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Bioelectrical Impedance Analysis (BIA) is a reliable, non-invasive, objective, and cost-effective body composition assessment method, with high reproducibility. This scoping review aims to evaluate the current scientific and clinical evidence on BIA for body composition assessment in oncology patients, under active treatment. Literature search was conducted through MEDLINE, CINAHL, Scopus and Web of Science databases, following PRISMA-ScR Guidelines. Inclusion criteria comprised studies reporting the use of BIA for body composition evaluation in adults with cancer diagnosis. Studies including non-cancer pathology or only assessing nutritional status were excluded. This scoping review comprised a total of 36 studies: 25 were original studies including 18 prospective studies, six cross-sectional studies and one retrospective study and 11 were systematic reviews. Population size for the included original articles ranged from 18 to 1217 participants, comprising a total of 3015 patients with cancer with a mean baseline Body Mass Index (BMI) ranging from 20.3 to 30.0 kg/m2 and mean age ranging between 47 and 70 years. Review articles included a total of 273 studies, with a total of 78,350 participants. The current review considered studies reporting patients with head and neck cancer (HNC) (n = 8), breast cancer (BC) (n = 4), esophageal cancer (EC) (n = 2), liver cancer (n = 2), pancreatic cancer (PC) (n = 3), gastric cancer (GC) (n = 3), colorectal cancer (CRC) (n = 8), lung cancer (LC) (n = 1), skin cancer (SK) (n = 1) and multiple cancer types (n = 6). BIA is a suitable and valid method for the assessment of body composition in oncology. BIA-derived measures have shown good potential and relevant clinical value in preoperative risk evaluation, in the reduction of postoperative complications and hospital stay and as an important prognostic indicator in persons with cancer. Future research on the diagnostic value and clinical applications of BIA and BIA-derived phase angle (PhA) should be conducted in order to predict its impact on patient survival and other clinical outcomes. [ABSTRACT FROM AUTHOR]

Simple Summary: Early identification of patients on antineoplastic therapy who are at risk for or already malnourished is critical for optimizing treatment success. Malnourished patients are at increased risk for being unable to tolerate the most effective 'level' and 'duration' of treatment, with grave implications for both the short- (during treatment) and long-term outcomes. Herein, we provide a practical PROtocol for NuTritional risk in Oncology (PRONTO) to enable oncologists to identify patients with or at risk of malnutrition for further evaluation and follow-up with members of the multidisciplinary care team (MDT). Additional guidance is included on the oncologist-led provision of nutritional support if referral to a dietary service is not available. Nutritional issues, including malnutrition, low muscle mass, sarcopenia (i.e., low muscle mass and strength), and cachexia (i.e., weight loss characterized by a continuous decline in skeletal muscle mass, with or without fat loss), are commonly experienced by patients with cancer at all stages of disease. Cancer cachexia may be associated with poor nutritional status and can compromise a patient's ability to tolerate antineoplastic therapy, increase the likelihood of post-surgical complications, and impact long-term outcomes including survival, quality of life, and function. One of the primary nutritional problems these patients experience is malnutrition, of which muscle depletion represents a clinically relevant feature. There have been recent calls for nutritional screening, assessment, treatment, and monitoring as a consistent component of care for all patients diagnosed with cancer. To achieve this, there is a need for a standardized approach to enable oncologists to identify patients commencing and undergoing antineoplastic therapy who are or who may be at risk of malnutrition and/or muscle depletion. This approach should not replace existing tools used in the dietitian's role, but rather give the oncologist a simple nutritional protocol for optimization of the patient care pathway where this is needed. Given the considerable time constraints in day-to-day oncology practice, any such approach must be simple and quick to implement so that oncologists can flag individual patients for further evaluation and follow-up with appropriate members of the multidisciplinary care team. To enable the rapid and routine identification of patients with or at risk of malnutrition and/or muscle depletion, an expert panel of nutrition specialists and practicing oncologists developed the PROtocol for NuTritional risk in Oncology (PRONTO). The protocol enables the rapid identification of patients with or at risk of malnutrition and/or muscle depletion and provides guidance on next steps. The protocol is adaptable to multiple settings and countries, which makes implementation feasible by oncologists and may optimize patient outcomes. We advise the use of this protocol in countries/clinical scenarios where a specialized approach to nutrition assessment and care is not available. [ABSTRACT FROM AUTHOR]

