Food intake and body composition in cancer cachexia

Lipid Metabolism Interplay in CRC—An Update

Colorectal cancer (CRC) to date still ranks as one of the deadliest cancer entities globally, and despite recent advances, the incidence in young adolescents is dramatically increasing. Lipid metabolism has recently received increased attention as a crucial element for multiple aspects of carcinogenesis and our knowledge of the underlying mechanisms is steadily growing. However, the mechanism how fatty acid metabolism contributes to CRC is still not understood in detail. In this review, we aim to summarize our vastly growing comprehension and the accompanied complexity of cellular fatty acid metabolism in CRC by describing inputs and outputs of intracellular free fatty acid pools and how these contribute to cancer initiation, disease progression and metastasis. We highlight how different lipid pathways can contribute to the aggressiveness of tumors and affect the prognosis of patients. Furthermore, we focus on the role of lipid metabolism in cell communication and interplay within the tumor microenvironment (TME) and beyond. Understanding these interactions in depth might lead to the discovery of novel markers and new therapeutic interventions for CRC. Finally, we discuss the crucial role of fatty acid metabolism as new targetable gatekeeper in colorectal cancer.

Assessing cachexia in older patients: Different definitions - But which one is the most practical for clinical routine?

OBJECTIVE

Patients with chronic inflammatory diseases and malignant tumors have an increased risk of cachexia. No consistent definition exists to rapidly identify cachexia in older patients with and without cancer.

METHODS

One-hundred patients (53% male) aged 70 +  years were included in the study by a university hospital. In addition to the detection of malnutrition and determination of body composition by bioelectrical impedance analysis, cachexia was assessed according to the well-established definitions of Evans (weight loss ≥ 5% within the last 12 months plus additional clinical parameters), Fearon (weight loss > 5% in 6 months) and Bozzetti (weight loss ≥ 10% of habitual weight). After a follow-up of 3.5 years, the mortality rate was recorded.

RESULTS

Thirty-three patients had a malignant tumor disease. The patients with a non-malignant underlying disease did not differ in their mental state, physical condition and state of health compared to patients with cancer. A higher percentage of patients with underlying malignancy had cachexia. There were significant differences in the body composition between the patients with or without cachexia. Cachectic patients exhibited a significantly lower skeletal muscle mass and fat mass. The risk of death was increased in cachectic patients of all three cachexia definitions.

CONCLUSION

For clinical daily routine, the assessments by a weight loss according to Fearon and Bozzetti are suggested to be practicable methods to detect cachexia in older patients with and without cancer.

Effects of nutritional intervention in head and neck cancer patients undergoing radiotherapy: A prospective randomized clinical trial

Head and neck malignant tumors have numerous locations of the disease. After patients receive radiotherapy, their nutritional status is very poor, thus the curative effect is unsatisfactory. The aims of the present study were to investigate and analyze the nutritional status of patients with head and neck cancer undergoing radiotherapy (RT) in order to provide positive nutrition intervention for assisting the radiotherapy effect. A total of 40 patients with head and neck cancer were selected using a method of subjective global assessment (SGA) to assess nutritional status, including calorie intake and energy expenditure. In a randomized, controlled study, 20 patients received intensive dietary counseling and nutritional therapy (G1) and 20 received regular dietary as controls (G0) preradiotherapy and postradiotherapy. The primary endpoint was calorie intake and energy expenditure. The secondary endpoint was SGA rating with nutritional therapy. At the end of RT, energy intake showed a net increase in G1 (1,691±301 kcal) compared with that in G0 (1,066±312 kcal) (P<0.05); energy expenditure increased in G1 (1,673±279 kcal) compared with G0 (1,490±298 kcal) (P<0.05). The prevalence of severe malnutrition following radiotherapy was significantly different between the two study groups (10 patients in G0 and 4 patients in G1; P<0.05). The number of the normal malnutrition patients postRT in G0 decreased from 4 to 2 and conversely, in G1 it increased from 3 to 6 (P<0.05). In conclusion, patients with head and neck cancer were most malnutritioned, which impacted on clinical outcome. Timely nutritional intervention can effectively prevent weight loss and muscle wasting. Additionally, it may improve quality of life by decreasing the frequency of severe malnutrition.

