Symptom burden in head and neck cancer: impact upon oral energy and protein intake.

PURPOSE: This study explored relationships between oral symptom burden (xerostomia, thick secretions, and mucosal sensitivity), energy and protein intake, and weight change over time among head and neck cancer (HNC) patients who have completed concurrent chemoradiation (CCR). METHODS: Symptom burden was assessed utilizing the Vanderbilt Head and Neck Symptom Survey version 2.0. Weight change was measured from diagnosis to treatment completion, and to the early, mid, and late recovery stage. Energy and protein intake were determined utilizing 24-h diet recalls. RESULTS: Forty-three adult patients treated for HNC enrolled in the study. Mean percentage weight loss from diagnosis to treatment completion was 7.91 ± 4.06 %. Within the mid-recovery stage significant inverse relationships were found between oral protein intake and xerostomia and mucosal sensitivity (r = -0.818, p = 0.012; r = -0.726, p = 0.032, respectively). After controlling for weight change, significant inverse relationships were found within the mid-recovery stage between oral energy intake and xerostomia and mucosal sensitivity (r = -0.740, p = 0.046; r = -0.751, p = 0.043, respectively). Significant, inverse relationships were also found between oral protein intake and xerostomia and mucosal sensitivity (r = -0.835, p = 0.019; r = -0.726, p = 0.033, respectively). CONCLUSIONS: Xerostomia and mucosal sensitivity were significantly related to oral energy and protein intake post-CCR in mid-recovery. Weight loss was greatest from diagnosis to treatment completion and continued through the mid-recovery stage. Assessment of oral symptom burden (xerostomia and mucosal sensitivity) and its impact on oral intake and weight post-CCR should be conducted routinely in good patient care.

Safety of increasing protein delivery with an enteral nutrition formula containing very high protein (VHP) and lower carbohydrate concentrations compared to conventional standard (SF) and high protein (HP) formulas.

BACKGROUND & AIMS: Studies demonstrate that caloric restriction in the first seven days in the ICU is safe. The amount of protein that should be delivered, however, is still unclear with clinical trials suggesting mixed results. Despite some capacity to customize the delivery of protein using supplemental modules, protein delivered is best determined by the concentration of protein contained in enteral formula (EF) ordered. This fact provides an opportunity to explore the potential clinical effects of protein delivery and lower carbohydrate intake on clinical outcomes compared with conventional enteral formulas. METHODS: Retrospective analysis of clinical outcomes according to the amount of protein delivered in critically ill patients admitted to intensive care units at Geisinger Health System. RESULTS: 2000 encounters (1899 patients) in patients on enteral nutrition were divided into three groups receiving EF with either ≤20% protein (standard formula - SF), 21-25% protein (high protein - HP) or > 25% protein (VHP). Protein intake increased up to day 7 (p < 0.0001). Patients on VHP received more protein than other groups (p < 0.0001). Multivariable regression analysis showed no evidence of harm. In fact, we observed increased mortality with SF and HP formulas at 30-days post-discharge when compared to patients on VHP even when the effects of other variables (including age, BMI, sex, primary diagnosis, diabetes, history of dialysis, ICU days kept NPO) were taken into consideration. CONCLUSIONS: Increasing protein intake while reducing carbohydrate intake appears to be safe. Further research aimed at defining a causative effect of increasing protein delivery while reducing carbohydrate load on outcomes is warranted.

Meeting Calorie and Protein Needs in the Critical Care Unit: A Prospective Observational Pilot Study.

BACKGROUND: Inadequate calorie and protein intake during critical illness is associated with poor clinical outcomes. Unfortunately, most critically ill patients do not consume adequate levels of these nutrients. An enteral formula with appropriate macronutrient composition may assist patients in meeting nutritional goals. DESIGN: This study was a single center, prospective, observational study of 29 adults in the medical intensive care unit who required enteral nutrition for at least 3 days. Subjects received a calorically dense, enzymatically hydrolyzed 100% whey peptide-based enteral formula for up to 5 days to assess the ability to achieve 50% of caloric goals within the first 3 days (primary outcome), the daily percentage of protein goals attained and gastrointestinal tolerance (secondary outcomes). RESULT: A total of 29 subjects consented and began the study. Four subjects dropped out before first day and 25 subjects were included in analyses. Subjects were aged 55.5 ± 16.9 years with mean body mass index (BMI) of 27.9 ± 7.5 kg/m2. Most (92%) subjects were on a mechanical ventilator and experienced organ failure. At least 50% of caloric and protein goals were achieved in 78.9% and 73.7% of the subjects, respectively, during the first 3 days. Overall, 75.0 ± 26.3% and 69.3 ± 26.7% of calorie and protein goals were achieved using the study formula. CONCLUSIONS: Subjects fed enterally with a calorically dense, enzymatically hydrolyzed 100% whey peptide-based enteral formula exceeded 50% of caloric and protein goals in most critically ill subjects included in this study. Use of study formula did not lead to severe gastrointestinal intolerance.

Nutrition support in surgical oncology.