This opinion paper presents a short review of the potential impact of protein on muscle anabolism in cancer, which is associated with better patient outcomes. Protein source is a topic of interest for patients and clinicians, partly due to recent emphasis on the supposed non-beneficial effect of proteins; therefore, misconceptions involving animal-based (e.g., meat, fish, dairy) and plant-based (e.g., legumes) proteins in cancer are acknowledged and addressed. Although the optimal dietary amino acid composition to support muscle health in cancer is yet to be established, animal-based proteins have a composition that offers superior anabolic potential, compared to plant-derived proteins. Thus, animal-based foods should represent the majority (i.e., ≥65%) of protein intake during active cancer treatment. A diet rich in plant-derived proteins may support muscle anabolism in cancer, albeit requiring a larger quantity of protein to fulfill the optimal amino acid intake. We caution that translating dietary recommendations for cancer prevention to cancer treatment may be inadequate to support the pro-inflammatory and catabolic nature of the disease. We further caution against initiating an exclusively plant-based (i.e., vegan) diet upon a diagnosis of cancer, given the presence of elevated protein requirements and risk of inadequate protein intake to support muscle anabolism. Amino acid combination and the long-term sustainability of a dietary pattern void of animal-based foods requires careful and laborious management of protein intake for patients with cancer. Ultimately, a dietary amino acid composition that promotes muscle anabolism is optimally obtained through combination of animal- and plant-based protein sources. [ABSTRACT FROM AUTHOR]

This practical guideline is based on the current scientific ESPEN guidelines on nutrition in cancer patients. ESPEN guidelines have been shortened and transformed into flow charts for easier use in clinical practice. The practical guideline is dedicated to all professionals including physicians, dieticians, nutritionists and nurses working with patients with cancer. A total of 43 recommendations are presented with short commentaries for the nutritional and metabolic management of patients with neoplastic diseases. The disease-related recommendations are preceded by general recommendations on the diagnostics of nutritional status in cancer patients. This practical guideline gives guidance to health care providers involved in the management of cancer patients to offer optimal nutritional care. [ABSTRACT FROM AUTHOR]

Summary Cancers are among the leading causes of morbidity and mortality worldwide, and the number of new cases is expected to rise significantly over the next decades. At the same time, all types of cancer treatment, such as surgery, radiation therapy, and pharmacological therapies are improving in sophistication, precision and in the power to target specific characteristics of individual cancers. Thus, while many cancers may still not be cured they may be converted to chronic diseases. All of these treatments, however, are impeded or precluded by the frequent development of malnutrition and metabolic derangements in cancer patients, induced by the tumor or by its treatment. These evidence-based guidelines were developed to translate current best evidence and expert opinion into recommendations for multi-disciplinary teams responsible for identification, prevention, and treatment of reversible elements of malnutrition in adult cancer patients. The guidelines were commissioned and financially supported by ESPEN and by the European Partnership for Action Against Cancer (EPAAC), an EU level initiative. Members of the guideline group were selected by ESPEN to include a range of professions and fields of expertise. We searched for meta-analyses, systematic reviews and comparative studies based on clinical questions according to the PICO format. The evidence was evaluated and merged to develop clinical recommendations using the GRADE method. Due to the deficits in the available evidence, relevant still open questions were listed and should be addressed by future studies. Malnutrition and a loss of muscle mass are frequent in cancer patients and have a negative effect on clinical outcome. They may be driven by inadequate food intake, decreased physical activity and catabolic metabolic derangements. To screen for, prevent, assess in detail, monitor and treat malnutrition standard operating procedures, responsibilities and a quality control process should be established at each institution involved in treating cancer patients. All cancer patients should be screened regularly for the risk or the presence of malnutrition. In all patients – with the exception of end of life care – energy and substrate requirements should be met by offering in a step-wise manner nutritional interventions from counseling to parenteral nutrition. However, benefits and risks of nutritional interventions have to be balanced with special consideration in patients with advanced disease. Nutritional care should always be accompanied by exercise training. To counter malnutrition in patients with advanced cancer there are few pharmacological agents and pharmaconutrients with only limited effects. Cancer survivors should engage in regular physical activity and adopt a prudent diet. [ABSTRACT FROM AUTHOR]

