Recommendations Summary

ONC: Nutrition Diagnosis of Malnutrition in Adult Oncology Patients 2013

Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.

• Recommendation(s)

  ONC: Nutrition Diagnosis of Malnutrition in Adult Oncology Patients

  The registered dietitian nutritionist (RDN) should use clinical judgment in interpreting nutrition assessment data to diagnose malnutrition in adult oncology patients. Early identification and diagnosis of malnutrition leading to intervention can positively impact body composition, function, quality of life (QoL), treatment tolerance and clinical outcomes.

  The presence of two or more of the following criteria or characteristics supports a nutrition diagnosis of malnutrition in the adult oncology patient (See Clinical Characteristics to Document Malnutrition).  

  • Insufficient energy intake
  • Unintended weight loss
  • Loss of subcutaneous fat
  • Loss of muscle mass 
  • Localized or generalized fluid accumulation (that may mask weight loss)
  • Reduced grip strength.

  Rating: Consensus
  Imperative

  • Risks/Harms of Implementing This Recommendation

    Failure to make a malnutrition diagnosis may lead to lack of nutrition intervention and increased risk of mortality. 

  • Conditions of Application

    • Consider advance directives when planning nutrition intervention
    • For some individuals, unintended weight loss may be irreversible due to underlying medical conditions
    • If necessary data are not available, the RDN should use professional judgment to request or obtain addition data. 

  • Potential Costs Associated with Application

    • Although medical nutrition therapy (MNT) costs and reimbursement vary, MNT is essential for improved outcomes
    • Accessibility and costs of additional laboratory testing should be considered.

  • Recommendation Narrative

    Nutrition Assessment for Adult Oncology Patients

    An adult oncology nutrition assessment should characterize and document the presence of (or expected potential for) altered nutrition status and nutrition impact symptoms that may result in a measurable adverse effect on body composition, function, QoL or clinical outcome and may also include indicators of malnutrition.

    The RDN's assessment should include the five domains of the Nutrition Care Process (NCP) and consider the six indicators of malnutrition (energy intake, interpretation of weight loss, body fat, muscle mass, fluid accumulation and reduced grip strength). See Clinical Characteristics to Document Malnutrition (White et al, 2012).

    The five domains of the NCP include the following. The Oncology expert work group has provided additional interpretations specific to the diagnosis of malnutrition in oncology patients:

    Food- or Nutrition-Related History

    Insufficient energy intake.

    Anthropometric Measurements

    Weight loss in elderly patients may have additional impact. The usual adult cutoff is BMI of 18.5kg/m², however studies of the elderly support an association between increased mortality and underweight (BMI under 20kg/m² or current weight compared with usual or desired body weight) or unintended weight loss (5% in 30 days or any further weight loss after meeting this criteria) (Grabowski et al, 2001; Fearon et al, 2013; Tan et al, 2009) 

    • Because weight loss is demonstrated to lead to poor outcomes, it is important to accurately determine a baseline weight. Weight loss or change should be defined as current weight compared to baseline weight. Baseline weight (include presence of under- or over-hydration) is defined as:
      • Usual body weight from medical records.
      • Weight taken when admitted to oncology service or, if not available:
        • Self-report of recent healthy weight
        • Consider rate of weight loss over specified time frame (Jensen et al, 2012)
        • Include presence of under- or over-hydration

    Biochemical Data, Medical Tests and Procedures

    • Careful interpretation may be required in oncology patients, as they can experience wide variations in glucose and WBC values due to type and timing of treatment
    • Other lab values determined to be outside of normal may indicate a need for diet modification of nutrients
    • The etiology-based malnutrition definitions are located at this link: Etiology-Based Malnutrition Definitions (Jensen et al, 2012). CRP should be used to evaluate the presence of inflammation (elevated* CRP may be indicative of inflammation). It is also important to differentiate between chronic disease-related malnutrition (lung, pancreatic and GI cancer, sarcopenic obesity and organ failure) and acute disease and injury-related malnutrition (major infection and surgery). Determining the presence and degree of inflammation determines the significance of any patient weight loss (Jensen et al, 2012; White et al, 2012).

