Nutrition in Clinical Practice

Cachexia in cancer patients is a major cause of morbidity and mortality. The syndrome of cachexia seems to be a facet of the inflammatory response to injury. This proinflammatory state is driven by an interdependent web of mediators such as cytokines, neurotransmitters, prostaglandins, neuroendocrine hormones, and tumor-derived catabolic factors. The resulting metabolic response to cancer prevents the effective use of calories provided and therefore blocks anabolism. The most promising interventions in cancer cachexia seem to depend on modulation of the inflammatory state (including nonsteroidal anti-inflammatory drugs and fish oil–based preparations). Suppression of the inflammatory milieu seems to allow nutrition to have an anabolic effect, resulting in gains in lean tissue with the potential to improve patient survival and quality of life.

Nutrition issues facing people with cancer are significant. The role of nutrition therapy is often assumed to be less important than pharmacologic interventions as outcomes are less clear in the literature. Especially important has been the focus on traditional outcomes such as morbidity and mortality rather than adopting a more patient-centered approach and including quality of life as a key outcome. There is a general failure to recognize weight loss early enough and to implement nutrition interventions, which are effective. The nutrition intervention should be composed of both a prescription and an implementation method. To achieve compliance, the nutrition therapy should be implemented in an aggressive manner. Data show that when compliance is achieved, outcomes in the form of improved quality of life and functional capacity can be achieved. For people with cancer and their care-givers, outcomes such as quality of life have meaning, and for patients with poor prognoses, this may hold more meaning than mortality and morbidity outcomes. Clinicians need to implement triage systems to identify patients for early intervention and focus on nutrient combinations. They need to be confident that with the right prescription and implementation, nutrition therapy can be successful and bring real benefit to patients with cancer.

Dietary arginine is commonly found in both plant and animal products and has also become popular as a dietary supplement over the past 20 years. Arginine has been shown to have a wide variety of effects on the body, including impact on the cardiovascular system, the immune system, and wound healing. Recently it has also been shown to interact with popular pharmaceutical therapies (ie, statin drugs) in a positive way. Research indicates that arginine is safe and has positive effects on the body when used for relatively short periods of time. Data regarding arginine's safety with long-term use in pharmaceutical amounts is still not available for select patient populations (ie, cancer patients).

Scurvy is a disease caused by vitamin C deficiency. In this study, a patient with scurvy is presented with soreness and ulcerations of the mouth that were previously diagnosed as oral lichen planus. This disease is relatively more common than scurvy in the United States. Physicians should be aware that even in developed countries, soreness of the mouth and ulceration can be seen in patients with scurvy and potentially be misdiagnosed as oral lichen planus.

Monitoring parameters for patients receiving long-term home parenteral nutrition (HPN) should include assessment of micronutrient status to avoid deficiencies and potential excesses of any micronutrient. This evaluation examined the effectiveness of a standardized micronutrient assessment tool administered semiannually to long-term HPN consumers, for identifying signs/symptoms of a suspected deficiency or excess. All patients assessed were receiving long-term HPN from a single home-infusion provider. Of the 275 micronutrient assessments evaluated, 30 patients were found to have a suspected deficiency. Laboratory tests were ordered for 13 patients: deficiencies were confirmed in 6 patients, no deficiency was found in 4 patients, and 1 patient was not deficient in the suspected micronutrients but was found deficient in others. The micronutrient assessment tool is effective in determining the suspected presence of micronutrient deficiencies. All long-term HPN patients should receive ongoing monitoring by a home care clinician, including an assessment of micronutrient status, to ensure adequacy of the nutrition support regimen.

The role of total parenteral nutrition (TPN) in the supportive care of cancer patients has evolved over the past 25 to 30 years. Multiple investigations and subsequent meta-analysis review of the results of selected randomized controlled trials have been conducted in an attempt to better define the tumor-bearing patient who is most likely to respond favorably to TPN intervention. A historical perspective on the evolution of TPN in cancer patients was provided by Dr Edward Copeland in his 1986 Jonathon E. Rhoads Lecture. This classic article is summarized and additional data from more recent publications are included to provide a current perspective of the role of TPN in cancer patients.

A new oral amino acid preparation was given to two groups of patients: group 1, five patients on hemodialysis; and group 2, five patients with chronic renal failure (CRF). In group 1, significant prediet and postdiet changes were: BUN 93 to 37 mg% (p smaller than .01); creatinine 13.0 to 9.7 mg% (p smaller than .001); phosphorus 6.6 to 4.2 mg% (p smaller than .05); uric acid 8.7 to 6.0 mg% (p smaller than .01); CO₂ 16.3 to 21.3 mEq/L (p smaller than .01); hematocrit 18.0 to 20.8% (p smaller than .05). In group 2: BUN 93 to 66 mg% (p smaller than .05); phosphorus 5.6 to 3.8 mg% (p smaller than .05); hematocrit 27.3 to 30.7% (p smaller than .05). Nitrogen balance was positive in all patients. It is concluded that this oral amino acid mixture is well-tolerated and can be utilized in CRF to attain protein anabolism.