Appetite Assessment of Hospitalized Cancer Patients in Brazil – A Validation Study

Gislaine Aparecida Ozório Maria Manuela Ferreira Alves de Almeida Sheilla de Oliveira Faria Thais de Campos Cardenas Dan Linetzky Waitzberg About the authors

Abstract

OBJECTIVES:

Appetite loss, a common symptom in cancer patients, contributes to worsened nutritional status. A validated specific tool to assess appetite is clinically useful for diagnosing and identifying symptoms and signs that could be reversed with nutritional and pharmacological therapies. The aim of this study is to produce a Brazilian Portuguese version of the Hill and Blundell visual analog scale (VAS) for appetite and investigate its validity among hospitalized cancer patients.

METHODS:

The original English VAS version was translated into Brazilian Portuguese in full accordance with the guidelines in the literature and adapted to the Brazilian context by conducting interviews and meetings with an expert committee until the final version was reached. Afterwards, the version was validated in hospitalized cancer patients in a cross-sectional study at São Paulo Cancer Institute (ICESP), where the relationships between breakfast intake (rest-ingestion index) and VAS were compared. The Spearman test was used to verify the correlation between the rest-ingestion index and the VAS ratings.

RESULTS:

Sixty-four patients with a mean age of 56.1 (±12.3) years answered the Portuguese VAS version, and their breakfast intake was evaluated. The mean rest-ingestion index was 18.8%. The correlations between the rest-ingestion index (food acceptance) and three questions of the Portuguese visual analog scale version were inverse and significant: first question (ρ -0.3028 p=0.0046), second question (ρ -0.2317 p=0.0319) and third question (ρ -0.3049 p=0.0043).

CONCLUSION:

The “Appetite Assessment Scale of Brazilian Oncology Patients” is a valid instrument to assess appetite in hospitalized cancer patients in Brazil.

Cancer; Appetite; Malnutrition; Visual Analog Scale


INTRODUCTION

Loss of appetite is common in cancer patients and can occur, among other factors, due to changes in the central nervous system and peripheral neurohormonal signs that govern appetite (11. Fearon KC, Voss AC, Hustead DS; Cancer Cachexia Study Group. Definition of cancer cachexia: effect of weight loss, reduced food intake, and systemic inflammation on functional status and prognosis. Am J Clin Nutr. 2006;83(6):1345-50. https://doi.org/10.1093/ajcn/83.6.1345.
https://doi.org/10.1093/ajcn/83.6.1345...
,22. Blum D, Omlin A, Baracos VE, Solheim TS, Tan BH, Stone P, et al. Cancer cachexia: a systematic literature review of items and domains associated with involuntary weight loss in cancer. Crit Rev Oncol Hematol. 2011;80(1):114-44. https://doi.org/10.1016/j.critrevonc.2010.10.004.
https://doi.org/10.1016/j.critrevonc.201...
).

The incidence rates in patients with advanced cancer can range from 39.0% to 81.5% for weight loss and 30.0% to 80.0% for anorexia (33. Vainio A, Auvinen A. Prevalence of symptoms among patients with advanced cancer: an international collaborative study. Symptom Prevalence Group. J Pain Symptom Manage. 1996;12(1):3-10. https://doi.org/10.1016/0885-3924(96)00042-5.
https://doi.org/10.1016/0885-3924(96)000...
). Lack of appetite was reported by 80.0% of patients in palliative care (44. Andrew IM, Waterfield K, Hildreth AJ, Kirkpatrick G, Hawkins C. Quantifying the impact of standardized assessment and symptom management tools on symptoms associated with cancer-induced anorexia cachexia syndrome. Palliat Med. 2009;23(8):680-8. https://doi.org/10.1177/0269216309106980.
https://doi.org/10.1177/0269216309106980...
). This broad variation reflects conditioning factors such as distinct assessment patterns, selection of different clinical populations (stages of cancer) and inconsistent methodologies including retrospective analysis of medical records, cross-sectional assessments and longitudinal designs.

