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e-SPEN Journal 7 (2012) e46ee49

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Original article

Undernutrition and nutritional supplements in Oncology: What do healthprofessionals and caregivers know? e A pilot survey

Catarina Ferreira a, Maria Camilo a, Rosa Pena b, Paula Ravasco a,*

aUnit of Nutrition and Metabolism, Institute of Molecular Medicine, Faculty of Medicine, University of Lisbon, Avenida Prof. Egas Moniz, 1649-028 Lisboa, PortugalbNutricia Advanced Medical Nutrition, Portugal

a r t i c l e i n f o

Article history:Received 10 August 2011Accepted 21 November 2011

Keywords:CancerUndernutritionSupplementsHealth professionalsCaregiversOutcomes

Abbreviations: HP, Health professionals; NS, Nutri* Corresponding author. Tel.: þ351 217985187; fax:

E-mail addresses: catarinajoaoferreira@gmail.com(M. Camilo), rosa.pena@nutricia.com (R. Pena), p.rava

2212-8263/$36.00 � 2011 European Society for Clinicdoi:10.1016/j.eclnm.2011.11.003

s u m m a r y

Background & aims: It is acknowledged the interrelationship between nutrition and cancer. Healthprofessionals (HP) and caregivers play a central role in undernutrition prevention/treatment. Our aimswere to appraise the knowledge of Oncology HP and cancer caregivers about undernutrition andnutritional 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< 0.002and 69%, p< 0.01, respectively). The majority of the caregivers (65%, p< 0.01) defined undernutrition asan inadequate food intake. Only 35% of caregivers were satisfied with the information received aboutnutrition. 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 wereprice (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 inturn worsens the disease. The lack of knowledge about nutrition among caregivers was obvious. Provinginformation about prevention/consequences of undernutrition is essential. Professionals and caregiversagreed that NS can be an effective strategy when intake is limited, however the cost can be limiting.

� 2011 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd. All rightsreserved.

1. Introduction

Scientific evidence supports that cancer-related undernutritionis multifactorial and carries numerous negative consequences forpatients and for the National Health System. Nutritional deterio-ration increasesmorbidity, reduces functional capacity, tolerance toanti-neoplastic treatments and Quality of Life. Undernutrition incancer is associated with increased length of stay and higher costsfor health care system.1e6

Individualized nutritional counseling and nutritional supple-ments (NS) are effective strategies to increase food intake. They arealso important to prevent weight loss associated with anti-neoplastic treatments and to avoid interruption of radiotherapyto the head/neck and gastrointestinal regions (ESPEN guidelines e2006).7 Cancer treatment involves the collaboration and interac-tion between several Health Professionals (HP); nevertheless, HP

tional supplements.þ351 217985142.(C. Ferreira), maria@fm.ul.ptsco@fm.ul.pt (P. Ravasco).

al Nutrition and Metabolism. Publ

lack of knowledge on nutrition has delayed the patients treatmentwith specialized nutrition professional.8,9

Based on this background, this study aimed to investigate theknowledgeofHPand caregivers of cancerpatients about nutritionandNS. The specific goals were: (1) to assess the knowledge of theconsequences of undernutrition in Oncology; (2) to evaluate theimportance given to specific NS for cancer patients; and (3) to inves-tigate possible strategies to optimize NS intake whenever necessary.

2. Population and methods

This cross sectional analytical study was developed according toHelsinki Declaration, adopted by World Medical Association in1964, amended in 1975 and actualized for the last time in 2002. Ittook place in different oncological care centers in Portugal. Allparticipants gave their informed consent.

2.1. Health professionals and caregivers

In this study 103 Portuguese HP from oncological departmentswere randomly included: 36% medical oncologists, 15% pediatric

ished by Elsevier Ltd. All rights reserved.

Fig. 1. Major clinical problems associated with undernutrition.

C. Ferreira et al. / e-SPEN Journal 7 (2012) e46ee49 e47

medical oncologists and 50% nurses. Additionally, 394 adults (�18years old), who were caregivers of cancer patients were included.Subjects from two groups were residents in Portugal.

2.2. Questionnaires

All data was collected from two questionnaires, one specific forHP and the other for caregivers. The questionnaires were filledduring an interview performed by different inquiry teams,throughout the country: North, Centre, Lisbon, Alentejo andAlgarve regions. The information was written in the official files,previously structured for introduction into computer database andstatistical analysis. The questionnaire included social and demo-graphic data, information on knowledge and value of undernutri-tion in cancer patients, as well as about NS.

Both questionnaires were divided into two parts: demographics,undernutrition and NS. For the demographics and HP character-ization, five questions were made, three with open answers andtwo with closed answers. About undernutrition and NS, the ques-tionnaire was composed by 44 questions, of which 19 had openanswers, 8 had scaled answers and 17 had closed answers. As forthe caregivers characterization, nine questions were asked, threewith open answers and six with closed answers. The questionnairewas composed by 44 questions of which 13 had open answers,eight had scaled answers and 23 had closed answers.

