Why it's important to maintain protein intake and muscle mass for your elderly oncology residents

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Jessica A. Iannotta, Savor Health
Jessica A. Iannotta, Savor Health

It's well known that cancer patients are prone to losing weight during their treatment, but many people may not realize how weight loss that occurs prior to diagnosis can have a major impact on response to treatment.

Up to 40% of cancer patients experience anorexia and weight loss prior to their cancer diagnosis, and 40% to 80% of patients experience malnutrition during cancer treatment.1 Even a weight loss of just 6% is associated with negative outcomes, including reduced response to treatment, survival and quality of life (QoL) 1 — and these factors all contribute to increased healthcare costs in a variety of direct and indirect ways.

The most vulnerable among these startling statistics is the elderly population, which has a higher risk of negative outcomes as they simultaneously experience the complications of aging while dealing with their diagnosis.

For those living in long-term care facilities, there are specific risks associated with weight loss and aging that caretakers should be aware of. One of the more profound effects of aging is sarcopenia, which is defined as the loss of muscle mass and physical function that occurs with advancing age.2

Researchers debate as to exactly what age this occurs — some studies note a loss of 1% to 2% percent of lean body mass (LBM) after the age of 50.2 Other studies show sarcopenia could start anywhere between the ages of 40 and 80, with a loss of up to 50% of LBM.4

Beyond its effect on the individual, sarcopenia has also been linked to reduced response to oncology treatment, survival and QoL, as well as increased length of hospital stay, readmission rates and healthcare costs. 1,2,3

Defining sarcopenia

Loss of LBM is a direct result of atrophy and shrinkage of muscle fibers with aging. 2 The rate of muscle loss will vary depending on factors including diet, lifestyle and comorbidities. Individuals diagnosed with cancer are at risk for loss of LBM due to the disease itself and side effects of treatment.

Often, calorie and protein requirements are elevated during treatment, but many people struggle to meet these needs due to side effects of treatment.1 In the elderly oncology population, sarcopenia is considered an independent risk factor for loss of independence, immobility and mortality.1 The combined effects of aging, disease, and cancer treatment put this population at high risk for sarcopenia and its complications.   

Nutrition for sarcopenia

During and after cancer treatment, protein is essential for many functions including maintaining muscle mass and providing the building blocks for replenishing blood cells.

Research supports that intake of adequate dietary protein is an effective intervention to preserve LBM.5 Daily protein needs may range between 0.8-2.0 grams of protein per kilogram body.1 Those who eat high quality protein frequently, which is considered two to three meals per day each containing 25-30g high quality protein, maintain more LBM.4 High quality proteins contain all essential amino acids and are highly digestible and bioavailable.4 Other interventions that may help improve nutritional status include supplementation of amino acids, Vitamin D or Omega-3 fatty acids, and encouraging physical activity.3

Sarcopenia in healthcare

As mentioned, sarcopenia is associated with more than just implications for the individual patient. Sarcopenia has a broad scale impact on healthcare systems, such as increased costs, higher readmission rates, longer hospital lengths of stay, and poor QoL measures.3

Readmissions

Readmission rates are viewed as a measure of quality care and associated with increased costs due to need for additional services. More recently, a concern surrounding high readmission rates is the reduced reimbursement from Medicare and Medicaid services.

Sarcopenic patients have higher admission and readmission rates. A comprehensive overview pooling results from six studies showed that elderly oncology patients with poor nutrition status had significantly higher rates of hospital admission and readmission in five of the six studies.3 Readmission rates were 40% higher (as high as 53%) in patients who lost over 20% of their body weight, compared to patients who lost less than 20% body weight during treatment.3

A review of the 2013 Healthcare Cost and Utilization Project (HCUP) is consistent in its report of readmission rates up to 50% higher among patients diagnosed with any form of malnutrition.6 When assessing types of malnutrition, individuals with protein-calorie malnutrition accounted for the largest number of readmissions.6

