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Eating When You Have Been Unwell

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EATING WHEN YOU

HAVE BEEN UNWELL

Information for patients and their carers

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Q. Do you know that eating a nourishing and balanced diet is important to help us healthy, active and independent?

When you are unwell, or recovering from an operation or infection, it can sometimes be hard to eat well. You might not feel like eating, or you may be suffering from symptoms or side effects of your illness, treatment or medications, which can affect your appetite and ability to eat.

This can make it difficult to get enough of what your body needs to recover and could lead you to becoming weaker and having less strength and energy than usual. You may find yourself losing weight, even if you are not trying to do so. Over time, if you do not have enough food to eat, you may unintentionally lose weight and become malnourished. It can also make you more likely to pick up an infection.

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Q. What are the main signs & symptoms of unintentional weight loss?

Unintentional weight loss can lead to a reduced quantity of body fat and/ or reduced muscle or bone strength. Healing times and your recovery period may be longer than expected. You may feel tired, have low energy levels or find it hard to keep warm. This in turn could also lead to other effects, such as reduced quality of life, digestive problems or your mood may be affected. Unintended weight loss is one of the key indicators of malnutrition.

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Q. Can you be overweight and malnourished?

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Undernutrition is usually associated with weight loss. But is highly possible that you are overweight but still suffer from malnutrition, mainly micronutrient malnutrition (deficiency of key micronutrients in diet). Though weight loss in overweight people is seen as a positive aspect, it is important to watch out for unintentional weight loss, no matter what weight you were initially. This weight loss may be due to loss of muscle as opposed to loss of fat, which can further hamper the overall health.

Q. How can you manage your diet when you have unintentional weight loss?

The best way to manage malnutrition is to ensure that your diet contains a balanced mix of nutrients such as macronutrients (energy, protein, fat etc) and micronutrients (vitamins & minerals). However, if you have a poor appetite or are having problems eating due to illness, it can be difficult to obtain all these nutrients from your diet.

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Q. What are Oral Nutritional Supplements (ONS)?

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Oral Nutritional Supplements (ONS) are supplementary oral intake of dietary food for special medical purposes in addition to the normal food which commonly added with nutrients including carbohydrate, protein, vitamins and minerals. They are usually prescribed by dietitians or doctors to people who have difficulties meeting their daily nutritional needs from food. ONS are one important nutrition intervention strategy for people with poor food intake, low appetite, and those with or at risk of malnutrition.

Q. Why have you been prescribed ONS?

Your healthcare professional (HCP) may feel you could benefit from taking ONS, if they think you require extra nutrition to meet your nutrient needs and you are not able to achieve this through diet alone. If you are unwell, or recovering from an illness, you may need more nutrients than usual due to increased requirements. However, your appetite might be poor and you could struggle to eat and drink enough. If this is the case, your HCP may prescribe ONS to bridge this nutrient gap.

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Q. How many ONS do you need to take a day?

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ONS can help improve your dietary intake but it is important that you take them every day as recommended by your HCP. Your HCP will explain how many ONS you should take to meet your daily nutritional needs. It is important that you try to take the recommended amount each day, for the recommended length of time, to help you achieve your nutritional goals. If in doubt, you can check with your HCP that issued your prescription.

Q. When should you take your ONS?

In general, people take their ONS when they feel like drinking or eating them. This may be between meals as a snack, first thing in the morning, or before bedtime. Others find it easier to take small amounts regularly throughout the day but try to get into a regular routine and take your ONS at the same time each day. However, please always follow the advice given by your HCP. You should try to avoid using your ONS as a meal replacement, where possible.

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Q. What happens if you forget to take it?

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In general, you can take your prescribed ONS whenever it’s most convenient for you. If you forget to take it at your normal time, try taking it before bedtime or first thing in the morning. It is important to try and take the recommended amount each day. Speak to your HCP if you are taking medications and have concerns.

Q. Do you still need to take your ONS if you manage to eat a meal?

ONS contains macronutrients and micronutrients such as energy, protein, vitamins & minerals which can help boost your dietary intake. They are designed to be taken in addition to your normal meals so it is important you take the prescribed amount each day between meals, like a snack. If you feel you no longer need them, you should seek the advice of your HCP before stopping your prescribed intake.

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Q. How long should you expect to continue taking your ONS?

