Reliability of nutritional assessment in patients with gastrointestinal tumors

Patients with gastrointestinal cancer and malnutrition are less likely to tolerate major surgical procedures, radiotherapy or chemotherapy. In general, they display a higher incidence of complications such as infection, dehiscence and sepsis, which increases the length of stay and risk of death, and reduces quality of life. The aim of this review is to discuss the pros and cons of different points of view to assess nutritional risk in patients with gastrointestinal tract (GIT) tumors and their viability, considering the current understanding and screening approaches in the field. A better combination of anthropometric, laboratory and subjective evaluations is needed in patients with GIT cancer, since malnutrition in these patients is usually much more severe than in those patients with tumors at sites other than the GIT.

Keywords:
Nutrition Assessment; Gastrointestinal Tract; Malnutrition; Prognosis; Morbidity.

Authorship

ALINE KIRJNER POZIOMYCK

- Programa de Pós-Graduação em Ciências Cirúrgicas, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul (UFRGS). Porto Alegre, RS, BrasilUniversidade Federal do Rio Grande do SulBrazilPorto Alegre, RS, Brazil- Programa de Pós-Graduação em Ciências Cirúrgicas, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul (UFRGS). Porto Alegre, RS, Brasil

ANA VALERIA GONÇALVES FRUCHTENICHT

GEORGIA BRUM KABKE

BERNARDO SILVEIRA VOLKWEIS

- Serviço de Cirurgia do Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS, BrasilHospital de Clínicas de Porto AlegreBrasilPorto Alegre, RS, Brasil- Serviço de Cirurgia do Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS, Brasil

JORGE LUIZ ANTONIAZZI

- Faculdade de Medicina, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brasil.Universidade Federal do Rio Grande do SulBrazilPorto Alegre, RS, Brazil- Faculdade de Medicina, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brasil.

LUIS FERNANDO MOREIRA

Endereço para correspondência: Luís Fernando Moreira E-mail: lufmoreira@hcpa.ufrgs.br

Conflito de interesse: nenhum.

SCIMAGO INSTITUTIONS RANKINGS

Tables

Tables (5)

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Table 1
Main objective and subjective methods used for nutritional assessment.

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Table 2
Advantages and disadvantages of subjective methods and nutritional assessment.

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Table 3
Advantages and disadvantages of anthropometric methods.

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Table 4
Advantages and disadvantages of laboratory methods.

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Table 5
Advantages and disadvantages of nutritional scores.

Table 1 Main objective and subjective methods used for nutritional assessment.

Objective
Anthropometrics	Body mass index, weight loss, skin-fold thickness and circumferences, adductor pollicis muscle thickness
Biochemical tests	Albumin, prealbumin, transferring, retinol-binding protein, nitrogen balance, creatinine-height index
Body composition	Bioelectrical impedance analysis
Functional tests	Hand grip strength, phase angle
Subjective	Subjective global assessment (SGA) and Patient-generated subjective global assessment (PG-SGA)

Table 2 Advantages and disadvantages of subjective methods and nutritional assessment.

Method	Advantage	Disadvantage
Subjective global assessment (SGA)	Simple Inexpensive Non-invasive Bedside use	Observer dependable Non-disease specific
Patient-generated subjective global assessment (PG-SGA)	Simple Inexpensive Non-invasive Bedside use Reproducible	Provides a good training for observers Unspecific to different types of cancer

Table 3 Advantages and disadvantages of anthropometric methods.

Method	Advantage	Disadvantage
Body Mass Index (BMI)	Simple Inexpensive Non-invasive Bedside use	Does not distinguish fat mass and lean mass Does not reflect body composition
Skinfold Thickness	Simple Inexpensive Non-invasive Bedside use	Database limited Insufficient correction factors (age, hydration status, physical activity, disease state) No standard for oncology
Bioimpedance	Simple Non-invasive Easy application / Shortly Accurate measurements	Requires several previous care (4h fasting, use of diuretics, exercise, alcohol intake)
Adductor Muscle Pollicis Thickness (APM) / Dinamometry	Simple Non-invasive Easy application/Shortly Accurate measurements	Does not evaluate the acute effects of cancer malnutrition Requires the evaluator training

Table 4 Advantages and disadvantages of laboratory methods.

Method	Advantage	Disadvantage
Albumin	Simple Inexpensive Independent indicator of survival in many cancers	Unreliable Affected by many factors and conditions Need better definition of baseline risk in cancer patients Reflects more on the severity of the disease than the nutritional status per se
C-Reactive Protein (CRP)	Independent prognostic indicator for some types of carcinoma Good correlation with other methods of nutritional assessment	Higher costs Alone is not cancer-specific
Pre-albumin	Sensitive stress level Good marker for visceral protein	Higher costs Non-disease specific Can be affected by non-nutritional factors (reduction in inflammation)
Retinol Binding Protein (RBP)	High sensitivity to protein and caloric restriction	Higher costs Few studies in cancer patients Potential confounder in vitamin A deficiency
Total Lymphocyte Count (TLC)	Associated with weight loss and visceral protein loss	May be affected by tumor type and use of chemotherapeutic drug

Table 5 Advantages and disadvantages of nutritional scores.

Method	Advantage	Disadvantage
Glasgow Prognostic Score (GPS)	Powerful method for diagnosis of nutritional status Long-term survival in some cancer surgery	Not assessed for short-term outcomes
Reilly Nutrition Risk Score	Mix of different approaches in nutritional methods	Adults and children in the same group Different types of cancer altogether
Prognostic nutritional index (PNI)	Good and accurate	Difficult to obtain the hypersensitivity skin tests
NUTRA*	Anthropometric, Subjective and Laboratory data targeting GIT cancer patients	Ongoing trial

*Developed by SSORG (Southern Surgical Oncology Research Group)

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Reliability of nutritional assessment in patients with gastrointestinal tumors

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[1] Endereço para correspondência: Luís Fernando Moreira E-mail: lufmoreira@hcpa.ufrgs.br