Risk factors for low muscle mass, malnutrition, and (probable-) sarcopenia in adults with or without a history of cancer in the UK Biobank.

BACKGROUND AND AIMS: Early identification of people at risk of cancer-related malnutrition, low muscle mass (LMM) and sarcopenia is crucial to mitigate the impact of adverse outcomes. This study investigated risk factors associated with LMM, malnutrition and (probable-) sarcopenia and whether these varied in people with or without a history of cancer. METHODS: Participants in the UK Biobank, with or without a history of cancer, who completed the Oxford WebQ at the baseline assessment were included. LMM was estimated from fat-free mass derived from bioelectrical impedance analysis, and low muscle strength from handgrip strength, and used to identify probable or confirmed sarcopenia following the European Working Group on Sarcopenia in Older People 2 definition. The Global Leadership Initiative on Malnutrition criteria were applied to determine malnutrition. Generalised linear models were used to estimate prevalence ratios (PR) for associations between risk factors (clinical, functional, nutritional) and study outcomes. RESULTS: Overall, 50,592 adults with (n = 2,287, mean ± SD 59.7 ± 7.1 years) or without (n = 48,305, mean ± SD 55.8 ± 8.2 years) cancer were included. For all participants (PRs [cancer, without cancer]), slow walking pace (PR 1.85; 1.99), multimorbidity (PR 1.72; 1.51), inflammation (PR 2.91; 2.07), and low serum 25(OH)D (PR 1.85, 1.44) were associated with higher prevalence of LMM, while higher energy intake (PR 0.55; 0.49) was associated with lower prevalence. Slow walking pace (PR 1.54 [cancer], 1.51 [without cancer]) and higher protein intake (PR 0.18 [cancer]; 0.11 [without cancer]) were associated with increased or decreased prevalence of malnutrition, respectively regardless of cancer status. Multimorbidity was the only common factor associated with higher prevalence (PR 1.79 [cancer], 1.68 [without cancer]) of (probable-)sarcopenia in all participants. CONCLUSION: Risk factors for LMM and malnutrition were similar in adults with and without cancer, although these varied between LMM and malnutrition. These findings have implications for the future of risk stratification, screening and assessment for these conditions and the development or modification of existing screening tools.

Meaningful consumer involvement in cancer care: a systematic review on co-design methods and processes.

OBJECTIVE: Although the benefits of consumer involvement in research and healthcare initiatives are known, there is a need to optimise this for all people with cancer. This systematic review aimed to synthesise and evaluate the application of co-design in the oncology literature and develop recommendations to guide the application of optimal co-design processes and reporting in oncology research, practice, and policy. METHODS: A systematic review of co-design studies in adults with cancer was conducted, searching MEDLINE, CINAHL, Embase and PsycINFO databases and included studies focused on two concepts, co-design and oncology. RESULTS: A total of 5652 titles and abstracts were screened, resulting in 66 eligible publications reporting on 51 unique studies. Four frameworks were applied to describe the co-design initiatives. Most co-design initiatives were designed for use in an outpatient setting (n = 38; 74%) and were predominantly digital resources (n = 14; 27%) or apps (n = 12; 23%). Most studies (n = 25; 49%) used a co-production approach to consumer engagement. Although some studies presented strong co-design methodology, most (n = 36; 70%) did not report the co-design approach and 14% used no framework. Reporting was poor for participant level of involvement, the frequency and time commitment of co-design sessions. Consumer participation level was predominantly collaborate (n = 25; 49%). CONCLUSIONS: There are opportunities to improve the application of co-design in oncology research. This review has generated recommendations to guide i) methodology and frameworks, ii) recruitment and engagement of co-design participants, and iii) evaluation of the co-design process. These recommendations can help drive appropriate, meaningful, and equitable co-design, leading to better cancer research and care.

Exploring dietitians' practice and perspectives on the role of dietary patterns during cancer treatment: A qualitative study.