Introduction: This paper is the compilation of two reports and presentations by medical students from Martin University, Slovakia, during their international intercampus training to promote "Clinical Research: Standing Committee on Research Exchange of the International Federation of Medical Students' Associations." Materials and methods: The students developed a clinical research training project in nutrition during July 2010 at the Unit of Nutrition and Metabolism of the Institute of Molecular Medicine (Faculty of Medicine, University of Lisbon) in collaboration with the Radiotherapy Department of Lisbon's Santa Maria University Hospital. Results: 1) The students learned to apply specific methods in scientific research, e.g. doing literature searches in the international PubMed database and creating a bibliographic database using the reference management software EndNote®; 2) they wrote two reports on predefined topics; 3) they prepared and presented the results using PowerPoint®. This training was also directed towards making the students familiar with nutritional sciences, a poorly known subject field to them because it is not included in the medical curriculum; this was indeed the central reason for their choice. In addition, the students took part in the hospital routine at the Radiotherapy Department and practiced body composition evaluation; all these activities aimed to promote the students' involvement in ongoing clinical nutrition research. Conclusions: These projects were designed to develop and expand medical students' knowledge in clinical nutrition in a real-life setting, as well as to foster effective learning and application of internationally accepted methods in the context of nutrition evaluation and research. [ABSTRACT FROM AUTHOR]

Rationale. Nutritional risk screening should be routine in order to select patients in need of nutrition care; this conduct change has to rely on education. In this project, radiotherapy department health professionals were trained on how to use the Malnutrition Universal Screening Tool (MUST), to foster its integration into cancer outpatient management; we also aimed to identify those more adherent to screening. Methods. Research dieticians (the standard) conducted interactive sessions with all physicians, nurses, and radiotherapy (RT) technicians, who were closely supervised to facilitate routine MUST integration. There were two phases: after the first session, phase 1 assessed 200 patients over 4 months; after the second session, phase 2 screened 450 patients, always before RT. Validity was evaluated comparing results from the standard against all other health professionals, adjusted for number. Results. RT technicians were most adherent to the MUST: 80% of patients in phase 1, increasing to 85% in phase 2. Nurses doubled their input, from 19% to 36%. Physicians had poor MUST integration, yet they progressively incorporated percentage weight loss into patient records, increasing from 57% in phase 1 to 84% in phase 2, independently of diagnosis and stage. The highest concordance ( coefficient) with dieticians was found with RT technicians' use of the MUST (p < .002) and percentage weight loss determination by physicians (p < .001). Conclusions. We show that systematic screening in cancer is feasible by all professionals involved, once a proximity teaching project is put into practice. RT technicians, who daily treat patients, were highly adherent to integrate the MUST and might be in charge of selecting at-risk patients. Physicians are unlikely to use the MUST, but acknowledged nutrition value and changed their routine by integrating recent percentage weight loss into their approach to patients. Our structured methodology may be used as a model for the development of teaching adapted to different departments with other realities. [ABSTRACT FROM AUTHOR]

