Introduction
Malnutrition is a prevalent concern among cancer patients undergoing treatment, significantly impacting their prognosis and quality of life. Factors such as reduced appetite, digestive issues, malabsorption, and metabolic disturbances contribute to this condition, particularly in those receiving chemotherapy [1]. Chemotherapy side effects, detailed extensively in resources like “Escott-stump S 2008 Nutrition And Diagnosis-related Care 6th Ed,” are known to induce a range of challenges including anemia, taste alterations (dysgeusia), temperature sensitivity changes, constipation, diarrhea, swallowing difficulties (dysphagia), dry mouth (xerostomia), fatigue, and early satiety [2]. These complications can severely limit food intake, culminating in substantial weight loss [3].
Nutritional intervention plays a crucial role in managing these challenges. As highlighted in “Nutrition and Diagnosis-Related Care,” the primary aims are to enhance the patient’s nutritional status, alleviate treatment-related side effects, provide personalized care, and improve dietary intake while respecting individual food preferences. The ultimate goal is to improve both treatment outcomes and the patient’s overall well-being [3, 4].
A cornerstone of nutritional intervention involves recommending frequent, small meals – typically 5-6 times daily – to maximize overall caloric intake, especially given chemotherapy-induced appetite loss and metabolic changes. When oral intake falls below 60% of the recommended daily requirement, alternative feeding methods like tube feeding or intravenous nutrition (parenteral nutrition) are considered [5]. However, oral feeding, tailored to the patient’s specific condition and preferences, remains the preferred approach whenever feasible. Dietary adjustments, such as offering hot or cold foods based on patient tolerance and adapting to evolving conditions, are essential. In situations requiring low-bacteria diets, appropriate food choices and patient education on dietary practices are implemented.
This case study documents the nutritional diagnosis and intervention process applied to a malnourished cancer patient undergoing chemotherapy at a hospital. The patient, initially admitted for general weakness, was identified as being at nutritional risk through a proactive nutritional assessment program. This study received ethical approval from the Kyung Hee University Hospital at Gangdong Institutional Review Board (KHNMC IRB 2013-116).
Case Presentation
On October 21, 2013, a 61-year-old male patient was admitted to the gastroenterology department due to general weakness. A comprehensive nutritional assessment was conducted, encompassing medical history, physical measurements, biochemical data, medical treatments, nutritional physical examination findings, and diet history. His medical history revealed diagnoses of diabetes mellitus and hypertension (both for 10 years), and rectal cancer (diagnosed 3 years prior). He had undergone an ileostomy in November 2011, followed by pre- and post-operative chemotherapy (LV5FU2). An ileostomy repair was performed in December 2012, and a liver wedge resection for liver metastasis in July 2013. He subsequently received four cycles of chemotherapy (FLOFOX4) ending in October 2013. His medications included Lantus, Apidra, and Nutriflex lipid peri with regular insulin. Chemotherapy was temporarily suspended due to his general weakness.
The initial nutritional screening took place on October 22, 2013. Upon admission, his physical measurements were: height 167 cm, weight 53.2 kg, ideal body weight (IBW) 61.4 kg (86.6% IBW), BMI 19.1 kg/m², and a significant weight loss of 11.6 kg (17.9%) in the preceding 3 months from his usual weight of 64.8 kg in July 2013. Biochemical analysis revealed: total protein/albumin 5.6/3.2 g/dL, hemoglobin/hematocrit 8.4 g/dL/25.4%, total lymphocyte count 741.2 cells/mm³, cholesterol 162 mg/dL, BUN/Cr 20/1.0 mg/dL, Ca/P 8.3/2.3 mg/dL, Na/K/Cl 132/4.2/98 mEq/L, C-reactive protein 6.28 mg/dL, HbA1c 9.7%, and casual glucose 470 mg/dL.
Nutritional physical examination identified stomatitis, nausea, and vomiting as chemotherapy side effects. His blood pressure was 142/83 mmHg. Diet history revealed appetite loss post-chemotherapy and a lack of prior nutrition education for cancer patients due to fatigue. In the week following his fourth chemotherapy cycle, his diet primarily consisted of six glasses of cola daily (480 kcal, 120g sugar) to alleviate stomatitis, nausea, and vomiting. Hospital food attempts, including soft foods like gruel, were unsuccessful due to pain and vomiting. Intravenous nutrition (Nutriflex lipid peri EOD) provided 465 kcal (C:P:F ratio 34.4:17.2:48.4, 40g carbohydrate, 20g protein, 25g fat). He was not consuming any oral nutritional supplements or bioactive substances and remained bedridden throughout the day.