    *Past interpretation of >10mg/L CRP has been used to indicate inflammation (Fearon et al, 2006). However, further research will elucidate more specific markers for use

    Nutrition-Focused Physical Findings and Client History

    • Loss of muscle mass [White et al, 2012; Prado et al, 2009 (Clin Cancer Res.)] 
      • Patients with loss of muscle mass experience greater treatment toxicity and shorter survival
      • As 50% of patients with advanced cancer have frank sarcopenia (Fearon, 2011) and the shortest survival times are among obese patients with sarcopenia (Tan et al, 2009), reducing weight at the possible expense of lean muscle mass in obese cancer patients should not be a priority
      • Low muscle mass is a common and independent predictor of immobility and mortality, is a particularly adverse prognostic indicator in obese patients and is associated with greater toxicities of chemotherapy leading to treatment interruptions including dose reductions, treatment delays and treatment termination [Fearon et al, 2013; Prado et al, 2009 (Clin Cancer Res.); Prado et al, 2009 (Curr Opin Support Palliat Care.); Prado et al, 2011; Antoun et al, 2010; Fearon, 2011]
      • Body weight has been used as an outcome in clinical trials in cancer-induced weight loss and only recently has research begun to focus on lean body mass as a primary outcome. Existing computerized tomography (CT) images used to diagnose and monitor disease progression are readily available and provide an opportunistic means for body composition analysis. Although this type of analysis is relatively new, its use will be common in the near future and offers the dietitian the ability to demonstrate value. Other methods of measuring muscle mass are bioelectrical impedence analysis (BIA), dual-energy X-ray absorptiometry (DXA) and anthropometry. Patients with loss of muscle mass experience greater treatment toxicity and shorter survival [Cruz-Jentoft et al, 2010; Prado et al, 2009 (Curr Opin Support Palliat Care.)].
    • Loss of subcutaneous fat  (White et al, 2012; Tan et al, 2009; Fearon, 2011) 
      • With the increase in obesity in Western society and patients with cancer in particular, reducing fat tissue should not be a priority
      • The important problem remains low muscle mass, since up to 50% of patients with advanced cancer have frank sarcopenia. The shortest survival times are among obese patients with sarcopenia (Tan et al, 2009).
    • Nutrition impact symptoms that impede intake, digestion or absorption such as anorexia, nausea, vomiting, diarrhea, constipation, stomatitis, mucositis, dysphagia, alterations in taste and smell, pain, depression and anxiety, can be caused by the cancer itself or the oncology treatment (American Cancer Society 2000; Kubrak, 2010; Wojtaszek et al, 2002)
    • Presence of pre-cachexia or cancer cachexia. Further nutrition assessment is needed for patients with lung, pancreatic or head and neck and gastrointestinal (GI) cancers or those who are at high risk for weight loss or have experienced unintentional weight loss.
      • See recommendation for Nutrition Assessment for the Stages of Cancer cachexia in Adult Oncology Patients.
    • Localized or generalized fluid accumulation (that may mask weight loss) (White et al, 2012) 
    • Reduced grip strength** or diminished functional status, as measured by Karnofsky score
    • Type of cancer therapy o treatment (medical or surgical).

    **Consult normative standards per device manufacturer.

    For recommended tools for use in assessing the nutritional status of adult oncology patients in ambulatory and acute care settings,  click here.  

  • Recommendation Strength Rationale

    Consensus.

  • Minority Opinions

    None.

• Supporting Evidence

  The recommendations were created from the evidence analysis on the following questions. To see detail of the evidence analysis, click the blue hyperlinks below (recommendations rated consensus will not have supporting evidence linked).

  • References
  • References not graded in Academy of Nutrition and Dietetics Evidence Analysis Process

    American Cancer Society.: Nutrition for the Person with Cancer: A Guide for Patients and Families. Atlanta, Ga: American Cancer Society, Inc., 2000.

    Antoun S, Baracos VE, Birdsell L, Escudier B, Sawyer MB. Low body mass index and sarcopenia associated with dose-limiting toxicity of sorafenib in patients with renal cell carcinoma. Ann Oncol. 2010 Aug; 21 (8): 1, 594-1, 598. Epub 2010 Jan 20. PMID: 20089558.

