Feasibility of a multimodal intervention on malnutrition in patients with lung cancer during primary anti-neoplastic treatment.

BACKGROUND: Wasting of body mass and skeletal muscle frequently develops in patients with cancer and is associated with impaired functional ability and poor clinical outcome and quality of life. This study aimed to evaluate the feasibility and explore the effect of a multimodal intervention targeting nutritional status in patients with non-small cell lung cancer receiving primary anti-neoplastic treatment. Additionally, predictive and prognostic factors of gaining skeletal muscle were explored. METHODS: This was a single-centre multimodal intervention trial using a historical control group. The multimodal intervention involved fish oil intake (2 g of eicosapentaenoic acid or docosahexaenoic acid daily), regular dietary counselling and unsupervised physical exercise twice weekly during the first three cycles of primary anti-neoplastic treatment. Feasibility was assessed through recruitment rate, completion rate and compliance rate with the intervention. Differences in skeletal muscle, body weight, and physical function between the intervention and historical control groups were analysed. Factors contributing to increased skeletal muscle were explored using univariate and multivariate ordinal logistic regression analyses. RESULTS: The recruitment and completion rates were 0.48 (n = 59/123) and 0.80 (n = 46/59), respectively. The overall compliance rate with all five individual interventions was 0.60 (n = 28/47). The individual compliance rates were 0.81 (n = 38/47) with fish oil intake, 0.94 (n = 44/47) with energy intake, 0.98 (n = 46/47) with protein intake, 0.51 (n = 24/47) with resistance exercise and 0.57 (n = 27/47) with aerobic exercise. No mean differences in skeletal muscle, body weight, or physical function were found between the intervention and control groups. However, a larger proportion of patients in the intervention group gained skeletal muscle (p < 0.02). The identified contributing factors of muscle gain were weight gain (OR, 1.3; p = 0.01), adherence to treatment plan (OR, 4.6; p = 0.02), stable/partial response (OR, 3.3; p = 0.04) and compliance to the intervention (OR, 7.4; p = 0.01). Age, sex, tumour stage, performance status, treatment type and baseline cachexia did not predict muscle gain. CONCLUSION: This three-dimensional intervention in patients with lung cancer undergoing primary anti-neoplastic treatment was feasible and increased the proportion of patients gaining skeletal muscle. Dietary counselling and fish oil use were useful strategies. The motivation for conducting unsupervised physical intervention was low. Clinical trials.gov identifier: NCT04161794.

High risk of disease-related malnutrition in gastroenterology outpatients.

OBJECTIVE: Disease-related malnutrition (DRM) in hospitalized patients is known to have significant negative impact on clinical outcomes. Meanwhile, DRM in gastroenterology outpatients is scarcely investigated. The aim of this study was to investigate the prevalence of unintentional weight loss (UWL) and reduced food intake (RFI) as contributors to the risk of DRM in outpatients. Furthermore, the aim was to investigate if UWL may be used as initial screening for DRM, based on the correlation between UWL and RFI. METHODS: All outpatients visiting the clinics for Medical and Surgery Gastroenterology, Aalborg University Hospital, Denmark, during 1 wk in September 2018, were invited to participate. Data regarding UWL within the past 3 mo, RFI the past week, and nutritional impact symptoms (NIS) were collected in this questionnaire-based cross-sectional study. Descriptive analysis, χ2 test, and multiple logistic regression analysis were used for statistics. RESULTS: Out of 348 eligible patients, 346 were included at the medical clinic (n = 170) and surgery clinic (n = 176). UWL occurred in 26%, with a mean weight loss of 7.1 kg (standard deviation [SD] 5.2), and 24% had RFI. A significantly increased risk of UWL was identified in patients with body mass index <18.5 kg/m2 (odds ratio 6.1; confidence interval 2.0-18.7; P = 0.003). NIS were more common in the medical clinic. The main self-reported reasons for NIS affecting UWL were lack of appetite (15% versus 12%), pain (14% versus 8%), and nausea (12% versus 3%). CONCLUSIONS: One in four outpatients experienced UWL to an extent that may have a significant negative impact on clinical outcome. A firm correlation was found between UWL and RFI. Thus, based on this superficial study, UWL may be used as initial screening for protein-energy malnutrition in the medical and surgery gastroenterology outpatient setting. The impact on clinical outcome and of early nutritional intervention in these settings need to be investigated.

