Factors contributing to weight loss, nutrition-related concerns and advice received by adults undergoing cancer treatment

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1 Advaces i Medical Scieces Vol. 53(2) 2008 pp DOI: /v Medical Uiversity of Bialystok, Polad Factors cotributig to weight loss, utritio-related cocers ad advice received by adults udergoig cacer treatmet Smith JL, Maliauskas BM *, Garer KJ, Barber-Heidal K Departmet of Nutritio ad Dietetics, East Carolia Uiversity, Greeville, USA * CORRESPONDING AUTHOR: Departmet of Nutritio ad Dietetics, East Carolia Uiversity, 148 Rivers Buildig, Greeville, NC , USA telephoe: (252) maliauskasb@ecu.edu (Breda Maliauskas) Received Accepted Advaces i Medical Scieces Vol. 53(2) 2008 pp DOI: /v Medical Uiversity of Bialystok, Polad ABSTRACT Purpose: The opiios ad perceptios of patiets are crucial throughout the cacer treatmet process, as treatmet is more effective whe patiet cocers are addressed. The preset study was desiged to idetify history of weight loss sice iitiatio of cacer treatmet, specific utritio-related problems ad cocers (icludig food aversios, factors cotributig to poor food itake ad perceived utritio-related problems), utritio advice received by cacer treatmet patiets, ad relatios betwee items studied ad reported uitetioal weight loss. Material ad Methods: A 23-item survey was completed by a coveiece sample of 79 patiets from treatmet ceters at a commuity hospital ad ocologist office, of which 66 were icluded i the fial aalysis. Descriptive statistics icluded meas, stadard error, 95% cofidece itervals, ad frequecy distributios. ANOVA ad Pearso χ2 were used to evaluate differeces i resposes by treatmet type ad relatios betwee items studied ad reported uitetioal weight loss. Twetyseve (41%) of the 66 (27 males, 39 females) were receivig radiatio, 20 (30%) chemotherapy, ad 19 (29%) both. Results: Uitetioal weight loss occurred for 41% sice iitiatio of treatmet (13% deficit), 27% had food aversios, 52% reported factors cotributig to poor food itake, 50% had utritio-related problems sice iitiatio of treatmet, ad 89% had received utritio advice. The prevalece of uitetioal weight loss was sigificatly greater amog patiets who reported havig food aversios, factors that had cotributed to poor food itake, or utritio-related problems. Coclusios: This study demostrates that adults commoly preset with factors that cotribute to poor food itake ad perceive utritio-related problems resultig from cacer treatmet. Further, there is a greater prevalece of uitetioal weight loss amog those who report food aversios ad perceive utritio-related problems. The fidigs provide a framework that may aid healthcare providers i recogizig utritio-related cocers ad eeds of cacer patiets. Key words: side effects, utritio status, dietary supplemets, food aversios ABBREVIATIONS ANOVA - Aalysis of variace BMI - Body mass idex CI - Cofidece iterval HIPAA - Health Isurace Portability ad Accoutability Act SEM - Stadard error of the mea INTRODUCTION Patiets with cacer are at risk for compromised utritio status. A major factor cotributig to weight loss ad malutritio amog cacer patiets is the hypermetabolic state iduced by the disease [1]. Hypermetabolism is multifactorial i ature, resultig from a icrease i proiflammatory ad acute phase protei resposes ad proteolysis-iducig factors [2]. Batterham ad Edwards reported that amog cacer patiets, restig eergy expediture was 7% greater tha healthy cotrols [3]. Bosaeus ad colleagues foud that

2 Smith JL et al. 199 hypermetabolism was preset i 48% ad sigificat weight loss i 43% of patiets whom they studied [1]. Moreover, the patiets were ot icreasig their oral itake to compesate for the elevated metabolic requiremets, ad thus the weight loss was attributed to decreased dietary itake i additio to icreased eergy eeds [1]. The primary cosequece of hypermetabolism is cachexia, a coditio i which loss of adipose ad muscle tissue depletes lea body mass ad visceral protei stores [4]. Hypermetabolism ad cachexia ca have detrimetal effects o utritio status, quality of life, ad overall survival amog cacer patiets [4]. A wide rage of utritio-related side effects are commo amog cacer patiets [5-12]. May side effects, icludig aorexia, early satiety, altered sese of taste ad smell, ad gastroitestial dysfuctio, compromise utriet itake [13]. Polisea reported that of 72 patiets o radiatio for lug, cervical, esophageal, prostate, ad head or eck cacers, 40% had loss of appetite ad 67% ivolutary weight loss [6]. Physical side effects from cacer treatmet are commo. Amog chemotherapy