BACKGROUND: Dietitians are nutrition professionals equipped with specialised skills required to prevent and treat malnutrition in cancer. Optimisation of dietary intake is recommended as the primary nutrition strategy for the treatment of cancer-related malnutrition. However, it is unclear whether dietary patterns, described as the combination, quantity, and frequency of food consumption, are considered. This study examined dietitians' current food-based management of malnutrition; explored dietitians' awareness of dietary patterns and assessed barriers and enablers to the use of dietary patterns in clinical practice. METHODS: This qualitative study consisted of semi-structured interviews with oncology dietitians. Dietitians were recruited through national nutrition societies, social media, and professional networks. Audio-recorded interviews were transcribed verbatim and analysed using inductive thematic analysis. RESULTS: Fourteen oncology dietitians from across four Australian states and territories participated. Three themes were identified: (i) principles to guide nutritional care, (ii) dietary patterns as a gap in knowledge and practice, and (iii) opportunities for better care with systems as both a barrier and enabler. Dietetic practice was food-focussed, encouraging energy and protein-rich foods consistent with nutrient-focussed evidence-based guidelines. Dietitians encouraged one of two nutrition-related approaches, either encouraging intake of 'any tolerated food' or 'foods supportive on longer-term health'. Dietitians were generally unaware of dietary patterns and questioned their relevance in certain clinical situations. A multidisciplinary team approach, adequate food service and dissemination of dietary patterns research and education were identified as opportunities for better patient care. CONCLUSIONS: Recommendations for the treatment of malnutrition vary between oncology dietitians and uncertainty exists regarding dietary patterns and their relevance in clinical practice. Further exploration into the role of dietary patterns to treat cancer-related malnutrition and education for dietitians are required prior to implementation of a dietary patterns approach into clinical practice.

Enhancing the provision of cancer nutrition information to support care through experience-based co-design: a mixed-methods study.

PURPOSE: Nutrition is essential within cancer care, yet patient and carer access to nutrition care and information is variable. This study aimed to (1) investigate patient and carer access and perceptions, and health professional views and practices, relating to cancer nutrition information and care; and (2) co-design interactive resources to support optimal nutrition care. METHODS: Patients and carers completed a survey regarding access to nutrition care and information. Seven multidisciplinary health service teams were invited to participate in a survey and focus group to assess barriers and enablers in nutrition practices. Focus groups were recorded, transcribed and thematically analyzed. Eligible patients, carers, and health professionals were invited to four virtual workshops utilizing experience-based co-design methods to identify nutrition priority areas and design resources. Workshop participant acceptability of the resources was measured. RESULTS: Of 104 consumer survey respondents (n = 97 patients, n = 7 carers), 61% agreed that it "took too much time to find evidence-based nutrition and cancer information", and 46% had seen a dietitian. Thirty-four of 38 health professionals completed the survey and 30 participated in a focus group, and it was identified the greatest barriers to delivering nutrition care were lack of referral services, knowledge or skill gaps, and time. Twenty participants (n = 10 patients and carers, n = 10 health professionals) attended four workshops and co-designed a suite of 46 novel resources rated as highly acceptable. CONCLUSION: Improved communication, training, and availability of suitable resources could improve access to and support cancer nutrition information and care. New, co-designed cancer nutrition resources were created and deemed highly acceptable to patients, carers, and health professionals.

Nutritional interventions during treatment for ovarian cancer: A narrative review and recommendations for future research.

Most women with ovarian cancer are diagnosed at an advanced stage (stage III or IV), when the intraabdominal spread of the tumour impacts nutrient intake and absorption. Up to 70 % of women with ovarian cancer are malnourished and approximately 40 % are affected by muscle loss at the time of diagnosis. Women with ovarian cancer are at high risk of nutritional decline due to invasive treatment and the severity of side-effects. This review explores the evidence evaluating nutritional interventions during treatment for ovarian cancer and their effect on nutritional status, muscle mass, and clinical outcomes. Perioperative immunonutrition has been investigated with mixed results for immediate postoperative outcomes. Individualised nutrition counselling as part of a multimodal prehabilitation programme prior to surgery shows promising results; however, the effects are limited by sample size. Nutrition counselling as part of a mixed intervention with exercise shows high acceptability and suggests improvements in dietary intake and quality of life during chemotherapy treatment, while oral nutritional supplements and nutrition education appear to reduce symptom burden. Individualised nutrition counselling during treatment also appears to be associated with improved overall survival; however, the evidence is limited to a single retrospective study. A key finding from this review is that, despite the high prevalence of malnutrition and muscle loss in women with ovarian cancer and the critical importance of addressing these modifiable prognostic factors, nutrition intervention studies are limited. Prospective studies with samples large enough to provide adequate power to evaluate intervention effectiveness are urgently required to inform optimal management.

Dietary patterns linked to lower odds of malnutrition are associated with all-cause and cancer mortality in adults with cancer.