This review article, the second in a series of articles to examine the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Guidelines for the Use of Parenteral and Enteral Nutrition in Adult and Pediatric Patients, evaluates the evidence related to the use of nutrition support in surgical oncology patients. Cancer patients develop complex nutrition issues. Nutrition support may be indicated in malnourished cancer patients undergoing surgery, depending on individual patient characteristics. As with the first article in this series, this article provides background concerning nutrition issues in cancer patients, as well as discusses the role of nutrition support in the care of surgical cancer patients. The goal of this review is to enrich the discussion contained in the clinical guidelines as they relate to recommendations made for surgical patients, cite the primary literature more completely, and suggest updates to the guideline statements in light of subsequently published studies.

Dietary Management of Blood Glucose in Medical Critically Ill Overweight and Obese Patients: An Open-Label Randomized Trial.

BACKGROUND: Enteral nutrition (EN) increases hyperglycemia due to high carbohydrate concentrations while providing insufficient protein. The study tested whether an EN formula with very high-protein- and low-carbohydrate-facilitated glucose control delivered higher protein concentrations within a hypocaloric protocol. METHODS: This was a multicenter, randomized, open-label clinical trial with parallel design in overweight/obese mechanically ventilated critically ill patients prescribed 1.5 g protein/kg ideal body weight/day. Patients received either an experimental very high-protein (37%) and low-carbohydrate (29%) or control high-protein (25%) and conventional-carbohydrate (45%) EN formula. RESULTS: A prespecified interim analysis was performed after enrollment of 105 patients (52 experimental, 53 control). Protein and energy delivery for controls and experimental groups on days 1-5 were 1.2 ± 0.4 and 1.1 ± 0.3 g/kg ideal body weight/day (P = .83), and 18.2 ± 6.0 and 12.5 ± 3.7 kcals/kg ideal body weight/day (P < .0001), respectively. The combined rate of glucose events outside the range of >110 and ≤150 mg/dL were not different (P = .54, primary endpoint); thereby the trial was terminated. The mean blood glucose for the control and the experimental groups were 138 (-SD 108, +SD 177) and 126 (-SD 99, +SD 160) mg/dL (P = .004), respectively. Mean rate of glucose events >150 mg/dL decreased (Δ = -13%, P = .015), whereas that of 80-110 mg/dL increased (Δ = 14%, P = .0007). Insulin administration decreased 10.9% (95% CI, -22% to 0.1%; P = .048) in the experimental group relative to the controls. Glycemic events ≤80 mg/dL and rescue dextrose use were not different (P = .23 and P = .53). CONCLUSIONS: A very high-protein and low-carbohydrate EN formula in a hypocaloric protocol reduces hyperglycemic events and insulin requirements while increasing glycemic events between 80-110 mg/dL.

Review of American Society for Parenteral and Enteral Nutrition (ASPEN) Clinical Guidelines for Nutrition Support in Cancer Patients: nutrition screening and assessment.

It is clear that cancer patients develop complex nutrition issues. Nutrition support may or may not be indicated in these patients depending on individual patient characteristics. This review article, the first in a series of articles to examine the A.S.P.E.N. Guidelines for the Use of Parenteral and Enteral Nutrition in Adult and Pediatric Patients Cancer Guidelines, evaluates the evidence related to the use of nutrition screening and nutrition assessment in cancer patients. This first article will provide background concerning nutrition issues in cancer patients as well as discuss the role of nutrition screening and nutrition assessment in the care of cancer patients. The goal of this review is to enrich the discussion contained in the Clinical Guidelines, cite the primary literature more completely, and suggest updates to the guideline statements in light of subsequent published studies. Future articles will explore the guidelines related to nutrition support in oncology patients receiving anticancer therapies.

Very high-protein and low-carbohydrate enteral nutrition formula and plasma glucose control in adults with type 2 diabetes mellitus: a randomized crossover trial.

BACKGROUND AND OBJECTIVES: Standard enteral nutrition (EN) formulas can  worsen hyperglycemia in diabetic patients. We hypothesized that altering the proportion of macronutrients in a formula; increasing protein while decreasing carbohydrate concentrations would improve glycemic response. The objective of this study was to demonstrate that an EN formula containing a very high concentration of protein (in the form of whey peptides) and low concentration of carbohydrate provide better control of postprandial blood glucose relative to a very high-protein/higher-carbohydrate formula. SUBJECTS AND METHODS: This was a randomized crossover clinical trial of 12 ambulatory adult subjects with type 2 diabetes. The primary outcome was glycemic response following a bolus of isocaloric amounts of two EN formulas; the secondary outcome was insulin response. Subjects were randomized to the experimental or the control formula, on two separate days, 5-7 days apart. RESULTS: Mean blood glucose concentrations at 10-180 min post-infusion and mean area under the curve for glucose over 240 min post-infusion were significantly lower with the experimental formula than with the control formula (71.99 ± 595.18 and 452.62 ± 351.38, respectively; p = 0.025). There were no significant differences in the mean insulin concentrations over time, insulinogenic indices, and first-phase insulin measurements. CONCLUSIONS: An EN formula containing high-protein and low-carbohydrate loads can significantly improve glucose control in subjects with type 2 diabetes in ambulatory settings as evidenced by observed improved glucose control without significant difference in insulin response.

