Therapeutic area

Cancer is one of the leading causes of morbidity and mortality worldwide, with approximately 14 million new cases in 2012 (1). In Spain, 247,771 new cases were diagnosed in 2015 and this figure is expected to increase to 315,413 new cases by 2035 (2).

The term cancer identifies and groups together a group of diseases, in which abnormal cells divide uncontrollably and can invade other tissues, spreading through the blood and/or lymphatic system (3).

There is a two-way relationship between nutritional status, eating habits, and cancer. An example of this relationship can be seen in overweight and/or obesity, which are responsible for 20% of cancers (4). On the other hand, malnutrition represents a frequent complication in cancer patients, affecting between 34 and 73% of patients in Spain (5–7). Poor nutritional status is associated with a worse prognosis and higher morbidity and mortality (8). In addition, malnutrition in cancer patients is also associated with higher healthcare costs (7).

For all these reasons, it is essential to establish adequate nutritional support that covers the specific needs of cancer patients in order to improve the prognosis and reduce the consequences of nutritional deterioration associated with cancer. In this area, the European Society for Clinical Nutrition and Metabolism (ESPEN) has recently published evidence-based guidelines for the nutritional approach to cancer patients (8,9); highlighting the following key points to improve the care of cancer patients:

• Screen the nutritional status of cancer patients early, regardless of their body mass index (BMI) and weight history. Reassess nutritional status on a regular basis.
• Expand nutritional assessment to include measures of anorexia, body composition, inflammatory biomarkers, resting energy expenditure, and physical function.
• Multimodal nutritional intervention with individualized plans, focused on increasing nutritional intake, decreasing inflammation and hypermetabolic stress, and increasing physical activity.

Persan Farma offers enteral nutrition formulas adapted to the nutritional needs of cancer patients, with the aim of maintaining or improving nutritional status, avoiding complications associated with malnutrition and thus improving both the prognosis and quality of life of patients.

Bibliography

1. World Health Organization [Internet]. Cancer, 2018 Feb [cited 2018 Mar 20]. Available from: http://www.who.int/mediacentre/factsheets/fs297/en/

2. Sociedad Española de Oncología Médica (SEOM). Las cifras del cáncer en España en 2018. Soc Española Oncol Médica. 2018;7,8.

3. Puente J, De Velasco G [Internet]. ¿Qué es el cáncer y cómo se desarrolla?, 2017 March 06 [cited 2018 Mar 20]. Available from: https://www.seom.org/es/informacion-sobre-el-cancer/que-es-el-cancer-y-como-se-desarrolla

4. cancerprogressreport.org [Internet]. Phliadelphia: American for Cancer Research, ©2017 [cited 2018 Mar 20]. Available from: http://www.cancerprogressreport.org/

5. Segura A, Pardo J, Jara C, Zugazabeitia L, Carulla J, de las Peñas R, et al. An epidemiological evaluation of the prevalence of malnutrition in Spanish patients with locally advanced or metastatic cancer. Clin Nutr. 2005;24(5):801–14.

6. Fernández López MT, Saenz Fernández CA, de Sás Prada MT, Alonso Urrutia S, Bardasco Alonso ML, Alves Pérez MT, et al. Desnutrición en pacientes con cáncer; una experiencia de cuatro años. Nutr Hosp. 2013;28(2):372–81.

7. Planas M, Álvarez-Hernández J, León-Sanz M, Celaya-Pérez S, Araujo K, García de Lorenzo A. Prevalence of hospital malnutrition in cancer patients: a sub-analysis of the PREDyCES®study. Support Care Cancer. 2016;24(1):429–35.

8. 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.

9. Arends J, Baracos V, Bertz H, Bozzetti F, Calder PC, Deutz NEP, et al. ESPEN expert group recommendations for action against cancer-related malnutrition. Clin Nutr. 2017;36(5):1187–96.

In recent years, advances have been made in both anesthetic techniques and surgery, using minimally invasive techniques. In addition, it is also noteworthy the introduction of multimodal rehabilitation programs (PRM), aimed at patients who are going to undergo a surgical procedure, with the intention of recognizing the individual needs of the patient, reducing the stress secondary to the surgical intervention, reducing the occurrence of complications and thus optimizing perioperative care; also reducing hospital stay and healthcare costs (1–3).

Surgical patients tend to present alterations in nutritional status as a result of the underlying pathology that motivates admission, the fasting period conditioned by the surgical process, and postoperative complications (4). The PREDyCES study determined that the prevalence of malnutrition in Spanish surgical services at the time of admission was around 17% and increased slightly, to 19.1%, at discharge (5). In this setting, preoperative malnutrition is associated with poorer perioperative outcomes, increasing morbidity and mortality and hospital stay (6).

For all these reasons, it is crucial to establish a correct nutritional approach early, already in the preoperative period, including screening and assessment of nutritional status for an adequate identification of patients at risk or already malnourished. Nutritional support in the preoperative period aims to maintain or improve nutritional status before surgery and thus reduce postoperative complications and hospital stay. The available scientific evidence supports that preoperative nutritional support significantly improves postoperative clinical outcomes in severely malnourished patients, especially if administered for 7 – 10 days. In addition, within the framework of MICs, it is also recommended to avoid overnight fasting by providing beverages containing carbohydrates. In the postoperative period, PRMs include the early reintroduction of oral feeding.In those cases in which oral intake does not cover 60% of the nutritional requirements in the first days during the postoperative period, the use of nutritional supplements should be assessed, with hypercaloric and hyperporteic formulas being of choice. Artificial nutrition will also be indicated in surgical patients who will be fasting for a period of more than 7 days (or more than 5 days if malnourished) or if postoperative complications arise that limit the patient’s ability to orally feed (7).