OBJECTIVES: Dietary patterns, characterised by protein, polyunsaturated fatty acids, and vitamin D, reduce the odds of malnutrition in cancer survivors. However, it is unclear whether these dietary patterns also improve prognosis. This study prospectively examined associations between dietary patterns linked to lower odds of malnutrition and the risk of all-cause and cancer mortality in adult cancer survivors from the UK Biobank cohort. DESIGN: Prospective observational study. SETTING AND PARTICIPANTS: Cancer survivors from the UK Biobank (mean ± SD, 7.1 ± 6.3 years since diagnosis) were included (n = 2415; 59.7 ± 7.1 years; 60.7% female). MEASUREMENTS: Dietary intake was estimated using the Oxford WebQ 24-h dietary assessment. Dietary patterns ('high oily fish and nuts', and 'low oily fish') were derived using reduced rank regression (response variables: protein (g/kg/day), polyunsaturated fatty acids (g/day) and vitamin D (µg/day)). Cox proportional hazard models estimated hazard ratios (HR) and 95% confidence intervals (CI) for all-cause and cancer mortality. Nonlinear relationships were examined using restricted cubic splines. Models were adjusted for demographic and health characteristics. Sub-group analyses investigated relationships in sub-samples of adults with i) high nutritional risk (lung, gastrointestinal, haematological, or head and neck tumours) and ii) recent cancer diagnosis (cancer diagnosis within two years prior to assessment). RESULTS: Deaths due to all-causes (n = 305) and cancer (n = 249) were identified during a median 10.4 (IQR: 10.2-10.8) years follow-up. There were no statistically significant linear associations between the dietary patterns and all-cause or cancer mortality. However, a U-shaped association between the 'high oily fish and nuts' pattern, characterised by higher intake of oily fish and nuts and seeds, and all-cause mortality (p-non-linearity = 0.004) was identified, as well as with all-cause (p-non-linearity = 0.006) and cancer mortality (p-non-linearity = 0.035) in adults with a high nutritional risk cancer diagnosis (lung, gastrointestinal, haematological, or head and neck tumours), indicating that both above and below mean intake was associated with increased risk. The 'low oily fish' pattern, characterised by lower oily fish but higher potato intake, also had a non-linear association with all-cause mortality (p-non-linearity = 0.046) where lower but not higher than mean intake increased mortality risk. No dietary patterns were significantly associated with mortality in adults with a recent cancer diagnosis. CONCLUSION: 'High oily fish and nuts' or 'low oily fish' dietary patterns that were protective against malnutrition were associated with risk of all-cause and cancer mortality in adults with cancer. Future research should assess the efficacy of these dietary patterns in the acute treatment period when malnutrition is most prevalent.

Longitudinal changes in body composition and diet after acute spinal cord injury.

OBJECTIVE: Spinal cord injury (SCI) is associated with low muscle mass and adiposity, however, to our knowledge, few studies have monitored the trajectory of changes over time. This study aimed to evaluate the timing, rate, magnitude, and site-specific changes in body composition and related changes in diet after SCI. METHODS: We assessed 39 patients with SCI. The analysis included five women. Of the participants, 51% had American Spinal Injury Association Impairment Scale (AIS) criteria A/B (motor complete) injuries, 18% had AIS C (sensory/motor incomplete) injuries, and 31% had AIS D (motor incomplete) injuries. The mean age of the patients was 43.2 y. They were 48.1 d post-injury and had their weight, diet, and body composition (bioimpedance spectroscopy) assessed every 2 wk. RESULTS: No significant linear changes were observed for any body composition measure. Total body fat mass (FM) changed 0.01 kg/2 wk when fitted to a quadratic model (P = 0.004), decreasing to week 15 and returning to baseline at week 28. Subgroup analysis revealed that arm lean tissue mass (LTM) increased in paraplegic versus tetraplegic participants (0.05 versus -0.01 kg/2 wk, P = 0.007). Participants with AIS A/B injuries lost FM (-0.17 kg; P = 0.010), whereas those with AIS C injuries gained appendicular LTM (ALTM; 0.15 kg; P = 0.017) and leg LTM (0.12 kg; P = 0.008) every 2 wk. Body composition remained stable in the AIS D group. Mean fortnightly changes were greater in the AIS A/B group than the C group for weight (mean difference -0.30 kg; P = 0.021), FM (-0.25 kg; P = 0.002), and leg LTM (-0.11 kg; P = 0.021) and AIS A/B versus D for FM (-0.42 kg; P = 0.013). Baseline energy and protein intakes were 2150 kcal (±741) and 102 g (±40) and decreased by 21.5 kcal (P = 0.016) and 1.3 g (P = 0.004) every 2 wk but were not associated with body composition changes. CONCLUSIONS: Neurologic level and severity of SCI, but not changes in diet, were the main determinants of heterogeneous body composition changes.

iCare - a self-directed, interactive online program to improve health and wellbeing for people living with upper gastrointestinal or hepato-pancreato-biliary cancers, and their informal carers: the study protocol for a Phase II randomised controlled trial.

