Assessment of technical knowledge on oral nutritional therapy between physicians and the nursing team of a private institution

Cancer patients face challenges that go beyond the tumor, including malnutrition. Malnutrition can be defined as a state resulting from a deficit of nutrients that leads to changes in body composition, mental state, and function; can damage the clinical outcome; and has a multifactorial etiology.1 Cederholm et al. (2015)2 suggest malnutrition as a body mass index (BMI) <18.5kg/m² or BMI<20kg/m²; for patients older than 70 years old. A BMI<22kg/m² associated with weight loss of >10% for an unspecified time or >5% in the last 3 months can also be used to diagnose a patient as being malnourished. However, the Global Leadership Initiative on Malnutrition suggests that the diagnosis be made considering five criteria, which are divided into phenotypic and etiological criteria. The phenotypic criteria include involuntary weight loss, low BMI, and reduced muscle mass; meanwhile, the etiological criteria include reduced food intake or nutrient absorption, the presence of acute or chronic inflammation, and the severity of the disease. To be diagnosed with malnutrition, the patient must meet at least one phenotypic criterion and one etiological criterion.3

Unintentional weight loss in hospitalized patients used in isolation is already a negative prognostic indicator, and studies indicate that approximately 31-87% of individuals diagnosed with cancer show substantial loss of body weight, which is a marker for malnutrition.4,5. Unlike malnutrition in noncancer patients, cancer-associated malnutrition results in a negative energy balance and loss of muscle mass caused not only by decreased food intake but also by metabolic disorders such as insulin resistance, increased basal metabolism rate, and increased lipolysis and proteolysis, which are due to the presence of systemic and catabolic inflammation that aggravate weight loss. Considering these factors, nutritional support is a strong ally to reverse malnutrition in cancer patients.6

Currently, it is estimated that, on average, the malnutrition rate in cancer patients varies from 20% to 80%; in addition, approximately 20% of cancer patients die due to malnutrition/cachexia.7

The main complications related to malnutrition include a delay in the healing process; impaired absorption and binding of proteins, hepatic metabolism, and renal elimination of drugs and their metabolites; worsening of the immune response; increased rates of infections and postoperative complications; increased risk of developing pressure injury; increased length of hospital stay; increased risk of mortality; and a considerable increase in hospital costs. In addition to negatively impacting patient metabolism, involution of the nutritional status can also affect cancer treatment outcomes.8,9

An epidemiological study carried out in Spain showed through the Global Subjective Assessment produced by the patient (ASG-PPP) that 96.7% of the patients were at nutritional risk and lacked early nutritional intervention. The authors observed that the patients with the greatest weight loss were those with tumors in the esophagus, stomach, or larynx.10

Nutritional support aims to significantly improve the response to treatment, contain weight loss and malnutrition, reduce the risk of complications, reduce morbidity and mortality, and provide a better quality of life for cancer patients. Among nutritional interventions, oral nutritional therapy (ONT) has been highlighted as its main objective is to increase the patient’s dietary intake.11-13

Oral nutritional supplements (ONS) are the main pillar of ONT. Available for oral consumption, these supplements can be found in ready-to-eat models (in tetra-pack packaging or in cans) or in powder form for reconstitution, and they are intended to complement food intake. ONS are indicated for patients who do not achieve their food intake requirements or for those who show weight loss; thus, their use helps the patients to recover their nutritional status.^[14] Supplements are considered as the first option, since they have physiological properties and are less invasive than other treatment methods; however, they should only be used as an aid for recovery or maintenance of nutritional status and not as an exclusive method of feeding or replacing meals.13-15

There are several types of nutritional supplements, which are divided into standard and specialized formulas, according to their purpose and composition. Currently, the nutritional supplement industry has a wide variety of products, including normal to hypercaloric; normal to hyperprotein; free of sucrose or sugar; fortified with immunomodulatory nutrients; free or high in fat; with or without flavor; with or without dietary fiber; and even products aimed at certain audiences or those with specific clinical conditions such as cancer patients, those with kidney or liver failure, among others.15 These products, in turn, help with several processes, namely muscle formation and function, cholesterol lowering, intestinal function, amino acid synthesis, cell division, immune system function, red blood cell formation, and energy metabolism including protein, carbohydrate, and fat metabolism.16

Several studies indicate that nutritional intervention should be an adjunct to cancer treatment. Moreover, a multidisciplinary approach allows better adherence to ONT, which is a key factor for successful treatment and recovery of patients.17

A previous study has evaluated 13 randomized clinical trials of oral nutritional intervention (nutrition counseling, ONT, or both) in patients diagnosed with cancer at nutritional risk/malnourished during anticancer treatment or palliative care and compared oral nutritional intervention with usual care.18 The findings suggest that interventions can improve the quality of life of patients who are at nutritional risk or are malnourished. Furthermore, the nutritional intervention was the most effective for patients whose disease is curable or for those who have a long disease-free period after treatment.

