Appetite Problems

Key Messages

  • Loss of weight (cachexia) and appetite (anorexia) are significant concerns for many palliative care patients, and independently predict a poorer prognosis. [1-3] 
  • The validated Patient Generated Subjective Global Assessment tool has been recommended for nutritional assessment in people with cancer-related cachexia. [4]
  • Often cachexia is poorly managed by health care professionals due to a lack of knowledge about screening and interventions and a lack of available resources, such as referral pathways. [5-7]
  • There is evidence to support the use of either progestogens (megestrol acetate or medroxyprogesterone acetate) [8] or corticosteroids [9,10] as appetite stimulants in advanced cancer, but less evidence to suggest that they are associated with any improvement in quality of life. [6,11]
  • Guidelines for managing anorexia and cachexia in advanced cancer patients are available. [6]
  • Nutritional counselling has been shown to improve some outcomes, including quality of life but evidence is limited. [7]
  • Artificial feeding in advanced dementia is ethically problematic and does not provide good palliation. In general, the focus should be on offering whatever oral intake the patient will accept, and on good mouth care. However, families and aged care staff may both require support and education in this area. [12,13]

 

 

 

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Review Collection

Evidence Summary

Definition and Prevalence

Loss of weight (cachexia) and appetite (anorexia) are significant concerns for many palliative care patients, and independently predict a poorer prognosis. [1-3] The palliative conditions in which cachexia and anorexia occur most frequently are progressive malignancy, HIV/AIDS, end-stage cardiac failure, end-stage respiratory failure, chronic renal failure, chronic liver disease, and advanced dementia. A focus on weight gain on its own may not result in meaningful clinical changes for palliative care patients. [14]

Potentially reversible contributors to appetite problems should be sought and treated as appropriate. These may include:

  • Mouth problems - mucositis, oral thrush
  • Nausea
  • Pain
  • Dysphagia
  • Constipation
  • Depression
  • Family, social and cultural expectations related to food, diet, and body weight
  • Inappropriate presentation of food
  • De-conditioning / reduced level of activity
  • Dysgeusia - changed sense of taste and smell
  • Malabsorption
  • Dyspnoea
  • Medication effects.

Assessment and Treatment

The relationship between catabolic state, hyper-metabolism, anorexia and nutritional intake, is extremely variable, complex and unpredictable. Appetite is a subjective symptom. Simple validated assessment tools are available, such as the Patient Generated Subjective Global Assessment. [15,16] However, expert consensus does not recommend any one tool over others. [6] With better understanding of cachexia anorexia syndrome, future treatments are likely to be multidimensional and initiated earlier. They may include appetite stimulants, tailored nutritional support and exercise, [17] and treatments to reverse the inflammatory drive associated with the syndrome. [18]

Assessment and treatment issues related to Cachexia Anorexia Syndrome, Appetite Stimulants and Artificial Nutrition are covered in more detail in the respective sub-section pages.

Practice Implications

See individual subsections for practice implications in Cachexia Anorexia Syndrome, Appetite Stimulants and Artificial Nutrition.

