Publications by authors named "Barbara S van der Meij"

24 Publications

  • Page 1 of 1

State of the art: the role of citrulline as biomarker in patients with chemotherapy- or graft-versus-host-disease-induced mucositis.

Curr Opin Clin Nutr Metab Care 2021 Jun 21. Epub 2021 Jun 21.

Amsterdam UMC, Vrije Universiteit Amsterdam, department of Nutrition & Dietetics, De Boelelaan 117, Amsterdam, The Netherlands HAN University of Applied Sciences, Nutrition, Dietetics and Lifestyle, Nijmegen, The Netherlands Bond University Nutrition and Dietetics Research Group, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, QLD, Australia.

Purpose Of Review: Serum or plasma citrulline levels are used as biomarker for a broad spectrum of intestinal functions. During high-dose chemotherapy, citrulline levels are decreased due to mucositis, a common side effect of chemotherapy. This may decrease intestinal function and result in diarrhea. In this review, most recent studies investigating citrulline as biomarker for intestinal function are discussed, with focus on patients with oncological diseases, specifically hematological malignancies with chemotherapy- or Graft-versus-Host-disease (GVHD)-induced mucositis.

Recent Findings: Citrulline has recently been widely studied in relation to intestinal function and various clinical conditions. It seems therefore a promising noninvasive biomarker in clinical practice for more than intestinal function alone. The association between citrulline levels and intestinal function in patients with hematological malignancies, with or without mucositis remains unclear, as no other parameters of intestinal function for this purpose were assessed.

Summary: In conclusion, citrulline seems to be a promising noninvasive biomarker for various intestinal conditions in general, and potentially for intestinal function in patients with chemotherapy- or GVHD-induced mucositis. It is unclear from recent literature whether high fecal volume or diarrhea as side effect, results in impaired intestinal function and severe malabsorption and if citrulline biomarkers can be useful to detect this.
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http://dx.doi.org/10.1097/MCO.0000000000000773DOI Listing
June 2021

The effect of oral omega-3 polyunsaturated fatty acid supplementation on muscle maintenance and quality of life in patients with cancer: A systematic review and meta-analysis.

Clin Nutr 2021 Jun 27;40(6):3815-3826. Epub 2021 Apr 27.

Bond University Nutrition and Dietetics Research Group, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, QLD, Australia; Dietetics and Foodservices, Mater Health, South Brisbane, QLD, Australia; Mater Research Institute, University of Queensland, Brisbane, QLD, Australia.

Background & Aims: Omega-3 polyunsaturated fatty acid (PUFA) supplementation has been proposed as a potential therapy for cancer-related malnutrition, which affects up to 70% of patients with cancer. The aim of this systematic review and meta-analysis was to examine the effects of oral omega-3 PUFA supplementation on muscle maintenance, quality of life, body weight and treatment-related toxicities in patients with cancer.

Methods: Randomised controlled trials in patients with cancer aged ≥18 years were retrieved from 5 electronic databases: MEDLINE (via PubMed), EMBASE, CENTRAL, CINAHL (via EBSCOhost), and Web of Science, from database inception until 31st of December 2019. The quality of included studies was assessed using the Cochrane risk of bias tool. Trials supplementing ≥600 mg/d omega-3 PUFA (oral capsules, pure fish oil or oral nutritional supplements) compared with a control intervention for ≥3 weeks were included. Meta-analyses were performed in RevMan to determine the mean differences (MD) in muscle mass, quality of life and body weight, and odds ratio (OR) for the incidence of treatment-related toxicities between omega-3 PUFA and control groups with 95% confidence intervals (CI) and I for heterogeneity.

Results: We included 31 publications in patients with various types of cancers and degrees of malnutrition. The Cochrane risk of bias tool graded most trials as 'unclear' or 'high' risk of bias. Meta-analyses showed no significant difference between omega-3 PUFA supplements and control intervention on muscle mass, quality of life and body weight. Oral omega-3 PUFA supplements reduced the likelihood of developing chemotherapy-induced peripheral neuropathy (OR: 0.20; 95% CI: 0.10-0.40; p < 0.001; I = 0%).

Conclusion: This systematic review and meta-analysis indicates that oral omega-3 PUFA supplementation does not improve muscle maintenance, quality of life or body weight in patients with cancer, but may reduce the incidence of chemotherapy-induced peripheral neuropathy. Well-designed large-scale randomised controlled trials in homogenous patient cohorts are required to confirm these findings.
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http://dx.doi.org/10.1016/j.clnu.2021.04.031DOI Listing
June 2021

Using the theoretical domains framework to inform strategies to support dietitians undertaking body composition assessments in routine clinical care.

BMC Health Serv Res 2021 May 28;21(1):518. Epub 2021 May 28.

Department of Dietetics & Foodservices, Mater Health, South Brisbane, Queensland, Australia.

Background: Malnutrition, sarcopenia and cachexia are clinical wasting syndromes characterised by muscle loss. Systematic monitoring by body composition assessment (BCA) is recommended for the diagnosis, treatment and monitoring of the syndrome(s). This study investigated practices, competency, and attitudes of Australian dietitians regarding BCA, to inform a local implementation process.

Methods: Applying the Action cycle in the Knowledge to Action framework, surveys were distributed to the 26 dietitians of an 800-bed tertiary hospital. The survey assessed barriers and enablers to performing routine BCA in clinical care. Results were categorised using the Theoretical Domains Framework (TDF) and suitable interventions mapped using the Behaviour Change Wheel.