BACKGROUND: Up to 70% of people diagnosed with upper gastrointestinal (GI) tract or hepato-pancreato-biliary (HPB) cancers experience substantial reductions in quality of life (QoL), including high distress levels, pain, fatigue, sleep disturbances, weight loss and difficulty swallowing. With few advocacy groups and support systems for adults with upper GI or HPB cancers (i.e. pancreas, liver, stomach, bile duct and oesophageal) and their carers, online supportive care programs may represent an alternate cost-effective mechanism to support this patient group and carers. iCare is a self-directed, interactive, online program that provides information, resources, and psychological packages to patients and their carers from the treatment phase of their condition. The inception and development of iCare has been driven by consumers, advocacy groups, government and health professionals. The aims of this study are to determine the feasibility and acceptability of iCare, examine preliminary efficacy on health-related QoL and carer burden at 3- and 6-months post enrolment, and the potential cost-effectiveness of iCare, from health and societal perspectives, for both patients and carers. METHODS AND ANALYSIS: A Phase II randomised controlled trial. Overall, 162 people with newly diagnosed upper GI or HPB cancers and 162 carers will be recruited via the Upper GI Cancer Registry, online advertisements, or hospital clinics. Patients and carers will be randomly allocated (1:1) to the iCare program or usual care. Participant assessments will be at enrolment, 3- and 6-months later. The primary outcomes are i) feasibility, measured by eligibility, recruitment, response and attrition rates, and ii) acceptability, measured by engagement with iCare (frequency of logins, time spent using iCare, and use of features over the intervention period). Secondary outcomes are patient changes in QoL and unmet needs, and carer burden, unmet needs and QoL. Linear mixed models will be fitted to obtain preliminary estimates of efficacy and variability for secondary outcomes. The economic analysis will include a cost-consequences analysis where all outcomes will be compared with costs. DISCUSSION: iCare provides a potential model of supportive care to improve QoL, unmet needs and burden of disease among people living with upper GI or HPB cancers and their carers. AUSTRALIAN AND NEW ZEALAND CLINICAL TRIALS REGISTRY: ACTRN12623001185651. This protocol reflects Version #1 26 April 2023.

The influence of pediatric cancer treatment on taste perception and food hedonics: a systematic review.

CONTEXT: Children with cancer are at risk of poor nutritional status during treatment and into survivorship. Objectively measured taste perception and self-reported food hedonics are 2 factors that may influence food intake. OBJECTIVE: This 2-armed systematic review examined whether chemotherapy and radiotherapy affect (1) taste perception and (2) hedonic experiences of children and survivors of childhood cancer. DATA SOURCE: A 2-armed systematic literature search was conducted in the Medline, CINAHL, Embase, and PsychInfo database until June 2022. The effects of cancer treatment on objective taste perception or food hedonics (ie, food liking or aversion and appetite) were examined. DATA EXTRACTION: Peer-reviewed articles published in English of studies that included children (aged <18 years) or survivors of childhood cancer (any age) were reviewed. Risk of bias was determined using the Evidence Analysis Library by the Academy of Nutrition and Dietetics. DATA ANALYSIS: A total of 1417 articles in the taste search arm and 3862 articles in the hedonics search arm were identified. Of these, 9 and 4 articles were eligible for review, respectively. Cancer treatment had highly variable effects on taste perception during treatment and into survivorship. Learned food aversions were experienced by children receiving chemotherapy treatment and liking of meats and salty foods by children with cancer was affected. The impact of treatment on appetite varied. CONCLUSIONS: Cancer treatment did not uniformly affect taste perception. Food liking may be negatively affected, and learned food aversions may develop during cancer treatment. To establish the clinical relevance of childhood cancer treatment on taste perception and food hedonics, more research is required. SYSTEMATIC REVIEW REGISTRATION: PROSPERO registration no.CRD42020207127.

Sex disparities in parenteral and enteral nutrition societies' leadership worldwide: a 20-year retrospective analysis.