Objective. Nutritional status in cancer has been mostly biased toward undernutrition, an issue now in dispute. Weaimed to characterize nutrition status, to analyze associations between nutritional and clinical/cancer-related variables, and to quantify the relative weights of nutritional and cancer-related features. Methods. The cross-sectional study included 450 nonselected cancer patients (ages 18-95 years) at referral for radiotherapy. Nutritional status assessment included recent weight changes, body mass index (BMI categorized by World Health Organization's age/sex criteria, and Patient-Generated Subjective Global Assessment (PG-SGA; validated/specific for oncology).Results. BMI identified 63% as ⩾25 kg/m2 (43% overweight, 20% obese) and 4% as undernourished. PG-SGA identified 29% as undernourished and 71% as well nourished. Crossing both methods, among the 319 (71%) well-nourished patients according to PG-SGA, 75% were overweight/obese and only 25% were well nourished according to BMI. Concordance between BMI and PG-SGA was evaluated and consistency was confirmed. More aggressive/ advanced stage cancers were more prevalent in deficient and excessive nutritional status: in 83%(n=235/ 282) of overweight/obese patients by BMI and in 85%(n=111/131) of undernourished patients by PG-SGA. Results required adjustment for diagnoses: greater histological aggressiveness was found in overweight/obese prostate and breast cancer; undernutrition was associated with aggressive lung, colorectal, head-neck, stomach, and esophageal cancers (p < .005). Estimates of effect size revealed that overweight/obesity was associated with advanced stage (24%), aggressive breast (10%), and prostate (9%) cancers, whereas undernutrition was associated with more aggressive lung (6%), colorectal (6%), and head neck (6%) cancers; in both instances, age and longer disease duration were of significance. Conclusion. Undernutrition and overweight/obesity have distinct implications and bear a negativeprognosis in cancer. This study provides novel data on the prevalence of overweight/obesity and undernutrition in cancer patients and their potential role in cancer histological behavior. [ABSTRACT FROM AUTHOR]

Summary: To devise a meaningful nutritional therapy in cancer, a greater understanding of nutritional dimensions as well as patients’ expectations and disease impact is essential. We have shown that nutritional deterioration in patients with gastrointestinal and head and neck cancer was multifactorial and mainly determined by the tumour burden and location. In a larger cohort, stage and location were yet again the major determinants of patients’ quality of life (QoL), despite the fact that nutritional deterioration combined with intake deficits were functionally more relevant than cancer stage. Based on this framework, the potential role of integrated oral nutritional support on outcomes was investigated. In a pilot study using individualized nutritional counselling on a heterogeneous patient population, the achieved improvement of nutritional intake was proportional to a better QoL. The role of early nutritional support was further analysed in a prospective randomized controlled trial in head and neck cancer patients stratified by stage undergoing radiotherapy. Pre-defined outcomes were: nutritional status and intake, morbidity and QoL, at the end and 3 months after radiotherapy. Nutritional interventions, only given during radiotherapy, consisted of three randomization arms: (1) individualized nutritional counselling vs. (2) ad libitum diet+high protein supplements vs. (3) ad libitum diet. Nutritional interventions 1 and 2 positively influenced outcomes during radiotherapy; however, 3 months after its completion individualized nutritional counselling was the single method capable of sustaining a significant impact on patients’ outcomes. The early provision of the appropriate mixture of foods and textures using regular foods may modulate outcomes in cancer patients. [Copyright &y& Elsevier]

Purpose: To investigate in cancer patients referred for radiotherapy (RT): (1) quality of life (QoL), nutritional status and nutrient intake, at the onset and at the end of RT; (2) whether individualised nutritional counselling, despite symptoms, was able to enhance nutrient intake over time and whether the latter influenced the patient''s QoL; and (3) which symptoms may anticipate poorer QoL and/or reduced nutritional intake.Material and methods: One hundred and twenty-five patients with tumours of the head–neck/gastrointestinal tract (high-risk: HR), prostate, breast, lung, brain, gallbladder, uterus (low-risk: LR) were evaluated before and at the end of RT. Nutritional status was evaluated by Ottery''s Subjective Global Assessment, nutritional intake by a 24-h recall food questionnaire and QoL by two instruments: EUROQOL and the European Organisation for the Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ)-C30.Results: Baseline malnutrition was prevalent in HR vs. LR (P=0.02); nutritional intake was associated with nutritional status (P=0.007); the latter did not change significantly during RT. In LR, baseline energy intake was higher than EER (P=0.001), and higher than HR’ intake (P=0.002); the latter increased (P<0.03), in spite of symptom increase anew and/or in severity (P=0.0001). According to both instruments, QoL was always better in LR vs. HR (P=0.01); at the end of RT, QoL improvement in HR was correlated with increased nutritional intake (P=0.001), both remained stable in LR.Conclusions: Individualised nutritional counselling accounting for nutritional status and clinical condition, was able to improve nutritional intake and patients’ QoL, despite self-reported symptoms. [Copyright &y& Elsevier]