Length of stay

Those with sarcopenia and poor nutrition status are likely to have a longer LOS in a healthcare facility. In a review of 11 research studies, 10 studies conclusively associated poor nutrition status — including LBM loss — with longer LOS. Average LOS is often up to five days longer for those with poor nutrition.3 Longer LOS directly incurs healthcare costs. Interventions such as malnutrition screening and dietitian intervention can improve LOS in the elderly oncology population.3

Quality of life

Quality of life (QoL) is another factor that is directly connected to sarcopenia in the elderly oncology population. One study showed patients who lost less than 10% of their body weight since their cancer diagnosis had a significantly higher QoL score than those who had lost more than 10% of their body weight.3 It has been shown that early and impactful nutrition intervention will likely improve QoL within this group.7

Overall, the clinical implications of sarcopenia go far beyond the individual. Elderly oncology patients with sarcopenia have more readmissions, longer LOS and poorer QoL.

All of these factors directly or indirectly increase costs. Those with protein-calorie malnutrition incur the highest healthcare costs, which can be 775 to 111% higher than patients without diagnosed malnutrition.6 In order to make an impact, early and frequent nutritional assessment is vital to diagnosing, preventing and treating sarcopenia and protein-calorie malnutrition.

Long-term care dietitians should utilize validated screening tools to assess elderly oncology patients for sarcopenia and malnutrition upon admission. In addition to screening, staff dietitians can complete a comprehensive nutrition assessment, utilizing clinical information to form effective interventions.

Nutritional interventions also should include tips on how to meet daily protein needs along with practical recommendations to maintain weight and prevent malnutrition.

Jessica A. Iannotta is a registered dietitian and certified specialist in oncology nutrition and the COO of Savor Health — a scalable, evidence-based personalized nutrition and exercise technology platform. Susan Bratton (right), a former Wall Street banker who represented early and growth stage healthcare services and insurance companies, is the CEO and founder of Savor Health.

References:

1.   Leser, M., Ledesma, N., Bergerson, S., & Trujillo, E. (2013). Oncology nutrition for clinical practice. United States: Oncology Nutrition Dietetic Practice Group.

2.   Robinson, S., Reginster, J., Rizzoli, R., Shaw, S., Kanis, J., Bautmans, I., . . . Rueda, R. (2017). Does nutrition play a role in the prevention and management of sarcopenia? Clinical Nutrition. doi:10.1016/j.clnu.2017.08.016

3.   Evidence Analysis Library: NUTRITION STATUS AND OUTCOMES IN ADULT ONCOLOGY PATIENTS (2013). (2013). Retrieved March 26, 2018, from https://www.andeal.org/topic.cfm?menu=5291&cat=4957

4.   Lonnie, M., Hooker, E., Brunstrom, J., Corfe, B., Green, M., Watson, A., . . . Johnstone, A. (2018). Protein for Life: Review of Optimal Protein Intake, Sustainable Dietary Sources and the Effect on Appetite in Ageing Adults. Nutrients,10(3), 360. doi:10.3390/nu10030360

5.   Kim, J. E., O'Connor, L. E., Sands, L. P., Slebodnik, M. B., & Campbell, W. W. (2016). Effects of dietary protein intake on body composition changes after weight loss in older adults: A systematic review and meta-analysis. Nutrition Reviews,74(3), 210-224. doi:10.1093/nutrit/nuv065

6.   Fingar, K. R., Weiss, A. J., Barrett, M. L., Elixhauser, A., Steiner, C. A., Guenter, P., & Brown, M. H. (2016). All-cause readmissions following hospital stays for patients with malnutrition, 2013. Healthcare Cost and Utilization Project. Retrieved March 26, 2018.

7.   Nourissat, A., Vasson, M., Merrouche, Y., Bouteloup, C., Goutte, M., Mille, D., . . . Chauvin, F. (2008). Relationship between nutritional status and quality of life in patients with cancer. European Journal of Cancer,44(9), 1238-1242. doi:10.1016/j.ejca.2008.04.006

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