BACKGROUND: Despite advancements in the global dialog surrounding sex and gender equity, an important gap persists with women markedly underrepresented in major roles within health care leadership. OBJECTIVES: We examined the extent of women's representation in prominent positions within parenteral and enteral nutrition (PEN) societies worldwide over a span of 2 decades. DESIGN: This retrospective analysis explored the sex distribution of society chairs, conference presidents, and editor-in-chief positions across 64 PEN societies between 2003 and 2022. Additionally, data on the first and last authors of endorsed clinical guidelines were collected from the 2 leading societies. RESULTS: Over the past 20 y, women held society chair positions in 34.4% of cases. The representation shifted from 30% during the decade from 2003 to 2012 to 40.5% from 2013 to 2022. Throughout these years, the numbers consistently ranged from 0 to 10; however, the median shifted upward from 1 during the first decade to 4 in the subsequent decade (P = 0.04). Of 420 congress presidencies, ∼30% were women. In endorsed guidelines, women were the first authors in 27.1% of cases (P < 0.001) and the last in 28.9% (P < 0.001) compared with men. Of the 123 journal editor-in-chief positions, women occupied 23 (18.7%). CONCLUSION: Over the last 2 decades, women have been consistently underrepresented in prominent leadership roles in PEN societies globally. Although there has been a noticeable shift toward more women in chair positions, true sex equality remains elusive. Moreover, sex disparities are even more pronounced in positions, such as conference presidents, authors of major guidelines, and editors-in-chief of society-affiliated journals. These data underscore the pressing need to enhance efforts toward sex equality across these domains.

Variance Decomposition of the Continuous Assessment of Interpersonal Dynamics (CAID) system: Assessing sources of influence and reliability of observations of parent-teen interactions.

The Continuous Assessment of Interpersonal Dynamics (CAID) is an observational tool that measures warmth and dominance dynamics in real time and is sensitive to individual, dyadic, and contextual influences. Parent-adolescent interpersonal dynamics, which conceptually map onto parenting styles, are an integral part of positive adolescent adjustment and protect against risky outcomes. The current study's goal was to test the degree to which sources of influence on CAID data observed in a previous study of married couples generalize to a sample of parent-adolescent dyads. We examined data from ten raters who rated moment-to-moment warmth and dominance using CAID in a sample of 61 parent-adolescent dyads (N = 122) who were largely non-Hispanic White (62%) or African American (30%) based on parent report (adolescent M age = 14; 57% female). Dyads interacted in four different discussion segments (situations). We applied Generalizability Theory to delineate several sources of variance in CAID parameters and estimated within and between-person reliability. Results revealed a number of different influences, including the person, kinsperson (adolescent versus parent), dyad, rater, situation, and interactions among these factors, on ratings of parent-adolescent interpersonal behavior. These results largely replicate results from married couples, suggesting that the factors that influence ratings of interpersonal interactions largely generalize across sample types.

Optimizing clinical nutrition research: the role of adaptive and pragmatic trials.

Evidence-based nutritional recommendations address the health impact of suboptimal nutritional status. Efficacy randomized controlled trials (RCTs) have traditionally been the preferred method for determining the effects of nutritional interventions on health outcomes. Nevertheless, obtaining a holistic understanding of intervention efficacy and effectiveness in real-world settings is stymied by inherent constraints of efficacy RCTs. These limitations are further compounded by the complexity of nutritional interventions and the intricacies of the clinical context. Herein, we explore the advantages and limitations of alternative study designs (e.g., adaptive and pragmatic trials), which can be incorporated into RCTs to optimize the efficacy or effectiveness of interventions in clinical nutrition research. Efficacy RCTs often lack external validity due to their fixed design and restrictive eligibility criteria, leading to efficacy-effectiveness and evidence-practice gaps. Adaptive trials improve the evaluation of nutritional intervention efficacy through planned study modifications, such as recalculating sample sizes or discontinuing a study arm. Pragmatic trials are embedded within clinical practice or conducted in settings that resemble standard of care, enabling a more comprehensive assessment of intervention effectiveness. Pragmatic trials often rely on patient-oriented primary outcomes, acquire outcome data from electronic health records, and employ broader eligibility criteria. Consequently, adaptive and pragmatic trials facilitate the prompt implementation of evidence-based nutritional recommendations into clinical practice. Recognizing the limitations of efficacy RCTs and the potential advantages of alternative trial designs is essential for bridging efficacy-effectiveness and evidence-practice gaps. Ultimately, this awareness will lead to a greater number of patients benefiting from evidence-based nutritional recommendations.