According to Paccagnella et al. (2010)19 early dietary intervention in patients diagnosed with head and neck cancer who were undergoing chemotherapy or radiotherapy resulted in a greater tolerance to treatment, improvement in symptoms, and less hospitalization. The results of this study suggest that this intervention should be started before treatment and should be continued until the end of the treatment.

Additionally, a retrospective study that aimed to evaluate the impact of nutritional supplementation on the length of hospital stay, hospital costs, and readmission of the patient showed that the use of ONS reduced the length of hospital stay by an average of 2-3 days, reduced hospital costs by US$4,734, and decreased the probability of these patients being readmitted within 30 days of discharge.20

In practice, ONT requires multidisciplinary work, considering that each specialty is responsible for a different part of the process. For example, the Medicine Department (except for professional nutritionists) is often the area in charge of prescribing supplements, and nurses and their assistants are responsible for their delivery and administration. However, these specialties have different views on supplementation; supplements can be considered as a medicine or as a product that supplements nutrition. The different understandings about the purpose of the supplement, when passed on to the patient, can cause some confusion about its real benefit; moreover, a variable representation about such a relevant treatment has an impact on the importance of ONT, resulting in increased efforts to be made to prevent or treat malnutrition and to plan follow-up care.21

It is essential that nutritional care is present from the early stages of the disease’s natural history, and its integration in the therapeutic strategy in the battle against cancer is essential.13-22 Considering that the success of ONT as a treatment as well as its use for the prevention of weight loss and malnutrition depends on a good understanding of the health care team working together, the present study aimed to assess the knowledge and conduct of professionals working with this resource.

A total of 105 professionals were included in this study, including 34 physicians (32.4%) and 71 nursing staff (67.6%). Among the nursing staff, 35 were nursing technicians (33.3%), 35 were nurses (33.3%), and only 1 was a nursing assistant (1%). In the physician category, 11 were physicians (10.5%), and 23 were residents (21.9%).

Tables 1 and 2 describe the frequency of responses by the physicians and nursing staff, in the proper order. The analysis of common questions is presented in Table 3.

The adherence of patients to ONT as a way to prevent and cope with malnutrition is directly linked to the knowledge of the team involved in the prescription, administration, and guidance of the patient, since they are responsible for transmitting all the necessary information for such a treatment. A team that does not have a unified view can create confusion for the main beneficiary of the treatment: the patient; this can lead to a reduced effectiveness and a poor adherence to the treatment by the patient.21

A systematic review by Baldwin et al. (2012)^[18] suggests that the use of ONS is associated with significant reductions in complications associated with unintentional weight loss, length of hospital stay, and mortality rates. Therefore, nutritional assistance is a great ally against malnutrition. In addition, the report on recommending procedures for ONS for malnourished clinical or surgical patients or those at risk of malnutrition prepared by the Ministry of Health of Brazil23 shows that the implementation of ONT is able to reduce costs by R$10,816.08 per death averted compared to enteral and parental nutritional therapies, while there are savings of R$4,231.70 due to avoiding readmission and R$283.06 for avoiding hospitalization.

Although doctors have the view that one of the benefits of ONS is the decrease in the chances of hospital readmission, most of the nursing team does not believe in this benefit. A study directed by Kaegi-Braun et al. (2021)24 found significantly lower rates of hospital readmission within 30 days in patients who received nutritional support; moreover, these patients had a lower mortality rate than those not receiving nutritional support.

In contrast to the results obtained by Brindisi et al. (2020)21 in which physicians classify food supplements as medication, there was unanimous agreement that ONS is a food supplement in the current study. Nevertheless, both groups claim that they did not have technical training regarding nutritional supplementation during their studies.

The nutritional risk criteria used in the questionnaires were based on a proprietary institutional tool. This study points out that several symptoms and conditions are neglected by professionals. For example, the presence of ascites, defined as the presence of free fluid of pathological origin in the abdominal cavity,25 was not often mentioned by the physicians or nursing staff as a criterion for patients to be at nutritional risk. This condition may be related to indigestion, as gastric capacity is reduced with an increased intra-abdominal pressure, which can lead to reduced food intake.26

The professionals also did not believe that patients with comorbidities, such as diabetes mellitus, would benefit from ONS. According to the Guidelines of the Brazilian Society of Diabetes,27 oral supplements promote greater glycemic control by reducing postprandial blood glucose and triglyceride levels, reducing insulin resistance, controlling the lipid profile, and reducing episodes of hypoglycemia. This finding indicates that further training of physicians and nurses regarding the benefits of ONS is needed.