There is an association between lack of appetite and radiotherapy. In patients with head and neck cancer, the amount of irradiation was related to the worsening of appetite. At 20 Gy of radiation, a lack of appetite was associated with lower sensitivity to taste. With a higher frequency (50 Gy), lack of appetite was associated with oral mucositis, dry mouth, low saliva production in the morning, reduction in taste sensitivity, analgesic use and frequency of oral care (55. Ogama N, Suzuki S, Umeshita K, Kobayashi T, Kaneko S, Kato S, et al. Appetite and adverse effects associated with radiation therapy in patients with head and neck cancer. Eur J Oncol Nurs. 2010;14(1):3-10. https://doi.org/10.1016/j.ejon.2009.07.004.
https://doi.org/10.1016/j.ejon.2009.07.0...
).

Loss of appetite was present in 64.0% of patients with gastroesophageal cancer. The highest intensity of appetite loss was associated with tumor size, staging, the impossibility of surgical treatment, weight loss, and dysphagia (66. McKernan B, Bydder S, Ebert M, Waterhouse D, Joseph D. A simple and inexpensive method to routinely produce customized neck supports for patient immobilization during radiotherapy. J Med Imaging Radiat Oncol. 2008;52(6):611-6. https://doi.org/10.1111/j.1440-1673.2008.02024.x.
https://doi.org/10.1111/j.1440-1673.2008...
). Similarly, in esophageal cancer patients, there is an association between loss of appetite and worse survival rates (77. Blazeby JM, Williams MH, Alderson D, Farndon JR. Observer variation in assessment of quality of life in patients with oesophageal cancer. Br J Surg. 1995;82(9):1200-3. https://doi.org/10.1002/bjs.1800820916.
https://doi.org/10.1002/bjs.1800820916...
,88. Fang FM, Tsai WL, Chiu HC, Kuo WR, Hsiung CY. Quality of life as a survival predictor for esophageal squamous cell carcinoma treated with radiotherapy. Int J Radiat Oncol Biol Phys. 2004;58(5):1394-404. https://doi.org/10.1016/j.ijrobp.2003.09.100.
https://doi.org/10.1016/j.ijrobp.2003.09...
).

Difficulties in the diagnosis of anorexia and the identification of anorexia-cachexia syndrome (SAC) lead to detrimental consequences for patients’ nutritional status (99. Davis MP, Dreicer R, Walsh D, Lagman R, LeGrand SB. Appetite and cancer-associated anorexia: a review. J Clin Oncol. 2004;22(8):1510-7. https://doi.org/10.1200/JCO.2004.03.103.
https://doi.org/10.1200/JCO.2004.03.103...
). SAC is characterized by weight loss (5.0% or greater) and inflammatory and metabolic abnormalities that include changes in the intermediary metabolism of carbohydrates, lipids and proteins (1010. Argilés JM, Olivan M, Busquets S, López-Soriano FJ. Optimal management of cancer anorexia-cachexia syndrome. Cancer Manag Res. 2010;2:27-38. https://doi.org/10.2147/CMAR.S7101.
https://doi.org/10.2147/CMAR.S7101...
).

Due to the high prevalence of appetite loss in cancer patients, it is of interest to have a specific tool to assess appetite and diagnose and identify the symptoms and signs that can be reversed with nutritional and pharmacological therapeutic strategies. The proper detection of appetite loss helps in the early indication of specific dietary and pharmacological measures (1111. Loprinzi CL, Ravdin PM, de Laurentiis M, Novotny P. Do American oncologists know how to use prognostic variables for patients with newly diagnosed primary breast cancer? J Clin Oncol. 1994;12(7):1422-6. https://doi.org/10.1200/JCO.1994.12.7.1422.
https://doi.org/10.1200/JCO.1994.12.7.14...
). However, the measurement of appetite is challenging because it is subjective and experienced differently by each individual.

In clinical studies, appetite is often assessed using visual analog scales (VASs), which record subjective sensations, such as hunger and fullness. The use of VASs has been particularly popular for the assessment of pain and appetite (1212. Stubbs RJ, Hughes DA, Johnstone AM, Rowley E, Reid C, Elia M, et al. The use of visual analogue scales to assess motivation to eat in human subjects: a review of their reliability and validity with an evaluation of new hand-held computerized systems for temporal tracking of appetite ratings. Br J Nutr. 2000;84(4):405-15. https://doi.org/10.1017/S0007114500001719.
https://doi.org/10.1017/S000711450000171...
).