Dietary patterns, malnutrition, muscle loss and sarcopenia in cancer survivors: findings from the UK Biobank.

PURPOSE: To identify dietary patterns derived from protein, polyunsaturated fatty acids (PUFA) and vitamin D and examine associations with malnutrition, low muscle mass and sarcopenia in cancer survivors. METHODS: This cross-sectional study included cancer survivors (n = 2415) from the UK Biobank (age [mean ± SD] 59.7 ± 7.1 years; 60.7% female). The Oxford WebQ 24-h dietary assessment estimated food and nutrient intakes. Reduced rank regression derived dietary patterns (response variables: protein [g/kg/day], PUFA [g/day] and vitamin D [µg/day]). Adjusted logistic regression analysis examined associations between dietary patterns and malnutrition, low muscle mass and sarcopenia. RESULTS: Three dietary patterns were identified: (i) 'high oily fish and nuts', characterised by higher oily fish and nuts and seeds intake; (ii) 'low oily fish', characterised by lower oily fish intake and higher potato intake; and (iii) 'meat and dairy', characterised by higher intake of meat, poultry and dairy. Eighteen percent of participants were malnourished, 5% had low muscle mass and 6.5% had sarcopenia. Odds of being malnourished were significantly lower with adherence to a 'high oily fish and nuts' pattern (OR: 0.57; 95% CI: 0.50, 0.65) and 'low oily fish' pattern (OR: 0.81; 95% CI: 0.73, 0.90). The 'meat and dairy' pattern was not associated with malnutrition. No dietary patterns were associated with low muscle mass or sarcopenia. CONCLUSIONS: Energy-rich dietary patterns were associated with lower odds of malnutrition in cancer survivors but did not influence muscle mass or sarcopenia risk. IMPLICATIONS FOR CANCER SURVIVORS: Better understanding of dietary patterns may improve cancer-related outcomes for cancer survivors.

Nutrition services during prostate cancer androgen deprivation therapy.

OBJECTIVE: Dietary interventions are effective strategies to mitigate multiple side effects from androgen deprivation therapy (ADT) in prostate cancer, however the perception of, and access to, nutrition services is relatively unknown. METHODS: A qualitative study using semistructured, audio recorded interviews was conducted in men with prostate cancer treated with ADT for ≥3 months. Interviews explored (1) side effects of ADT and drivers for dietary change, (2) accessibility, barriers, facilitators and use of nutrition services and (3) the preferences for nutrition service delivery. Data were coded using interpretative descriptive techniques of textual interview data, and systematically summarised to generate thematical patterns, using NVivo software. RESULTS: Interviews were completed of 20 men with prostate cancer treated with ADT (25.5±20.1 months). Thematic analysis revealed four overarching themes-(1) the changes from ADT: men revealed that weight gain, loss of muscle and strength from ADT were daily struggles that negatively impact body image and components of masculinity reduced; (2) strategies to take control: several dietary changes were trialled and restrictive in foods and nutrients. Barriers to accessing nutrition specialists were the cost for the service and absence of a clear referral pathway; (3) importance of nutrition knowledge: demand for specialised nutrition services with knowledge in addressing side effects from ADT; (4) diverse patients need diverse nutrition support: that includes peer or partner support, and technology supported nutrition content. CONCLUSION: Evidence-based nutrition services are an unmet need for men treated with ADT. Future work is required to develop services that can be readily available and accessible to improve prostate cancer survivorship care.

Machine learning models to predict outcomes at 30-days using Global Leadership Initiative on Malnutrition combinations with and without muscle mass in people with cancer.

