Assessment, Intervention, and Outcomes / Malnutrition Management in Oncology/ Balanced Nutritional Therapy is key to Onco Nutrition Management.
Cancer is a leading cause of morbidity and mortality, accounting for nearly 10 million deaths globally. The nutritional status of patients with cancer can vary at presentation and throughout the continuum of cancer care. Many patients experience unintentional weight loss even before diagnosis. Malnutrition is one of the most common and significant issues during cancer treatment, and poor nutritional management may impede treatment progress.
India, being a multicultural nation with varied nutritional habits and local beliefs, requires individualized nutritional therapy. An individual’s dietary intake, physical activity, body composition, predominant metabolic pattern, medical history, and the type and stage of cancer all influence nutrition planning. Clinical Nutrition Therapists are responsible for conducting nutritional screening and assessment. Nutritional screening should be performed during the first outpatient consultation or within 24 hours for inpatients, as it helps identify patients at risk of malnutrition. Nutritional assessment should be repeated throughout treatment.
Tools such as the Malnutrition Universal Screening Tool (MUST), Nutritional Risk Screening-2002 (NRS-2002), and Mini Nutritional Assessment (MNA) are suitable for screening. Subjective Global Assessment (SGA) and Patient Generated-Subjective Global Assessment (PG-SGA for literate individuals) are validated tools for assessing adult oncology patients. SGA should be complemented with biochemical parameters. Imaging techniques help detect muscle loss and fat infiltration. For patients at risk of malnutrition, sarcopenia, or cachexia, muscle mass can be assessed using dual X-ray absorptiometry (DEXA), CT scans at the level of the third vertebra, or bioimpedance analysis (BIA). Simple tools such as handgrip strength, gait-speed tests, and nutrition-focused physical examinations can also be included.
Nutritional assessment should identify the stage of cachexia, as nutritional intervention is most effective during pre-cachexia. Assessment may include inflammatory markers such as C-reactive protein, serum albumin, hyperglycemia, and symptoms like anorexia.
A well-balanced diet rich in protein, fiber, phytonutrients, and antioxidants, and low in saturated fats and refined sugars, is appropriate to meet caloric needs. Early enteral nutrition reduces the risk of malnutrition compared with oral feeding. Appropriate nutrition may reduce symptom burden, improve cancer outcomes, and support survivorship.
Energy requirements for cancer patients are similar to those of healthy individuals, typically 25–30 kcal/kg/day. Based on resting energy expenditure (REE), lifestyle, nutritional status, severity of malnutrition, cancer stage, comorbidities, and metabolic abnormalities, caloric needs can be adjusted. Protein requirements are individualized, as patients often struggle to meet recommendations. SEOM clinical guidelines recommend 1.2–1.5 g/kg/day, while ESPEN guidelines suggest more than 1 g/kg/day, up to 1.5 g/kg/day. Insufficient protein intake during cancer treatment can result in sarcopenia and related complications. Whey protein isolate supplementation is known to improve nutritional status, immunity, and muscle strength.
Carbohydrate and fat intake, as primary energy sources, should be adjusted based on BMI, comorbidities, and the risk of lifestyle-related non-communicable diseases. Fiber requirements follow the Recommended Dietary Allowance (RDA), which is 40 g per 2000 kcal/day.
While antioxidant supplementation during chemotherapy may improve therapeutic efficiency and survival rates, evidence is inconclusive. There is also a potential risk of antioxidants interfering with chemotherapy or radiotherapy. Therefore, supplementation should be assessed by a clinician or clinical dietitian. Probiotic supplementation helps reduce treatment-related side effects such as radiation-induced diarrhea and decreases the need for anti-diarrheal medication.
Post-surgery, metabolic stress causes loss of lean mass, homeostatic disruption, and reduced aerobic capacity. Preoperative nutrition varies from 14 days for severely malnourished patients to 5 days for malnourished individuals. Arginine, omega-3 fatty acids, and nucleotides may be considered as oral or enteral immune nutrition if needed.
Nutritional intervention is crucial both during hospitalization and after discharge. During radiation therapy (RT), individualized nutritional counseling and/or oral nutritional supplements (ONS) help improve intake, body weight, and quality of life. Proper education on swallowing techniques should also be provided during enteral nutrition.
During chemotherapy, nutritional requirements increase. A balanced diet is planned according to the patient’s nutritional status. Supplementation with long-chain omega-3 fatty acids or fish oil can help stabilize or improve appetite, food intake, lean body mass, and body weight in selected individuals. In chemo-radiation therapy—where both chemotherapy and radiation are combined—symptoms such as anorexia, mucositis, nausea, vomiting, and diarrhea are common. In these cases, nutritional status must be closely monitored, and nutrients adjusted according to individual needs.