According to studies that have evaluated appetite, VASs are sensitive to several types of experimental manipulations, including changes in diet composition (1313. de Castro JM, Elmore DK. Subjective hunger relationships with meal patterns in the spontaneous feeding behavior of humans: evidence for a causal connection. Physiol Behav. 1988;43(2):159-65. https://doi.org/10.1016/0031-9384(88)90232-6.
https://doi.org/10.1016/0031-9384(88)902...
,1414. Stubbs RJ, van Wyk MC, Johnstone AM, Harbron CG. Breakfasts high in protein, fat or carbohydrate: effect on within-day appetite and energy balance. Eur J Clin Nutr. 1996;50(7):409-17.), changes in energy intake (1515. de Graaf C. The validity of appetite ratings. Appetite. 1993;21(2):156-60. https://doi.org/10.1016/0195-6663(93)90008-8.
https://doi.org/10.1016/0195-6663(93)900...
) and administration of drugs that stimulate or inhibit appetite (1616. Woods CA, Cumming B. The impact of test medium on use of visual analogue scales. Eye Contact Lens. 2009;35(1):6-10. https://doi.org/10.1097/ICL.0b013e3181909b03.
https://doi.org/10.1097/ICL.0b013e318190...
17. Almiron-Roig E, Green H, Virgili R, Aeschlimann JM, Moser M, Erkner A. Validation of a new hand-held electronic appetite rating system against the pen and paper method. Appetite. 2009;53(3):465-8. https://doi.org/10.1016/j.appet.2009.09.014.
https://doi.org/10.1016/j.appet.2009.09....
18. Das SK, Gilhooly CH, Golden JK, Pittas AG, Fuss PJ, Dallal GE, et al. Long Term Effects of Energy-Restricted Diets Differing in Glycemic Load on Metabolic Adaptation and Body Composition. Open Nutr J. 2007;85(4):1023-30. 19. Barkeling B, Rössner S, Sjöberg A. Methodological studies on single meal food intake characteristics in normal weight and obese men and women. Int J Obes Relat Metab Disord. 1995;19(4):284-90. 20. Nematy M, O’Flynn JE, Wandrag L, Brynes AE, Brett SJ, Patterson M, et al. Changes in appetite related gut hormones in intensive care unit patients: a pilot cohort study. Crit Care. 2006;10(1):R10. https://doi.org/doi:10.1186/cc3957.
https://doi.org/doi:10.1186/cc3957...
21. Stratton RJ, Stubbs RJ, Elia M. Short-term continuous enteral tube feeding schedules did not suppress appetite and food intake in healthy men in a placebo-controlled trial. J Nutr. 2003;133(8):2570-6. https://doi.org/10.1093/jn/133.8.2570.
https://doi.org/10.1093/jn/133.8.2570...
).

In Brazil, there are no records of validated scales for the evaluation of appetite among cancer patients. A widely used validated version is beneficial for conducting clinical and epidemiological research on this topic and for use in clinical practice. Thus, this study was performed with the objective of producing a Brazilian Portuguese version of the Hill and Blundell VAS for the assessment of appetite and to investigate its validity.

METHODS

This study was conducted at São Paulo Cancer Institute (ICESP) in Brazil from January to September 2013. The project was approved by the Research Ethics Committee of the Faculty of Medicine of São Paulo University (CEP-FMUSP) (protocol n° 6639).

The present study consisted of two parts: translation and validation.

The VAS developed by Hill & Blundell (1982) was chosen because it is a nonextensive scale, easy to understand, complete and used/validated in other languages (1212. Stubbs RJ, Hughes DA, Johnstone AM, Rowley E, Reid C, Elia M, et al. The use of visual analogue scales to assess motivation to eat in human subjects: a review of their reliability and validity with an evaluation of new hand-held computerized systems for temporal tracking of appetite ratings. Br J Nutr. 2000;84(4):405-15. https://doi.org/10.1017/S0007114500001719.
https://doi.org/10.1017/S000711450000171...
,1414. Stubbs RJ, van Wyk MC, Johnstone AM, Harbron CG. Breakfasts high in protein, fat or carbohydrate: effect on within-day appetite and energy balance. Eur J Clin Nutr. 1996;50(7):409-17.,). It is a VAS with five questions. On each 100-mm line, an appetite sensation is paired with the opposing sensation (for example, ‘hungry’ and ‘not hungry’).

