Malnutrition in cancer

Sabrina Kempe is a freelance writer for the medical team. She studied biology, specializing in molecular biology, human genetics and pharmacology. After her training as a medical editor in a renowned specialist publisher, she was responsible for specialist journals and a patient magazine. Now she writes articles on medical and scientific topics for experts and laypeople and edits scientific articles by doctors.

More about the experts All content is checked by medical journalists.

Malnutrition and weight loss in cancer are not uncommon. If rapid muscle breakdown occurs, the body consumes dangerously, which is known as tumor cachexia. Read more about the topic here: What are the causes of malnutrition and weight loss in cancer? Why can malnutrition go hand in hand with weight gain and obesity? How do you recognize malnutrition? What can doctor and patient do against malnutrition?

ICD codes for this disease: ICD codes are internationally recognized codes for medical diagnoses. They can be found, for example, in doctor's letters or on certificates of incapacity for work. C50C16C34C19C18C15C61C20

Malnutrition: Often risky weight loss

Malnutrition (malnutrition) means that those affected are not supplied with enough energy, proteins or other nutrients. This can lead to dangerous weight loss in cancer patients (or other patients).

When do we speak of malnutrition?

When exactly one speaks of malnutrition, international experts jointly redefined in 2019 as part of the "Global Leadership Initiative on Malnutrition" (GLIM). They created criteria for the patient's appearance (phenotype) and the cause of the disease (etiology). In order for there to be malnutrition, it is sufficient if a phenotypic and an etiological criterion occur together - not all of the following criteria have to be present!

Phenotypic criteria:

involuntary weight loss of at least five percent in six months
Underweight measured using a low body mass index (BMI) of less than 20 kg / m2 or less than 22 kg / m2 in people over 70 years of age
decreased muscle mass (sarcopenia)

Etiological criteria:

Reduced food intake of less than half for a week or a long-standing (chronic) digestive disorder through which too few nutrients can be absorbed from the food (malabsorption)
acute or chronic inflammation throughout the body (systemic inflammation)

A cancer patient, for example, who involuntarily loses more than five percent of his weight within six months and at the same time eats too little for at least a week, is considered to be malnourished.

Also affected by malnutrition are, for example, patients whose muscle mass is decreasing and who at the same time suffer from inflammation simmering in the body - even if those affected cannot measure these criteria themselves and may not even notice them. Because if the muscle mass decreases, this does not necessarily have to result in weight loss.

In general, weight loss and being underweight are not a prerequisite for a diagnosis of malnutrition. Cancer patients who are overweight or even obese can also be malnourished. Malnutrition is often overlooked in them!

Weight gain with malnutrition

Another paradox is that even cancer patients who gain weight quickly can suffer from malnutrition. The rapid weight gain can be caused, for example, by the accumulation of fluid in the tissue (edema) or in the abdominal cavity (ascites) or by the growth of fat deposits. These phenomena have been described in women with breast cancer who have received chemotherapy, anti-hormone therapy, or cortisone or who have exercised less and consumed more calories because of the disease. Weight gain, like weight loss in cancer, worsens the prognosis.

Every cancer patient should be checked regularly for malnutrition. If necessary, remind your doctor about it! In particular, if your weight changes in any unusual way (up or down) you should seek medical advice. It is important to find out the reason for this and fix it if possible.

How common is malnutrition in cancer?

Malnutrition in cancer is widespread: Depending on the type of tumor, stage of the disease and age, it affects a quarter to almost three quarters of all cancer patients. Malnutrition occurs more frequently in patients with cancer in the digestive tract (stomach cancer, colon cancer, esophageal cancer, pancreatic cancer) and in the head and neck area (e.g. thyroid cancer) than in patients who suffer from breast or prostate cancer, for example.

Reasons for weight loss in cancer

Weight loss is a very common consequence of malnutrition. In general, the body loses weight if the energy balance is negative over a long period of time. There can be several reasons for this:

Too few nutrients are supplied to the body with food (for energy production and as building materials).
The body cannot properly absorb nutrients due to problems in the digestive tract.
The body uses up more nutrients than it can absorb from food.

