Elsevier

Nutrition

Volumes 67–68, November–December 2019, 110550
Nutrition

Review
Use and effects of oral nutritional supplements in patients with cancer

https://doi.org/10.1016/j.nut.2019.07.002Get rights and content

Introduction

Cancer and its treatment are often associated with disease and treatment-related side effects, leading to diminished nutritional intake and involuntary weight loss. Possible causes of weight loss and malnutrition in cancer include the following:

  • Catabolic effects of the tumor/abnormal metabolism of nutrients;

  • Inadequate intake due to tumor-induced anorexia;

  • Reduced food intake secondary to treatment side effects such as nausea, vomiting, stomatitis, constipation, and malabsorption;

  • Obstruction caused by the tumor or as a consequence of treatment; and

  • Pain, anxiety, fatigue, or depression [1].

It has been reported that weight loss and malnutrition are associated with poorer treatment outcomes [2], [3]. Even in the present era of obesity, involuntary weight loss is still highly prevalent in patients with cancer. A recent review depicts weight loss in large numbers of patients with cancer (from 10% of patients with prostate cancer, up to 70% of those with pancreatic cancer), especially those with cancers of the upper gastrointestinal (GI) tract [4].

It is now widely acknowledged that nutrition interventions in patients with cancer can improve nutritional intake, maintain or improve body weight, improve body composition, improve quality of life (QoL), reduce toxicity, and possibly prolong survival.

If patients are able to eat, it is important to first encourage a normal diet that is high in energy and protein, before starting supplements, to reach nutritional requirements. This includes choosing foods with a high(er) nutrient density, food fortification, or the use of extra snacks. The diet should be individually adapted to factors impeding nutritional intake, such as anorexia, nausea, taste and smell alterations, mucositis, constipation, dysphagia, chronic and abdominal pain, diarrhea, as well as aspects of GI function potentially responsible for these symptoms [5]. Oral nutritional supplements (ONS) should be considered when the intake remains insufficient, despite adaptations to the diet. Although there are no strict guidelines, ONS are usually prescribed if intake is (expected to be) <75% of requirements.

Section snippets

What are oral nutritional supplements?

ONS are commercially produced multi-nutrient liquid, semisolid, or powder products that provide macro- and micronutrients with the aim of increasing oral nutritional intake. ONS are intended for the exclusive or partial feeding of patients whose nutritional requirements cannot be met by normal foods. ONS are different from supplements that provide vitamins, minerals, and trace elements in a pill format (also known as food supplements) and labeling and composition must comply with the Commission

How and when to use ONS

ONS should be recommended between or after meals and not before meals or as a meal replacement. This helps to maximize effectiveness and not affect appetite for usual meals. For ONS to be effective, at least two daily servings should be prescribed, for a period of ≥3 mo [8]. Patients prescribed ONS should be reviewed at regular intervals, to monitor adherence, to assess progress toward treatment goals, or to decide whether discontinuation is necessary in case of, for example, progressive

Effectiveness of oral nutritional supplements

Several systematic reviews and meta-analyses have been published on the effects of ONS, alone, or as part of dietary counseling, on clinical outcomes. Of note, the studies included in these meta-analyses involved heterogeneous groups of patients: malnourished or not, different types of cancer, different cancer stages, and different types of treatment (chemotherapy, radiotherapy, surgery).

A systematic review by Baldwin et al. [11] showed that oral nutritional interventions are effective at

ω-3 fatty acids

There has been much debate on the beneficial and possible adverse effects of ONS enriched with ω-3 fatty acids. Cancer-specific ONS enriched with ω-3 fatty acids have been developed with the idea of diminishing the cancer-associated inflammatory response. The safety of these products has been discussed as an interaction was observed between high fish-oil consumption and chemotherapy effectiveness in preclinical studies [18], [19]. To date, clinical data are not supporting the attenuation of

Immunomodulating nutrition

Immunomodulating nutrition refers to ONS enriched with immunomodulating nutrients, such as arginine, glutamine, nucleotides, and/or ω-3 fatty acids. Often, these nutrients are provided in one product, so effects of the single nutrients cannot be distinguished. In patients undergoing surgery for upper GI cancers, positive effects of these immunomodulating nutrients have been described. A systematic review by Kim et al., included 28 studies with ONS (12 studies) or tube feeding (14 studies) or

Use of ONS in palliative care

Use of ONS in palliative care should be assessed on an individual basis. As long as patients are treated (palliative treatment may last months to years), ONS are recommended to patients with a deficient nutrient intake to improve treatment outcomes. When a patient's condition is deteriorating, the disadvantages of ONS may outweigh the advantages, and ONS should be carefully (re)considered. Emphasis always should be on the enjoyment of food and drinks and maximizing QoL.

Summary

ONS play an important role in helping patients reach their recommended nutritional goals during cancer treatment. Consistent positive effects have been shown for increased nutritional intake and increased body weight. Positive effects on clinical outcomes are less well demonstrated, but larger, non–cancer-specific reviews showed positive effects. To be effective, ONS should be adapted to fit into the diet under supervision of a dietitian, as part as nutritional counseling, also taking into

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    • Impact of oral nutritional supplements in post-discharge patients at nutritional risk following colorectal cancer surgery: A randomised clinical trial

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      The use of ONS developed for special medical purposes can increase nutrients and energy through the oral route to complement insufficient regular food intake [1,2]. Numerous studies have shown the beneficial impacts of ONS on nutritional status and clinical outcomes [3–6]. In addition to these beneficial effects, ONS treatment can lead to overall medical cost savings; it is also cost effective [7,8].

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