Translation

Four independent translators (native Brazilians), including three health professionals (nutritionists) and one English teacher, translated the VAS from English into Brazilian Portuguese. A synthesis of the translations was agreed upon by consensus between translators (V1). Eleven participants were interviewed to verify their comprehension of V1. Those patients completed the scale with assistance: questions were read aloud by the interviewer. Participants were asked about their understanding of the scale and were invited to offer suggestions that could clarify its meaning. An expert committee reviewed all of the reports and reached consensus on a new version (V2).

Four independent native English speakers who fluently speak Brazilian Portuguese created a back translation into English. The translators were blinded to the original version. The back translations were synthesized by consensus between translators (V3) and were compared with the original version of the scale to verify the reliability. The main authors (Hill and Blundell) examined this combined version and gave consent for its use.

Finally, based on the consensus of the researchers and a multiprofessional nutritional therapy team from ICESP, the final version in Brazilian Portuguese was created (Version 4 - Appetite Assessment Scale of Brazilian Oncology Patients “EAA-BR”-“Escala Avaliação Apetite em Pacientes Oncológicos Brasileiros”) (Figure 1).

Figure 1
(a) Original visual analog scale; (b) Appetite Assessment Scale of Brazilian Oncology Patients “EAA-BR”.

Validation of the EAA-BR

To perform the validation of the EAA-BR, a preliminary cross-sectional study was performed in clinically and surgically hospitalized patients from August to September 2013. The inclusion criteria were 18 years of age or older, conscious and guided state according to the nursing team (Glasgow 15, Richmond Agitation-Sedation Scale (RASS) 0 and negative Confusion Assessment Method (CAM)), consumption of an exclusively oral diet (normal or soft) and ability to provide meaningful informed consent.

Exclusion criteria were the use of enteral or parenteral nutrition, reduced level of consciousness or severe psychiatric illness, aerosol or contact isolations, inability to perceive taste after partial or total glossectomy, presence of brain tumor or cranial trauma, severe pain that could interfere with food intake, dysphagia and inability to understand the questions of the VAS.

Data on age, sex, oncological diagnosis, reason and length of hospital stay, body mass index (BMI) and presence of weight loss ≥5% in the last 3 months (prior to admission) were collected from the electronic medical chart. The use of corticosteroids within two days prior to the interview date was verified.

Nutritional Risk Screening - 2002 (NRS-2002) (2222. Kondrup J, Rasmussen HH, Hamberg O, Stanga Z; Ad Hoc ESPEN Working Group. Nutritional risk screening (NRS 2002): a new method based on an analysis of controlled clinical trials. Clin Nutr. 2003;22(3):321-36. https://doi.org/10.1016/S0261-5614(02)00214-5.
https://doi.org/10.1016/S0261-5614(02)00...
) and Global Subjective Assessment (ASG) (2323. Detsky AS, McLaughlin JR, Baker JP, Johnston N, Whittaker S, Mendelson RA, et al. What is subjective global assessment of nutritional status? JPEN J Parenter Enteral Nutr. 1987;11(1):8-13. https://doi.org/10.1177/014860718701100108.
https://doi.org/10.1177/0148607187011001...
) were used to assess nutritional risk and nutritional status, respectively. BMI was classified according to the World Health Organization proposal (2424. WHO. World Health Organization. Obesity: Preventing and Managing the Global Epidemic: Report of the WHO Consultation of Obesity. Geneva: World Health Organization, 1997.) for individuals aged up to 60 years and according to the Pan American Health Organization (2525. OPAS. Organizaçao ao Pan-Americana. Informe preliminar da 36a Reunion del Comite Asesor de Investigacionesem Salud - Encuesta Multicentrica - Salud Bienestar Envejecimento (SABE) em America Latina y el Caribe, 2001.) for individuals aged 60 years and over.