Physicians participating in this study collectively believed that patients who present with weight loss are eligible to receive ONS; however, in clinical practice, most patients are referred for nutritional monitoring only when there is a severe loss of weight. There are also many patients who are not provided with nutritional consultation and do not receive a medical prescription for food support. A study by Lorton et al. (2020)28 has demonstrated that 40% of malnourished patients do not receive adequate nutritional support. According to the National Oncology Nutrition Consensus,29 oral supplements are great allies against weight loss, preventing it from occurring and, in some cases, even weight gain being noticed.

Although the literature is clear regarding the nutritional status depletion that systemic treatment can cause, physicians and nurses in this study believe that there are no such negative effects. However, Carniatto et al. (2018)30 have shown that patients undergoing concomitant treatment have a greater acute toxicity to the treatment. In a paper presented by Rebouças et al. (2011)31 radiotherapy combined with chemotherapy in patients diagnosed with head and neck cancer is linked to a higher frequency in grade 3 acute toxicity.

Physicians as well as nurses and technicians do not consider enteral and parenteral nutritional therapy at home as a risk factor for malnutrition; however, the presence of nutritional support is not synonymous with the treatment being adequate. Mazur et al. (2014)32 have reported that home enteral nutritional therapy has several factors that hamper the administration of tube feeding in the home context, for example, financial aspects can lead to the impossibility of purchasing formula, leading to an inadequate food supply and thus causing malnutrition. In addition, adaptation of family to a new daily life can also contribute to food insecurity.

Even without training on the proposed subject, most physicians and nursing staff notice the improvement in the nutritional status of patients who use ONS. However, even without adequate training, they felt able to guide patients regarding the consumption of ONS that they prescribed and administered, respectively. These findings corroborate the results presented by Spiro et al. (2016),33 who suggest that oncologists believe that the nutritional status of patients and nutritional interventions are relevant for patients undergoing anticancer treatment. Yet they are unable to identify patients at nutritional risk and to refer those who would benefit from nutritional therapy at an early stage. Their study also found that malnutrition is not widely recognized by other health professionals.

When nutritional care takes place in a multidisciplinary way, health outcomes are more favorable to the patient’s quality of life. Such care should involve all health professionals such as dietitians, physicians, and nurses at all levels of care involving nutritional screening, assessment, planning, implementation, evaluation and ultimately the monitoring of evidence- based care delivery.34

The study by Vrkatić et al. (2022)35 points out that high-quality continuing medical education related to nutrition is capable of increasing medical knowledge and skills in relation to nutritional care, training professionals with greater confidence in the skills needed for nutritional interventions. This also mentions that the lack of training and nutritional education can have a vital impact on the nutritional information provided to patients, which may compromise the safety and efficiency of nutritional counseling, putting the patient at risk.

Continuing education in cancer nutrition is essential for every multidisciplinary team, since nutrition is an important part of treatment and not just a complement.^[36] Nutritional education interventions, such as the creation of workshops, protocols and discussion of clinical cases, increase the quality of nutritional therapy, this study also points out that there was an improvement in clinical practice after the application of training for physicians, impacting on a shorter period of fasting and greater achievement of nutritional goals.37

Nutritional diagnosis must be carried out in parallel with disease diagnosis so that early nutritional intervention is possible, thus affording better clinical outcomes.38

The present study has some limitations, such as the use of a questionnaire designed for this study, based on other similar research, but not validated. In addition, the research was conducted with only one medical specialty, since other specialties, such as surgeons, have greater knowledge about nutritional supplements due to institutional protocols that encompass this type of nutritional therapy. Finally, the nursing staff evaluated was only those who had care with the inpatient.

There is a great difference in knowledge about ONS among medical and nursing professionals. Interdisciplinary technical training is essential for the success of ONT as a tool for preventing and combating malnutrition. Although nutrition is not a part of the curriculum in other areas of health care, hospitals must carry out training to improve knowledge regarding this topic so that ONT can be implemented.

TMM Final approval of manuscript, Manuscript writing

CRK Collection and assembly of data, Conception and design, Data analysis wand interpretation, Final approval of manuscript, Manuscript writing

JPF Final approval of manuscript, Manuscript writing