Clelia Madeddu

Medical Oncology

Department of Medical Sciences and Public Health

University of Cagliari, Italy

Session: Optimise nutritional strategies for excellent cancer care

Disturbance of taste and risk of malnutrion

Disclosure

I do not have any conflict of interest to declare.

According to WHO’s constitution, the health of a population is not only a condition set by the absence of illness but also determined by the “quality of life” (QOL).

QOL involves aspects of social wellbeing as well as maintenance of full physical and mental modalities.

Cancer patients include a large percentage of elderly people and they may have complicated hospitalization and receive medical treatments involving drugs as well as chemo- and radiotherapy.

The QOL for these individuals is often diminished due to lack of appetite, leading to malnutrition and derived secondary diseases such as gastric malfunctioning, aphasia, and a number of other physiological dysfunctions.

These conditions are often exacerbated by loneliness; more and more adults are singles who eat their meals in solitude or on the move. Furthermore, elderly people in nursing homes and hospitals tend to eat less food because the food is not tasty enough or prepared and presented under conditions that do not stimulate the appetite.

Appetite, choice and acceptance of food, and the amount of food consumed, as well as the satiety and satisfaction after a meal are key factors that are intimately linked to the sensory perception of food.Food flavor, i.e., taste, smell, mouthfeel, and chemesthetic sensation, all have influence on the amount of food taken in and the degree of satiety.

Centrality of quality of life

Taste is an important sensation that serves to evaluate the nutritious content of food, support oral intake and prevent ingestion of potentially toxic substances. It is commonly used to describe pleasure associated with food consumption and is related to several sensations including tactile (texture), temperature, and smell that are perceived when placing a substance inthe mouth.

Taste definition and physiology

Sweet, umami bitter

❖ preference for sweet direct us to food with carbohydrates and plenty of energy and calories❖ saltiness indicates foods with vital ions, such as sodium and potassium❖ sour suggests whether a fruit or vegetable is unripe❖ bitter is a warning signal of poisonous compounds❖ finally, for most kind of foodstuff umami signals high contents of amino acids and protein

Taste infuences the quality and composition of diet

Umami is stimulated by free monosodium glutamate (MSG), the sodium salt of the amino acid glutamic acid, in a peculiar synergy with certain free 5′-ribonucleotides, specifically inosinate (inosine-5′-monophosphate, IMP) and guanylate (guanosine-5′-monophosphate, GMP), which in a synergistic fashion potentiate the umami receptors’ sensitivityto glutamate. Umami can be considered the essence of deliciousness, which can enhance the sensory perception of a meal and moreover limit the craving forsalt, fat, and sugar.

The feedback to the brain along the gut-brain axis is a signal of satiety and satisfaction

signal to the body that protein-rich food is on the way

The total effect of these mechanisms is a homeostatic control of energy

Biological mechanisms of reduced food intake in elderly

Losses of taste and smell are common in elderly and result from normal aging, certain disease states (especially Alzheimer disease), medications,surgical interventions, and environmental exposure.

exacerbate disease states

impair nutritional status

impair immunity

weight loss

ageusia (absence of taste)hypogeusia (diminished sensitivity of taste) dysgeusia (distortion of normal taste)anosmia (absence of smell)hyposmia (diminished sensitivity of smell)dysosmia (distortion of normal smell)

Representative medical conditions and drugs thatcan alter the sense of taste and smell in the elderly

HyposalivationOral cavity infections(mucositis)Oral cavity damage

Results: Variation in objective and subjective assessment methodologies has resulted in difficulties interpreting the literature.Taste-smell changes (TSC) prevalence varies depending on stage of disease and treatment regimens, from 16% to 70% and 50% to 70% during CT and RT, respectively. TSCs in patients who are treatment-naıve, receiving hormone or immunotherapy treatment, post-treatment and cancer survivors have not been adequately studied. TSCs are associated with impaired nutritional status. The relationship between cancer-associated symptoms and nutritional status is not clearly defined.

