Understanding Food Insecurity and Malnutrition During Cancer Treatment

The NOURISH trial is addressing food insecurity and malnutrition in patients undergoing treatment for their blood cancers.

One of the many issues that patients with cancer face is food insecurity and malnutrition, according to Dr. Anna Arthur, who added that based on this gap in the treatment space, investigators launched the NOURISH trial (Nutrition Outreach in Systems of Healthcare) which will investigate the impact of addressing these needs among patients with blood cancers undergoing transplant or cellular therapy.

“We know that individuals who are diagnosed with cancer and going through treatment are at higher risk of compromised nutritional status and malnutrition compared with healthy individuals without cancer,” said Arthur, the study’s primary investigator, in an interview with CURE®.

In the interview, Arthur delved into insights on the NOURISH trial and highlighted the importance of addressing food insecurity and malnutrition in patients with cancer. She also shared what types of foods are most important for patients with cancer to consume during their treatments.

Arthur is currently the Director of the Medical Nutrition Science Program, as well as a tenure-track Assistant Professor in the Department of Dietetics and Nutrition at the University of Kansas Medical Center.

CURE: How does food insecurity impact cancer treatment outcomes overall for patients?

Arthur: Patients [with cancer] who start treatment malnourished, or who become malnourished during their cancer treatment, are at higher risk of several different negative outcomes. These [outcomes] include reduced quality of life; increased susceptibility to infection and illness; increased hospital admissions, as well as increased time spent in the hospital if they're admitted; and reduced tolerance to cancer treatment. This could lead to things like treatment breaks, delays in initiating their treatment, dose reductions in the treatment that they're receiving, or even in severe cases, early cessation of treatment.

These factors also put these individuals at higher risk of morbidity and mortality. When a patient [has] a cancer diagnosis and [is] going through cancer treatment, [they are more likely to be] at a higher risk of compromised nutrition, if they are also food insecure and unable to afford or access the food that they need to help maintain their nutritional status during treatment. This [is] an added obstacle in the prevention of malnutrition and optimizing nutritional status.

What types of foods are most important for patients with cancer to consume during their treatments? Which nutrients might act like fuel for the body to recover during treatment?

There are recommendations that we give to patients with cancer during treatment for dietary intake, as well as how we prioritize types of medical nutrition therapy interventions that we provide. [These recommendations are highly] individualized; [they] vary depending on what type of cancer patients have, what stage the cancer is when diagnosed, the type of treatment that they're going to receive and other health conditions that they may be presenting with.

For patients with cancer that are at high risk for malnutrition, focusing on foods that are high in calories and high in protein are often prioritized to help minimize weight loss and with maintenance and prevention of muscle mass loss. We know that weight loss, especially in the form of muscle loss, during cancer treatment, is associated with those [poor] outcomes. Therefore, maintaining the adequate intake of calories and protein during cancer treatment can help reduce the risk of those negative outcomes, minimize that weight loss and preserve muscle mass. [This is] so that the patient can better tolerate their treatment, enhancing their recovery after treatment.

How does the NOURISH trial aim to simplify the process of accessing nutritious foods for these patients?

We'll be providing patients with bags of food that are provided by our food bank partners at each of the four cancer centers that we are doing this trial at. We're working in Kansas City with Harvesters Food Bank, and these food bags will provide enough food for two to three days of balanced nutrition for one person. When patients come into clinic for their cancer treatment, they'll receive their bags in a discrete manner, and they'll also be receiving bags two times per week.

We anticipate, by providing the food bag when they come in for their cancer treatment, we're ensuring that they have the food that they need to maintain their nutritional status, and that avoids having to procure the food themselves, either at a grocery store or at a food pantry, which can be a really major burden during a very stressful time in their life, when patients are not feeling well. Additionally, [if the patients are] food insecure, they may also lack resources like money and transportation to be able to go out and get food on their own.

In addition to the food bags, we’re providing patients with recipes and video cooking demonstrations in the bag and on a centralized website so that patients and their care partners can know and don't have to figure out on their own how to use the content of the bags that they receive. [This] helps them manage the side effects they may be experiencing so that they can get the nutrition that they need, even if they are experiencing symptoms and side effects.

How do you envision it influencing cancer care and health system policies in the future, particularly regarding food insecurity and malnutrition in these patients?

I'm hopeful that we will be successful in demonstrating positive outcomes; the positive outcomes that we're mainly looking at are cost effectiveness as well as reduced malnutrition or preventing malnutrition.

This trial could then pave the way for other health systems and cancer centers around the country to provide a similar program to patients who need it as part of their standard of care. That would be beneficial for food insecure patients, and maybe even someday, we could reach a point where we could provide food for all patients with cancer, regardless of food insecurity.

Why is it important for patients with cancer undergoing transplant or cellular therapy to prioritize calorie and protein intake, even if it means adjusting their normal, healthy diet?

As a registered dietitian and nutritionist, I am trained to prioritize nutrition problems that patients come to us with based on what the most urgent need is the. During cancer treatment, often the most urgent need is to prevent or treat malnutrition and help manage side effects, preventing the loss of muscle mass.

Cancer treatment is not the time to focus on losing weight. While we still must be attentive to other nutrition-related issues that the patients may present to us with, like diabetes or high cholesterol or micronutrient deficiencies, minimizing weight loss and muscle mass loss during cancer treatment is the highest priority, even in patients who are overweight or obese.

There's quite a bit of data showing that somebody can be malnourished and have low muscle mass, even if they're obese. It is really important that we prioritize preventing malnutrition and weight loss. A lot of times in patients who are diagnosed [with cancer] who are overweight or obese, they think, ‘I'm losing weight so easily now, great,’ but it is really not, especially if that's muscle.

How can patients advocate for themselves if they're experiencing food insecurity or malnutrition?

In patients experiencing food insecurity or malnutrition that haven't been identified and addressed by their care team, I would encourage the patient themselves or their care partner, if they have social support with them, to speak up about their concern to one of the members of their care team, whether it be a physician, a nurse, a registered dietitian, social worker, or someone else. That care team member can help refer them to the appropriate health care provider, like a dietitian or a social worker, which would be the most common types of providers that could help refer them and connect with resources that would help address those needs.

Oftentimes food insecurity and malnutrition are overlooked, especially malnutrition among individuals who are overweight or obese. If they're having a difficult time consuming a regular diet, as much food as they consumed prior to their diagnosis, or if they are having trouble accessing food, affording food, they should not be afraid to advocate for themselves and ask for help with those things.

Transcript has been edited for clarity and conciseness.

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