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Your HCP should review and monitor your progress and may agree goals you would like to achieve whilst taking ONS, such as maintaining or gaining weight, increasing energy levels or until you feel able to eat and drink enough to meet your nutritional requirements. They will also assess how long you need to continue taking your ONS.

Q. What should you do if you can’t manage or don’t like the ONS you have been prescribed?

If you are struggling to consume the amount you have been prescribed or are not keen on the flavor you have received, speak to your HCP. There are lots of different styles and flavors of ONS available. Styles include milkshake, juice and dessert style. There is also a wide variety of flavors and volumes.

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Q. Can I heat them?

Yes, you can gently warm your ONS especially if you want to add certain flavors to soups, hot drinks, or custard. However do not boil them as you risk destroying some of the nutrients.

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Q. Can I freeze them?

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Yes, pour the ONS into a freezer-safe container, ice cube tray or ice lolly mould, and freeze. These make a refreshing snack for hot weather or may help to relieve a sore mouth.

Q. What should you do if you start to lose weight unexpectedly, or have a poor appetite when you stop taking ONS?

If you notice changes in your appetite, weight or are unable to eat enough food, discuss your concerns with your HCP as soon as possible. If you have seen a dietitian and they have given you any information, you should take this with you when you visit your HCP next time.

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Medical Nutrition in Cancer Care

Medical Nutrition in Cancer Care

Why is nutrition important when you have cancer?

Cancer treatment, particularly chemotherapy and radiotherapy, can affect what a patient is able to eat and/or drink, and how well their body absorbs and uses the nutrients it gets from food. In addition, cancer itself can raise the body’s metabolic rate so that it is burning off muscle (‘lean body mass’) at a much higher rate than normal, a condition known as ‘cachexia’1. Together, these factors cause many patients (between 30% and 80%) to lose weight as they progress through their cancer journey, from diagnosis, through to treatment and recovery. This weight loss can have significant and negative effect on the health of a patient, being associated with increased complications, more rapid disease progression, and even delaying or leading to suboptimal treatment – with implications for rates of survival3-5.

It is important that cancer patients understand the implications of weight loss – and are armed with the nutritional information necessary to help them regain and/or maintain their bodyweight.

Is there a cancer diet?

Whilst there are no direct cancer-causing foods or specific cancer fighting foods (‘anti-cancer foods’), it is important to obtain enough of particular nutrients to support the body during cancer treatment. Guidelines suggest that cancer patients should consume twice the amount of protein as a healthy person, to rebuild muscle strength6. Energy, in the form of calories, is also important6. Cancer patients also need enough micronutrients, which are key for the normal functioning of the body; for example, Vitamin D, where Vitamin D deficiency is common amongst cancer patients7,8. However, in general, people tend to eat less when they are not feeling well. Because of the effects of cancer and its treatment, it can be difficult to get enough of the right nutrition from a normal diet alone to keep the body as strong as it needs to be. At this point, a healthcare team may recommend the use of medical nutrition.

What is medical nutrition?

Also known as oral nutritional supplements (ONS), medical nutrition is specially designed foods and drinks that help people with disease-related malnutrition meet their nutritional needs. Classified as ‘foods for special medical purposes’, medical nutrition must be used under the supervision of a qualified healthcare professional.

Designed to help boost nutritional intake, they should be taken in addition to what a patient is able to eat and drink rather than replacing ordinary foods and drinks. Medical nutrition is available in a range of different flavours and formats and in a range of different nutrient compositions. This means that cancer patients can benefit from a medical nutrition regime tailored not only to their nutritional needs but also to their taste and format preferences.

If a patient is unable to eat at all, some variants of medical nutrition can, when taken in sufficient quantities, be used as a sole source of nutrition as they contain all the nutrients a body needs to function. Medical nutrition can also be administered via a tube to the stomach (enterally) for those who cannot consume food and drinks via the mouth.

What types of medical nutrition are available?

Adherence to the medical nutrition regimen recommended by a healthcare professional is important so that a patient can feel the full benefits of their nutritional support. For this purpose, there are many different flavours and formats of medical nutrition so patients can select those they like best and can keep their intake varies to avoid format fatigue.