Results: Twenty-two dietitians (84.6%) completed the survey. Barriers to BCA were identified in all TDF domains, particularly in Knowledge, Skills, Social/professional role and identity, Beliefs about capabilities, and Environmental context and resources. Enablers existed in domains of: Skills; Beliefs about consequences; Goals; Environmental context and resources; Social influences; Intentions; Optimism; Reinforcement.

Conclusions: This study showed that hospital dietitians experience individual, team, and organisational barriers to adopt BCAs in clinical practice. We were able to formulate targeted implementation strategies to overcome these barriers to assist BCA adoption into routine practice.
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http://dx.doi.org/10.1186/s12913-021-06375-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8161923PMC
May 2021

Plasma levels of platinum-induced fatty acid [16:4n-3] do not affect response to platinum-based chemotherapy: A pilot study in non-small cell lung cancer patients.

Clin Nutr ESPEN 2020 12 7;40:263-268. Epub 2020 Oct 7.

Faculty of Agriculture, Life and Environmental Sciences, University of Alberta, Canada. Electronic address:

Background & Aims: Pre-clinical studies suggest that 16:4(n-3) in purified form or as a component of fish oil might induce platinum-based chemotherapy resistance. Our aim was to determine plasma total and free 16:4(n-3) before and during platinum-based chemotherapy in non-small cell lung cancer (NSCLC) patients supplemented with fish oil or provided standard care, and to explore relationships between plasma 16:4(n-3) levels and tumor response to treatment.

Methods: In a retrospective, secondary data analysis of a prior clinical trial, plasma from patients with NSCLC (n = 21) who underwent platinum-based chemotherapy and were assigned to 2.2 g/day of eicosapentaenoic (EPA) plus 1.1 g DHA/day as fish oil (FO; n = 12) or received no intervention (standard care; SC; n = 9). Plasma 16:4(n-3) was quantified as free and esterified (total) fatty acid using HPLC-MS/MS. Plasma 16:4(n-3) levels were evaluated over time in relation to fish oil supplementation and response to platinum-based therapy, and compared with a group of healthy subjects (REF; n = 11).

Results: Plasma 16:4(n-3) was detected in all samples. The percentage change/day in plasma esterified (total) 16:4(n-3) was higher for FO versus SC group (2.7 versus -1.8%/d, U = 20, p = 0.02), but change in plasma free 16:4(n-3) was not different between FO and SC. Median plasma free and esterified 16:4(n-3) were similar between responders and non-responders to platinum-based chemotherapy. Total and free plasma 16:4(n-3) fatty acids were similar between NSCLC patients and REF (NSCLC vs REF: total 16:4(n-3): 122.9 vs. 95.2 nM and free 16:4(n-3) 23.9 vs. 27.6 nM).

Conclusions: This first of its kind study that evaluated plasma 16:4(n-3) in NSCLC patients showed that 16:4 (n-3) was elevated during FO supplementation, independent of fish oil supplementation or platinum-based chemotherapy.
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http://dx.doi.org/10.1016/j.clnesp.2020.09.009DOI Listing
December 2020

Malnutrition Screening and Assessment in the Cancer Care Ambulatory Setting: Mortality Predictability and Validity of the Patient-Generated Subjective Global Assessment Short form (PG-SGA SF) and the GLIM Criteria.

Nutrients 2020 Jul 30;12(8). Epub 2020 Jul 30.

Dietetics and Foodservices, Mater Health, Brisbane, 4101 QLD, Australia.

Background: A valid malnutrition screening tool (MST) is essential to provide timely nutrition support in ambulatory cancer care settings. The aim of this study is to investigate the validity of the Patient-Generated Subjective Global Assessment Short Form (PG-SGA SF) and the new Global Leadership Initiative on Malnutrition (GLIM) criteria as compared to the reference standard, the Patient-Generated Subjective Global Assessment (PG-SGA).

Methods: Cross-sectional observational study including 246 adult ambulatory patients with cancer receiving in-chair intravenous treatment at a cancer care centre in Australia. Anthropometrics, handgrip strength and patient descriptive data were assessed. Nutritional risk was identified using MST and PG-SGA SF, nutritional status using PG-SGA and GLIM. Sensitivity (Se), specificity (Sp), positive and negative predictive values and kappa (k) were analysed. Associations between malnutrition and 1-year mortality were investigated by Cox survival analyses.

Results: A PG-SGA SF cut-off score ≥5 had the highest agreement when compared with the PG-SGA (Se: 89%, Sp: 80%, k = 0.49, moderate agreement). Malnutrition risk (PG-SGA SF ≥ 5) was 31% vs. 24% (MST). For malnutrition according to GLIM, the Se was 76% and Sp was 73% (k = 0.32, fair agreement) when compared to PG-SGA. The addition of handgrip strength to PG-SGA SF or GLIM did not improve Se, Sp or agreement. Of 100 patients who provided feedback, 97% of patients found the PG-SGA SF questions easy to understand, and 81% reported that it did not take too long to complete. PG-SGA SF ≥ 5 and severe malnutrition by GLIM were associated with 1-year mortality risk.

Conclusions: The PG-SGA SF and GLIM criteria are accurate, sensitive and specific malnutrition screening and assessment tools in the ambulatory cancer care setting. The addition of handgrip strength tests did not improve the recognition of malnutrition or mortality risk.
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http://dx.doi.org/10.3390/nu12082287DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7468976PMC
July 2020

Early Signs of Impaired Gut Function Affect Daily Functioning in Patients With Advanced Cancer Undergoing Chemotherapy.