When cancer sufferers cannot or cannot eat enough, the body does not receive enough nutrients such as carbohydrates, fats and proteins. In order to still get enough energy for the vital processes, the body breaks down fat reserves and muscle mass - the patient quickly loses weight and gets into a downward spiral:

Since the energy gained in this way is just sufficient for the bare essentials and the muscle mass is also reduced (sarcopenia), the patients feel limp and powerless - they move less, which increases the muscle loss even further and further increases the weight loss.

In addition, the skeletal muscles are gradually broken down with increasing age, even in healthy people. The technical term for this is age-associated sarcopenia. In addition, the body also loses skeletal muscle mass during chemotherapy. This chemotherapy-induced sarcopenia is about 1.6 times higher in men than in women.

Patients with esophageal cancer are particularly at risk for a chemotherapy-induced reduction in muscle mass.

Loss of appetite and change in taste

When cancer patients no longer want to eat, there can be fears behind it. Some sufferers fear that the food they eat will also feed the tumor. That is why they limit themselves to eating - in the hope that this will deprive the cancerous tumor of energy and thus "starve" it. But instead of damaging the tumor, they primarily deprive themselves of the strength they urgently need for therapy and life with cancer.

Other fears and other emotional stresses such as grief, anger or depression can cause people with cancer to lose appetite.

In other cases, the loss of appetite in cancer is related to pain, shortness of breath, or discomfort. In addition, poor appetite can be a side effect of cancer treatments (chemotherapy, targeted therapies, immunotherapies).

Sometimes malnutrition in cancer can also be attributed to the fact that the perception of taste is changed or reduced - either by the treatment or by the tumor itself. Those affected then no longer taste the food or they can hardly perceive different tastes. As a result, they eat less or nothing at all - malnutrition occurs.

Nausea and vomiting

Sometimes treatment for cancer causes nausea and / or vomiting - especially chemotherapy. Affected people have no appetite or cannot keep enough food with them - they lose weight.

The severity of nausea and vomiting varies depending on the cancer drug administered. These side effects occur particularly frequently during treatment with the chemotherapeutic agent cisplatin. It also depends on the type of medication and its dosage whether nausea and vomiting occur directly during treatment or hours or days later and how long the symptoms persist (hours to days).

Vomiting and nausea under cancer therapies are usually triggered directly by the drug in question. In addition, emotional factors (such as the fear of nausea) can aggravate the symptoms in cancer patients.

diarrhea

Diarrhea, a common side effect of cancer drugs, can also contribute to weight loss in cancer. Radiation therapy in the abdominal area can also cause diarrhea. If the food moves too quickly through the body and the nutrients cannot be used, the patient quickly loses weight. It is therefore very important that you speak to your doctor about any diarrhea that may occur, even if the subject may be uncomfortable for you.

Dry mouth and inflamed oral mucosa

Dry mouth is a possible side effect of chemotherapy, immunotherapies, and targeted therapies. Radiation in the head area, which affects the salivary glands, can also result in a dry mouth. In addition, inflammation of the lining of the mouth (mucositis) with sores or sores in the mouth may develop. Both factors - dry mouth and inflamed oral mucosa - can make it difficult for those affected to eat due to swallowing difficulties and pain and thus promote malnutrition in cancer.

Unfavorable location of the tumor

The tumor itself can mechanically prevent cancer patients from eating enough. For example, if the cancer is at the entrance to the stomach, it is difficult for food to get past it and into the stomach. Colon cancer that is well advanced can in turn obstruct the intestine (bowel obstruction) and make normal digestion impossible.

Organs completely or partially removed

If organs that are important for the absorption and digestion of food (e.g. esophagus, stomach) had to be removed in whole or in part from cancer patients, this promotes malnutrition.

>> Larynx, esophagus

If the larynx or esophagus has had to be removed, people will find it difficult to swallow. In addition, they can become over-sensitive to certain foods and develop fear of suffocation.

