and an imbalance in the production and degradation processes of muscle proteins.¹

Figure 1. Pathophysiology and Impact of Cancer Cachexia⁶

The Impact of Malnutrition on Outcomes of Cancer Treatment

Malnutrition is associated with longer hospital stay and higher rate of admission, higher rates of infection and longer hospital stays, delayed wound healing, deterioration of the immune system, and cancer-related mortality, not to mention poorer quality of life. Nearly 80% of advanced cancer patients develop cachexia, for which there is no cure.³ As with cancer itself, prevention is better than a cure.⁷ Given the negative effects of cachexia on tolerance of cancer treatment, quality of life, and survival, optimising nutritional status early will establish a better foundation for health.

Nutritional Screening and Assessment

The Prevalence of Malnutrition in Oncology (PreMiO) study (n=1952) revealed that 51% of cancer patients had nutritional impairment at their first medical oncology visit and 43% were at risk for malnutrition. Over 40% of patients were experiencing anorexia and, during the prior six months, 64% of patients lost weight (1 to 10 kg).⁸ When critically interpreting the meaning behind these findings, it is clear nutritional assessment and early intervention is called for in cancer patients.

Some important basic measures that must not be overlooked are a patient’s medical history, food intake (i.e. amount, energy density, nutritional density, etc.), physical activity level, weight changes and other anthropometric measures (e.g. body mass index [BMI]), and laboratory test results. Bioelectrical impedance analysis (BIA) is also indicated to assess for reductions in muscle mass. These should be repeated periodically, not just once.¹

Early Interventions to Help Prevent Cancer Cachexia

Energy Requirements

The European Society for Clinical Nutrition and Metabolism (ESPEN) guidelines recommend that the total energy expenditure (TEE), unless measured individually, should be assumed to be similar to that of healthy individuals. Generally, this ranges between 25 and 30 kcal/kg/day (105 to 125 kJ/kg/day), meaning that an individual weighing 70 kg should aim to consume between 1750 to 2,100 kcal/day (7350 and 8750 kJ/day) to maintain their current weight and nutritional state. TEE can also be measured individually or estimated from standard formulas for resting energy expenditure (REE) and standard values for physical activity level (PAL). However, the most important course of action is to adapt the provision of energy to the observations/clinical effects of nutrition on body weight and muscle mass.

Reductions in food intake should be recognised and addressed early. Commercially available oral nutritional supplements are often needed to ensure adequate nutritional intake. Increasing meal frequency by portioning several smaller meals throughout the day is a strategy that can help to reach energy intake targets.²

Protein

Cancer cachexia studies suggest that a high protein diet (1 to 1.5 g/kg) is required to maintain or improve muscle mass, combined with exercise.^2,9 The ESPEN guidelines state that protein intake should be above 1 g/kg/day but preferably around 1.5 g/kg/day. Further evidence suggests that intakes closer to 2 g/kg/day may be necessary to support positive protein balance in some patients, though this is not advisable for patients with impaired kidney function.²

Good food sources of protein include fish, poultry, dairy, red meat (in moderation), with smaller amounts in legumes and rice, nuts, and seeds. Oral nutritional supplements or protein powders should also be considered where appropriate.

Omega-3 Fatty Acids

Energy and protein supplements alone do not improve cancer cachexia. Effective nutritional therapy must also include anti-inflammatory nutrients, to address an important pathophysiological factor of cancer cachexia.¹⁰

Omega-3 fatty acids are the most studied nutraceutical concerning cancer cachexia, demonstrating promising effects on the modulation of proteolytic pathways, stimulating protein synthesis and decreasing inflammation. Several experimental studies indicate the omega-3 supplementation may attenuate and possibly even reverse losses of muscle mass associated with cachexia. Clinical trials demonstrate a tendency towards benefit in the maintenance/gain of lean muscle mass with omega-3 fatty acid supplementation.¹¹ Current evidence remains unclear, though the ESPEN guidelines recommend the use of fish oil and omega-3 fatty acids in cancer patients.²

Salmon, sardines, chia seeds, flaxseeds, and walnuts are dietary sources of high omega-3 fatty acids. Eating at least two serves of fish (preferably oily fish) per week is consistent with recommendations made by the National Health and Medical Research Council (NHMRC).¹²