Evidence Gaps

  • The European Association for Palliative Care (EAPC) is refining definitions of cachexia for palliative care, reviewing the significance of secondary nutritional impact syndromes, and studying the psychosocial outcomes of cachexia and anorexia, and developing a decision tool. [15]
  • Some screening tools for appetite require external validation, and specific Quality of Life assessment tools are needed. [19]
  • Study of the differences between specific cachexia syndromes - cancer, chronic renal failure and cardiac failure - is evolving. [15]
  • Many studies with weight gain as an outcome do not identify how weight is gained - whether as muscle, fat, or oedema. Skeletal muscle mass, rather than total weight, is most closely associated with functional status. Other relevant outcomes such as quality of life, performance state, exercise and activity levels are now being studied in addition to changes in weight. [14]
  • Significant muscle wasting (sarcopenia) may occur in patients with maintained body weight due to fat; the possibility of assessing this with CT scanning is being studied in order to identify those patients with early stages of cachexia who might benefit from earlier intervention. [20]
  • 'Early satiety' is when a person wants to eat but can only take small amounts due to a sense of fullness. It is common in cancer patients and may be separate from other appetite problems, or it may co-exist with anorexia or nausea. Autonomic neuropathy may be a contributing factor. Early satiety is not well understood, but has been identified as an area for further research. [21]
  • Dysgeusia (abnormalities of the sense of taste) have been found to be common during cancer treatment (56 - 76% estimated prevalence). It is often associated with other oral symptoms, and with a worse quality of life. Treatments that have been studied include prophylaxis with zinc and amifostine, which have been shown to be of small benefit. Dietary and educational counselling may be of some assistance. [22]
  • The benefits of NSAIDs may be enhanced when used in combination with other appetite stimulators, although evidence for particular combinations remains low. [6,11]
  • Inflammatory markers, including C-reactive protein and others, are being studied for potential clinical use as screening and monitoring tools in the cachexia anorexia syndrome, and as a possible intervention target. [23,24] Genetic polymorphisms are being investigated in the search for susceptibility biomarkers. [24]
  1. Vigano A, Dorgan M, Buckingham J, Bruera E, Suarez-Almazor ME. Survival prediction in terminal cancer patients: a systematic review of the medical literature. Palliat Med. 2000 Sep;14(5):363-74.
  2. Teunissen SC, Wesker W, Kruitwagen C, de Haes HC, Voest EE, de Graeff A. Symptom prevalence in patients with incurable cancer: a systematic review. J Pain Symptom Manage. 2007 Jul;34(1):94-104. Epub 2007 May 23.
  3. Zhang F, Shen A, Jin Y, Qiang W. The management strategies of cancer-associated anorexia: a critical appraisal of systematic reviews. BMC Complement Altern Med. 2018 Aug 9;18(1):236. doi: 10.1186/s12906-018-2304-8.
  4. Dy SM, Lorenz KA, Naeim A, Sanati H, Walling A, Asch SM. Evidence-based recommendations for cancer fatigue, anorexia, depression, and dyspnea. J Clin Oncol. 2008 Aug 10;26(23):3886-95.
  5. Cooper C, Burden ST, Cheng H, Molassiotis A. Understanding and managing cancer-related weight loss and anorexia: insights from a systematic review of qualitative research. J Cachexia Sarcopenia Muscle. 2015 Mar;6(1):99-111. doi: 10.1002/jcsm.12010. Epub 2015 Mar 31.
  6. Arends J, Bachmann P, Baracos V, Barthelemy N, Bertz H, Bozzetti F, et al. ESPEN guidelines on nutrition in cancer patients. Clin Nutr. 2017 Feb;36(1):11-48. doi: 10.1016/j.clnu.2016.07.015. Epub 2016 Aug 6.
  7. Baldwin C, Spiro A, Ahern R, Emery PW. Oral nutritional interventions in malnourished patients with cancer: a systematic review and meta-analysis. J Natl Cancer Inst. 2012 Mar 7;104(5):371-85. doi: 10.1093/jnci/djr556. Epub 2012 Feb 15.
  8. Ruiz Garcia V, López-Briz E, Carbonell Sanchis R, Gonzalvez Perales JL, Bort-Marti S. Megestrol acetate for treatment of anorexia-cachexia syndrome. Cochrane Database Syst Rev. 2013 Mar 28;3:CD004310.
  9. Yavuzsen T, Davis MP, Walsh D, Le Grand S, Lagman R. Systematic review of the treatment of cancer-associated anorexia and weight loss. J Clin Oncol. 2005 Nov 20;23(33):8500-11.
  10. Miller S, McNutt L, McCann MA, McCorry N. Use of corticosteroids for anorexia in palliative medicine: a systematic review. J Palliat Med. 2014 Apr;17(4):482-5.
  11. Advani SM, Advani PG, VonVille HM, Jafri SH. Pharmacological management of cachexia in adult cancer patients: a systematic review of clinical trials. BMC Cancer. 2018 Nov 27;18(1):1174. doi: 10.1186/s12885-018-5080-4.
  12. Royal College of Physicians and British Society of Gastroenterology. Oral feeding difficulties and dilemmas. A guide to practical care, particularly towards end of life. London: Royal College of Physicians; 2010.
  13. Sampson EL, Candy B, Jones L. Enteral tube feeding for older people with advanced dementia. Cochrane Database Syst Rev. 2009 Apr 15;(2):CD007209.
  14. Dahele M, Fearon KC. Research methodology: cancer cachexia syndrome. Palliat Med. 2004 Jul;18(5):409-17.
  15. Blum D, Omlin A, Fearon K, Baracos V, Radbruch L, Kaasa S, et al. Evolving classification systems for cancer cachexia: ready for clinical practice? Support Care Cancer. 2010 Mar;18(3):273-9.
  16. 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 Oct;80(1):114-44. Epub 2011 Jan 8.
  17. Al-Majid S, Waters H. The biological mechanisms of cancer-related skeletal muscle wasting: the role of progressive resistance exercise. Biol Res Nurs. 2008 Jul;10(1):7-20.
  18. Bartosch-Härlid A, Andersson R. Cachexia in pancreatic cancer - mechanisms and potential intervention. E Spen Eur E J Clin Nutr Metab. 2009 Dec;4(6):e337-43.
  19. Miller J, Wells L, Nwulu U, Currow D, Johnson MJ, Skipworth RJE. Validated screening tools for the assessment of cachexia, sarcopenia, and malnutrition: a systematic review. Am J Clin Nutr. 2018 Dec 1;108(6):1196-1208. doi: 10.1093/ajcn/nqy244.
  20. Prado CM, Birdsell LA, Baracos VE. The emerging role of computerized tomography in assessing cancer cachexia. Curr Opin Support Palliat Care. 2009 Dec;3(4):269-75.
  21. Davis MP, Walsh D, Lagman R, Yavuzsen T. Early satiety in cancer patients: a common and important but underrecognized symptom. Support Care Cancer, 2006 Jul;14(7):693-8. Epub 2006 Apr 20.
  22. Hovan AJ, Williams PM, Stevenson-Moore P, Wahlin YB, Ohrn KE, Elting LS, et al. A systematic review of dysgeusia induced by cancer therapies. Support Care Cancer 2010;18(8):1081-7. Epub 2010 May 22.
  23. Walsh D, Mahmoud F, Barna B. Assessment of nutritional status and prognosis in advanced cancer: interleukin-6, C-reactive protein, and the prognostic and inflammatory nutritional index. Support Care Cancer. 2003 Jan;11(1):60-2. Epub 2002 Aug 21.
  24. Tan BH, Ross JA, Kaasa S. Skorpen F, Fearon KCH, European Palliative Care Research Collaborative. Identification of possible genetic polymorphisms involved in cancer cachexia: a systematic review. J Genet. 2011 Apr;90(1):165-77.

Last updated 15 October 2019