>> stomach

Patients who have had their stomachs removed and who now have a replacement stomach can face the following problems:

You can only eat small amounts and are therefore full quickly.
The food "slips" too quickly through the stomach (fall emptying, dumping syndrome), which can lead to upper abdominal pain, diarrhea, circulatory problems or hypoglycaemia.
The sphincter at the entrance to the stomach is missing, which is why chyme can flow back into the esophagus. This causes the esophagus to become inflamed (esophagitis).
Fat digestion is often impaired.
Many patients can no longer tolerate milk sugar (lactose) (lactose intolerance).

>> pancreas

The problems that arise after an operation on the pancreas depends on which part of the organ had to be cut out: If the head of the pancreas has been removed, various digestive enzymes, which the organ normally releases into the small intestine, are missing. Without the tail of the pancreas, the organ can no longer produce enough of the blood sugar lowering hormone insulin. Sufferers develop high blood sugar levels, develop diarrhea and lose weight.

>> intestines

If parts of the small or large intestine are missing or the large intestine has been completely removed, digestion is impaired: diarrhea, mushy stools and weight loss can result.

Tumor cachexia

A special form of malnutrition is severe wasting, the so-called tumor cachexia. It affects up to 85 percent of cancer patients. With the help of its messenger substances, the tumor manipulates the metabolism and the immune system for its own purposes:

It ensures that metabolic products such as proteins are broken down to a greater extent - even if the person concerned barely moves (catabolic metabolic situation). This causes the skeletal muscles to shrink throughout the body (sarcopenia). In addition, storage fats are broken down intensively, and the cells consume much more energy than usual. In addition, there is constant inflammation throughout the body (systemic inflammation). This also counteracts muscle building (anabolic resistance). The consequences of these processes are:

Loss of appetite, taste disturbances and feeling of fullness prematurely
persistent, involuntary weight loss
Tiredness, listlessness and constant exhaustion (fatigue)
Reduction in performance
Loss of muscle mass and strength (sarcopenia)
decreased quality of life

Those affected are in a vicious circle: the body reserves dwindle, but the patients still have no appetite and therefore do not eat enough - they lose weight. Because they feel listless and weak, they move less, which further stimulates the breakdown of the muscles. In addition, it is more difficult for the body to build muscle again.

Stages of tumor cachexia

Tumor cachexia can be divided into three stages:

Precachexia: This is the precursor to cachexia. It is characterized by weight loss of less than five percent, loss of appetite, and changes in metabolism.
Cachexia: The symptoms are weight loss of more than five percent or a reduction in BMI of less than two percent or muscle loss and weight loss of more than two percent, as well as decreased food intake and systemic inflammation.
Refractory cachexia: "Refractory" means that it can no longer be influenced by therapies. Affected people show a severe loss of fat and muscle mass. Their life expectancy is less than three months.

After "blood poisoning" (sepsis), cachexia is the second most common cause of death in cancer patients. Early intervention is therefore extremely important - because once the last (refractory) stage has been reached, therapy no longer promises success.

End-stage tumor cachexia

When cancer treatment fails, the patient is dying. Here, too, there is tumor cachexia or severe weight loss: In end-stage cancer, up to 80 percent of those affected have the three symptoms of anorexia, weight loss and sarcopenia. It is often the case that the patients feel that it is coming to an end and they therefore consciously forego food. This is part of the normal process of dying, but is often difficult for relatives to accept.

Consciously abstaining from food does not let the dying starve to death, but often even helps them walk with dignity! In this case, forced food intake would be wrong for the person concerned.

What are the consequences of malnutrition in cancer?

Malnutrition in cancer is problematic because it ...

demonstrably reduces the quality of life,
creates or intensifies fears or depression, makes you listless and reduces your ability to concentrate,
causes muscle mass to shrink, leads to fatigue, rapid physical exhaustion and weakness,
causes hair loss, dry and flaky skin,
makes you more susceptible to infections,
reduces the functionality of the red blood cells,
reduces cardiac output, disrupts the heart rhythm and leads to high blood pressure,
weakens the respiratory muscles,
makes cancer therapy less tolerable for the patient (stronger side effects),
reduces the response of the tumor to therapy,
promotes wound healing disorders after operations,
worsens the prognosis for the course of the disease and thus reduces the chances of survival.