JPEN J Parenter Enteral Nutr 2021 05 13;45(4):752-760. Epub 2020 Jul 13.

Center for Translational Research in Aging and Longevity, Department of Health and Kinesiology, Texas A&M University, College Station, Texas, USA.

Background: Gastrointestinal symptoms are common during chemotherapy, but underlying disturbances in gut function and their impact on daily life are unclear. This study investigates gut function in a heterogenous group of cancer patients with gastrointestinal symptoms during chemotherapy and its relation to anabolic response, muscle health, and daily functioning.

Methods: In 16 patients with solid tumors (mostly stage III+IV) undergoing chemotherapy (T) and 16 healthy (H) matched controls, small-intestinal membrane integrity was measured by urine sugar tests. Protein digestion, absorption, and anabolic response to a conventional protein supplement were analyzed by stable-tracer methods. Muscle mass and strength and daily functioning were assessed.

Results: Eighty-one percent of T patients reported gastrointestinal symptoms. Small-intestinal membrane permeability was similar, but active glucose transport was lower in the T group (T, 35.5% ± 3.4% vs H, 48.4% ± 4.7%; P = .03). Protein digestion and absorption tended to be lower in the T group (0.67 ± 0.02 vs 0.80 ± 0.04; P = .08). Net protein anabolic response to feeding was comparable, although lower in cancer patients with recent weight loss. Gut permeability negatively correlated to hand grip strength, global health, and physical functioning, and active-transport capacity positively correlated to global health in the T group.

Conclusion: Advanced cancer patients with gastrointestinal symptoms during chemotherapy, particularly those with recent weight loss, show signs of impaired gut function negatively affecting muscle health, daily functioning, and anabolic response to feeding.
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http://dx.doi.org/10.1002/jpen.1941DOI Listing
May 2021

Presence or Absence of Skeletal Muscle Dysfunction in Chronic Obstructive Pulmonary Disease is Associated With Distinct Phenotypes.

Arch Bronconeumol (Engl Ed) 2021 Apr 28;57(4):264-272. Epub 2020 Feb 28.

Center for Translational Research in Aging & Longevity, Department of Health and Kinesiology, Texas A&M University, College Station, TX, United States. Electronic address:

Introduction: Reduced skeletal muscle function and cognitive performance are common extrapulmonary features in Chronic Obstructive Pulmonary Disease (COPD) but their connection remains unclear. Whether presence or absence of skeletal muscle dysfunction in COPD patients is linked to a specific phenotype consisting of reduced cognitive performance, comorbidities and nutritional and metabolic disturbances needs further investigation.

Methods: Thirty-seven patients with COPD (grade II-IV) were divided into two phenotypic cohorts based on the presence (COPD dysfunctional, n=25) or absence (COPD functional, n=12) of muscle dysfunction. These cohorts were compared to 28 healthy, age matched controls. Muscle strength (dynamometry), cognitive performance (Trail Making Test and STROOP Test), body composition (Dual-energy X-Ray Absorptiometry), habitual physical activity, comorbidities and mood status (questionnaires) were measured. Pulse administration of stable amino acid tracers was performed to measure whole body production rates.

Results: Presence of muscle dysfunction in COPD was independent of muscle mass or severity of airflow obstruction but associated with impaired STROOP Test performance (p=0.04), reduced resting O saturation (p=0.003) and physical inactivity (p=0.01), and specific amino acid metabolic disturbances (enhanced leucine (p=0.02) and arginine (p=0.06) production). In contrast, COPD patients with normal muscle function presented with anxiety, increased fat mass, plasma glucose concentration, and metabolic syndrome related comorbidities (hypertension and dyslipidemia).

Conclusion: COPD patients with muscle dysfunction show characteristics of a cognitive - metabolic impairment phenotype, influenced by the presence of hypoxia, whereas those with normal muscle function present a phenotype of metabolic syndrome and mood disturbances.
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http://dx.doi.org/10.1016/j.arbres.2019.12.034DOI Listing
April 2021

Effects of acute oral feeding on protein metabolism and muscle protein synthesis in individuals with cancer.

Nutrition 2019 Nov - Dec;67-68:110531. Epub 2019 Jun 24.

Center for Translational Research in Aging & Longevity, Department of Health and Kinesiology, Texas A&M University, College Station, Texas, USA.

Weight loss and muscle loss are common in individuals living with cancer, with ≤50% experiencing involuntary weight loss at any time point in their cancer journey, and between 11% and 74% having sarcopenia or significant muscle loss. These changes in body composition are related to poor outcomes such as increased treatment toxicity, impaired quality of life, and reduced survival duration. Poor outcomes are not restricted to those who are underweight with severe weight loss; sarcopenia alone has been shown to be a prognostic marker across all body mass index categories, ranging from underweight to obesity To understand the mechanism of nutrition interventions in cancer and to develop effective future interventions, it is necessary to look at the acute effects of feeding on the response of the body and the ability to reach an anabolic response. The aim of this study was to explore and summarize the emerging evidence on metabolic effects of acute oral interventions on whole body protein kinetics and muscle protein synthesis in individuals with cancer.
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http://dx.doi.org/10.1016/j.nut.2019.06.012DOI Listing
October 2020

Family in Rehabilitation, Empowering Carers for Improved Malnutrition Outcomes: Protocol for the FREER Pilot Study.

JMIR Res Protoc 2019 Apr 30;8(4):e12647. Epub 2019 Apr 30.

Bond University Nutrition & Dietetics Research Group, Faculty of Health Sciences and Medicine, Bond University, Robina, Australia.