Fish oil and treatment of cancer cachexia

Cancer cachexia is a syndrome characterized by high prevalence and multifactorial etiology. The pathophysiology of cancer-induced weight loss is mainly due to failure of food intake and to various metabolic abnormalities, including hypermetabolism. Multiple biologic pathways are involved in this process, including pro-inflammatory cytokines, neuroendocrine hormones and tumour specific factors such as proteolysis inducing factor (PIF). As a result, a protein and energy depletion is observed that is greater than what would be expected based on the simple decrease of food intake and is associated with marked reduction of lean body mass (LBM). Therapy requires a multi-model approach with control of reduced food intake and of the metabolic abnormalities. Combination treatment with nutritional support and modulation of metabolic/inflammation changes is promising. In this regard, n-3 fatty acids in dose of at least 1.5 g/day for a prolonged time to advanced cancer patients with weight loss, are associated with an improvement of clinical, biological and functional parameters and with amelioration of quality of life.

The influence of early supplementation of parenteral nutrition on quality of life and body composition in patients with advanced cancer

BACKGROUND

According to current evidence, most organizations, including the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.), do not recommend the routine use of artificial nutrition for patients with cancer. Despite the recommendation for parenteral nutrition (PN), data for early PN supplementation (PNS) in patients with an advanced malignancy are extremely limited, especially in terms of the affects on nutrition outcomes, body composition, and quality of life (QOL), as well as effects on oncologic outcomes. The aim of the study was to evaluate the effect of PNS on body composition and the quality of life in patients with advanced malignancies.

METHODS

One hundred fifty-two consecutive patients with advanced cancer were prospectively randomized to either use of oral enteral nutrition supplement (PN-) or use of oral enteral nutrition supplement plus supplemental PN (PN+). Body weight, body mass index (BMI), and caloric intake were assessed, and hemoglobin (g/dL) and serum albumin (g/L) were measured. Body composition was assessed by body impedance analysis (BIA), and QOL was evaluated by European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 questionnaire every 6 weeks.

RESULTS

No significant differences were evident at baseline between the 2 groups for age, gender, medical diagnosis, weight, BMI, or QOL. A statistically significant difference in mean BMI was observed by week 48 for the PN+ group (PN+ = 21.9, PN-= 20.5, p = .0149), by week 6 in mean body cell mass (PN+ = 55%, PN-= 50,1%, p < .001), mean albumin (PN+ = 40.2 g/L, PN-= 36.2 g/L, p = .015), mean QOL (PN+ = 55.7, PN-= 50.9, p = .035). The cumulative survival rate was significantly greater in the PN+ group (p < .0001).

CONCLUSIONS

According to the positive effect of supplemental PN on survival, body composition, and QOL, additional controlled studies must be conducted to confirm these findings.

Early and enduring nutritional and functional results of pylorus preservation vs classic Whipple procedure for pancreatic cancer

BACKGROUND AND AIMS

There have been many supportive data that the pylorus-preserving pancreatoduodenectomy (PPPD) might be equal to the classic Whipple pancreatoduodenectomy (PD) in terms of oncological radicality. However, few reports are available on the early postoperative and enduring functional changes, nutritional status, body composition, and quality of life years after surgery. The aim of this study was to compare nutritional and functional results of the different techniques in a retrospective evaluation and prospective cohort study.

PATIENTS AND METHODS

In May 1998, the standard surgical approach in the Department of Surgery, University-Hospital Mannheim, changed from PD to PPPD. The early postoperative and enduring functional changes, quality of life, oncological radicality, and nutritional status after years were compared between 128 patients after PD and 111 patients after PPPD. In a retrospective manner, the intra- and postoperative course was evaluated. In survivors, we prospectively analyzed the functional, nutritional, and oncological outcomes after 54 months (mean) in PD and after 24 months (mean) in PPPD patients.