Recognize malnutrition

Anyone with cancer should keep an eye on their own weight: weigh yourself regularly and write down the measured values. You can notice an inexplicable change in weight at an early stage. Then contact your doctor immediately - he can determine whether you are suffering from malnutrition and possibly even tumor cachexia.

At the same time, it is also the job of your doctor to check you regularly for malnutrition (screening) - regardless of whether you have noticed a rapid change in weight.With the help of a special protocol, it records your nutritional status, your illness situation and your age. If the doctor notices an increased risk of malnutrition during this screening, further analyzes follow, which must also be repeated regularly:

Questions about your diet
Determination of your body composition (muscle and fat percentage) with the help of computed tomography and / or a bioelectrical impedance analysis (BIA) - the latter measures the resistance (impedance) that the body opposes to an alternating current applied via electrodes
Measurement of your muscle function with a hand strength test and / or a sit-stand test (getting up from sitting 5 times and sitting down again usually takes less than 16 seconds)
Measurement of your physical capacity, for example using a 400-meter walk test (usually less than six minutes) or a walking speed test (usually more than 0.8 meters per second)

If the diagnosis of malnutrition has been established, the doctor must clarify whether it is a simple malnutrition without inflammation in the body or malnutrition with inflammation (tumor cachexia). To do this, your doctor will regularly measure the level of inflammation in your body using certain blood values - including C-reactive protein (CRP) and serum albumin. If the CRP value is above 10 milligrams per liter (mg / l) and the serum albumin is below 35 grams per liter (g / l), this greatly worsens the prognosis of the cancer.

Treatment of malnutrition in cancer

The treatment of malnutrition or tumor cachexia consists of three important pillars:

Identifying and treating the causes: First of all, it must be clarified where the malnutrition comes from in order to then remedy these causes if possible. If, for example, side effects of tumor therapy such as nausea or diarrhea are the reason for the malnutrition, these must be treated consistently (e.g. with medication).
Compensating for or stopping weight loss: In order to compensate for the weight loss, the malnourished body must receive enough energy from food in the future. In some situations, however, such as after the stomach has been removed, it is often difficult to gain weight. Then at least an attempt should be made to maintain the current weight.
Training muscles: Cancer sufferers need regular physical training in order to stop the breakdown of muscles and to be able to build muscles again, if possible.

The most important goal of the treatment is to make you feel good again and improve your quality of life.

Treat tumor / therapy side effects

>> Loss of appetite: Eat what you like and whenever you have an appetite. Try to eat several smaller meals throughout the day. Eat in company or read while eating or in front of the TV - distraction makes it easier to eat. Arrange your dishes in a varied, visually appealing and colorful way. Spices and herbs also stimulate the appetite. Exercise regularly, it stimulates the appetite. In addition, your doctor can prescribe appetite-stimulating medication for you.

>> Pain: If you are in pain, be sure to talk to your doctor. There are several ways to adequately treat pain.

>> Nausea and vomiting: Nausea and vomiting can be managed well with appropriate medication - the so-called antiemetics. These are given to cancer patients as an infusion through the vein (intravenous) as a preventive measure before chemotherapy. If necessary, another dose can be given (as an infusion or in tablet form).

>> Inflammation of the oral mucosa: You should consult your dentist even before drug cancer therapy or radiation therapy in order to treat any existing cavities and gingivitis. Careful oral hygiene before, during, and after therapy will help prevent infection. If there is an infection in the mouth anyway, the doctor can treat it with appropriate medication.

>> Diarrhea: The most important measure in the case of diarrhea is to compensate for the loss of water and salts (electrolytes) - with plenty of drinking and, if necessary, appropriate solutions that can be bought in the pharmacy (electrolyte solutions). In addition, you need to adjust your diet for the time of diarrhea: Avoid high-fiber foods such as whole-grain bread, nuts or dried fruits. Instead, eat white bread, pasta, rice, eggs, chicken, and yogurt, and foods high in potassium like bananas, oranges, and peaches.