Background: Interventions to improve the nutritional status of older adults and the integration of formal and family care systems are critical research areas to improve the independence and health of aging communities and are particularly relevant in the rehabilitation setting.

Objective: The primary outcome aimed to determine if the FREER (Family in Rehabilitation: EmpowERing Carers for improved malnutrition outcomes) intervention in malnourished older adults during and postrehabilitation improve nutritional status, physical function, quality of life, service satisfaction, and hospital and aged care admission rates up to 3 months postdischarge, compared with usual care. Secondary outcomes evaluated include family carer burden, carer services satisfaction, and patient and carer experiences. This pilot study will also assess feasibility and intervention fidelity to inform a larger randomized controlled trial.

Methods: This protocol is for a mixed-methods two-arm historically-controlled prospective pilot study intervention. The historical control group has 30 participants, and the pilot intervention group aims to recruit 30 patient-carer pairs. The FREER intervention delivers nutrition counseling during rehabilitation, 3 months of postdischarge telehealth follow-up, and provides supportive resources using a novel model of patient-centered and carer-centered nutrition care. The primary outcome is nutritional status measured by the Scored Patient-Generated Subjective Global Assessment Score. Qualitative outcomes such as experiences and perceptions of value will be measured using semistructured interviews followed by thematic analysis. The process evaluation addresses intervention fidelity and feasibility.

Results: Recruitment commenced on July 4, 2018, and is ongoing with eight patient-carer pairs recruited at the time of manuscript submission.

Conclusions: This research will inform a larger randomized controlled trial, with potential for translation to health service policies and new models of dietetic care to support the optimization of nutritional status across a continuum of nutrition care from rehabilitation to home.

Trial Registration: Australian New Zealand Clinical Trials Registry Number (ACTRN) 12618000338268; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=374608&isReview=true (Archived by WebCite at http://www.webcitation.org/74gtZplU2).

International Registered Report Identifier (irrid): DERR1-10.2196/12647.
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http://dx.doi.org/10.2196/12647DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6658316PMC
April 2019

Establishing an evidenced-based dietetic model of care in haemodialysis using implementation science.

Nutr Diet 2019 04 21;76(2):150-157. Epub 2019 Mar 21.

Department of Dietetics and Foodservices, Mater Health, Brisbane, Queensland, Australia.

Aim: To establish an evidence-based dietetics service in an in-centre haemodialysis unit utilising implementation science.

Methods: The service was developed through the Knowledge-to-Action Framework. The steps of the Action Cycle were addressed through a literature review, identification of evidence-based guidelines, benchmarking and local staff engagement. The theoretical domains framework (TDF) was used to identify barriers/enablers, and behaviour change wheel to determine appropriate interventions. To monitor, evaluate outcomes and assess sustained knowledge use we employed multidisciplinary team engagement and database use. Audit data were collected at baseline, 6 and 12 months on nutrition assessment (Patient-Generated Subjective Global Assessment), intervention timeliness and alignment to dietetic workforce recommendations. Descriptive statistics, McNemar tests and a linear mixed model were applied.

Results: Barriers existed in the knowledge, skills, environmental context and resources TDF domains. Suitable interventions were identified with training on nutritional management of haemodialysis patients delivered to 148 nurses, and nutrition management recommendations summarised into local procedural resources. A database to prompt and monitor outcome measures was created and indicated that over 18 months post-service commencement, eligible patients received nutrition assessment at least 6-monthly, aligning with recommendations. Prevalence of malnutrition was 28% (n = 9/32) at baseline, 23% (n = 5/22) at 6 months and 20% (n = 4/20) at 12 months (P = 0.50).

Conclusions: We demonstrated benefits to service development and implementation with implementation science providing a structured and methodical approach to translating guidelines into practice. Development of training, resources and prompts for outcome measures has supported the establishment of an evidence-based dietetics service in a haemodialysis unit.
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http://dx.doi.org/10.1111/1747-0080.12528DOI Listing
April 2019

Nutrition process improvements for adult inpatients with inborn errors of metabolism using the i-PARIHS framework.

Nutr Diet 2019 04 7;76(2):141-149. Epub 2019 Mar 7.

Department of Dietetics and Food Services, Mater Health, Brisbane, Queensland, Australia.

Aim: This project aimed to implement consensus recommendations and innovations that improve dietetic services to promote timely referral to optimise nutritional management for adult inpatients with inborn errors of metabolism (IEM).

Methods: The i-PARIHS framework was used to identify service gaps, implement innovations and evaluate the innovations within this single-site study. The constructs of this framework are: (i) review of the evidence; (ii) recognising patients and staff knowledge and attitudes; (iii) acknowledging the local context; and (iv) the facilitators role. This included a literature review and metabolic centre service comparisons to investigate dietetic referral and foodservice processes to inform the innovation. A 12-month chart audit (6 months retrospective and prospective of implemented innovation, respectively) to evaluate newly established dietetic referral and IEM nutrition provision procedures was also completed.

Results: The innovations implemented encompassed a clinical alert triggering urgent referral, nutrition sick day plans and metabolic diet and formula prescription via an 'alert' tab in electronic records. Eleven metabolic protein-restricted diets and nine formula recipes were introduced. Prior to the innovations, only 53% (n = 19/36) of inpatients with IEM were assessed by the dietitian and received appropriate nutrition within 24 hours. Following implementation of the innovations, 100% (n = 11/11) of inpatients with IEM received timely dietetic assessment and therapeutic nutrition.