BACKGROUND: Equipment to assess muscle mass is not available in all health services. Yet we have limited understanding of whether applying the Global Leadership Initiative on Malnutrition (GLIM) criteria without an assessment of muscle mass affects the ability to predict adverse outcomes. This study used machine learning to determine which combinations of GLIM phenotypic and etiologic criteria are most important for the prediction of 30-day mortality and unplanned admission using combinations including and excluding low muscle mass. METHODS: In a cohort of 2801 participants from two cancer malnutrition point prevalence studies, we applied the GLIM criteria with and without muscle mass. Phenotypic criteria were assessed using ≥5% unintentional weight loss, body mass index, subjective assessment of muscle stores from the PG-SGA. Aetiologic criteria included self-reported reduced food intake and inflammation (metastatic disease). Machine learning approaches were applied to predict 30-day mortality and unplanned admission using models with and without muscle mass. RESULTS: Participants with missing data were excluded, leaving 2494 for analysis [49.6% male, mean (SD) age: 62.3 (14.2) years]. Malnutrition prevalence was 19.5% and 17.5% when muscle mass was included and excluded, respectively. However, 48 (10%) of malnourished participants were missed if muscle mass was excluded. For the nine GLIM combinations that excluded low muscle mass the most important combinations to predict mortality were (1) weight loss and inflammation and (2) weight loss and reduced food intake. Machine learning metrics were similar in models excluding or including muscle mass to predict mortality (average accuracy: 84% vs. 88%; average sensitivity: 41% vs. 38%; average specificity: 85% vs. 89%). Weight loss and reduced food intake was the most important combination to predict unplanned hospital admission. Machine learning metrics were almost identical in models excluding or including muscle mass to predict unplanned hospital admission, with small differences observed only if reported to one decimal place (average accuracy: 77% vs. 77%; average sensitivity: 29% vs. 29%; average specificity: 84% vs. 84%). CONCLUSIONS: Our results indicate predictive ability is maintained, although the ability to identify all malnourished patients is compromised, when muscle mass is excluded from the GLIM diagnosis. This has important implications for assessment in health services where equipment to assess muscle mass is not available. Our findings support the robustness of the GLIM approach and an ability to apply some flexibility in excluding certain phenotypic or aetiologic components if necessary, although some cases will be missed.

Low muscle mass, malnutrition, sarcopenia, and associations with survival in adults with cancer in the UK Biobank cohort.

BACKGROUND: Low muscle mass (MM) is a common component of cancer-related malnutrition and sarcopenia, conditions that are all independently associated with an increased risk of mortality. This study aimed to (1) compare the prevalence of low MM, malnutrition, and sarcopenia and their association with survival in adults with cancer from the UK Biobank and (2) explore the influence of different allometric scaling (height [m2 ] or body mass index [BMI]) on low MM estimates. METHODS: Participants in the UK Biobank with a cancer diagnosis within 2 years of the baseline assessment were identified. Low MM was estimated by appendicular lean soft tissue (ALST) from bioelectrical impedance analysis derived fat-free mass. Malnutrition was determined using the Global Leadership in Malnutrition criteria. Sarcopenia was defined using the European Working Group on Sarcopenia in Older People criteria (version 2). All-cause mortality was determined from linked national mortality records. Cox-proportional hazards models were fitted to estimate the effect of low MM, malnutrition, and sarcopenia on all-cause mortality. RESULTS: In total, 4122 adults with cancer (59.8 ± 7.1 years; 49.2% male) were included. Prevalence of low MM (8.0% vs. 1.7%), malnutrition (11.2% vs. 6.2%), and sarcopenia (1.4% vs. 0.2%) was higher when MM was adjusted using ALST/BMI compared with ALST/height2 , respectively. Low MM using ALST/BMI identified more cases in participants with obesity (low MM 56.3% vs. 0%; malnutrition 50% vs. 18.5%; sarcopenia 50% vs. 0%). During a median 11.2 (interquartile range: 10.2, 12.0) years of follow up, 901 (21.7%) of the 4122 participants died, and of these, 744 (82.6%) deaths were cancer-specific All conditions were associated with a higher hazard of mortality using either method of MM adjustment: low MM (ALST/height2 : HR 1.9 [95% CI 1.3, 2.8], P = 0.001; ALST/BMI: HR 1.3 [95% CI 1.1, 1.7], P = 0.005; malnutrition (ALST/height2 : HR 2.5 [95% CI 1.1, 1.7], P = 0.005; ALST/BMI: HR 1.3 [95% CI 1.1, 1.7], P = 0.005; sarcopenia (ALST/height2 : HR 2.9 [95% CI 1.3, 6.5], P = 0.013; ALST/BMI: HR 1.6 [95% CI 1.0, 2.4], P = 0.037). CONCLUSIONS: In adults with cancer, malnutrition was more common than low MM or sarcopenia, although all conditions were associated with a higher mortality risk, regardless of the method of adjusting for MM. In contrast, adjustment of low MM for BMI identified more cases of low MM, malnutrition, and sarcopenia overall and in participants with obesity compared with height adjustment, suggesting it is the preferred adjustment.

Can sarcopenia predict survival in locally advanced rectal cancer patients?