To validate the EAA-BR, it was compared in relation to the amount of food effectively ingested by the patient during breakfast. The application of the appetite scale (EAA-BR) was performed before the meal, and the total amount of food consumed at the test meal was measured by weighing food items before and after eating to the nearest 1 g (Dayhome®, Sao Paulo, SP). The rest-ingestion index was calculated according to the following formula: rest-ingestion index (%) = (quantity rejected (g) / quantity offered (g)) x 100 (2626. Ferreira D, Guimarães TG, Marcadenti A. [Acceptance of hospital diets and nutritional status among inpatients with cancer]. Einstein. 2013;11(1):41-6. https://doi.org/10.1590/S1679-45082013000100008.
https://doi.org/10.1590/S1679-4508201300...
).

For descriptive analysis, quantitative variables were presented as the mean and standard deviation. The Shapiro-Wilk test was used to assess normality. For the variables that were not normally distributed, the Spearman test was used to verify the correlation between the rest-ingestion index and the EAA-BR ratings. Significance was accepted at the level of p<0.05. Those older than 60 years were considered elderly.

RESULTS

Sixty-four patients were evaluated. The mean age was 56.1 (±12.3) years; 52.3% were females. Gynecological cancer (29.7%) was the most prevalent, followed by malignant gastrointestinal tumors (21.9%) and urological tumors (21.9%). The majority (88.4%) either received or were receiving some type of cancer treatment during data collection (Table 1).

Table 1
Sociodemographic and clinical characteristics of the study sample.

The use of corticosteroids was present in 31.3% of patients. One-fourth of the patients (25.6%) had significant weight loss (≥5%) in the last 3 months prior to admission. Cancer treatment was the main reason for hospital admission, with surgical reasons being the most prevalent (80.7%). The second reason for hospitalization was related to the presence of symptoms, including headache, dyspnea, paresthesia, nausea, vomiting, hyperkalemia, diarrhea, weakness, vaginal bleeding, hypoxemia/hemoptysis, mental confusion, dizziness, among others. The mean hospital stay until the interview was 5.7±6.5 days, with a total hospitalization time of 11.2±11.5 days (Table 1).

The mean BMI was 26.6±7.0 kg/m2, and 51.6% were classified as eutrophic (Table 2).

Table 2
Nutritional characteristics of the patients.

The mean rest-ingestion index was 18.8%. Among the patients who consumed less than 50% of the food offered, the most reported reasons for not accepting were lack of appetite (17%), nausea/vomiting (15%) and amount of food offered (15%).

The correlation between the rest-ingestion index and food acceptance was inverse and significant for three questions: the first question (ρ -0.3028 p=0.0046), the second question (ρ -0.2317 p=0.0319) and the third question (ρ -0.3049 p=0.0043) (Table 3).

Table 3
Correlation between EAA-BR scores and rest-ingestion index of patients.

DISCUSSION

There were no validated questionnaires for the assessment of appetite in Brazilian Portuguese. This study demonstrated that the EAA-BR is a valid and acceptable measure for assessing appetite in Brazilian cancer patients.

The rest-intake index revealed different results from those of the study by Ferreira et al. (2626. Ferreira D, Guimarães TG, Marcadenti A. [Acceptance of hospital diets and nutritional status among inpatients with cancer]. Einstein. 2013;11(1):41-6. https://doi.org/10.1590/S1679-45082013000100008.
https://doi.org/10.1590/S1679-4508201300...
). According to these authors, the rest-lunch intake index was 37.0% and significantly higher among the undernourished patients, as detected by the Subjective Global Assessment (PG-SGA) (p=0.004). A likely explanation is that, at breakfast, patients have greater food acceptance because of night fasting. In addition, breakfast foods, in general, do not produce odors, which could cause nausea (2626. Ferreira D, Guimarães TG, Marcadenti A. [Acceptance of hospital diets and nutritional status among inpatients with cancer]. Einstein. 2013;11(1):41-6. https://doi.org/10.1590/S1679-45082013000100008.
https://doi.org/10.1590/S1679-4508201300...
).