Medical nutrition support cancer patients meet their nutritional needs

Boosting nutritional intake via medical nutritional supplements has been shown in clinical trials to benefit cancer patients in several different ways, for example:

Medical nutrition: how much and for how long?

Every patient is different and has different nutritional needs, depending on the severity of their weight loss and/or cancer cachexia. Prescriptions or recommendations for medical nutrition are often for between 1 and 3 units or bottles a day but this varies depending on the patient’s needs.

It is also important to understand that medical nutrition doesn’t work overnight – it takes time to rebuild the strength lost through the effects of cancer. The healthcare professional managing the nutritional needs of a cancer patient should be able to advise for how long they need to take medical nutrition. It can be anything from a few weeks to a few months, or more. It is important that patients speak with their healthcare professional before stopping taking medical nutrition.

References

1. Fearon K et al. Lancet Oncol, 2011;12(5):489-95.

2. Ryan et al. Proc Nutr Soc. 2016;75(2):199-211.

3. Andreyev HJ et al. Eur J Cancer. 1998;34(4)p.503-9.

4. Prado CM et al. Cancer Chemother Pharmacol, 2011; 67(1):p.93-101.

5. Fearon KC. Eur J Cancer 2008;44(8): p.1124-32.

6. Arends J, et al. ESPEN guidelines on nutrition in cancer patients. Clin Nutr, 2016;ePub Curr Opin

     Support Palliat Care. 2013 Sep; 7(3): 272-277. Vitamin D in the cancer patient.

7. Kurt A. Kennel and Matthew T. Drake

8. Burden ST, et al. J Cachexia Sarcopenia Muscle, 2017.

9. Baldwin et al. J Natl Cancer Inst, 2012;104(5):371-385.

10. Kabata P, et al. Support Cancer Care, 2015; 23(2):365-70.

11. Manasek V. et al. Klin Onkol, 2016.

12. Martin L Senesse P et al. J Clin Oncol 2015 Jan 1: 33(1):p.90-9.

13. De Waele et al. Appetite, 2016;91:298-301.

Intro to Cancer & Medical Nutrition

Introduction to Cancer & Medical Nutrition

What is cancer?

Cancer is a disease where cells, the building blocks of all our organs and tissues, begin to behave abnormally, dividing uncontrollably to create more and more abnormal cells. These can form a lump called a tumour in a particular part of the body.

One of the first signs of cancer could be the patient feeling the lump – or tumour. Other cancer symptoms include feeling tired, unexpected pain, or unexplained weight loss (i.e., not due to a new diet or exercise regimen). A confirmed diagnosis can be life-changing event for both patients and the people around them. A patients likely to experience not only cancer signs as physical symptoms but also emotional stress and sometimes depression.

How is cancer treated?

Treatment for a cancer will depend on many factor, for example how big the tumour is, whether it has spread to other parts of the body and the general health of the patient. The field of oncology – the study of cancer – has three main cancer treatment options: surgery (to try and remove the tumour) and radiotherapy and chemotherapy (to try and shrink the tumour).

The oncologist is the doctor who treats cancer and provides medical care for a person diagnosed with cancer. Whichever treatment – or combination of treatments – a patient is advised to undergo, it is important that the body is as strong as it can be before, during and after, to tolerate and recover from what can be a difficult process. However, weight loss, a common side effect of cancer and its treatment, can leave the body weakened1

What types of cancer cause the most weight loss?

Cancer can happen in almost all parts of the body and can take a significant physical toll on the patient. But some cancers are more likely to cause serious physical challenges such as extreme weight loss2. These include gastrointestinal cancer (e..g., colon cancer, stomach cancer, bowel cancer and pancreatic cancer) as well as head and neck cancer (e.g., oral cancer, head cancer, neck cancer and lung cancer)2. For different reasons these cancers affect the ability of the patient to consume and digest food effectively2.

The impact of cancer on body strength.

Keeping the body strong can be difficult during cancer because of several factors. The cancer itself and the body’s natural defense mechanisms can cause a patient’s metabolic rate to rise, which can result in loss of body weight, particularly muscle (‘lean body mass’)3,4. Weight loss can be worsened by low appetite, nausea and taste changes, including when normal foods take on a metallic flavor, all of which can reduce food intake5.

The impact of weight loss on treatment success.