patiets, dysgeusia has resulted i reduced cosumptio of foods at meals, socializatio, ad overall health maiteace [10]. Polisea foud that 70% of patiets o radiatio therapy experieced taste chages, ausea, vomitig, diarrhea, dysphagia, ad/or chewig difficulties [6]. Kalma ad Villai reported that chemotherapy-iduced fatigue ad associated weight loss, egative mood, prologed stress, ad pai occurred i 80% to 96% of cacer patiets [11]. Food aversios are frequetly reported as side effects of cacer treatmet. Hutto ad colleagues foud that amog chemotherapy patiets, 86% experieced chages i smell ad/or taste that resulted i decreased eergy itake [9]. Radiatio therapy for head ad eck cacer also may affect taste by causig tissue damage, decrease i saliva productio ad ageusia [2]. Dysgeusia from cacer treatmet ofte leads to food aversios ad, cosequetly, a decrease i overall food itake ad diet quality [8]. Curret medical utritio therapy for patiets udergoig cacer treatmet focuses o preservig lea body mass, prevetig or reversig utriet deficiecies, miimizig utritio-related side effects, ad improvig quality of life. A combiatio of ogoig dietary couselig, idividualized utritioal therapies, ad exercise is curretly recommeded. Specific utritioal therapies iclude cosumptio of small, frequet ad well-balaced meals ad esurig adequate hydratio. The use of utriet-dese oral supplemets is commo, ad i patiets who are uable to cosume adequate amouts of calories ad utriets, short-term utritio support i the form of eteral or paretal utritio may be warrated to prevet malutritio ad improve outcomes [13]. There has bee extesive research idicatig that side effects of cacer treatmet compromise utritioal status. May researchers have surveyed cacer treatmet patiets to determie specific factors relatig to poor itake ad food aversios, whereas patiet perceptios regardig utritiorelated cocers ad sources of utritio advice were very limited. The opiios ad perceptios of patiets are crucial throughout the treatmet process, as it is likely that treatmet would be more effective whe patiet cocers ad eeds are addressed. The aims of the preset study were to idetify the prevalece of uitetioal weight loss sice iitiatio of cacer treatmet, idetify the prevalece of specific utritiorelated problems ad cocers reported sice iitiatio of cacer treatmet, icludig food aversios, factors cotributig to poor food itake, ad perceived utritio-related problems, utritio advice received, ad relatios betwee these items studied ad reported uitetioal weight loss amog cacer patiets. MATERIALS AND METHODS Study Desig ad Participats The study protocol was approved by the Istitutioal Review Board at the educatio istitute ad hospital at which the data were collected ad i compliace with HIPAA guidelies. Siged iformed coset was obtaied from all participats. Data collectio occurred from October 2006 to March 2007 i a chemotherapy ifusio ceter, a radiatio therapy ceter, ad ipatiet rooms i the medical ocology uit from a sigle 140-bed acute care facility located i a rural geographic locatio i the cetral Atlatic regio of the Uited States ad i the waitig area of a hospital-affiliated ocologist s office. Study participats icluded a coveiece sample of 79 patiets who were curretly udergoig radiatio ad/or chemotherapy for cacer treatmet. Other iclusio criteria icluded cacer diagosis i the past five years, duratio of cacer treatmet of at least oe time per week, 18 years of age or older ad o-pregat female. All participats recruited met iclusio criteria ad agreed to participate. Survey Developmet A pilot survey was adapted from the Memorial Symptoms Assessmet Scale ad the Fuctioal Assessmet of Cacer Therapy Scale [14,15] by a cliical dietitia who is employed at the facility where the data was collected. Two dietitias reviewed the survey for cotet validity. The survey was the pilot tested amog 10 patiets udergoig cacer treatmet (five chemotherapy, five radiatio), who met iclusio criteria ad varied i age ad cacer type, ad both sexes were represeted equally. Modificatios to the survey were made based o the pilot test results. The fial self-admiistered survey was a 23-item questioaire that requested iformatio about demographic characteristics, athropometric data, cacer type ad curret treatmet, food aversios ad other factors cotributig to poor food itake, utritio-related problems, utritio-related advice received, ad sources (people ad media) of utritio iformatio. Four employees of the hospital, icludig the dietitia who completed the pilot