Home parenteral nutrition provision modalities for chronic intestinal failure in adult patients: An international survey.

BACKGROUND & AIMS: The safety and effectiveness of a home parenteral nutrition (HPN) program depends both on the expertise and the management approach of the HPN center. We aimed to evaluate both the approaches of different international HPN-centers in their provision of HPN and the types of intravenous supplementation (IVS)-admixtures prescribed to patients with chronic intestinal failure (CIF). METHODS: In March 2015, 65 centers from 22 countries enrolled 3239 patients (benign disease 90.1%, malignant disease 9.9%), recording the patient, CIF and HPN characteristics in a structured database. The HPN-provider was categorized as health care system local pharmacy (LP) or independent home care company (HCC). The IVS-admixture was categorized as fluids and electrolytes alone (FE) or parenteral nutrition, either commercially premixed (PA) or customized to the individual patient (CA), alone or plus extra FE (PAFE or CAFE). Doctors of HPN centers were responsible for the IVS prescriptions. RESULTS: HCC (66%) was the most common HPN provider, with no difference noted between benign-CIF and malignant-CIF. LP was the main modality in 11 countries; HCC prevailed in 4 European countries: Israel, USA, South America and Oceania (p < 0.001). IVS-admixture comprised: FE 10%, PA 17%, PAFE 17%, CA 38%, CAFE 18%. PA and PAFE prevailed in malignant-CIF while CA and CAFE use was greater in benign-CIF (p < 0.001). PA + PAFE prevailed in those countries where LP was the main HPN-provider and CA + CAFE prevailed where the main HPN-provider was HCC (p < 0.001). CONCLUSIONS: This is the first study to demonstrate that HPN provision and the IVS-admixture differ greatly among countries, among HPN centers and between benign-CIF and cancer-CIF. As both HPN provider and IVS-admixture types may play a role in the safety and effectiveness of HPN therapy, criteria to homogenize HPN programs are needed so that patients can have equal access to optimal CIF care.

Exploring the dietary protein intake and skeletal muscle during first-line anti-neoplastic treatment in patients with non-small cell lung cancer.

BACKGROUND: Loss of skeletal muscle mass is the corner stone of cancer cachexia, but no effective therapies are yet identified. The optimal protein quantity and pattern to support muscle mass maintenance in cancer patients is unknown. The aim of the current exploratory study was to observe the pattern and quantity of dietary protein intake as well as the prevalence of muscle wasting in patients with inoperable non-small cell lung cancer (NSCLC) undergoing primary anti-neoplastic treatment. The secondary aim was to assess the potential contributory factors associated with maintenance of muscle mass. METHOD: A longitudinal observational study was conducted in patients with NSCLC undergoing first line of anti-neoplastic treatment. Nutrient intake was assessed by repeated 24-h recalls and skeletal muscle by routine thoraco-abdominal CT scans at baseline and after three cycles of treatment. Descriptive analyses, paired samples t-test, binomial logistic and linear regression analyses were performed. RESULTS: Out of 186 consecutively screened patients, 62 were included and 52 patients were available for analysis. Protein intake increased from baseline to follow up, but were lower in muscle wasters (1.0 g/kg/d) than in muscle maintainers (1.4 g/kg/d). The majority of the meals contributed less than 20 g of protein and less than 10% of the meals contributed at least 40 g of protein. Significant loss of skeletal muscle area was observed in 26 out of 52 patients. A higher protein intake (OR 18.7, p = 0.01), energy intake (OR 1.1, p = 0.04) and stable body weight (OR 1.2, p = 0.03) were associated with muscle maintenance in the univariate regression, whereas age, sex, cachexia, tumour stage, treatment adherence and response did not. In the multivariate regression, a trend was seen for protein intake (OR 35.2, p = 0.08) and body weight (OR 1.2, p = 0.06). CONCLUSION: Muscle wasting occurred frequently and early during primary anti-neoplastic treatment. Protein intake seems important for maintaining skeletal muscle. Validated dietary methods in cancer patients must be identified and the optimal protein quantity and intake pattern to support muscle maintenance should be explored in future trials.