Plasma glucose and insulin response to two oral nutrition supplements in adults with type 2 diabetes mellitus.

OBJECTIVE: The purpose of this clinical trial was to compare the glucose usage of two oral nutritional supplement (ONS) products and to assess whether a diabetes-specific formulation provides improved glucose stabilization and management compared with a standard formula. RESEARCH DESIGN AND METHODS: A total of 12 subjects with type 2 diabetes (7 males and 5 females) completed a randomized, cross-over design trial. Each subject consumed isocaloric amounts of either the standard ONS or the diabetes-specific formula ONS on different dates, 1 week apart. Glucose and insulin measures were recorded at baseline, and 10, 20, 30, 60, 90, 120, 150, 180, 210 and 240 min after the beverage was consumed and then used to calculate area under the curve (AUC) for each subject. RESULTS: The mean glucose AUC was lower in the diabetes-specific ONS group than in the standard group (p<0.0001), but there was not a significant difference observed for mean insulin AUC (p=0.068). A sensitivity analysis of the mean insulin AUC measures was performed by removing a potential outlier from the analysis, and this resulted in a significant difference between the groups (p=0.012). First-phase insulin measures and an insulinogenic index calculated for the beverages showed no significant differences. CONCLUSIONS: On the basis of the results of this trial of 12 subjects, the diabetes-specific ONS appears to provide better glucose maintenance in persons with type 2 diabetes when compared to the standard formula ONS. TRIAL REGISTRATION NUMBER: NCT02612675.

Perioperative nutrition support in cancer patients.

Malnutrition and weight loss negatively affect outcomes in surgical cancer patients. Decades of research have sought to identify the most appropriate use of nutrition support in these patients. National and international guidelines help to direct clinicians' use of nutrition support in surgical patients, but a number of specific issues concerning the use of nutrition support continue to evolve. This review focuses on 5 key issues related to perioperative nutrition support in cancer patients: (1) Which perioperative cancer patients should receive nutrition support? (2) How can the nutrition status and requirements of these patients be optimally assessed? (3) What is the optimal route of administration (parenteral nutrition vs enteral nutrition) and composition of nutrition support in this setting? (4) When should feedings be initiated? (5) What is the role of glycemic control in these patients?

Dietary and nutritional needs of patients after therapy for head and neck cancer.

BACKGROUND: The number of cancer survivors in the general population is increasing. Oral and dental status affects patients' quality of life and oral function, which, in turn, may affect nutritional intake and general health. The authors review the importance of oral health and the role of the oral health care provider in supporting dietary intake and providing nutritional guidance. METHODS: The authors provide a brief review of oral complications of therapy and nutritional guidelines for patients with head and neck cancer. RESULTS: Oral adverse effects of head and neck cancer treatment include salivary gland dysfunction, taste change, orofacial pain and mucosal sensitivity, oral infection, tissue defects and necrosis, trismus and fibrosis, progressive dental and periodontal disease, and problems with prosthesis function. CONCLUSIONS: Managing oral adverse effects of treatment may have an impact on dietary and nutritional intake, as well as on quality of life. Dietary modifications may be needed because of the patient's oral function and may include modification of food texture and flavor, as well as the use of dietary supplements. CLINICAL IMPLICATIONS: As part of the patient's health care team, dental care professionals should be aware of the oral adverse effects of cancer therapy, as well as their role in recognizing and treating the resulting oral conditions. In addition, they should provide guidance to patients to support their oral dietary and nutritional intake.

Dietary and nutritional needs of patients undergoing therapy for head and neck cancer.

BACKGROUND: Nutrient and caloric intake is critical during therapy for head and neck cancer. METHODS: The authors review the oral complications experienced by, and dietary and nutritional needs of, patients during therapy. They also present recommendations for oral care and calorie and nutrient intake. CONCLUSIONS: Oral health care professionals can assist patients during treatment for cancer in maintaining oral, systemic and nutritional health, as well as in controlling oral symptoms. Recovery from the acute toxicities of therapy often requires diet modification, tube feeding or both to meet patients' energy and nutrient demands. CLINICAL IMPLICATIONS: Effective management of oral complications of therapy for cancer is necessary to facilitate oral intake throughout treatment. Oral health care professionals should be part of the multidisciplinary team helping meet the needs of patients during treatment.

Importance of nutritional screening in treatment of cancer-related weight loss.

Weight loss is common in patients with cancer. Many factors, such as physiological abnormalities, response to the tumour, and treatment, contribute to this weight loss. Cancer-related weight loss affects a patient's response to treatment, as well as survival and quality of life. Several nutritional screening and assessment tools have been developed for patients with cancer. This review describes the weight loss seen in patients with cancer as well as the methods of screening for nutritional deterioration and weight loss early in a cancer diagnosis. Nutritional approaches to the supportive care of patients with cancer are also discussed.