Conclusions: Implementation of innovations developed using the i-PARIHS framework is effective in timely notification of the metabolic dietitian of referrals. This ensures optimal nutritional management during admissions which is required in this group of high-risk patients.
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http://dx.doi.org/10.1111/1747-0080.12517DOI Listing
April 2019

Increased amino acid turnover and myofibrillar protein breakdown in advanced cancer are associated with muscle weakness and impaired physical function.

Clin Nutr 2019 10 15;38(5):2399-2407. Epub 2018 Nov 15.

Center for Translational Research in Aging & Longevity, Dept. Health and Kinesiology, Texas A&M University, 675 John Kimbrough Blvd, College Station, TX 77843-4253, USA. Electronic address:

Background & Aims: Muscle wasting in cancer negatively affects physical function and quality of life. This study investigates amino acid metabolism and the association with muscle mass and function in patients with cancer.

Methods: In 16 patients with advanced cancer undergoing chemotherapy and 16 healthy controls, we administered an intravenous pulse and prime of stable amino acid tracers. We took blood samples to measure the Rate of appearance (Ra), whole body production (WBP), clearance (Cl), and post absorptive whole body net protein breakdown (WBnetPB). Plasma amino acid concentrations and enrichments were analysed by LC-MS/MS. We assessed muscle mass, handgrip/leg/respiratory muscle strength and reported physical activity, quality of life, and physical function.

Results: Muscle strength was lower in cancer patients than in healthy controls. Total and limb muscle mass, reported physical activity and WBnetPB were comparable. WBP and Cl of tau-methylhistidine, leucine, glutamine and taurine were higher in cancer patients as well as glycine Cl. Amino acid metabolism was correlated with low muscle mass, strength, physical function and quality of life.

Conclusions: Myofibrillar protein breakdown and production of amino acids involved in muscle contractility are up regulated in patients with cancer undergoing chemotherapy and related to muscle weakness and reduced physical outcomes.
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http://dx.doi.org/10.1016/j.clnu.2018.10.022DOI Listing
October 2019

Amino acid kinetics and the response to nutrition in patients with cancer.

Int J Radiat Biol 2019 04 3;95(4):480-492. Epub 2018 May 3.

c Department Health and Kinesiology , Center for Translational Research in Aging & Longevity, Texas A&M University , College Station , TX , USA.

Purpose: Amino acids are involved in many physiological processes in the body and serve as building blocks of proteins which are the main component of muscle mass. Often patients with cancer experience muscle wasting, which is associated with poor outcomes. The purpose of this paper is to discuss amino acid kinetics in cancer, review the evidence on the response to nutrition in patients with cancer, and to give recommendations on the appropriate level of amino acid or protein intake in cancer. Current evidence shows that amino acid kinetics in patients with cancer are disturbed, as reflected by increased and decreased levels of plasma amino acids, an increased whole body turnover of protein and muscle protein breakdown. A few studies show beneficial effects of acute and short-term supplementation of high protein meals or essential amino acid mixtures on muscle protein synthesis.

Conclusions: Cancer is associated with disturbances in amino acid kinetics. A high protein intake or supplementation of amino acids may improve muscle protein synthesis. Future research needs to identify the optimal level and amino acid mixtures for patients with cancer, in particular for those who are malnourished.
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http://dx.doi.org/10.1080/09553002.2018.1466209DOI Listing
April 2019

Poor Appetite and Dietary Intake in Community-Dwelling Older Adults.

J Am Geriatr Soc 2017 Oct 26;65(10):2190-2197. Epub 2017 Jul 26.

Department of Health Sciences and the EMGO Institute for Health and Care Research, Faculty of Earth and Life Sciences, VU University Amsterdam, Amsterdam, The Netherlands.

Background/objectives: Poor appetite in older adults leads to sub-optimal food intake and increases the risk of undernutrition. The impact of poor appetite on food intake in older adults is unknown. The aim of this study was to examine the differences in food intake among older community-dwelling adults with different reported appetite levels.

Design: Cross-sectional analysis of data from a longitudinal prospective study.

Setting: Health, aging, and body composition study performed in the USA.

Participants: 2,597 community-dwelling adults aged 70-79.

Measurements: A semi-quantitative, interviewer-administered, 108-item food frequency questionnaire designed to estimate dietary intake. Poor appetite was defined as the report of a moderate, poor, or very poor appetite in the past month and was compared with good or very good appetite.

Results: The mean age of the study sample was 74.5 ± 2.8 years; 48.2% were men, 37.7% were black, and 21.8% reported a poor appetite. After adjustment for total energy intake and potential confounders (including biting/chewing problems), participants with a poor appetite had a significantly lower consumption of protein and dietary fiber, solid foods, protein rich foods, whole grains, fruits, and vegetables, but a higher consumption of dairy foods, fats, oils, sweets, and sodas compared to participants with very good appetite. In addition, they were less likely to report consumption of significant larger portion sizes.

Conclusion: Older adults reporting a poor appetite showed a different dietary intake pattern compared to those with (very) good appetite. Better understanding of the specific dietary intake pattern related to a poor appetite in older adults can be used for nutrition interventions to enhance food intake, diet variety, and diet quality.
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http://dx.doi.org/10.1111/jgs.15017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5641246PMC
October 2017

Protein anabolic resistance in cancer: does it really exist?

Curr Opin Clin Nutr Metab Care 2016 Jan;19(1):39-47

Center for Translational Research in Aging & Longevity, Department of Health and Kinesiology, Texas A&M University, College Station, Texas, USA.