As reported by Ferreira et al., an excessive amount of food offered was one of the reasons for not accepting the meal (2626. Ferreira D, Guimarães TG, Marcadenti A. [Acceptance of hospital diets and nutritional status among inpatients with cancer]. Einstein. 2013;11(1):41-6. https://doi.org/10.1590/S1679-45082013000100008.
https://doi.org/10.1590/S1679-4508201300...
). In addition, they described lack of appetite (26%), lack of flavor (40.0%) and monotony of preparations (33.0%) as reasons for not accepting the diet. Decreased food intake may also occur due to changes in general habits, hospital environment and dissatisfaction with dietary preparations. Food offered in hospitals is commonly judged as insipid, tasteless, cold, and served early. Patients hospitalized at ICESP (unpublished data) routinely evaluate the quality of the meals offered as excellent in terms of temperature, flavor and mealtime. This result was obtained from quality questionnaires regarding the service itself.

Flint et al. (2727. Flint A, Raben A, Blundell JE, Astrup A. Reproducibility, power and validity of visual analogue scales in assessment of appetite sensations in single test meal studies. Int J Obes Relat Metab Disord. 2000;24(1):38-48. https://doi.org/10.1038/sj.ijo.0801083.
https://doi.org/10.1038/sj.ijo.0801083...
) evaluated the reproducibility, power and validity of the Blundell VAS (1982). As in our study, they compared the VAS score against single meal intake. All VAS questions were correlated with subsequent energy intake, which is partially in agreement with our observations. In our study, there was a negative correlation between the three questions of the EAA-BR and subsequent food consumption, that is, the lower the appetite, the greater the rest-ingestion index.

The scores of two questions (“How thirst do you feel?” and “How full do you feel?”) did not show a significant association with food acceptance or the rest-ingestion index. A possible explanation for our findings is that some patients reported drinking water prior to completing the questionnaire, which could have influenced their perception of thirst and difficulty in understanding the question “How full do you feel?”, which may have influenced patients’ response to the question. This paper had some limitations. First, only a small number of patients were evaluated. Second, the measure of rest-ingestion from only one daily meal (breakfast) can be considered as a bias and should be repeated with lunch and dinner.

It is of interest to carry out new studies with a greater number of patients and applying the EAA-BR to other meals and on subsequent days.

The EAA-BR appears to be sensitive for the assessment of appetite, presenting a significant correlation between questions about the food cravings, hunger, and prospective food consumption and dietary intake of cancer patients. The EAA-BR can be used routinely by health professionals for the quick and effective identification of the level of appetite of patients.

CONCLUSION

The culturally adapted version of Blundel’s original English tool (1982) in Brazilian Portuguese (EAA-BR) demonstrated good validity compared with rest-ingestion measures when applied to cancer patients. This questionnaire could be a useful tool for evaluating appetite in Brazilian cancer patients in future studies.