The Patient-Generated Subjective Global Assessment scored him at 15, indicating a need for symptom management and focused nutritional support. Estimated nutritional requirements were 1600-1860 kcal energy (30-35 kcal/kg based on 53.2 kg weight) and 64-85 g protein (1.2-1.6 g/kg).
Two nutritional diagnoses were established: 1) Malnutrition due to decreased food intake related to chemotherapy side effects (stomatitis, nausea, vomiting) and insufficient nutrition knowledge. Evidence included 17.9% weight loss in 3 months and consuming only 28% of required nutrients in the past week. 2) Lack of knowledge regarding appropriate food and nutrient choices, possibly driven by fear of eating and reliance on cola post-chemotherapy.
Nutritional interventions for the first diagnosis involved recommending a diabetic thin rice gruel diet (1700 kcal, 72g protein) and adjusting intravenous nutrition to compensate for oral intake, aiming for ≥ 30% of hospital food intake alongside intravenous support. Hospital-provided food was soft and non-irradiated to accommodate stomatitis, with close post-dietary change monitoring. For the second diagnosis, patient counseling focused on the importance of a varied diet, hospital-provided diabetic thin rice gruel (considering preferences and lactose intolerance), cessation of cola consumption (due to nausea exacerbation), and encouragement to try hospital foods.
Figure 1.
The second screening visit occurred on October 24, 2013, reassessing physical measurements, biochemical data, medical status, nutritional physical findings, and diet history. Physical measurements remained unchanged. Biochemical results showed: total protein/albumin 5.1/3.1 g/dL, Hgb/Hct 8.5 g/dL/25.7%, TLC 712 cells/mm³, cholesterol 135 mg/dL, BUN/Cr 19/1.0 mg/dL, Ca/P 7.8/1.6 mg/dL, Na/K/Cl 138/50/107 mEq/L, and blood glucose levels fluctuating (10/22-10/24). Nutritional physical examination revealed ongoing nausea and vomiting after specific foods (e.g., orange juice induced vomiting, apple juice tolerated). Vital signs were stable at 135/80 mmHg. Diet history indicated patient education on diabetic thin rice gruel, non-irritating foods, and nutritional supplement drinks.
Dietary intake now included hospital food: 20% of rice gruel, 50% of steamed eggs and nutritional beverages, and 100% of soup and apple juice (1050 kcal, C:P:F ratio 56.0:14.4:29.6, 147g carbohydrate, 37.2g protein, 34.5g fat), supplemented with intravenous nutrition (Hepasol inj 500 mL/day; 200 kcal, 50g protein). Post-first screening, the patient explored various foods and began using a wheelchair. Nutrient requirements remained consistent. Nutrition monitoring showed partial achievement of initial goals, with hospital food intake at 62% of total consumption and a change in intravenous nutrition (Hepasol/day replacing Nutriflex lipid peri EOD). Following the second intervention, cola consumption ceased, and dietary diversity improved, indicating goal attainment.
Post-second screening, revised nutritional diagnoses were: 1) Excessive protein supplementation due to intravenous protein administration exceeding oral intake, resulting in 125% of required protein intake. 2) Continued lack of nutrition knowledge stemming from insufficient education on chemotherapy and food preparation. Interventions included discontinuing intravenous protein supplementation and recommending patient education on food choices and preparation strategies to manage chemotherapy side effects. The goal was to achieve energy and protein intake > 70% of requirements and maintain or increase body weight. Continuous monitoring and outpatient care post-discharge were deemed essential.
Discussion
This case study underscores the significant impact of chemotherapy side effects on nutritional status, leading to unintentional weight loss and malnutrition due to stomatitis, nausea, and vomiting. Nutritional interventions, guided by the nutrition care process framework detailed in resources like “Nutrition and Diagnosis-Related Care 6th ed,” effectively increased the patient’s oral food intake, with further improvements anticipated through ongoing care. This aligns with previous research demonstrating the effectiveness of personalized nutrition education in boosting caloric and protein intake in cancer patients [7, 8].
It is plausible that proactive patient education regarding chemotherapy side effects and dietary management, initiated after the first chemotherapy cycle, could have mitigated ingestion problems from stomatitis during subsequent cycles and prevented significant weight loss. This highlights the critical need for educating all chemotherapy patients about nutritional management strategies and ensuring continuous monitoring throughout their treatment journey. Furthermore, in this specific case, it is notable that despite repeated diagnoses of malnutrition during hospital readmissions for the second chemotherapy round, proactive malnutrition management was not implemented earlier. This emphasizes the importance of consistent and vigilant nutritional care for oncology patients.
Figure 2.
Footnotes
No conflict of interest declared by the authors.
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