If these measures are not sufficient, your doctor can prescribe medication to treat your diarrhea. First, a so-called μ-opioid receptor agonist such as loperamide is tried. If this does not work sufficiently, an opiate-containing drug (such as opium tincture) is used.

High calorie diet

As a cancer patient with malnutrition and weight loss, you urgently need nutritional therapy and / or regular nutritional advice. A nutritionist or dietician will analyze your previous diet with you. You will then receive an individually adapted nutrition plan and helpful tips. Often the exact opposite of what is recommended to healthy people is recommended (e.g. high-fat meals).

Only take dietary supplements if you have discussed this beforehand with your doctor or nutritionist, so as not to negatively influence the cancer therapy!

>> Eating rich in energy: The diet of cancer patients with malnutrition should be particularly rich in energy (provided they are not overweight). Since cancer patients can often only eat small amounts at once or have little appetite, the menu should contain as much fat as possible. This means: Whenever possible, you should enrich your meals with fat (e.g. vegetable oils, butter, cream, margarine, lard or bacon).

Some study results suggest that omega-3 fatty acids (more precisely: eicosapentaenoic acid, EPA) could be particularly helpful. Good suppliers for EPA are cold water fish such as anchovies, herrings, mackerel, sardines and salmon. Omega-3 fatty acids are also found in linseed, walnut and rapeseed oil.

>> Beverages containing calories: Also drink diluted fruit juices, milkshakes, cocoa and sodas to give your body the energy it needs.

>> Consume a lot of protein: Cancer patients need a lot of protein and many protein building blocks (amino acids). We recommend 1.5 to 2 grams of protein per kilogram of body weight daily. For a person weighing 60 kg, this corresponds to 90 to 120 grams of protein per day. Meat, eggs, cheese, fish as well as shellfish and crustaceans provide a lot of protein, but also some vegetable products such as legumes, nuts and grains. Animal proteins are, however, more beneficial for building muscle than vegetable ones.

>> Astronaut food: In addition, for the treatment of malnutrition in cancer it can make sense to resort to drinking and additional food (supplementation), also known as "astronaut food". The so-called supplements contain highly concentrated protein. They are available, for example, as protein powder that can be stirred into milk. Ready-to-drink food that is taken as a snack is also helpful. It is also helpful to use protein concentrates before a tumor operation to prevent malnutrition after the operation.

>> Lots of small meals: It is better to eat five to six small meals throughout the day instead of a few larger ones. This reduces the pressure of having to eat a lot at once.

Take a close confidante (friend, relative, etc.) with you to nutritional advice. He can help to absorb the large amount of information and recommendations.

Artificial nutrition

When it is not possible to get enough food naturally, the nutrients must be artificially introduced into the body. That sounds terrifying at first, but it is vital. For some patients, artificial feeding can even be a relief because it takes the pressure off of having to eat a certain amount on a regular basis.

There are different forms of artificial nutrition:

enteral nutrition: All the necessary nutrients are fed directly into the gastrointestinal tract via a probe, thus bypassing the oropharynx.
Parenteral nutrition: In this variant, the nutrients are introduced directly into the bloodstream as an infusion (more precisely: into a vein). This type of artificial nutrition is used when the digestive organs are not functioning properly because, for example, an inoperable tumor is blocking the stomach or intestines.

Some cancer patients are given tube feeding (enteral feeding) in addition to their normal diet if they cannot ingest enough nutrients orally. Other patients must only be fed artificially (enteral and / or parenteral).

Physical activity

To treat malnutrition Regular muscle training prevents the breakdown of muscles and promotes their rebuilding. The most effective training is guided by a physiotherapist or sports medicine practitioner and consists of:

Endurance training (three times a week at least 30 minutes each time)
Strength and posture training (twice a week)

Such training is difficult to manage for frail patients. It is therefore all the more important to exercise in everyday life (walks, climbing stairs, etc.). Researchers were also able to achieve good results with these patients with so-called electromyostimulation. The muscles are stimulated by electrical stimuli. This can also counteract the loss of muscle mass due to malnutrition in cancer.

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