Weight loss during cancer can have a negative impact on treatment because chemotherapy and radiotherapy doses are based on, amongst other factors, body mass index, or BMI. Cancer research show a significant changes to BMI from the point of diagnosis can result in a patient receiving a suboptimal dose, or it could delay treatment altogether6. Besides chemotherapy and radiotherapy, BMI can also impact outcomes of a patient undergoing surgery7. If a patient cannot get the nutrients they need to maintain or regain weight through a normal diet alone, a healthcare professional may recommend medical nutrition, also known as oral nutritional supplements.

The role of medical nutrition in cancer

Medical nutrition are foods for special medical purposes and must be used under medical supervision. They are available in a range of flavours and formats, and include high protein, high energy, nutritionally complete drinks, desserts, and powders. Medical nutrition can be taken between meals to support and boost the amount of nutrition a patient consumes each day or, if a patient is unable to eat at all, can be used as a sole source of nutrition. There are also variants of medical nutrition that can be administered via a tube directly into the stomach (‘enteral’ nutrition).

Medical nutrition, when started early in a cancer patient’s journey can contribute to maintain weigh, this is important to continue cancer therapy and is related to better treatment outcomes8. Taking medical nutrition in line with a healthcare professional’s advice can also help to reduce incidence of complications, reduce time in hospital and support improvement of quality of life.

Please speak to your healthcare professional if oral nutritional supplements may be suitable for you.

What is cancer?

Cancer is a disease where cells, the building blocks of all our organs and tissues, begin to behave abnormally, dividing uncontrollably to create more and more abnormal cells. These can form a lump called a tumour in a particular part of the body.

One of the first signs of cancer could be the patient feeling the lump – or tumour. Other cancer symptoms include feeling tired, unexpected pain, or unexplained weight loss (i.e., not due to a new diet or exercise regimen). A confirmed diagnosis can be life-changing event for both patients and the people around them. A patients likely to experience not only cancer signs as physical symptoms but also emotional stress and sometimes depression.

How is cancer treated?

Treatment for a cancer will depend on many factor, for example how big the tumour is, whether it has spread to other parts of the body and the general health of the patient. The field of oncology – the study of cancer – has three main cancer treatment options: surgery (to try and remove the tumour) and radiotherapy and chemotherapy (to try and shrink the tumour).

The oncologist is the doctor who treats cancer and provides medical care for a person diagnosed with cancer. Whichever treatment – or combination of treatments – a patient is advised to undergo, it is important that the body is as strong as it can be before, during and after, to tolerate and recover from what can be a difficult process. However, weight loss, a common side effect of cancer and its treatment, can leave the body weakened1

What types of cancer cause the most weight loss?

Cancer can happen in almost all parts of the body and can take a significant physical toll on the patient. But some cancers are more likely to cause serious physical challenges such as extreme weight loss2. These include gastrointestinal cancer (e..g., colon cancer, stomach cancer, bowel cancer and pancreatic cancer) as well as head and neck cancer (e.g., oral cancer, head cancer, neck cancer and lung cancer)2. For different reasons these cancers affect the ability of the patient to consume and digest food effectively2.

The impact of cancer on body strength.

Keeping the body strong can be difficult during cancer because of several factors. The cancer itself and the body’s natural defense mechanisms can cause a patient’s metabolic rate to rise, which can result in loss of body weight, particularly muscle (‘lean body mass’)3,4. Weight loss can be worsened by low appetite, nausea and taste changes, including when normal foods take on a metallic flavor, all of which can reduce food intake5.

The impact of weight loss on treatment success.

Weight loss during cancer can have a negative impact on treatment because chemotherapy and radiotherapy doses are based on, amongst other factors, body mass index, or BMI. Cancer research show a significant changes to BMI from the point of diagnosis can result in a patient receiving a suboptimal dose, or it could delay treatment altogether6. Besides chemotherapy and radiotherapy, BMI can also impact outcomes of a patient undergoing surgery7. If a patient cannot get the nutrients they need to maintain or regain weight through a normal diet alone, a healthcare professional may recommend medical nutrition, also known as oral nutritional supplements.

The role of medical nutrition in cancer

Medical nutrition are foods for special medical purposes and must be used under medical supervision. They are available in a range of flavours and formats, and include high protein, high energy, nutritionally complete drinks, desserts, and powders. Medical nutrition can be taken between meals to support and boost the amount of nutrition a patient consumes each day or, if a patient is unable to eat at all, can be used as a sole source of nutrition. There are also variants of medical nutrition that can be administered via a tube directly into the stomach (‘enteral’ nutrition).