Lifestyle Factors and Early Clinical Outcome in Patients With Acute Stroke: A Population-Based Study.

BACKGROUND AND PURPOSE: We examined the associations of individual and combined lifestyle factors with early adverse stroke outcomes. METHODS: A total of 82 597 patients were identified from nationwide registries. Lifestyle factors at the time of stroke admission included body mass index (kg/m2), smoking habits, and alcohol intake, which were grouped (healthy, moderately healthy, moderately unhealthy, and unhealthy). The associations between lifestyle and outcomes were examined using multivariable regression. RESULTS: A total of 18.3% had a severe stroke, 7.8% pneumonia, 12.5% urinary tract infection, and 9.9% died within 30 days. The association between lifestyle, stroke severity, and mortality, respectively, differed according to sex. Unhealthy lifestyle was associated with lower risk of severe stroke (adjusted odds ratio [OR], 0.73; 95% confidence interval [CI], 0.63-0.84) and 30-day mortality among men (adjusted OR, 0.71; 95% CI, 0.58-0.87), but not among women (severe stroke: adjusted OR, 1.14; 95% CI, 0.85-1.55, and mortality: adjusted OR, 1.34; 95% CI, 0.90-1.99). No sex differences were found for pneumonia and urinary tract infection. Unhealthy lifestyle was not associated with a statistically significant increased risk of developing in-hospital pneumonia (adjusted OR, 1.30; 95% CI, 0.98-1.73) or urinary tract infection (adjusted OR, 0.98; 95% CI, 0.72-1.33). Underweight was associated with a higher 30-day mortality (men: adjusted OR, 1.71; 95% CI, 1.50-1.96, and women: adjusted OR, 1.46; 95% CI, 1.34-1.60). CONCLUSIONS: Healthy lifestyle was not associated with a lower risk of adverse stroke outcomes, in particularly among men. However, underweight may be a particular concern being associated with an increased risk of adverse outcomes among both sexes.

Advances in clinical nutrition in GI surgery.

This review addresses recent relevant advances to clinical nutrition regarding gastrointestinal disease surgery. Medline Ovid, EMBASE and Central were searched systematically in April 2014. Inclusion criteria were randomized controlled trials, non-randomized controlled trials and observational studies evaluating nutritional support in gastrointestinal surgery published within 5 years. The review included 56 relevant studies. Themes were: nutrition screening and risk factors predict outcome; preoperative nutritional support; shortening fasting periods and including carbohydrate solutions; early nutrition after surgery; immune modulating nutrition; synbiotics, growth hormone, omega-3 and oral, enteral and parenteral nutrition in combination. Screening for nutritional risk is profound, with special focus on dietary intake in the past week. Age and severity of disease need to be included in the screening system. Patients at severe nutritional risk benefit from nutritional therapy before surgery. New standards are developing quickly and clinical guidelines on surgery should include updated knowledge within clinical nutrition.

Effects of perioperative supplementation with omega-3 fatty acids on leukotriene B4 and leukotriene B5 production by stimulated neutrophils in patients with colorectal cancer: a randomized, placebo-controlled intervention trial.

Omega-3 fatty acids (n-3 FA) may have beneficial clinical and immune-modulating effects in surgical patients. In a randomized, double-blind, prospective, placebo-controlled trial, 148 patients referred for elective colorectal cancer surgery received an n-3 FA-enriched oral nutritional supplement (ONS) providing 2.0 g of eicosapentaenoic acid (EPA) and 1.0 g of docosahexaenoic acid (DHA) per day or a standard ONS for seven days before surgery. On the day of operation, there was a significant increase in the production of leukotriene B5 (LTB5) (p < 0.01) and 5-hydroxyeicosapentaenoic acid (5-HEPE) (p < 0.01), a significant decrease in the production of leukotriene B4 (LTB4) (p < 0.01) and a trend for a decrease in the production of 5-hydroxyeicosatetraenoic acid (5-HETE) (p < 0.1) from stimulated neutrophils in the active group compared with controls. There was no association between LTB4 values and postoperative complications. In conclusion, oral n-3 FA exerts anti-inflammatory effects in surgical patients, without reducing the risk of postoperative complications.