Intensive individualized nutritional counseling requires nutrition professionals with specific experience in oncology. If the patient is unable to achieve his or her nutritional requirements via regular foods, nutritional supplements may be prescribed, the composition of which is based on detection of dietary deficits as well as a detailed intake questionnaire. Any nutritional intervention must be based on the need for an adequate intake and also must take into consideration other relevant factors such as digestive and absorptive capacity, the need for alleviation or arrest of symptoms, and any psychological issues. [ABSTRACT FROM AUTHOR]

Summary: Background & aims: It is acknowledged the interrelationship between nutrition and cancer. Health professionals (HP) and caregivers play a central role in undernutrition prevention/treatment. Our aims were to appraise the knowledge of Oncology HP and cancer caregivers about undernutrition and nutritional supplements (NS) and to assess the relevance given to NS. Methods: 103HP and 394 adult caregivers of cancer patients were randomly selected to the inquiry. Results: HP and caregivers stated that cancer patients were at higher undernutrition risk (95%, p <0.001 & 57%, p <0.05, respectively) and considered that undernutrition increase cancer severity (85%, p <0.002 and 69%, p <0.01, respectively). The majority of the caregivers (65%, p <0.01) defined undernutrition as an inadequate food intake. Only 35% of caregivers were satisfied with the information received about nutrition. Once undernutrition was diagnosed, 46% physicians and 45% nurses advised the use of NS (p <0.05). Only 14% of caregivers knew cancer NS (p <0.001). Reasons for low NS consumption were price (60%, p <0.009) and lack of information (57%, p <0.01). Conclusions: For the HP involved in this study, cancer is a major risk factor for undernutrition and which in turn worsens the disease. The lack of knowledge about nutrition among caregivers was obvious. Proving information about prevention/consequences of undernutrition is essential. Professionals and caregivers agreed that NS can be an effective strategy when intake is limited, however the cost can be limiting. [ABSTRACT FROM AUTHOR]

Objectives: The objective of this review article is to present the most recent intervention studies with EPA on nutritional outcomes in cancer patients, e.g. nutritional status, weight & lean body mass. Methods: For this purpose a PubMed® and MedLine®search of the published literature up to and including January 2014 that contained the keywords: cancer, sarcopenia, EPA,ω-3 fatty acids, weight, intervention trial, muscle mass was conducted. The collected data was summarized and written in text format and in tables that contained: study design, patient' population, sample size, statistical significance and results of the intervention. The paper will cover malignancy, body composition, intervention with EPA, physiological mechanisms of action of EPA, effect of EPA on weight and body composition, future research. Results: In cancer patients deterioration of muscle mass can be present regardless of body weight or Body Mass Index (BMI). Thus, sarcopenia in cancer patients with excessive fat mass (FM), entitled sarcopenic obesity, has gained greater relevance in clinical practice; it can negatively influence patients' functional status, tolerance to treatments & disease prognosis. The search for an effective nutritional intervention that improves body composition (preservation of muscle mass and muscle quality) is of utmost importance for clinicians and patients. The improvement of muscle quality is an even more recent area of interest because it has probable implications in patients' prognosis. Eicosapentaenoic acid (EPA) has been identified as a promising nutrient with the wide clinical benefits. Several mechanisms have been proposed to explain EPA potential benefits on body composition: inhibition of catabolic stimuli by modulating pro-inflammatory cytokines production and enhancing insulin sensitivity that induces protein synthesis; also, EPA may attenuate deterioration of nutritional status resulting from antineoplastic therapies by improving calorie and protein intake as well. Conclusions: Indeed, cancer-related sarcopenia/cachexia is a multifactorial syndrome characterized by inflammation, anorexia, weight loss, and muscle/adipose tissue loss mediated by proin-flammatory cytokines, e.g. TNF-α and IL-6, resulting in increased chemotherapy toxicity, costs, morbidity and mortality. With this review we found that EPA can reduce inflammation and has the potential to modulate nutritional status/body composition. In view of the modest survival benefits of chemotherapy/radiotherapy in some cancers, important issues for physicians are to optimize well-being, Quality of Life via nutritional status and adequate body composition. Thus, improvement in nutritional status is a central outcome. [ABSTRACT FROM AUTHOR]