Purpose Of Review: Preventing unintentional weight and muscle loss is of crucial importance to maintain the condition and well-being of patients with cancer, improve treatment response and tolerance, and prolong survival. Anabolic resistance might explain why some cancer patients do not respond to nutritional intervention, but does recent evidence actually support this? We will discuss recent literature that casts doubt on attenuated anabolic potential in cancer.

Recent Findings: Although anabolic resistance was observed in the past, more recent studies have shown that advanced cancer patients have an anabolic potential after intake of high-quality proteins. Furthermore, a consistent linear relationship is observed in cancer between (essential) amino acid availability from the diet and net protein gain. The studied cancer patients, however, were often characterized by a normal or obese body weight, following the trend in the general population, and mild systemic inflammation. Factors like recent chemotherapy, surgery, or cachexia do not seem to attenuate the anabolic potential to feeding.

Summary: Cancer patients have a normal anabolic potential which relates to the amount of essential amino acids in the meal. It remains to be determined if this is also the case in weak cancer patients with a short life expectancy and high systemic inflammation.
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http://dx.doi.org/10.1097/MCO.0000000000000236DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4731087PMC
January 2016

Let Them Eat Fish.

JAMA Oncol 2015 Sep;1(6):840

Center for Translational Research in Aging and Longevity, Texas A&M University, College Station.

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http://dx.doi.org/10.1001/jamaoncol.2015.2053DOI Listing
September 2015

Variety within a cooked meal increases meal energy intake in older women with a poor appetite.

Appetite 2015 Dec 28;95:571-6. Epub 2015 Aug 28.

Department of Health Sciences and the EMGO Institute for Health and Care Research, Faculty of Earth and Life Sciences, VU University Amsterdam, De Boelelaan 1085, 1081 HV, Amsterdam, The Netherlands; Department of Nutrition and Dietetics, Internal Medicine, VU University Medical Center, PO Box 7057, 1007 MB Amsterdam, The Netherlands.

Background: Effective strategies to increase dietary intake in older persons with a poor appetite are needed. Previous studies have shown that increasing diet variety may increase dietary intake. This has not been tested in older adults with a poor appetite.

Objective: We investigated if an increased variety of foods within a cooked meal results in a higher meal energy intake in older women with a poor appetite.

Methods: This study was a randomized, controlled, cross-over trial among 19 older (>65 years) women with a poor appetite. Two cooked meals of similar weight and energy density (except starch) were served under standardized conditions on two weekdays: a test meal consisting of three different varieties of vegetables, meat or fish, and starch components, and a control meal without variety. Participants ate ad libitum and the actual consumed amounts and their nutritional content were calculated. Data were analyzed by mixed linear models.

Results: Average intake in energy was 427 kcal (SD 119) for the test meal with variety and 341 kcal (SD 115) for the control meal without variety. This resulted in a statistically significant (for period effects adjusted) mean difference of 79 kcal (95% CI = 25-134). Total meal intake in grams was also higher for the test meal with variety (48 g, 95% CI = 1-97) but protein intake (g) was not (3.7 g, 95% CI = -1.4 to 8.8). This was consistent for all meal components except starch and within each component three varieties were consumed equally.

Conclusions: The results of the present study suggest that increasing meal variety may be an effective strategy to increase energy intake in older adults with a poor appetite.
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http://dx.doi.org/10.1016/j.appet.2015.08.029DOI Listing
December 2015

Specific food preferences of older adults with a poor appetite. A forced-choice test conducted in various care settings.

Appetite 2015 Jul 12;90:168-75. Epub 2015 Mar 12.

Department of Health Sciences, VU University Amsterdam, Amsterdam, The Netherlands; Department of Epidemiology and Biostatistics, VU University Medical Center, Amsterdam, The Netherlands.

A poor appetite in older adults is an important determinant of reduced food intake and undernutrition. Food preferences may influence food intake. The aim of this study was to investigate food preferences of older adults with a poor appetite and compare these with preferences of older adults with a good appetite. Older adults (n = 349, aged 65-101 years) in nursing/residential care homes, hospitals or at home receiving home care participated in a computer-based forced-choice food preference assessment. Self-reported appetite in the past week was classified as 'good' or 'poor' using a validated instrument. Food preferences were determined by counting the relative frequency of choices for food images according to 11 dichotomous categories: high/low 1) protein; 2) fat; 3) carbohydrates; 4) fiber; 5) variation; and 6) animal/vegetarian proteins; 7) sweet/savory taste; 8) solid/liquid texture; 9) dairy/non-dairy; with/without 10) sauce or 11) color variation. Specific food preferences in participants with a poor appetite were identified by one-sample t-tests comparing frequencies to the expected value of 48. Preference differences between those with a good and a poor appetite were analyzed using GLM adjusting for confounders. The results showed that older adults with a poor appetite (n = 113; 32.4%) preferred variation (51.6 vs. 48, P < 0.001), color variation (55.9 vs. 48, P < 0.01), non-dairy (53.0 vs. 48, P < 0.001), high-fiber (51.8 vs. 48, P < 0.05), and solid texture (53.5 vs. 48, P < 0.05). Participants with a poor appetite had a higher frequency score for variation than participants with a good appetite (51.6 vs. 48.5, P < 0.001). In conclusion, older adults with a poor appetite may have specific food preferences. Their preference for variation differs from those with a good appetite. These results may be used to develop meals that are preferred by older adults with poor appetite in order to increase food intake and prevent undernutrition.
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http://dx.doi.org/10.1016/j.appet.2015.03.011DOI Listing
July 2015

Novel nutritional substrates in surgery.

