EAL

Recommendations Summary

ONC: Nutrition Assessment Criteria for 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: Assessment of Food/Nutrition-Related History of Adult Oncology Patients

The registered dietitian nutritionist (RDN) should assess the food, beverage and nutrient intake and related history of adult oncology patients including, but not limited to the following:
- Energy and protein intake
- Changes in food and fluid/beverage intake
- Adequacy and appropriateness of nutrient intake or nutrient administration
- Actual daily intake from enteral nutrition (EN) and parenteral nutrition (PN) and other nutrient sources
- Changes in type, texture, or temperature of food and liquids
- Use of medical food supplements (MFS)
- Food avoidance and intolerances
- Meal or snack pattern changes
- Prescription medications, over-the-counter medications, herbal preparations and complementary or alternative medicine products
- Factors affecting access to food.
Assessment of the above factors is needed to effectively determine nutrition diagnoses and plan the nutrition interventions. Inability to achieve optimal nutrient intake may contribute to poor outcomes.

Rating: Consensus
Imperative

ONC: Assessment of Anthropometric Measurement in Adult Oncology Patients

The RDN should assess the following anthropometric measurements in adult oncology patients:
- Height and weight
- Weight change
- Body Mass Index (BMI).
Any weight loss that is unintended in adult oncology patients has potential significance, as oncology patients often experience weight loss prior to admission to oncology services. 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.

Assessment of the above factors is needed to effectively determine nutrition diagnoses and plan the nutrition interventions.

Rating: Consensus
Imperative

ONC: Assessment of Biochemical Data, Medical Tests, and Procedures on Adult Oncology Patients

The RDN should evaluate available data and recommend as indicated: Biochemical data, medical tests and procedures of adult oncology patients. Examples include:
- Glucose
- White blood cell (WBC)
- Nutritional anemia profile (hemoglobin, hematocrit, folate, B₁₂, iron)
- Electrolyte and renal profile
- Liver function
- Inflammatory profile, including C-reactive protein (CRP)
- Gastrointestinal (GI) function tests (i.e., swallowing study, abdominal films, gastric emptying, transit time).
Assessment of these factors is needed to effectively determine nutrition diagnoses and plan the nutrition interventions.

Rating: Consensus
Imperative

ONC: Assessment of Nutrition-Focused Physical Findings and Client History of Adult Oncology Patients

The RDN should evaluate available data regarding the nutrition-focused physical findings and client history of adult oncology patients including, but not limited to:
Nutrition-focused physical findings:
- Age greater than 65 years
- Loss of muscle mass
- Loss of subcutaneous fat
- Presence of pressure ulcers or wounds
- Nutrition impact symptoms including but not limited to: Nausea, vomiting, diarrhea, constipation, stomatitis, mucositis, alterations in taste and smell and anxiety
- Changes in appetite
- Vital signs
- Functional indicators (i.e., Karnofsky score, grip strength)
- Localized or generalized fluid accumulation.
Client history:
- Patient/Family/Client Medical/Health history:
  
  Nutrition impact symptoms including but not limited to: Dysphagia, depression and pain fatigue
  
  Medical treatment or therapy
  
  Other diseases, conditions and illnesses including cancer cachexia.
Social history: Psychological/socioeconomic factors (e.g., social support).

Assessment of the above factors is needed to effectively determine nutrition diagnoses and plan the nutrition interventions.
Rating: Consensus
Imperative
- Risks/Harms of Implementing This Recommendation
  There are no potential risks or harms associated with the application of this recommendation.
- Conditions of Application
  - The RDN should consider use of an assessment tool validated in the setting (inpatient or ambulatory/outpatient) in which the tool intended for use as part of the complete nutrition assessment
  - RDNs should be appropriately trained to conduct a nutrition-focused physical exam
  - If necessary data are not available, the RDN should use professional judgment to request or obtain addition data.
- Potential Costs Associated with Application
  Accessibility and costs of additional 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 assessment 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; and 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
    
    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]
    
    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
    
    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).
  - Localized or generalized fluid accumulation (that may mask weight loss)(White et al, 2012)
  - 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)
  - Reduced grip strength** or diminished functional status, as measured by Karnofsky score
    
    **Consult normative standards per device manufacturer.
  - 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.
  - Type of oncology treatment.
  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.