Concerning the topic of undernutrition, both groupswere inquiredabout the definition, causes and susceptibility of cancer patients toundernutrition, as well as the influence of undernutrition on diseaseprogression. HP were also asked about the risk factors and treatmentof undernutrition, the evaluation of cancer patients nutritional statusand which measures were taken after a possible diagnosis of under-nutrition. Caregivers were asked to indicate possible strategies forundernutrition treatment and the satisfaction on the informationabout this topic, when provided by professionals and/or health care.

Regarding NS, the knowledge and value of specific products forcancer patients, plus the possible strategies considered efficient toincrease the NS consumption were inquired. HP were asked toestimate the NS intake by the patients, and also to describe themain factors determining its prescription. In addition, it was askedto: the definition of NS, examples of these products and if theywould take them if advised.

2.3. Statistic analysis

Statistical analyzes were performed using SPSS 16.0 forWindows (SPSS Inc, Chicago, USA 2003). It was used frequencyanalysis for descriptive data and the Chi-square test to evaluatedifferences between prevalence of categorical variables. Thesignificance was established at a level of p< 0.05.

3. Results

3.1. Health professionals

The HP distribution according to the clinical practice andcountry region is illustrated on Table 1. We found that 79% of HP

Table 1Distribution of health professionals by clinical practice and country region.

Clinical practice Country region Total

North Centre South

Oncologists 14 8 15 37Pediatric oncologists 7 2 6 15Nurses 20 10 21 51

Total 41 20 42 103

were concerned with undernutrition and for them, undernutritionwas mainly related to cancer (95%), deficient intake (88%) andpsychiatric diseases (86%), p< 0.001 (Fig. 1). Moreover, 85% of HPconsidered that undernutrition increases cancer severity(p< 0.002) with a greater probability of other complications (91%),decreased responsiveness of the body (85%), discontinuation ofanti-neoplastic treatments (75%) and increased risk of mortality(61%).

Therewere 42% of physicians and 49% of nurses who assessed alltheir patients’ nutritional status (p< 0.05). It was asked if specificprocedures were undertaken after undernutrition diagnosis: 80% ofnurses reported patients to their physician (p< 0.05), 69% ofphysicians and 65% of nurses emphasized the importance ofa “healthy diet” (p< 0.01), and 46% of physicians and 45% of nursesadvised the use of NS (p< 0.05), Fig. 2. In respect to NS, 89% ofphysicians were prescribers and when we asked “in which youbased your choice”, they referred based their choice on nutritionalcomposition (100%), taste (96%) and energy value (94%), (p< 0.002)(Fig. 3). For 82% of HP, cancer specific supplements were important,but most (75%) stated that they were only used by less than 50% ofpatients. The reasons pointed for the low intake were cost (30%)and lack of information on NS (20%).

3.2. Caregivers

The caregivers distribution according to the age and countryregion is illustrated in Table 2; there is a greater percentage ofcaregivers from the Lisbon area and aged between 45 and 54 yearsold. Data showed that 65% of caregivers defined undernutrition,through a questionwith open answer, as an inadequate food intake(p< 0.01), Fig. 4, and 57% considered cancer patients at a higherundernutrition risk (p< 0.05). For 69%, the disease severity

Fig. 2. Therapeutical approach after undernutrition diagnosis.

Fig. 3. Influencing factors on the choice of NS.

Fig. 4. Undernutrition definition.

C. Ferreira et al. / e-SPEN Journal 7 (2012) e46ee49e48

increased in undernourished patients (p< 0.01), for 82% undernu-trition decreased anti-neoplastic treatments’ efficacy, increased thesusceptibility to other complications (p< 0.002), and for 59% itincreased the risk of mortality (p< 0.02). Only 35% of caregiverswere satisfied with the nutrition information received and whenwe asked “which information about nutrition would you like toreceive”, they considered a priority learning how to preventundernutrition (p< 0.01), Fig. 5.

Relative to NS, 79% of caregivers knew that they existed(p< 0.003), but seldom knew what they contained. Only 14% knewcancer specific NS (p< 0.001). For the majority (87%), diet was thebest treatment for undernutrition, but cancer specific supplementswere considered important (p< 0.001), Fig. 6, and 91% would useNS if they were advised to, p< 0.002. Major limitations for NSintake were high costs (60%, p< 0.009) and lack of information(57%, p< 0.01). Thus, a wider awareness of the benefits of NS (38%),affordable prices (31%) and physicians’ knowledge on the issue ofNS (21%), were depicted in the questionnaire as the most effectivestrategies to increase the use of NS in cancer patients, Fig. 7.