Proc Nutr Soc 2013 Aug 15;72(3):277-87. Epub 2013 Feb 15.

Department of Surgery, VU University Medical Center, Amsterdam, The Netherlands.

Pharmaco-nutrients have beneficial effects on protective and immunological mechanisms in patients undergoing surgery, which are important for recovery after injury and in combating infectious agents. The aim of this review article was to outline the potential of the administration of nutritional substrates to surgical patients and the underlying mechanisms that make them particularly important in peri-operative care. Surgery causes a stress response, which has catabolic effects on the body's substrate stores. The amino acid glutamine is a stimulating agent for immune cells. It activates protective mechanisms through its role as a precursor for antioxidants and it improves the barrier function of the gut. Arginine also enhances the function of the immune system, since it is the substrate for T-lymphocytes. Furthermore, n-3 PUFA stabilise surgery-induced hyper-inflammation. Taurine is another substrate that may counteract the negative effects of surgical injury on acid-base balance and osmotic balance. These pharmaco-nutrients rapidly become deficient under the influence of surgical stress. Supplementation of these nutrients in surgical patients may restore their protective and immune-enhancing actions and improve clinical outcome. Moreover, pre-operative fasting is still common practice in the Western world, although fasting has a negative effect on the patient's condition and the recovery after surgery. This may be counteracted by a simple intervention such as administering a carbohydrate-rich supplement just before surgery. In conclusion, there are various nutritional substrates that may be of great value in improving the condition of the surgical patient, which may be beneficial for post-operative recovery.
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http://dx.doi.org/10.1017/S0029665112003047DOI Listing
August 2013

Pre-cachexia and cachexia at diagnosis of stage III non-small-cell lung carcinoma: an exploratory study comparing two consensus-based frameworks.

Br J Nutr 2013 Jun 16;109(12):2231-9. Epub 2012 Nov 16.

Department of Nutrition and Dietetics, Internal Medicine, VU University Medical Center, P.O. Box 7057, 1007 MB, Amsterdam, The Netherlands.

Despite the development of consensus-based frameworks to define cancer cachexia, the validity and usefulness of these frameworks are relatively unknown. The aim of the present study was to study the presence of pre-cachexia and cachexia in patients with stage III nonsmall-cell lung carcinoma (NSCLC) by using a cancer-specific framework and a general framework for cachexia, and to explore the prognostic value of pre-cachexia and cachexia. In forty patients at diagnosis of stage III NSCLC, weight loss, fat-free mass, handgrip strength, anorexia and serum biochemistry, assessed before the first chemotherapy, were used to define ‘cancer cachexia’ or ‘cachexia’. The cancer-specific framework also classified for pre-cachexia and refractory cachexia. Additionally, quality of life was assessed by the European Organisation for Research and Treatment of Cancer–Quality of Life Questionnaire C30. Groups were compared using independent t tests, ANOVA, Kaplan–Meier and Cox survival analyses. Based on the cancer-specific framework, pre-cachexia was present in nine patients (23%) and cancer cachexia was present in seven patients (18%). Cancer cachexia was associated with a reduced quality of life (P = 0.03) and shorter survival (hazard ratio (HR) = 2.9; P = 0.04). When using the general framework, cachexia was present in eleven patients (28%), and was associated with a reduced quality of life (P = 0.08) and shorter survival (HR = 4.4; P = 0.001). In conclusion, pre-cachexia and cachexia are prevalent in this small population of patients at diagnosis of stage III NSCLC. For both frameworks, cachexia appears to be associated with a reduced quality of life and shorter survival. Further studies are warranted to more extensively explore the validity and prognostic value of these new frameworks in cancer patients.
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http://dx.doi.org/10.1017/S0007114512004527DOI Listing
June 2013

n-3 PUFAs in cancer, surgery, and critical care: a systematic review on clinical effects, incorporation, and washout of oral or enteral compared with parenteral supplementation.

Am J Clin Nutr 2011 Nov 21;94(5):1248-65. Epub 2011 Sep 21.

Department of Nutrition and Dietetics, VU University Medical Center Amsterdam, Netherlands.

Background: n-3 (omega-3) Fatty acids (FAs) may have beneficial effects in patients with cancer or in patients who undergo surgery or critical care.

Objective: Our aim was to systematically review the effects of oral or enteral and parenteral n-3 FA supplementation on clinical outcomes and to describe the incorporation of n-3 FAs into phospholipids of plasma, blood cells, and mucosal tissue and the subsequent washout in these patients.

Design: We investigated the supplementation of n-3 FAs in these patients by using a systematic literature review.

Results: In cancer, the oral or enteral supplementation of n-3 FAs contributed to the maintenance of body weight and quality of life but not to survival. We did not find any studies on parenteral supplementation of n-3 FAs in cancer. In surgical oncology, we did not find any studies on enteral supplementation of n-3 FAs. However, postoperative parenteral supplementation in surgical oncology may reduce the length of a hospital stay. For general surgery, we did not find any studies on enteral supplementation of n-3 FAs, and evidence on parenteral supplementation was insufficient. In critical care, enteral supplementation of n-3 FAs had beneficial effects on clinical outcomes; evidence on parenteral supplementation in critical care was inconsistent. The incorporation of n-3 FAs in plasma and blood cells was slower with enteral supplementation (4-7 d) than with parenteral supplementation (1-3 d). The washout was 5-7 d.

Conclusions: This review shows the beneficial effects of n-3 FA supplementation in cancer, surgical oncology, and critical care patients. Supplementation in these specific patient populations could be considered with the route of administration taken into account.
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http://dx.doi.org/10.3945/ajcn.110.007377DOI Listing
November 2011

Nutrition during trimodality treatment in stage III non-small cell lung cancer: not only important for underweight patients.

