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Nutrition During Cancer

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Nutritional Impact Symptoms (NIS)

NIS: overview

A number of symptoms and complications of advanced cancer, anticancer treatment, or medical co-morbidities can interfere with patients’ appetite and ability to eat or digest food. The broad spectrum of impediments to oral nutritional intake can be conceptualized as nutrition impact symptoms (NIS). NIS seem to occur frequently in clinical care, such as taste and smell alterations, mucositis, nausea, constipation, pain and its treatment, or shortness of breath.

Cancer cachexia-anorexia syndrome is influenced by NIS. Despite the impact of these symptoms on oral nutritional intake, they have rarely been systematically assessed and original research has so far focused either on brief nutritional screening instruments or on comprehensive assessments of nutritional problems. The systematic assessment and treatment of NIS deserves attention since the majority of these symptoms can be treated by supportive care measures and their negative impact on oral nutritional intake may be potentially halted.

Frequency of NIS in advanced cancer patients

A recent study by Omlin A et al (J Cachexia Sarcopenia Muscle 2013;4:55–61) explored the frequency of NIS in advanced cancer patients, based on a 12-item NIS checklist. Consecutive patients from an outpatient nutrition-fatigue clinic completed the NIS checklist. Oncology outpatients not seen in the nutrition-fatigue clinic were matched for age, sex, and tumor to serve as controls. In 52 nutrition-fatigue clinic patients, a mixed cancer population [involuntary weight loss in 2 months 5.96 % (mean)], the five most frequent NIS were taste and smell alterations, constipation, abdominal pain, dysphagia, and epigastric pain.

  Nutrition - fatigue clinic
Control patients
p value
Symptom load
(mean ± SD)
Anorexia 32.7 ± 23.4 30.04 ± 18.9 0.44
Pain 53.8 ± 29.3 17.9 ± 18.5 <0.0001
Fatigue 52.5 ± 28.4 26.0 ± 29.3 0.002
Nausea 17.9 ± 23.3 5.9 ± 13.8 0.003
Dyspnea 211.7 ± 19.2 11.7 ± 19.2 0.63

Table 1. Symptom load in the nutrition-fatigue clinic patients compared to the matched patient population (based on standardized symptom load scores)

  Nutrition-fatigue clinic (n=52;percentage)
  N %
Stomatitis 4 7.7
Taste and smell alterations 14 26.9
Dysphagia 6 11.5
Epigastric pain 5 9.6
Abdominal pain 7 13.5
Constipation 10 19.2
Diarrhea 4 7.7
Defecation after meal 3 5.8
Pain 3 5.8
Dyspnea 0 0
Fatigue 5 9.6

Table 2. Frequency of nutrition impact symptoms (NIS) rated as 3 (moderate) and 4 (a lot) by the NIS checklist in patients assessed in the nutrition- clinic

NIS assessment checklist

This Nutritional Impact Symptoms (NIS) checklist was originally published by Omlin A et al (J Cachexia Sarcopenia Muscle 2013;4:55–61). It was developed based on a literature review, multiprofessional clinical expert opinions, and clinical experience. Anorexia and early satiety were considered to be directly cachexia associated and therefore not included in the checklist. It includes 8 symptoms potentially affecting the function or integrity of the gastrointestinal system; in addition, it includes 4 other complex syndromes that can be associated with decreased nutritional intake. In order to keep the checklist short, an open question was added to allow patients to report individual-specific NIS.

The checklist consists of one page and the items are filled in by the patients. A four categorical scale was chosen. 1 = none, 2 = little, 3 = moderate, 4 = a lot. A threshold of 3 or more was chosen and considered significant to assess NIS in advanced cancer patients, in the study by Omlin et al.

Table 3. NIS Checklist used in the study by Omlin et al.

I have reduced appetite and/or reduced oral intake because of None (1) Little (2) Moderate (3) A lot (4)
Taste and smell alterations        
Pain in the stomach        
Abdominal pain        
Constipation (better appetite after bowel movements)        
Defecation after meals        
Other reasons        

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