REFERENCES

  • 1
    Fearon KC, Voss AC, Hustead DS; Cancer Cachexia Study Group. Definition of cancer cachexia: effect of weight loss, reduced food intake, and systemic inflammation on functional status and prognosis. Am J Clin Nutr. 2006;83(6):1345-50. https://doi.org/10.1093/ajcn/83.6.1345
    » https://doi.org/doi:10.1093/ajcn/83.6.1345
  • 2
    Blum D, Omlin A, Baracos VE, Solheim TS, Tan BH, Stone P, et al. Cancer cachexia: a systematic literature review of items and domains associated with involuntary weight loss in cancer. Crit Rev Oncol Hematol. 2011;80(1):114-44. https://doi.org/10.1016/j.critrevonc.2010.10.004
    » https://doi.org/doi:10.1016/j.critrevonc.2010.10.004
  • 3
    Vainio A, Auvinen A. Prevalence of symptoms among patients with advanced cancer: an international collaborative study. Symptom Prevalence Group. J Pain Symptom Manage. 1996;12(1):3-10. https://doi.org/10.1016/0885-3924(96)00042-5
    » https://doi.org/doi:10.1016/0885-3924(96)00042-5
  • 4
    Andrew IM, Waterfield K, Hildreth AJ, Kirkpatrick G, Hawkins C. Quantifying the impact of standardized assessment and symptom management tools on symptoms associated with cancer-induced anorexia cachexia syndrome. Palliat Med. 2009;23(8):680-8. https://doi.org/10.1177/0269216309106980
    » https://doi.org/doi:10.1177/0269216309106980
  • 5
    Ogama N, Suzuki S, Umeshita K, Kobayashi T, Kaneko S, Kato S, et al. Appetite and adverse effects associated with radiation therapy in patients with head and neck cancer. Eur J Oncol Nurs. 2010;14(1):3-10. https://doi.org/10.1016/j.ejon.2009.07.004
    » https://doi.org/doi:10.1016/j.ejon.2009.07.004
  • 6
    McKernan B, Bydder S, Ebert M, Waterhouse D, Joseph D. A simple and inexpensive method to routinely produce customized neck supports for patient immobilization during radiotherapy. J Med Imaging Radiat Oncol. 2008;52(6):611-6. https://doi.org/10.1111/j.1440-1673.2008.02024.x
    » https://doi.org/doi:10.1111/j.1440-1673.2008.02024.x
  • 7
    Blazeby JM, Williams MH, Alderson D, Farndon JR. Observer variation in assessment of quality of life in patients with oesophageal cancer. Br J Surg. 1995;82(9):1200-3. https://doi.org/10.1002/bjs.1800820916
    » https://doi.org/doi:10.1002/bjs.1800820916
  • 8
    Fang FM, Tsai WL, Chiu HC, Kuo WR, Hsiung CY. Quality of life as a survival predictor for esophageal squamous cell carcinoma treated with radiotherapy. Int J Radiat Oncol Biol Phys. 2004;58(5):1394-404. https://doi.org/10.1016/j.ijrobp.2003.09.100
    » https://doi.org/doi:10.1016/j.ijrobp.2003.09.100
  • 9
    Davis MP, Dreicer R, Walsh D, Lagman R, LeGrand SB. Appetite and cancer-associated anorexia: a review. J Clin Oncol. 2004;22(8):1510-7. https://doi.org/10.1200/JCO.2004.03.103
    » https://doi.org/doi:10.1200/JCO.2004.03.103
  • 10
    Argilés JM, Olivan M, Busquets S, López-Soriano FJ. Optimal management of cancer anorexia-cachexia syndrome. Cancer Manag Res. 2010;2:27-38. https://doi.org/10.2147/CMAR.S7101
    » https://doi.org/doi:10.2147/CMAR.S7101
  • 11
    Loprinzi CL, Ravdin PM, de Laurentiis M, Novotny P. Do American oncologists know how to use prognostic variables for patients with newly diagnosed primary breast cancer? J Clin Oncol. 1994;12(7):1422-6. https://doi.org/10.1200/JCO.1994.12.7.1422
    » https://doi.org/doi:10.1200/JCO.1994.12.7.1422
  • 12
    Stubbs RJ, Hughes DA, Johnstone AM, Rowley E, Reid C, Elia M, et al. The use of visual analogue scales to assess motivation to eat in human subjects: a review of their reliability and validity with an evaluation of new hand-held computerized systems for temporal tracking of appetite ratings. Br J Nutr. 2000;84(4):405-15. https://doi.org/10.1017/S0007114500001719
    » https://doi.org/doi:10.1017/S0007114500001719
  • 13
    de Castro JM, Elmore DK. Subjective hunger relationships with meal patterns in the spontaneous feeding behavior of humans: evidence for a causal connection. Physiol Behav. 1988;43(2):159-65. https://doi.org/10.1016/0031-9384(88)90232-6
    » https://doi.org/doi:10.1016/0031-9384(88)90232-6
  • 14