BACKGROUND: There is mounting evidence that suggests sarcopenia can be used to predict survival outcomes in patients with colon cancer. However, the effect on locally advanced rectal cancer (LARC) is less clear. We sought to determine the association between sarcopenia on Overall Survival and Recurrence-free Survival (OS and RFS) in patients with LARC undergoing multimodal treatment. METHODS: A retrospective study was undertaken of all pre-treatment stage 2-3 rectal cancer patients who underwent neo-adjuvant treatment and surgery with curative intent between January 2010 and September 2016 at Western Health. Sarcopenia was measured on pre-treatment staging scans at the third lumbar vertebrae and defined using cohort-derived, sex-specific thresholds. Primary outcomes were OS and RFS. RESULTS: A total of 132 patients with LARC were analysed. Sarcopenia: Hazard ratio (HR) 3.71; 95% CI, 1.28-10.75, P = 0.016 was independently associated with worse Overall Survival following multivariate analysis. There was no significant relationship between sarcopenia and RFS: Time ratio (TR) 1.67; 95% CI 0.52-5.34, P = 0.386. CONCLUSION: Sarcopenia was found to be an independent risk factor for worse overall survival, but not recurrence free survival, in patients with locally advanced rectal cancer undergoing neo-adjuvant chemo-radiotherapy and surgery with curative intent.

Co-design of a cancer nutrition care pathway by patients, carers, and health professionals: the CanEAT pathway.

PURPOSE: Limited practical resources exist to guide optimal nutrition care for patients, carers, and health professionals (HPs). This study aimed to co-design a cancer nutrition care pathway to guide and improve the provision of consistent, evidence-based care with consumers and HPs. METHODS: This study utilised an experienced-based co-design (EBCD) approach over five stages. Stage 1 involved stakeholder engagement and a literature review. Stage 2 included a survey and focus groups with patients/carers. Co-design workshops were conducted within stage 3, key stakeholder consultation within stage 4, and the finalisation and dissemination of the cancer nutrition care pathway formed stage 5. Results of stages 3 to 5 are the focus of this paper. RESULTS: Two co-design workshops were held with patients, carers, and HPs (n = 32 workshop 1; n = 32 workshop 2), who collectively agreed on areas of focus and key priorities. Following this, a consultation period was completed with patients, carers, and HPs (n = 45) to refine the pathway. The collective outcome of all study stages was the co-design of a cancer nutrition care pathway (the CanEAT pathway) defining optimal cancer nutrition care that combines evidence-based practice tips into a centralised suite of resources, tools, and clinical guidance. CONCLUSION: The CanEAT pathway was co-designed by patients, carers, and HPs. The EBCD approach is a meaningful way to develop targeted improvements in cancer care. The CanEAT pathway is freely available to guide and support patients, carers, and HPs to aid the implementation of optimal nutrition care into clinical practice.

Relationship between global leadership initiative on malnutrition (GLIM) defined malnutrition and survival, length of stay and post-operative complications in people with cancer: A systematic review.

BACKGROUND & AIMS: The predictive validity of the GLIM criteria for survival, length of hospital stay (LOHS) and post-operative complications among people with cancer have not been systematically reviewed. This systematic review aims to determine whether GLIM malnutrition is predictive of these outcomes, and whether the predictive validity is affected by how phenotypic and etiologic criteria are assessed. METHODS: Cohort studies published after 2018 were systematically reviewed according to PRISMA guidelines from Embase, Medline Complete and CINAHL Complete. Risk of bias and methodologic quality were assessed using the Journal of the Academy of Nutrition and Dietetics' Quality Criteria Checklist tool for Primary research. RESULTS: In total, 21 studies were included, including 28,726 participants. All studies investigated survival, where 18 reported GLIM malnutrition is associated with decreased survival. LOHS was investigated in six studies, with all finding an association between GLIM malnutrition and longer LOHS. Post-operative complications were assessed in seven studies, of which five reported GLIM malnutrition was predictive of increased post-operative complications. Methods to assess the GLIM phenotypic and etiologic criteria varied, with consistent predictive ability for survival regardless of method of assessing reduced muscle mass. However, predictive ability was more variable across different measures of inflammation and reduced intake. CONCLUSION: GLIM malnutrition was consistently predictive of worse clinical outcomes. Different measures of reduced muscle mass did not affect the predictive ability of GLIM for survival. However, variation in assessment of the etiologic criteria resulted in varying predictive ability of the GLIM diagnosis for survival.