Anorexia: early satiety, taste changes, and food aversions (N=95)

Goldberg’s eight-item ‘Chemosensory Questionnaire’ (H&N)A Swedish 33-question toolThe ‘Taste and Smell Survey’, etc…

“Could you please tell me about any changes you’ve been experiencing with your senses of taste and smell changes at the moment?”

Modifying taste and smell experiences

Managing meals when not being able to cook (ready made meals, support of family members for cooking,….)

Finding emotional support in family and friends

Managing social eating

Understanding TSAs

Negotiating importance of TSAs

Thinking positively

Professional sector

Personal sector

- Providing advice and support- Acting on weight loss

Belqaid K, Tishelman C, Orrevall Y, Månsson-Brahme E, Bernhardson B-M (2018) Dealing with taste and smellalterations: A qualitative interview study of people treated for lung cancer. PLoS ONE 13(1): e0191117.

❖ reduced food intake and as a consequence:

-insufficient caloric intake* and malnutrition ------>unintentional weight loss and sarcopenia

-muscle wasting due to low aminoacid availability and subsequent decrease in protein synthesis

- protein energy malnutrition in turn compromise muscle mass and strength and quality of life

❖ Loss of eating pleasure

❖ inability to enjoy meals with family members

❖ alter food enjoyment, preferences and intake, thereby potentially contributing to involuntary weight

loss and undernutrition

❖ cause negative emotions such as disappointment, frustration and sadness, interfering with social

rituals around meal situations, and altering routines and roles within the family

CONSEQUENCES OF TASTE CHANGES

Taste changes and risk of malnutrion

A substantial decrease in Calorie intake (430–1100 kcal/day) associated with severe taste-smell changes has been reported in advanced cancer. Average energy intake in these patients (19 kcal/kg BW/day) is reported to be significantly below basal metabolic rates (22–24 kcal/kg/day).

Not only is energy intake reduced, but a limited range of foods, some nutritionally inferior, may be consumed. In one study, up to 55% experienced an unpleasant smell and a bitter taste with high-protein foods, especially red meat, and so avoided them. This may compound the dysregulated protein metabolism observed in cancer and potentiate muscle wasting and malnutrition.

Subjects with severe chemosensory complaints showed substantially lower energy intakes (by 900-1,100 kcal/day), higher rates of weight loss, and lower QOL scores than subjects with mild or moderate chemosensory complaints

Therapies for cancer-associated malnutrition

- Nutrition counselling by a health care professional is regarded as the 1st line of nutrition therapy. Professional counselling is a dedicated and repeated professional communication process that aimsto provide patients with a thorough understanding of nutritional topics that can lead to lastingchanges in eating habits.

- Clearly, the best way to maintain or increase energy and protein intake is with normal food. However, this is often difficult and, in addition to counselling, oral nutritional supplements are required. Oral nutritional supplements are commercially available homogeneous and usuallynutritionally complete nutrient mixtures for oral consumption and are most often recommended to supplement volitional food intake

Arends J., et al. ESPEN guidelines on nutrition in cancer patients Clinical Nutrition 2017;36:11-48

Prevention and management of taste disorders

*Zinc sulphate (45 mg tid) was compared to placebo during RT in 18 patients and improvement in taste was seenin those on zinc based upon whole-mouth threshold taste testing. Another trial compared zinc sulphate (45 mg/day) versus placebo in 169 patients during RT, and found fewer patients in the zinc group reporting taste change (73% vs. 84%; P = 0.16)

*

Halyard MY, Jatoi A, Sloan JA, Bearden 3rd JD, Vora SA, et al. Does zinc sulfate prevent therapy-induced taste alterations in head and neck cancer patients? Results of phase III double-blind, placebo-controlled trial from the North Central Cancer Treatment Group (N01C4). Int J Radiat Oncol Biol Phys 2007;67:1318–22

Ripamonti C, Zecca E, Brunelli C, Fulfaro F, Villa S, Balzarini A, et al. A randomized, controlled clinical trial to evaluate the effects of zinc sulphate on cancer patients with taste alterationscaused by head and neck irradiation. Cancer 1998;82:1938–45.