J Thorac Oncol 2011 Sep;6(9):1563-8

Department of Nutrition and Dietetics, VU University Medical Center, Amsterdam, The Netherlands.

Introduction: Trimodality treatment for stage III non-small cell lung cancer (NSCLC), consisting of chemoradiotherapy followed by surgery, is associated with treatment-related toxicity, malnutrition, and postoperative complications. The aim of this retrospective study was to investigate the predictive value of nutritional parameters on postoperative morbidity, mortality, and survival.

Methods: Patients with stage III NSCLC undergoing concurrent chemoradiotherapy followed by surgery in one center between 2003 and 2009 were included. Age, sex, forced expiratory volume in 1 second, body mass index, weight change, and surgical and pathological factors were recorded and related to the occurrence of postoperative complications/mortality, overall survival (OS), and progression-free survival.

Results: Of 51 study patients, 17 (33%) had overweight (body mass index ≥ 25) at start of treatment and 20 patients (39%) were malnourished at hospital admission for surgery. Postoperative complications occurred in 25 patients (49%), 6 had major complications, and 2 died within 90 days after surgery, but no significant predictive factors were found. Overall, weight loss ≥5% during induction period was associated with shorter OS (p = 0.03), but especially overweight patients experiencing weight loss ≥5% during induction period (n = 7) had shorter OS (hazard ratio 4.63, p = 0.005; log-rank p = 0.04) and progression-free survival (hazard ratio 6.03, p = 0.007).

Conclusions: This study indicates that malnutrition especially in overweight patients negatively influences survival outcomes of trimodality treatment for stage III NSCLC.
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http://dx.doi.org/10.1097/JTO.0b013e3182208e90DOI Listing
September 2011

Oral nutritional supplements containing (n-3) polyunsaturated fatty acids affect the nutritional status of patients with stage III non-small cell lung cancer during multimodality treatment.

J Nutr 2010 Oct 25;140(10):1774-80. Epub 2010 Aug 25.

Department of Nutrition and Dietetics, Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands.

Eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), (n-3) fatty acids from fish oil, have immune-modulating effects and may improve nutritional status in cancer. The objective of this study was to investigate the effects of an oral nutritional supplement containing (n-3) fatty acids on nutritional status and inflammatory markers in patients with non-small cell lung cancer (NSCLC) undergoing multimodality treatment. In a double-blind experiment, 40 patients with stage III NSCLC were randomly assigned to receive 2 cans/d of a protein- and energy-dense oral nutritional supplement containing (n-3) fatty acids (2.0 g EPA + 0.9 g DHA/d) or an isocaloric control supplement. EPA in plasma phospholipids, energy intake, resting energy expenditure (REE), body weight, fat free mass (FFM), mid-upper arm circumference (MUAC), and inflammatory markers were assessed. Effects of intervention were analyzed by generalized estimating equations and expressed as regression coefficients (B). The intervention group (I) had a better weight maintenance than the control (C) group after 2 and 4 wk (B = 1.3 and 1.7 kg, respectively; P < 0.05), a better FFM maintenance after 3 and 5 wk (B = 1.5 and 1.9 kg, respectively; P < 0.05), a reduced REE (B = -16.7% of predicted; P = 0.01) after 3 wk, and a trend for a greater MUAC (B = 9.1; P = 0.06) and lower interleukin-6 production (B = -27.9; P = 0.08) after 5 wk. After 4 wk, the I group had a higher energy and protein intake than the C group (B = 2456 kJ/24 h, P = 0.03 and B = 25.0 g, P = 0.01, respectively). In conclusion, a protein- and energy-dense oral nutritional supplement containing (n-3) fatty acids beneficially affects nutritional status during multimodality treatment in patients with NSCLC.
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http://dx.doi.org/10.3945/jn.110.121202DOI Listing
October 2010

Validation of predictive equations for resting energy expenditure in adult outpatients and inpatients.

Clin Nutr 2008 Feb 24;27(1):150-7. Epub 2007 Oct 24.

Department of Nutrition and Dietetics, VU University Medical Center, P.O. Box 7057, 1007 MB Amsterdam, The Netherlands.

Background & Aims: When individual energy requirements of adult patients cannot be measured by indirect calorimetry, they have to be predicted with an equation. The aim of this study was to analyze which resting energy expenditure (REE) predictive equation was the best alternative to indirect calorimetry in adult patients.

Methods: Predictive equations were included when based on weight, height, gender and/or age. REE was measured with indirect calorimetry. The mean squared prediction error was used to evaluate how well the equations fitted the REE measurement.

Results: Eighteen predictive equations were included. Indirect calorimetry data were available for 48 outpatients and 45 inpatients. Also a subgroup of 42 underweight patients (BMI<18.5) was analyzed. The mean squared prediction error was 233-426 kcal/d and the percentage of patients with acceptable prediction was 28-52% for adult patients depending on the equation used. The FAO/WHO/UNU (1985) equation including both weight and height had the smallest prediction error in adult patients (233 kcal/d), outpatients (182 kcal/d), inpatients (277 kcal/d) as well as underweight patients (219 kcal/d).

Conclusions: The REE of adult outpatients, inpatients and underweight patients can best be estimated with the FAO/WHO/UNU equation including weight and height, when indirect calorimetry is not available.
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http://dx.doi.org/10.1016/j.clnu.2007.09.001DOI Listing
February 2008
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