    Stubbs RJ, van Wyk MC, Johnstone AM, Harbron CG. Breakfasts high in protein, fat or carbohydrate: effect on within-day appetite and energy balance. Eur J Clin Nutr. 1996;50(7):409-17.
  • 15
    de Graaf C. The validity of appetite ratings. Appetite. 1993;21(2):156-60. https://doi.org/10.1016/0195-6663(93)90008-8
    » https://doi.org/doi:10.1016/0195-6663(93)90008-8
  • 16
    Woods CA, Cumming B. The impact of test medium on use of visual analogue scales. Eye Contact Lens. 2009;35(1):6-10. https://doi.org/10.1097/ICL.0b013e3181909b03
    » https://doi.org/doi:10.1097/ICL.0b013e3181909b03
  • 17
    Almiron-Roig E, Green H, Virgili R, Aeschlimann JM, Moser M, Erkner A. Validation of a new hand-held electronic appetite rating system against the pen and paper method. Appetite. 2009;53(3):465-8. https://doi.org/10.1016/j.appet.2009.09.014
    » https://doi.org/doi:10.1016/j.appet.2009.09.014
  • 18
    Das SK, Gilhooly CH, Golden JK, Pittas AG, Fuss PJ, Dallal GE, et al. Long Term Effects of Energy-Restricted Diets Differing in Glycemic Load on Metabolic Adaptation and Body Composition. Open Nutr J. 2007;85(4):1023-30.
  • 19
    Barkeling B, Rössner S, Sjöberg A. Methodological studies on single meal food intake characteristics in normal weight and obese men and women. Int J Obes Relat Metab Disord. 1995;19(4):284-90.
  • 20
    Nematy M, O’Flynn JE, Wandrag L, Brynes AE, Brett SJ, Patterson M, et al. Changes in appetite related gut hormones in intensive care unit patients: a pilot cohort study. Crit Care. 2006;10(1):R10. https://doi.org/doi:10.1186/cc3957
    » https://doi.org/doi:10.1186/cc3957
  • 21
    Stratton RJ, Stubbs RJ, Elia M. Short-term continuous enteral tube feeding schedules did not suppress appetite and food intake in healthy men in a placebo-controlled trial. J Nutr. 2003;133(8):2570-6. https://doi.org/10.1093/jn/133.8.2570
    » https://doi.org/doi:10.1093/jn/133.8.2570
  • 22
    Kondrup J, Rasmussen HH, Hamberg O, Stanga Z; Ad Hoc ESPEN Working Group. Nutritional risk screening (NRS 2002): a new method based on an analysis of controlled clinical trials. Clin Nutr. 2003;22(3):321-36. https://doi.org/10.1016/S0261-5614(02)00214-5
    » https://doi.org/doi:10.1016/S0261-5614(02)00214-5
  • 23
    Detsky AS, McLaughlin JR, Baker JP, Johnston N, Whittaker S, Mendelson RA, et al. What is subjective global assessment of nutritional status? JPEN J Parenter Enteral Nutr. 1987;11(1):8-13. https://doi.org/10.1177/014860718701100108
    » https://doi.org/doi:10.1177/014860718701100108
  • 24
    WHO. World Health Organization. Obesity: Preventing and Managing the Global Epidemic: Report of the WHO Consultation of Obesity. Geneva: World Health Organization, 1997.
  • 25
    OPAS. Organizaçao ao Pan-Americana. Informe preliminar da 36a Reunion del Comite Asesor de Investigacionesem Salud - Encuesta Multicentrica - Salud Bienestar Envejecimento (SABE) em America Latina y el Caribe, 2001.
  • 26
    Ferreira D, Guimarães TG, Marcadenti A. [Acceptance of hospital diets and nutritional status among inpatients with cancer]. Einstein. 2013;11(1):41-6. https://doi.org/10.1590/S1679-45082013000100008
    » https://doi.org/doi:10.1590/S1679-45082013000100008
  • 27
    Flint A, Raben A, Blundell JE, Astrup A. Reproducibility, power and validity of visual analogue scales in assessment of appetite sensations in single test meal studies. Int J Obes Relat Metab Disord. 2000;24(1):38-48. https://doi.org/10.1038/sj.ijo.0801083
    » https://doi.org/doi:10.1038/sj.ijo.0801083

Publication Dates

  • Publication in this collection
    14 Oct 2019
  • Date of issue
    2019

History

  • Received
    14 Mar 2019
  • Accepted
    21 July 2019
Creative Common - by 4.0
This is an Open Access article distributed under the terms of the Creative Commons License (https://creativecommons.org/licenses/by/4.0/) which permits unrestricted use, distribution, and reproduction in any medium or format, provided the original work is properly cited.
Faculdade de Medicina / USP Rua Dr Ovídio Pires de Campos, 225 - 6 and., 05403-010 São Paulo SP - Brazil, Tel.: (55 11) 2661-6235 - São Paulo - SP - Brazil
E-mail: clinics@hc.fm.usp.br