Medical nutrition, when started early in a cancer patient’s journey can contribute to maintain weigh, this is important to continue cancer therapy and is related to better treatment outcomes8. Taking medical nutrition in line with a healthcare professional’s advice can also help to reduce incidence of complications, reduce time in hospital and support improvement of quality of life.

Please speak to your healthcare professional if oral nutritional supplements may be suitable for you.

References

1. Ryan et al. Proc Nutr Soc, 2016;75(2):199-211.

2. Bozzetti 2008 and 2001; Bosaeus 2001 Hebuterne et al, 2014 JPEN J Parenter Enteral Nutr;38(2):196-204

3. DeWys et al. Am J Med, 1980;69:49;1-7.

4. Prado CM et al. Cancer Chemother Pharmacol, 2011; 67(1):93-101.

5. IJpma I, Timmermans ER, Renken RJ, et al. Nutr Cancer. 2017;69(1)L140-145.

6. Ross PJ et al, 2004 Br J Cancer; 90(10):1905-11

7. Medicine (Baltimore). 2015 Oct; 94(42): e1769. The Impact of Body Mass Index on the Surgical Outcomes of Patients With Gastric Cancer. A 10-Year, Single-Institution Cohort Study

8. Martin L et al. J Clin Oncol, 2015 :33(1):90-9.

Weight Loss in Cancer

Weight Loss in Cancer

Cancer and weight loss

Weight loss and cancer are closely linked. In fact, weight loss is one of the most common side-effects in people diagnosed with cancer1. Although common, it’s not something that should be ignored as it can affect treatment and recovery2.

Do you always lose weight with cancer?

Between 30% and 80% of patients may lose weight at some point during their disease, depending on the site of the tumor1. Worryingly, malnutrition is considered the cause of between 20% and 40% of all cancer-related deaths3.

Why do you lose weight with cancer?

There are lots of reasons why patients lose weight when they have cancer. Before diagnosis, unexplained weight loss may be an early sign that something is wrong, particularly in cancers affecting the lungs, pancreas, stomach or esophagus4. This is caused by the body releasing substances called cytokines, which help fight the disease but also have the unfortunate side effect of causing weight loss and muscle loss, as well as a loss of appetite5.

Before and especially during treatment (e.g., chemotherapy, radiotherapy), a person may not feel like eating or drinking because of a lack of appetite or because of mouth ulcers, a dry mouth, constipation, diarrhea, nausea, vomiting, tatse changes or pain. Treatment can also negatively affect how well the body absorbs and uses the nutrients it gets from food5, further worsening weight loss.

Although weight loss is common in cancer, eating less can mean the body may not get the energy protein, and other nutrients it needs at a time when it needs to be at its strongest to undergo treatment. It should therefore not be ignored. 

What is cancer cachexia?

Losing weight can be a good thing, especially for those who have always struggled to manage their weight – but when undergoing cancer treatment is not the right time. This is because when cancer patients lose weight, they mostly lose the strong, protective muscle tissue needed to help fight cancer, rather than fat tissue6. This loss of muscle tissue (or ‘lean body mass’) os known as cachexia6. Cachexia can lead to mental and physical tiredness but also, perhaps more importantly, can lower a patient’s tolerance to their treatment which could negatively affect their chances of survival1,6.

How does a patient's body mass index affect treatment success?

The optimal chemotherapy dose for a patient is based on, amongst other factors, weight, and height, also known as body mass index (BMI). Any changes in a patient’s weight from when they were first diagnosed can have a direct and negative impact as the patient may no longer be able to tolerate the full dose, more seriously, a significant reduction in BMI could delay treatment altogether7-9. By maintaining good nutritional intake, patients can help reduce the risk of losing additional muscle weight in the future, helping to ensure the body can tolerate the optimum treatment dose.

What is cancer cachexia?

Losing weight can be a good thing, especially for those who have always struggled to manage their weight – but when undergoing cancer treatment is not the right time. This is because when cancer patients lose weight, they mostly lose the strong, protective muscle tissue needed to help fight cancer, rather than fat tissue6. This loss of muscle tissue (or ‘lean body mass’) os known as cachexia6. Cachexia can lead to mental and physical tiredness but also, perhaps more importantly, can lower a patient’s tolerance to their treatment which could negatively affect their chances of survival1,6.