4. Discussion

It is highly positive that HP claimed to care about the under-nutrition; whilewith caregivers therewas a clear lack of knowledgeon the definition of undernutrition in cancer. Yet, both groupsconsidered cancer patients at nutritional risk and that the diseaseseverity increases in case of undernutrition. It is relevant that thetwo groups recognized the increase in mortality as a consequenceof undernutrition. Thus, a major finding of this study was that it isessential to inform professionals and caregivers about nutritioncare, because both are fundamental in the prevention and treat-ment of undernutrition.

There are many studies to illustrate that cancer stage andlocation are major factors for nutritional deterioration, and furtheremphasize the role of nutritional intake deficits, which may occur

Table 2Distribution of caregivers by age and country region.

Age (years) Country region Total

North Centre Lisbon Alentejo Algarve

18e24 17 27 21 1 2 6825e34 24 22 21 3 2 7235e44 14 20 13 6 2 5545e54 24 13 34 5 2 7855e64 15 12 19 5 2 53�65 25 14 19 6 4 68

Total 119 108 127 26 14 394

early on and may worsenwith disease progression. Cancer locationand its progression are central to nutritional decline. Timely andappropriate interventions for cancer patients require adoption ofroutine nutritional screening and assessment.10 It should be valuedthat approximately 50% of HP affirmed that they assessed nutri-tional status of their patients. However, this study did not evaluatethe methods used during this assessment. Therefore, it should bea priority to develop studies that evaluate the methods used by HPto assess nutritional risk and status of their patients, given theurgency in standardizing these practices.11 In comparison toanother study, the majority of specialist oncological trainees (80%)expressed uncertainty or a lack of confidence in their ability toidentify undernutrition.12 The Patient-Generated Subjective GlobalAssessment (PG-SGA) is a validated tool to assess the nutritionalstatus of cancer patients. This method emphasizes parameters asthe weight history (usual and current weights, weight loss in theprevious 6 months, last month and two weeks), food intake, signsand symptomswith nutritional impact (nausea, vomiting, anorexia,diarrhea, etc.), functional capacity and physical examination. Theuse and explanation of thismethod by differentiated HPwould helpthe patient and caregivers to understand the factors that influencenutritional status in Oncology. On the other hand, and consideringour results, caregivers wanted to receive more information fromHPabout nutritional recommendations to prevent undernutrition.However, one study showed that the three major barriers tonutritional intervention by specialist oncological trainees, werereported to be lack of clear guidelines, lack of knowledge and lack oftime. Thus, in this study the majority (80%) of professionals wantedadditional training in this area.11 So, it is necessary to provideeffective, concise and relevant nutritional education interventions

Fig. 5. Wanted information about undernutrition.

Fig. 6. Importance given to the existence of specific NS for cancer patients.

Fig. 7. Strategies to increase the NS consumption on cancer patients.

C. Ferreira et al. / e-SPEN Journal 7 (2012) e46ee49 e49

to HP in cancer. A combination of an integrated nutrition curric-ulum during the education, together with post-graduated educa-tion for both physicians and nurses should be established.12

Supplements can be effective when food intake is insufficient.Nevertheless, only a small percentage (14%) of caregivers identifiedcorrectly these products; hence it is crucial to inform them aboutthe existence and benefits of NS. Interestingly, they also wanted tolearn the difference between NS, mineral and vitamin supplementsand dietary supplements. Both professionals and caregivers valuedspecific NS for cancer patients; however, both considered themcostly and identified the need to have more available informationabout these products in order to increase intake. Hence, involvingdietitians in training and teaching multidisciplinary teams isfundamental. Many strategies can be applied, e.g. preparingbrochures, providing training to caregivers but also to HP about theimportance of monitoring weight, food intake, signs/symptomswith nutritional impact.

Although recognizing the limitations inherent to the use of thequestionnaires in this study, it was found consistent signs of theurgency of teaching and integrating nutrition in the treatment ofcancer patients, acknowledged by professionals and caregivers.Ideally, methods of validation and reliability testing are required.

5. Conclusion

It was well established, for the HP and caregivers inquired, thatcancer is a major risk factor for undernutrition and nutritionaldeterioration worsens the disease. Half of the HP assessed patients’nutritional status and attempted to improve their nutritionalintake. On the other hand, the lack of knowledge about nutritionand prevention of undernutrition among caregivers was clear. It isessential to provide information about the consequences ofundernutrition and how to improve nutritional intake. NS can be aneffective strategy when intake is limited. In this study, theprescription of NS was determined by composition and taste, butprice was a major limitation for their use. National Health Servicesubsidization of NS would allow their cost reduction. Appropriatemeasures to increase awareness of HP and caregivers about nutri-tion are crucial for the implementation of effective nutritionaltherapies.

Conflict of interestNone.

Acknowledgements

This study was partially supported by a Grant from the“Fundação para a Ciência e Tecnologia” (RUN 437).

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