    Cruz-Jentoft AJ, Baeyens JP, Bauer JM, Boirie Y, Cederholm T, Landi F, Martin FC, Michel JP, Rolland Y, Schneider SM, Topinková E, Vandewoude M, Zamboni M; European Working Group on Sarcopenia in Older People. Sarcopenia: European consensus on definition and diagnosis: Report of the European Working Group on Sarcopenia in Older People. Age Ageing. 2010 Jul; 39 (4): 412-423. doi: 10.1093/ageing/afq034. Epub 2010 Apr 13. PMID: 20392703

    Fearon K, Arends J, Baracos V. Understanding the mechanisms and treatment options in cancer cachexia. Nat Rev Clin Oncol. 2013 Feb; 10 (2): 90-99. doi: 10.1038/nrclinonc.2012.209. Epub 2012 Dec 4. PMID: 23207794.

    Fearon KC. Cancer cachexia and fat-muscle physiology. N Engl J Med. 2011 Aug 11; 365 (6): 565-567. No abstract available. PMID: 21830971.

    Fearon KC, Voss AC, Hustead DS; Cancer Cachexia Study Group. Definition of cancer cachexia: effect of weight loss, reduced food intake, and systemic inflammation on functional status and prognosis. Am J Clin Nutr. 2006 Jun; 83 (6): 1, 345-1, 350. PMID: 16762946.

    Grabowski DC and Ellis JE. High body mass index does not predict mortality in older people: analysis of the Longitudinal Study of Aging. J Am Geriatr Soc. 2001 Jul; 49 (7): 968-979. PMID: 11527490.

    Jensen GL, Hsiao PY, Wheeler D. Adult nutrition assessment tutorial. JPEN J Parenter Enteral Nutr. 2012 May; 36 (3): 267-274. Epub 2012 Mar 8.

    Kubrak C, Olson K, Jha N, Jensen L, McCargar L, Seikaly H, Harris J, Scrimger R, Parliament M, Baracos VE. Nutrition impact symptoms: key determinants of reduced dietary intake, weight loss, and reduced functional capacity of patients with head and neck cancer before treatment. Head Neck. 2010 Mar; 32(3): 290-300. doi: 10.1002/hed.21174. PMID: 19626639.

    Prado CM, Baracos VE, McCargar LJ, Reiman T, Mourtzakis M, Tonkin K, Mackey JR, Koski S, Pituskin E, Sawyer MB. Sarcopenia as a determinant of chemotherapy toxicity and time to tumor progression in metastatic breast cancer patients receiving capecitabine treatment. Clin Cancer Res. 2009 Apr 15; 15 (8): 2, 920-2, 926. Epub 2009 Apr 7. PMID: 19351764.

    Prado CM, Birdsell LA, Baracos VE. The emerging role of computerized tomography in assessing cancer cachexia. Curr Opin Support Palliat Care. 2009 Dec; 3 (4): 269-275. Review. PMID: 19667996.

    Prado CM, Lima IS, Baracos VE, Bies RR, McCargar LJ, Reiman T, Mackey JR, Kuzma M, Damaraju VL, Sawyer MB. An exploratory study of body composition as a determinant of epirubicin pharmacokinetics and toxicity. Cancer Chemother Pharmacol. 2011 Jan; 67 (1): 93-101. Epub 2010 Mar 5. PMID: 20204364.

    Tan BH, Birdsell LA, Martin L, Baracos VE, Fearon KC. Sarcopenia in an overweight or obese patient is an adverse prognostic factor in pancreatic cancer. Clin Cancer Res. 2009 Nov 15;15 (22): 6, 973-6, 979. Epub 2009 Nov 3. PMID: 19887488.

    White JV, Guenter P, Jensen G, Malone A, Schofield M; Academy Malnutrition Work Group, A.S.P.E.N. Malnutrition Task Force, A.S.P.E.N. Board of Directors. J Acad Nutr Diet. 2012 May; 112 (5): 730-738. Epub 2012 Apr 25.

    Wojtaszek CA, Kochis LM, Cunningham RS: Nutrition impact symptoms in the oncology patient. Oncology Issues 17 (2): 15-7, 2002.