3 200 Factors cotributig to weight loss, utritio-related cocers ad advice received by adults udergoig cacer treatmet Table 1. Age ad Athropometric Characteristics of Adults Receivig Cacer Treatmet (N = 66). Radiatio Chemotherapy Radiatio/Chemotherapy Measure M ± SEM 95% CI M ± SEM 95% CI M ± SEM 95% CI F p Age (years) a 66 ± 3 61, ± 3 64, ± 2 57, 66 (2,65) = BMI (kg/m 2 ) a 26.4 ± , ± , ± , 28.8 (2,65) = Uitetioal weight loss sice iitiatio of treatmet (kg) b Uitetioal weight loss (% usual weight) b 13.2 ± , ± , ± , 19.5 (2,26) = ± 3 8, 21 9 ± 4 1, ± 3 8, 20 (2,26) = a radiatio ( = 20), chemotherapy ( = 19), radiatio/chemotherapy ( = 27). b radiatio ( = 10), chemotherapy ( = 7), radiatio/chemotherapy ( = 10). testig, two urses, ad a office maager, recruited patiets ad admiistered the survey. The dietitia traied the other members of the research team o how to recruit ad admiister the survey to willig participats. Statistical Aalysis Aalyses were performed usig JMP IN software [16]. Descriptive statistics icluded mea, stadard error of the mea, 95% cofidece itervals, ad frequecy distributios. Differeces i resposes for cotiuous variables by treatmet classificatio were evaluated usig ANOVA with Tukey- Kramer hoestly sigificat differece for post-hoc compariso of all pairs. Pearso χ 2 was used to evaluate differeces i resposes by treatmet classificatio for omial data ad for evaluatig relatios betwee items studied ad reported uitetioal weight loss. A alpha level of 0.05 was used for all statistical tests. RESULTS A total of 79 participats completed the questioaire, 13 were excluded due to icomplete data. The fial aalysis icluded data from the remaiig 66 (27 males, 39 females), which represets 84% of total participats recruited. Mea age (± SEM) of participats was 65 ± 1 years (95% CI 62, 68), which was similar by treatmet classificatio (Tab. 1). The primary site of cacer origi that participats were receivig treatmet icluded breast ( = 17), lug ( = 17), prostate ( = 9), lymphoma, myeloma, or sarcoma ( = 7), other orga ( = 15), ad leukemia ( = 1). Eightee of the 66 participats (27%) reported metastasis. The mea legth of time from cacer diagosis to iitiatio of treatmet was 3 ± 1 moths (95% CI 1, 5), from diagosis to completig the survey was 15 ± 3 moths (95% CI 8, 22), ad from iitiatio of treatmet to completig the survey was 11 ± 3 moths (95% CI 5, 17), which were similar by treatmet classificatio, F(2,64) = 0.58, p = 0.56, F(2,64) = 0.32, p = 0.73, F(2,64) = 0.22, p = Twety-seve of the 66 participats (41%) were receivig radiatio, 20 (30%) chemotherapy, ad 19 (29%) both. Twety-seve of the 66 participats (41%) reported uitetioal weight loss sice iitiatio of treatmet, which did ot differ by treatmet classificatio, χ 2 (1, N = 66) = 0.98, p = 0.61 (Tab. 1). The mea loss for those reportig uitetioal weight loss was 11 ± 2 kg (95% CI 7, 15), which was a mea deficit of 13 ± 2% (95% CI 10, 17) curret weight, ad was similar by treatmet classificatio. Categories of food classes associated with food aversios, factors cotributig to poor food itake, ad perceived utrietrelated problems are reported i Tab. 2. A food aversio was defied as avoidace of food category that the participat curretly foud uappealig although they had liked prior to iitiatio of treatmet. Eightee of the 66 participats (27%) reported havig food aversios. Meat or fish, fried foods, strogly flavored foods, ad strog-smellig foods were the primary categories with food aversios. Of the 34 participats (52%) who reported factors cotributig to poor food itake sice the iitiatio of treatmet, the majority reported geeral loss of appetite (25 of 34, 74%) ad taste chages (18 of 34, 53%), whereas fatigue, difficulty swallowig, ad ausea were also commo (9 to 15 of 34, 26% to 44%). Thirty-three of the 66 participats (50%) reported havig utritio-related problems sice iitiatio of treatmet. Eatig a balaced diet, cosumig sufficiet eergy ad protei, ad obtaiig adequate amouts of vitamis ad mierals were the most frequetly reported utriet-related cocers. There was a sigificatly greater prevalece of uitetioal weight loss amog participats who reported experiecig ay of the food aversios evaluated, χ 2 (1, N = 66) = 13.92, p < 0.01, ay factor cotributig to poor food itake, χ 2 (1, N = 64) = 5.58, p = 0.02, or ay perceived utritio-related problem, χ 2 (1, N = 65) = 13.48, p < I the category of perceived utritio-related problems, a sigificatly greater prevalece of uitetioal weight loss was reported amog participats who perceived ot eatig a balaced diet, χ 2 (1, N = 33) = 6.30, p = 0.01, ad those who perceived losig too much weight, χ 2 (1, N = 33) = 9.43, p < Nutritio advice received ad sources of utritio iformatio are reported i Tab. 3. Fifty-ie of the 66 participats (89%) had received utritio advice. Participats could choose more tha oe aswer, if applicable. The most