Multivitamin and Mineral Supplement

The risk of micronutrient deficiency is higher in all forms of malnutrition. As such, the use of a multivitamin and mineral supplement that provides micronutrients in amounts approximately equal to the recommended daily intake (RDI) is recommended. This applies to oncology patients during chemotherapy and radiotherapy, according to the ESPEN.²

Exercise

Maintaining or increasing levels of physical activity in cancer patients is encouraged to support muscle mass, physical function and metabolic pattern. Physical exercise intervention trials have closely followed guidelines set for the general population. However, for some cancer patients, taking a daily walk is enough to help reduce the risk of atrophy due to inactivity depending on their condition. For others, physical exercise programs conducted by appropriately trained professionals may be necessary.²

From Pill to Plate

Nutritional interventions are important in cancer, from prevention through to treatment. Natural health practitioners are well positioned to exercise vigilant nutritional assessment and provide individualised nutritional counselling, adjacent to the patient’s cancer care team. Maintaining an energy intake proportional to TEE, increasing protein intake in those susceptible to cancer cachexia, regularly consuming fish and other foods rich in omega-3 fatty acids, supplementing with a multivitamin and mineral supplement, and exercising regularly should be encouraged in cancer patients.²

Please contact Clinical Support for further information if prescribing nutrient supplements during cancer treatment.

References

1. Kim DH. Nutritional issues in patients with cancer. Intest Res. 2019 Oct;17(4):455-462. DOI: 10.5217/ir.2019.00076

2. Arends J, Bachmann P, Baracos V, Barthelemy N, Bertz H, Bozzetti F, et al. ESPEN guidelines on nutrition in cancer patients. Clin Nutr. 2017 Feb;36(1):11-48. DOI: 10.1016/j.clnu.2016.07.015

3. National Cancer Institute. Cancer cachexia: after years of no advances, progress looks possible [Internet]. Bethesda: National Institutes of Health; 2022 [cited 2023 Mar 10]. Available from: https://www.cancer.gov/about-cancer/treatment/research/cachexia

4. Baker Rogers J, Syed K, Minteer JF. Cachexia [Internet]. Treasure Island: StatPearls; 2022 [cited 2023 May 15]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470208/

5. Ardeljan AD, Hurezeanu R. Sarcopenia [Internet]. Treasure Island: StatPearls; 2022 [cited 2023 May 15]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560813/

6. Dev R, Wong A, Hui D, Bruera E. The evolving approach to management of cancer cachexia. Oncology (Williston Park). 2017 Jan;31(1):23-32.

7. Harvard Public Health. The cancer miracle isn’t a cure [Internet]. Boston: Harvard TH Chan School of Public Health; 2019 [cited 2023 May 15]. Available from: https://www.hsph.harvard.edu/magazine/magazine_article/the-cancer-miracle-isnt-a-cure-its-prevention/

8. Muscaritoli M, Lucia S, Farcomeni A, Lorusso V, Saracino V, Barone C, et al. Prevalence of malnutrition in patients at first medical oncology visit: the PreMiO study. Oncotarget. 2017 Oct;8(45):79884-79896. DOI: 10.18632/oncotarget.20168

9. Prado CM, Purcell SA, Laviano A. Nutrition interventions to treat low muscle mass in cancer. J Cachexia Sarcopenia Muscle. 2020 Apr;11(2):366-380. DOI: 10.1002/jcsm.12525

10. Tanaka K, Nakamura S, Narimatsu H. Nutritional approach to cancer cachexia: a proposal for dietitians. Nutrients. 2022 Jan;14(2):345. DOI: 10.3390/nu14020345

11. Malta FAPS, Estadella D, Gonçalves DC. The role of omega 3 fatty acids in suppressing muscle protein catabolism: a possible therapeutic strategy to reverse cancer cachexia? J Funct Foods. 2019 Mar;54:1-12. DOI: 10.1016/j.jff.2018.12.033

12. National Health and Medical Research Council. Nutrient reference values for Australia and New Zealand including recommended dietary intakes [Internet]. Canberra ACT: National Health and Medical Research Council; 2006 [cited 2022 Jan 17]. Available from: https://www.nhmrc.gov.au/sites/default/files/images/nutrient-refererence-dietary-intakes.pdf