Ref. Oral Oncology 46 (2010) 77–81

Small frequent meals and snacks that are energy-dense and easy to eat are the best option for patients experiencing early satiety and reduced appetite.Food should be served in pleasant surroundings, with small portions served on small plates so as not to overwhelm patients. Careers should avoid expressing concern over poor intake. Although fat is a high energy source, food should not contain a lot of fat because it delays gastric emptying and may exacerbate nausea and vomiting. During end-stage disease, there are also changes in taste perception and food sensitivities that result in reduced tolerance for extremes in temperature and flavour, and a reduced appetite for meat, thus leading to preferences for bland, starch-based foods. To increase intake, fluids or ice chips should be served between feedings rather than with them. Owing to compromised immune status, no raw eggs, meat, fish, or poultry should be served. Just as in medical treatment, the primary goal of nutritional support is to provide compassionate palliative care to the terminally ill patient by improving comfort and relief of symptoms.

Nutritional strategies

A simple way to increase umami in the food is by reduction and concentration of flavor compounds in boiling water and sauces. At the same time, increasing umami will lower the need for salt and sugar in the food.Glutamate stimulates appetite and enhances saliva and immunoglobulin A secretion that leads to a smoothening of mastication and swallowing. Immunoglobulin A secretion promotes the immune system and oral health, protecting teeth and mucosa from infections. A larger saliva volume improves the nutritional status by promoting digestion and nutrient availability in the gut.Optimizing umami in the food to elderly and hospitalized individuals may well improve their QOL.

Brisbois TD, de Kock IH, Watanabe SM, Mirhosseini M, Lamoureux DC, Chasen M, et al. Delta-9-tetrahydrocannabinolmay palliate altered chemosensory perception in cancer patients: results of a randomized, double-blind, placebo-controlled pilot trial. Ann Oncol. 2011;22(9):2086–93.

A randomised, double-blind, placebo-controlled, pilot trial investigated the effects of oral dronabinol on appetite, taste perception and food consumption in cancer patients with poor appetite and chemosensory alterations.The study employed an individual dose titration design in which patients were adjusted from a dose of 2.5 mg dailydronabinol (or placebo) up to a maximum of 20 mg/day based on treatment efficacy and the presence of unwantedside effects. The authors demonstrated a significant improvement over placebo in appetite, taste and protein consumption with dose-titrated dronabinol.

Wang A, Duncan SE , Lesser GJ , Ray WK , Dietrich AM. Effect of lactoferrin on taste and smell abnormalities induced by chemotherapy: a proteome analysis. Food Funct. 2018;9(9):4948-4958.

Lactoferrin supplementation significantly decreased the concentration of salivary Fe (P = 0.025), increased the abundance (P < 0.05) of salivary α-amylase and Zn-α-2-GP, and led to an overall increase of expression (≥2-fold changes) of immune proteins including immunoglobulin heavy chain, annexin A1, and proteinase inhibitor. Abundance of α-amylase and SPLUNC2 were further increased (P < 0.05) at 30-day post-Lactoferrin supplementation in cancer patients. At the same time, total taste and smell abnormalities score was significantly reduced (P < 0.001)

There is no gold standard assessment tool for Taste changes. Heterogeneity in study methods hinders conclusiveidentification of the most appropriate way to measure them. Subjective measures may reflect the patient experience and more reliably predict changes in dietary behaviour. The true prevalence and severity of Taste changes at all stages of cancer could then be established.

Addressing the association between TSCs, other symptoms of cancer and dietary intake may enable improvement or maintenance of the nutritional status of cancer patients. It has been shown that in older people sensory enhancement of food can increase dietary intake, resulting in improvedfunctional status.

Early recognition of malnutrition and contributory symptoms such as TSCs, e.g. through use of a screening toolincorporating assessment of TSCs, is therefore vital.

Conclusions

Thank you for your attention