4 Smith JL et al. 201 Table 2. Reported Food Aversios, Factors Cotributig to Poor Food Itake, ad Perceived Nutriet-related Problems amog Adults Udergoig Cacer Treatmet (N = 66). Measure % of total (N=66) % of participats reportig food aversios (=18) Food aversios Meat or fish Strogly-flavored 44 8 Fried 44 8 Strog-smellig 33 6 Fatty 27 5 Salty 22 4 Spicy 22 4 Starchy 11 2 Measure % of total (N=66) % of participats reportig poor food itake (=34) Factors cotributig to poor food itake Geeral loss of appetite Taste chages Fatigue Nausea 26 9 Trouble swallowig 26 9 Diarrhea 21 7 Mouth pai 18 6 Heartbur 15 5 Vomitig 15 5 Stomach pai 12 4 Geeral pai 12 4 Measure % of total (N=66) % of participats reportig utritio-related problems (=33) Perceived utritio-related problems Not eatig a balaced diet Not eatig eough protei Not eatig eough calories Losig too much weight Not gettig eough vitamis/ mierals Not drikig eough water 27 9 Not eatig eough fat 10 3 commo advice icluded to drik utritioal supplemets as well as more water, eat small, frequet meals, ad take a multivitami. Oe participat had received advice to take herbs or use alterative remedies. The primary sources of utritio iformatio icluded physicias, urses, books or magazies, ad family members or frieds. There was ot a sigificat differece i uitetioal weight loss whe evaluatig ay of the primary sources of utritio iformatio used by participats, χ 2 (1, N = 66) = 1.98, p = DISCUSSION The preset study reviews self-reported weight loss history ad idetifies specific utritio-related cocers of cacer patiets. We idetified a 13% mea uitetioal weight loss amog adult cacer patiets, mea age 65 ± 1 year. Fidigs from our study are similar to Bosaeus ad colleagues, who reported weight loss i excess of 10% of body weight amog 43% of

5 202 Factors cotributig to weight loss, utritio-related cocers ad advice received by adults udergoig cacer treatmet Table 3. Nutritio Advice Received ad Sources of Nutritio Advice amog Adults Udergoig Cacer Treatmet (N = 66). Measure % of total (N=66) % of participats receivig utritio advice (=59) Nutritio advice received Drik supplemets (e.g., Esure, Boost) Drik more water Eat small, frequet meals Take a multivitami Gai weight 23 9 Eat more protei 15 6 Eat more calories 13 5 Take herbs or other alterative remedies Exercise more 8 3 % of total (N=66) % of participats reportig source of utritio advice (=40) 3 1 Source of utritio advice Physicia Nurse Book or magazie Family member or fried 20 8 Dietitia 5 2 Iteret 5 2 the cacer patiets whom they studied [1]. Palombie foud that amog the cacer patiets whom they studied, regardless of cacer type, a 5% uitetioal weight loss was associated with poor progosis [2]. These researchers further idicated that uitetioal weight loss ca be a early idicator of a compromised utritioal status amog cacer patiets. Nutritio care goals of cacer patiets iclude prevetig or reversig utriet iadequacies, preservig lea body mass, miimizig utritio-related side effects ad maximizig quality of life [13]. These goals ca more readily be accomplished, at least i part, by early idetificatio ad treatmet of utritio problems ad side effects that are experieced. We foud that the most commo food aversios were toward meats/fish, strogly flavored foods, ad fried foods, whereas the most commo factors cotributig to poor itake were loss of appetite, taste chages ad fatigue. Further, the most commo utritio advice received icluded to drik utritio supplemets, drik more water, ad eat small, frequet meals. This advice is i accordace with recommedatios for idividuals udergoig cacer treatmet who preset with food aversios or poor itake. The America Cacer Society recommeds eatig a sack or small meal every two to three hours, havig high-eergy, high-protei foods available, ad drikig eight to 10 cups of water daily [17]. Patiets with cacer seek utritio advice ad iformatio for a variety of reasos. Two commo reasos iclude a overall cocer about utritioal status after cacer diagosis ad the belief that utritio affects how oe respods to cacer treatmet [18]. May patiets who have wo their battle agaist cacer focus o prevetio of cacer recurrece, acceleratig the cacer recovery process, ad improvig quality of life ad log-term treatmet outcomes [13, 19]. Nutritio advice was commoly received amog 89% of participats i the preset study, primarily by physicias, urses, frieds ad family members. Few patiets i the curret study received iformatio from the iteret (2%) or cliical dietitias (2%). The America Cacer Society reports that may cacer patiets seek advice from frieds ad family members, but cautios patiets that this advice may ot be scietifically soud [17]. Patiet perceptios are critical for effective supportive care by family members ad caregivers ad may allow dietitias to tailor dietary advice to idividual patiet cocers. Based o the cumulative fidigs of this study, we suggest that healthcare practitioers participate i ope discussios with cacer patiets i their care to esure that evidece-based utritio-related advice is provided. The most commo factors cotributig to poor food itake ad perceived utritiorelated problems idetified i this study could be used as a startig poits for screeig, assessmet, ad treatmet that alleviate utritio-related problems. For example, a checklist regardig utritio-related problems ad cocers, completed by the patiet ad/or care provider while the patiet is waitig to receive treatmet, could immediately pipoit problem areas, which the ca be documeted ad commuicated

6 Smith JL et al. 203 to appropriate members of the healthcare team. Therefore, uderstadig patiet perceptios will allow the cliicia to tailor utritioal therapy ad advise patiets based o idividual cocers. The idetified issues could be addressed before the patiet leaves the treatmet ceter ad moitored over time. A example of such a checklist, a screeig tool kow as the scored Patiet-Geerated Subjective Global Assessmet (PG-SGA), could be useful for this purpose as it icludes a physical examiatio ad a medical history, ad assigs a malutritio-risk score to determie the appropriate level of utritio itervetio [20]. Oe limitatio of our study is it did ot icorporate the physical examiatio, medical history, ad scorig compoets icluded i the PG-SGA. Sice our study focused more specifically o utritio-related factors as perceived by the patiets themselves as opposed to physical data ad utritioal status, ad because a large compoet of the PG-SGA is coducted subjectively by the cliicia, our tool was felt to be more appropriate cosiderig the ature of our study. Results from this study idicated that family members are a importat source of utritio advice for cacer patiets. Mello ad colleagues reported that spouses ad adult childre are most commoly the caregivers for cacer patiets, ad oftetimes accompay the patiet to treatmet sessios [21]. Cliicias treatig cacer patiets should emphasize to family members the importace of patiet perceptios i providig effective supportive care ad soud utritio advice. Placig books, magazies, ad pamphlets i waitig ad treatmet areas at physicia offices ad chemotherapy ifusio ceters may be a iexpesive ad effective meas of dissemiatig reliable utritio-related iformatio to patiets ad caregivers. The iformatio provided should offer practical, evidece-based recommedatios that address commo factors cotributig to poor food itake, such as geeral loss of appetite, taste chages, fatigue, ausea, ad dysphagia, ad perceived utritio-related problems, such as eatig sufficiet amouts of high quality protei ad calories, cosumig a balaced diet that is adequate i vitamis ad mierals, ad strategies desiged to prevet uitetioal weight loss. Future research should determie if providig educatio materials i cacer treatmet ceters that address commoly perceived utritio-related problems ca improve utritio-related health outcomes amog patiets udergoig cacer treatmet. Sice this study elisted a small sample size, further research i larger patiet populatios usig the survey tool alog with collectig follow-up qualitative data is warrated. Specifically, combiig a screeig tool, such as the PG-SGA with a focused utritio-related survey, such as the oe used i the preset study, may be useful to evaluate patiet perceptios of their utritio-related problems i the cotext of their physical data ad utritioal status. ACKNOWLEDGEMENTS The authors thak the admiistratio for their support, ad selected staff for their role i recruitmet at Setara Obici Hospital ad Virgiia Ocology Associates, Ic, i particular to Alise Pulliam, MPA, RD, CNM, of Setara Obici Hospital. REFERENCES 1. Bosaeus I, Daeryd P, Ludholm K. Dietary itake, restig eergy expediture, weight loss ad survival i cacer patiets. J Nutr Nov;132(11 Suppl):3465S-3466S. Review. 2. Palombie J. Cacer-related weight loss. Cli J Ocol Nurs Dec;10(6): Batterham MJ, Edwards C. How Elevated is Restig Eergy Expediture i Cacer: A Meta-Aalysis. J Am Diet Assoc Aug;106(8 Suppl):A Tisdale MJ. Wastig i cacer. J Nutr Ja;129(1S Suppl):243S-246S. Review. 5. 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