Cancer risk in inflammatory bowel disease according to patient phenotype and treatment: a Danish population-based cohort study.

OBJECTIVES: Population-based studies of site-specific cancer risk in patients with inflammatory bowel disease (IBD) according to IBD phenotype and treatment are lacking. We studied cancer risk in a well-characterized population-based IBD cohort from North Jutland County, Denmark. METHODS: A total of 1,515 patients were diagnosed with ulcerative colitis (UC) and 810 with Crohn's disease (CD) during 1978-2002. Patients were followed until 31 December 2010 for occurrence of incident cancer, identified in the Danish Cancer Registry. Observed numbers of cancer were compared with expected numbers (based on age- and sex-specific background rates) and presented as standardized incidence ratios (SIRs) with 95% confidence intervals (CIs). RESULTS: Patients with UC were not at increased risk of cancer overall (SIR, 1.12; 95% CI, 0.97-1.28) despite increased risk of prostate cancer (SIR, 1.82; 95% CI, 1.17-2.71). Patients with CD had a 55% increased risk of cancer overall (SIR, 1.55; 95% CI, 1.29-1.84) related to young age, colonic disease, smoking, and thiopurine exposure. Patients were at increased risk of small bowel cancer (SIR, 15.18; 95% CI, 1.84-54.78), lung cancer (SIR, 2.13; 95% CI, 1.19-3.52 (associated with female gender and smoking)), colorectal cancer in males (SIR, 2.43; 95% CI, 1.05-4.78), cervical dysplasia (SIR, 1.65; 95% CI, 1.10-2.37 (associated with young age at diagnosis, smoking, 5-aminosalicylic acid, and thiopurine exposure)), and non-Hodgkin lymphoma (SIR, 3.43; 95% CI, 1.38-7.07 (unrelated to thiopurine exposure)). CONCLUSIONS: Patients with CD, but not UC, have an overall excess risk of cancer. Clinical characteristics of IBD patients at excess risk differ by cancer subtype.

Increase in incidence and prevalence of inflammatory bowel disease in northern Denmark: a population-based study, 1978-2002.

OBJECTIVES: Although incidence rates of inflammatory bowel disease have been reported worldwide, few long-term population-based studies with current time-trend analyses exist. We therefore examined time trends in the incidence rate of inflammatory bowel disease in a 25-year study period, and estimated the prevalence in 2002. All patients diagnosed between 1978 and 2002 were included as incident cases (n=2,326) and all patients living in North Jutland County on 31 December 2002 were used to estimate prevalent cases (n=2,205). METHODS: Medical records of all patients diagnosed with ulcerative colitis and Crohn's disease in the North Jutland County Hospital Discharge Registry were reviewed to examine if the diagnostic criteria were fulfilled. Age-specific and gender-specific standardized incidence rates were calculated. RESULTS: For ulcerative colitis, incidence rates in women increased from 8.3 (95% confidence interval (CI): 6.7-9.9) in 1978-1982 to 17.0 (95% CI: 14.7-19.3) per 100,000 person-years in 1998-2002. The corresponding figures for men were 7.7 (95% CI: 6.1-9.3) and 16.7 (95% CI: 14.4-18.8) per 100,000 person-years. For Crohn's disease, the incidence rates in women increased from 4.1 (95% CI: 3.0-5.2) in 1978-1982 to 10.7 (95% CI: 8.8-12.5) per 100,000 person-years in 1998-2002. The corresponding figures for men were 3.2 (95% CI: 2.1-4.2) and 8.5 (95% CI: 6.9-10.2) per 100,000 person-years. The prevalence of ulcerative colitis and Crohn's disease was 294 and 151 per 100,000 inhabitants, respectively. CONCLUSIONS: A marked and parallel increase was seen in both ulcerative colitis and Crohn's disease in both genders during the last 25 years, with a corresponding high prevalence of both diseases.