RESULTS

The PPPD and PD groups did not differ according to age, gender, preoperative condition, or tumor localization. The PPPD group demonstrated favorable results (p<0.05) for operation time (PPPD 341+/-74 vs PD 386+/-89 min), blood loss (793+/-565 vs 1,000+/-590 ml), blood transfusions (416+/-691 vs 653+/-776 ml), delayed gastric emptying (6 vs 13%), and hospital stay (20 vs 24 days). However, a possible bias has to be mentioned since more T4 stages were diagnosed in the PD group (3 vs 11%), and even more extended (venous) resections were performed in the PD group (7 vs 24%). Morbidity (32 vs 30%) and mortality (5 vs 3%) did not differ between the two groups. After 24 months (PPPD, n=22) and 54 months (PD, n=16), there was no difference in global quality of life in recurrence-free patients. While the preoperative body weight was reached after 4 months (median) in the PPPD group, it was reached after 6 months (p<0.05) in the PD group. Bioelectrical impedance analysis (BIA) revealed a significantly (p<0.05) lower total body water (55 vs 60%) and significantly higher total body fat (26 vs 18%) in PPPD than in PD patients. Long-term follow-up showed no significant statistical differences in survival between both groups.

CONCLUSION

Besides favorable postoperative outcome in specific aspects and equal oncological outcome of PPPD, pylorus preservation seems to have advantages in enduring functional and nutritional status years after surgery for pancreatic cancer.

Body composition and time course changes in regional distribution of fat and lean tissue in unselected cancer patients on palliative care—Correlations with food intake, metabolism, exercise capacity, and hormones

BACKGROUND

Several investigations that yielded different results in terms of net changes in body composition of weight-losing cancer patients have been reported that employed a variety of methods based on fundamentally different technology. Most of those reports were cross-sectional, whereas to the authors' knowledge there is sparse information available on longitudinal follow-up measurements in relation to other independent methods for the assessment of metabolism and performance.

METHODS

For the current report, the authors evaluated time course changes in body composition (dual-energy X-ray absorptiometry) with measurements of whole body and regional distribution of fat and lean tissue in relation to food and dietary intake, host metabolism (indirect calorimetry), maximum exercise capacity (walking test), and circulating hormones in cancer patients who were receiving palliative care during 4-62 months of follow-up. The entire cohort comprised 311 patients, ages 68 years +/- 3 years who were diagnosed with solid gastrointestinal tumors (84 colorectal tumors, 74 pancreatic tumors, 73 upper gastrointestinal tumors, 51 liver-biliary tumors, 3 breast tumors, 5 melanomas, and 21 other tumor types).

RESULTS

Decreased body weight was explained by loss of body fat, preferentially from the trunk, followed by leg tissue and arm tissue, respectively. Lean tissue (fat-free mass) was lost from arm tissue, whereas trunk and leg tissue compartments increased, all concomitant with declines in serum albumin, increased systemic inflammation (C-reactive protein, erythrocyte sedimentation rate), increased serum insulin, and elevated daily caloric intake; whereas serum insulin-like growth factor 1 (IGF-1), resting energy expenditure, and maximum exercise capacity remained unchanged in the same patients. Serum albumin levels (P < 0.001), whole body fat (P < 0.02), and caloric intake (P < 0.001) predicted survival, whereas lean tissue mass did not. Daily intake of fat and carbohydrate was more important for predicting survival than protein intake. Survival also was predicted by serum IGF-1, insulin, leptin, and ghrelin levels (P < 0.02 - P < 0.001). Serum insulin, leptin, and ghrelin (total) levels predicted body fat (P < 0.001), whereas IGF-1 and thyroid hormone levels (T3, free T3) predicted lean tissue mass (P < 0.01). Systemic inflammation primarily explained variation in lean tissue and secondarily explained loss in body fat. Depletion of lean arm tissue was related most to short survival compared with the depletion of lean leg and trunk tissue.

