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Malnutrition and cancer

  • Disease-related malnutrition occurs frequently in patients with cancer and is a major cause of morbidity and mortality
  • Decreased dietary intake, cancer cachexia (characterised mainly by loss of appetite, weight loss and muscle wasting), and nutritional status may all contribute to cancer-related malnutrition. The nutritional status may result from the local effects of the tumour itself, the host response to the tumour, and/or the treatment modalities involving combinations of chemotherapy, radiotherapy and surgical regimens which produce various acute and chronic symptoms that all limit eating
  • Malnutrition can be identified by using a validated screening tool such as the ‘Malnutrition Universal Screening Tool’ (‘MUST’) and/or local screening tools
  • The consequences of malnutrition in cancer patients include the impairment of immune function, performance status, muscle function and associated debilitating morbidities such as depression and fatigue
  • In addition, responses to chemotherapy are decreased, chemotherapy-induced toxicity increases, and complications are more frequent and severe. However, the major consequence of progressive weight loss and nutritional deterioration is reduced survival. Cancer-related malnutrition is also associated with significant healthcare-related costs

Nutritional screening and support

  • The nutritional status of patients diagnosed with cancer and entering the care pathway will vary from patient to patient. Early nutrition screening can help to identify malnutrition risk and any problems that may affect how well the patient’s body can deal with the impact of the subsequent cancer treatment
  • Nutritional support is required for cancer patients to prevent and manage malnutrition and improve treatment efficacy; it may reduce the side-effects of anti-cancer treatment and improve quality of life (QoL)
  • Nutritional support can help patients maintain their weight or prevent weight loss, decrease problems with the treatment and aid recovery
  • Nutritional screening is recommended on first contact with the care setting. Once an individual has been highlighted at risk of malnutrition, regular screening and monitoring is recommended to determine any improvement or deterioration and action required
  • Nutritional interventions can include dietary advice, oral nutritional supplements (ONS), enteral tube feeding (ETF) and in some instances parenteral nutrition. Nutritional support can help patients to maintain weight, improve tolerance to treatment, maximise outcomes, and improve QoL
  • Patients may require nutritional support from the onset at diagnosis, during treatment and throughout the whole patient journey, with early use of ONS. ONS can improve energy intake and reduce weight loss in cancer. Nutritional intervention with ONS can also improve QoL in patients who are malnourished and may also result in cost savings
  • Patients may require ONS to meet their daily nutritional requirements. Systematic reviews and NICE Clinical Guidance 32 have demonstrated ONS clinical efficacy and cost-effectiveness of ONS in the management of malnutrition, particularly among those patients with a low body mass index (BMI<20 kg/m2)
  • There is also a low threshold in particular patients undergoing radiotherapy to progress to ETF if they are unable to meet their nutritional requirements orally

Dietary advice for patients with lung cancer

  • Many patients with lung cancer not only lose weight, but also find it difficult to eat and drink due to the presence of the tumour and the impact of cancer treatment. They may also have difficulty preparing and sourcing meals and drinks. Dietary advice is therefore important to help them manage these issues
  • Patients can be given advice on eating energy and protein-rich meals and snacks, maintaining a varied diet so that their vitamin and mineral needs are met, food fortification and consuming small frequent meals and snacks. In addition consideration should be given to those patients requiring a texture-modified diet due to swallowing problems
  • Certain chemotherapy agents require an empty stomach to optimise absorption, and therefore, healthcare professionals may need to advise patients to avoid eating one hour before, or up to two hours after taking such medication. In terms of tumour and treatment related side-effects impacting on normal food intake, symptom control using appropriate pharmaceutical agents should be prioritised individually for each patient. Seek advice from a doctor or oncology pharmacist as appropriate
  • Dietary advice—hints and tips:
    • aim for three small meals and three small snacks a day
    • encourage high-energy and protein-rich food choices e.g. full fat milk instead of semi-skimmed, mix grated cheese or cream into foods such as mashed potato and soups
    • keep high-energy snacks within easy reach. Cheese and crackers, biscuits, cakes, nuts, crisps, dried fruit, and peanut butter on toast are a good way to get extra calories and protein throughout the day
    • have nourishing drinks in between meals other than tea, coffee, and water
    • avoid drinking too much fluid with meals

Range and selection of ONS

  • There are a wide range of ONS styles (milkshake, juice, yoghurt, savoury), formats (liquid, powder, pudding, pre-thickened), types (high protein, low volume, fibre containing) energy densities (1–2.4 kcal/ml) and flavours available to suit a wide range of patient needs. Most ONS provide approximately 300 kcal, 12 g protein and a full range of vitamins and minerals per serving
  • Many patients requiring ONS can be managed using 1.5–2.4 kcal/ml. The amount of fluid in a standard ONS is approximately 200 ml; however, for patients with a small appetite and/or those who are breathless or who have difficulty drinking larger volumes of fluid, there are more concentrated supplements available which contain the same amount of nutrition, but in only 125 ml. When commencing ONS the considerations outlined are important
  • Considerations when commencing ONS:
    • establish preferred flavours, likes and dislikes e.g. milk or juice, sweet or savoury
    • test preferences and compliance with a prescribable ‘starter pack’
    • prescribe preferred product/flavour; two ONS/day (range 1–3/day—see pathway below)
    • refer to a dietitian where possible and particularly if ONS is the sole source of nutrition or patients have complex needs
    • modular ONS—that provide one or two nutrients—in either powdered or liquid format should only be used under dietetic supervision
    • if the patient is also diabetic their blood sugars may need to be monitored more closely if appropriate

Lung cancer nutritional care pathway

Lung cancer nutritional care pathway 1280x1756

Nutrition starter pack

  • A nutrition starter pack for patients and carers, which gives them some basic nutritional support information, has been developed in conjunction with the National Lung Cancer Forum for Nurses
  • The following three two-page A4 leaflets are available to download from www.lungcancernutrition.com:
    • Practical tips for eating
    • Using oral nutritional supplements
    • Managing common symptoms
  • Nutritional information may also be available via your local dietetic team
  • Further advice on nutrition in cancer can also be found at www.nutritionincancer.co.uk

full guideline available from…


The British Association for Parenteral and Enteral Nutrition. A practical guide for lung cancer nutritional care. November 2014.

First included: February 2017.