Overview
Based on thorough assessment by a dietitian, individuals will be stratified into moderate or high-risk categories which leads to targeted and specialist prehabilitation intervention respectively1
Modified from MacMillan Prehabilitation interventions triangle1
Which clinicians provide targeted and specialist nutrition intervention
Clinicians providing targeted and specialist intervention should be qualified dietitians and should be familiar with the following guidelines to help guide nutrition intervention in the oncology population:
- ESPEN practical guideline: clinical nutrition in surgery- update 20252
- ESPEN practical guideline: clinical nutrition in cancer3
- ESPEN guidelines on nutrition in cancer patients4
- Clinical Oncology Society of Australia: position statement on cancer-related malnutrition and sarcopenia5.
Targeted nutrition intervention
Who
Individuals assessed as mild/moderate or suspected malnutrition (SGA B or PG-SGA 4-8) require targeted dietitian intervention9.
How – nutrition intervention goals
The exact prescription of nutrition intervention is not known, but there is agreeance in available evidence-based guidelines on the overall goals of nutrition intervention for individuals undergoing cancer surgery.
Overall nutrition goals for all targeted and specialist individuals2-4:
- Prevent / reverse malnutrition and correct nutrition-identified problems
- Support muscle mass gain (anabolism).
Specialist nutrition intervention
Who
Individuals assessed as severe malnutrition (SGA C or PG-SGA ≥9) require specialist dietitian intervention 9.
How – nutrition intervention goals
The overall nutrition goals are the same for targeted and specialist nutrition intervention (see above goals). However, those individuals with severe malnutrition (PG-SGA C) will require more intensive intervention strategies to meet nutrient requirement targets, and more frequent reviews by the dietitian (e.g. 1-2 weekly monitoring), compared to those with mild/moderate malnutrition.
Specific specialist intervention considerations for severe malnutrition
For individuals assessed as severely malnourished (PG-SGA C) consider delaying surgery for a period of 7-14 days of enteral or parenteral nutrition2,4,10. Parenteral nutrition is only considered in malnourished individuals where enteral nutrition is unable to meet requirements and a period of 7-14 days is recommended.
Further nutritional intervention strategies to consider (emerging evidence)
Interest is growing on the effectiveness of using specific protein amino acids for building muscle, with a particular focus on the branched chain amino acid leucine, which is the predominant amino acid in whey protein, and its metabolite β-hydroxy-β-methylbutyrate (HMB). Whey-based protein is commonly used in practice, but evidence in this area is still inconsistent and further research is needed before recommending use of these products in practice5,7,8.
There is increasing evidence of the benefits of immunonutrition supplements, containing a combination of arginine, glutamine, omega-3 fatty acids and nucleotides, that can potentially modulate activities of the immune system and reduce infectious complications post surgery when given 5-7 days prior to surgery +/- 5-7 days post surgery. This has led to nutrition practice guidelines recommending use of immunonutrition in malnourished individuals undergoing major cancer surgery, specifically in UGI cancer patients3.
Timing of intervention
For all targeted and specialised individuals, aim to commence nutrition intervention for a minimum of 4 weeks prior to surgery in order to make effective improvements in nutrition status, but nutrition intervention in a little as 2 weeks pre-surgery can be effective to maintain current nutrition status and prevent further decline2.
However, if an individual is undergoing neoadjuvant chemotherapy +/- radiotherapy, ongoing review by their cancer treatment team should involve malnutrition screening, and referral to the dietitian for nutrition management over the treatment course should occur if nutritional issues arise.
Frequency of review
Nutrition review frequency of targeted and specialist individuals is based on clinical judgement, on an individual basis, related to risk of or severity of malnutrition and presence of nutrition impact symptoms. Individuals undergoing neoadjuvant chemotherapy +/- radiotherapy also require nutritional monitoring.
Individuals undergoing targeted intervention (mild/moderate malnutrition) should be reviewed after their initial assessment, for example within 2 to 6 weeks. Those requiring specialist intervention (severe malnutrition) should be reviewed more frequently, for example every 1-4 weeks. Some evidence suggests that individuals benefit from at least 3 reviews11.
Review consultations can be conducted face to face or via telehealth (phone if telehealth not available).
At each review, individuals should have reviewed as a minimum:
- Comprehensive nutrition assessment, including (at a minimum):
- Anthropometry + weight history
- Nutritional impact symptoms
- Dietary intake
- Diagnosis of nutritional status / malnutrition (PG-SGA)
- Estimation of nutritional requirements (aim for min 100-125kJ/kg/day and 1.2g protein/kg/day).
Barriers and enablers
Behaviour change is a key pillar in the measure of success in prehabilitation. Motivation and behaviour change details how to identify and enhance individual engagement to overcome common barriers in prehabilitation. Of note these are some considerations to maximise nutrition-related patient and service outcomes:
- Consider use of online tools that monitor food and fluid intake to enhance compliance e.g. food diaries
- Collaborate with individuals to set meaningful goals
- Recruit support from the patient’s support network i.e. partners/friends attend appointments with the patient.
To assist individuals with their compliance with nutrition strategies, it is important to have close collaboration with the medical team to help address nutrition impact symptoms with medical management as required.
To ensure fidelity and consistency amongst clinicians, a model of care or operational guideline is encouraged to be developed pertaining to your health service.