CONCLUSIONS

The current results demonstrated that body fat was lost more rapidly than lean tissue in progressive cancer cachexia, a phenomenon that was related highly to alterations in the levels of circulating classic hormones and food intake, including both caloric amount and diet composition. The results showed importance in the planning of efficient palliative treatment for cancer patients.

Fish oil supplementation in F1 generation associated with naproxen, clenbuterol, and insulin administration reduce tumor growth and cachexia in Walker 256 tumor-bearing rats

Weanling female Wistar rats were supplemented with fish oil (1 g/kg body weight) for one generation. The male offspring received the same supplementation until to adult age. Rats supplemented with coconut fat were used as reference. Some rats were inoculated subcutaneously with a suspension (2 x 10(7) cells/mL) of Walker 256 tumor. At day 3, when the tumor was palpable, rats were treated with naproxen (N) (0.1 mg/mL), clenbuterol (Cb) (0.15 mg/kg body weight), and insulin (I) (10 U/kg body weight). At day 14 after tumor inoculation, the animals were killed. Tumor was removed and weighed. Blood, liver, and skeletal muscles were also collected for measurements of metabolites and insulin. In both tumor-bearing untreated rats and tumor-bearing rats supplemented with coconut fat, tumor growth, triacylglycerol, and blood lactate levels were higher, and glycogen content of the liver, blood glucose, cholesterol and HDL-cholesterol levels were lower as compared with the non-tumor-bearing and fish oil supplemented groups. Fish oil supplementation of tumor-bearing rats led to a partial recovery of the glycogen content in the liver and a full reversion of blood glucose, lactate, cholesterol, and HDL-cholesterol levels. The treatment with N plus Cb plus I attenuated cancer cachexia and decreased tumor growth in both coconut fat and fish oil supplemented rats. In conclusion, chronic fish oil supplementation decreased tumor growth and partially recovered cachexia. This beneficial effect of fish oil supplementation was potentiated by treatment with naproxen plus clenbuterol plus insulin.

Nutritional status of patients with advanced cancer: the value of using the subjective global assessment of nutritional status as a screening tool

In patients suffering from advanced neoplastic disease, malnutrition is a common complication affecting both the survival and quality of life. In order to monitor early dietary interventions, an assessment of patients' nutritional status is essential. We assessed the nutritional status of 46 patients using two different methods: 1) an objective method of nutritional assessment and 2) the subjective global assessment (SGA) technique. It was found that 28 patients were characterized as malnourished by means of the objective method and 30 patients according to the SGA. The correlation of the results of the assessments between the two methods was high and a validation test of the SGA gave a sensitivity of 96% and specificity of 83%. The most frequent symptoms affecting food intake were anorexia, early satiety, dry mouth, pain and nausea. The results show that the SGA represents an easy method for assessment of the nutritional status in such cancer patients and that it can therefore be used as a screening tool. The high incidence of malnutrition in this group of patients, and their rare use of nutrient supplements, both indicate the importance of early nutritional assessment, and nutritional intervention when appropriate.

Fasting in healthy individuals and adaption to undernutrition during chronic disease

During long-term fasting, gluconeogenesis from amino acids was thought to lessen, when ketone bodies from lipolysis became a major fuel source. Thus, muscle mass is conserved. However, recent studies show that this adaptation does not occur in chronic undernourishment. In cancer, chronic undernutrition without disease, and HIV infection, carbohydrate utilization is high. Enhanced hepatic glucose production occurs in active inflammatory bowel disease and in underweight cancer patients. Repletion of tissue after undernutrition is energetically inefficient because of enhanced diet induced thermogenesis (following anorexia nervosa) and decreased fat, and increased protein, oxidation (in tuberculosis).

Nutritional assessment in the critically ill

Essentially, there have not been any outstanding recent developments in nutritional assessment techniques. However, it would appear that the acceptance that there is no absolute gold standard for nutritional assessment has led to the development of disease specific and clinically relevant subjective global type-assessments, which are user-friendly and effective tools. The further development of dual frequency bioelectrical impedance models may allow for greater accuracy in the differentiation of alterations in body composition.