How does a patient's body mass index affect treatment success?

The optimal chemotherapy dose for a patient is based on, amongst other factors, weight, and height, also known as body mass index (BMI). Any changes in a patient’s weight from when they were first diagnosed can have a direct and negative impact as the patient may no longer be able to tolerate the full dose, more seriously, a significant reduction in BMI could delay treatment altogether7-9. By maintaining good nutritional intake, patients can help reduce the risk of losing additional muscle weight in the future, helping to ensure the body can tolerate the optimum treatment dose.

What nutrients are most important in cancer?

Good nutrition is all about getting the balance right – the balance of nutrients that a patient’s body needs to function well, to cope with treatment and to keep as active as possible. However, in cancer, some nutrients are particulary important:

Protein:
important for building and repairing body cells, getting enough protein is important for cancer patients wanting to maintain or regain lean body mass. International guidelines recommend cancer patients consume almost twice the amount that a healthy person needs (>1g of protein/kg of body weight and preferably 1.5g/kg vs 0.75g/kg for the general healthy population)10

Omega-3 polyunsaturated fatty acids:
with anti-inflammatory properties, this nutrient can help stabilize or improve appetite, food intake, lean body mass and body weight10

Micronutrients, such as vitamins, minerals, and trace elements:
cancer patients often have micronutrient deficiencies due both to reduced food intake and the aggressive nature of some treatments11,12

Dietary fibre:
essential to a balanced diet, cancer patients can benefit from consuming the right quality of fibre to improve stool consistency, especially those who are suffering from diarrhea as a side effect of their radiotherapy or chemotherapy1

What to do if you are struggling to eat or losing weight?

If a cancer patient is struggling to eat and drink, has lost weight unintentionally, or has concerns about their diet, they should talk to their healthcare professional. It is important to remember that they don’t need to wait to be asked about their concerns. It is ok to start the conversation with the oncologist and and the supporting healthcare team.

Medical nutrition is important to keep the body strong

If after dietary counselling by a qualified healthcare professional a patient is still struggling to eat and drink and/or maintain weight, they may be advised to start taking medical nutrition supplements, also known as oral nutrition supplements (ONS). Medical nutrition (or ONS) are specially designed foods and drinks that help people with disease-related malnutrition meet their nutritional needs, providing the extra energy, protein, vitamins, and minerals they need. They are known as ‘foods for special medical purposes’ and should be used under medical supervision.

Medical nutrition, particularly if given to patients early in their cancer journey, has been clinically proven to reduce weight loss. This is important to continue cancer therapy and is therefore related to better treatment outcomes14.

Medical nutrition is available in a range of flavours and formats including milkshakes, juice style, yoghurt style, powders, and desserts.

Please speak to your healthcare professional if oral nutritional supplements may be suitable for you.

References

1. Ryan et al. Proc Nutr Soc, 2016;75(2):199-211.

2. Bozzetti 2008 and 2001; Bosaeus 2001 Hebuterne et al, 2014 JPEN J Parenter Enteral Nutr;38(2):196-204

3. Andreyev HJ et al. Eur J Cancer. 1998;34(4)p.503-9.

4. Hebuterne X et al. JPEN, 2014;38:196.

5. Argilés JM, et al. Curr Opin Support Palliat Care 2009; 3: 263-68.

6. Fearon K et al. Lancet Oncol, 2011;12(5):489-95.

7. Capuano G, et al. Head Neck 2008;30:503-8

8. Andreyev HJ, et al. Eur J Cancer, 1998;34:503-9.

9. Rickard KA, et al. Cancer 1983;52:587-98.

10. Arends J, et al. ESPEN guidelines on nutrition in cancer patients Clin Nutr, 2016; epub.

11. Grober U, et al. Nutrients, 2016;8(3):163.

12. Ströhle A, et al. Oncology Reports, 2010;24(4):815-28.

13. Garcia-Peris P, et al. Eur J Clin Nutr, 2016;70(2):170-174.

14. Martin L Senesse P et al. J Clin Oncol 2015 Jan 1: 33(1):90-9.

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