Persan Farma offers enteral nutrition formulas adapted to the nutritional needs of surgical patients, in order to maintain or improve nutritional status and thus prevent surgical complications associated with malnutrition.

Bibliography

1. Carli F, Scheede-Bergdahl C. Prehabilitation to Enhance Perioperative Care. Anesthesiol Clin [Internet]. 2015;33(1):17–33. Available from: http://dx.doi.org/10.1016/j.anclin.2014.11.002
2. Dong Q, Zhang K, Cao S, Cui J. Fast-track surgery versus conventional perioperative management of lung cancer-associated pneumonectomy: A randomized controlled clinical trial. World J Surg Oncol [Internet]. 2017;15(1):1–7. Available from: http://dx.doi.org/10.1186/s12957-016-1072-5
3. Muller S, Zalunardo M, Hubner M. A fast-track program reduces complications and lenght of hospital stay after open colonic surgery. Gastroenterology. 2009;136:842–7.
4. Mohamed AA-I, Álvarez J. Guía de actuación: Soporte Nutricional en el Paciente Quirúrgico. 1-222 p.
5. Álvarez-Hernández J, Planas Vila M, León-Sanz M, García de Lorenzo A, Celaya-Pérez S, García-Lorda P, et al. Prevalencia y costes de la malnutriciónn en pacientes hospitalizados; estudio PREDyCES. Nutr Hosp. 2012;27(4):1049–59.
6. Braga M, Ljungqvist O, Soeters P, Fearon K, Weimann A, Bozzetti F. ESPEN Guidelines on Parenteral Nutrition: Surgery. Clin Nutr [Internet]. 2009 Aug;28:378–86. Available from: http://dx.doi.org/10.1016/j.clnu.2009.04.002
7. Ocón M, Ramírez J, Gimeno J. Nutrición en el paciente quirúrgico. In: Gil A, director. Tratado de Nutrición Nutrición y enfermedad. Tomo V, 3ª Edición. Madrid: Editorial Medica Panamericana; 2017. p. 645–57.

The elderly population is very vulnerable from a nutritional point of view. According to Ruiz López et al., the prevalence of calorie-protein malnutrition affects around 3-5% of older adults living at home, and approximately 40-60% of elderly people living in nursing homes or who are hospitalized (1).

Special mention should be made of elderly people who are in a situation of dependency, such as the geriatric elderly and the frail elderly, as they may have problems developing geriatric syndromes. These syndromes are: immobility, instability, incontinence, intellectual impairment, infections, malnutrition, iatrogenesis, vision and hearing disorders, etc.

In short, they are sets of symptoms and signs of multiple causes that produce disability and negatively interfere with the life of the elderly (2).

There are a large number of factors that interfere with nutritional status in old age, such as longevity, physical and cognitive deterioration, frailty, excess of drugs to treat different pathologies, constipation, dysphagia, lack of appetite for food, lack of teeth (1) and the development of geriatric syndromes.

As pointed out by the Nutrition Group of the Spanish Society of Geriatrics and Gerontology, the consequences of malnutrition in the elderly are very serious as it causes a decrease in quality of life, affects the immune system, increases the risk of pressure ulcers, increases hospital stay, resulting in an increase in morbidity and mortality. And all this translates into an increase in healthcare costs (3).

Based on scientific evidence, the ESPEN (European Society for Clinical Nutrition and Metabolism) guidelines on enteral nutrition in geriatrics, “with a recommendation grade A, recommend the use of oral nutrition supplements in malnourished patients or those at risk of malnutrition to increase energy, protein and micronutrient intake, maintain or improve nutritional status, and improve survival” (4).

At Persan Farma we are committed to offering a range of products that meet the nutritional requirements of this type of patient, in order to avoid the consequences of malnutrition and improve their quality of life.

Bibliography

1. Ruiz López M.D, Artacho Martín-Lagos R, Quiles Morales J.L. Nutrición del adulto mayor. En: Gil Hernández Á, director. Tratado de nutrición, tomo IV; 3ª Edición. Madrid: Panamericana; 2017. p. 433-463.
2. Robles Raya Mª.J et al. Definición y objetivos de la especialidad de geriatría. Tipología de ancianos y población diana. Tratado de geriatría para residentes. Madrid: International Marketing & Communication, S.A; 2006. p. 25-32.
3. Valoración del estado nutricional en geriatría: declaración de consenso del Grupo de Nutrición de la Sociedad Española de Geriatría y Gerontología. Rev Esp Geriatr Gerontol. 2016; 51 (1): 52-57.
4. Volkert D, Berner Y N, Berry E, et al. ESPEN Guidelines on Enteral Nutrition: Geriatrics. Clin Nutr 2006; 25: 330-360.

Neurological diseases are a heterogeneous group of pathologies that affect the central nervous system (CNS) and the peripheral nervous system (PNS). These include: multiple sclerosis, Parkinson’s disease, Alzheimer’s disease and other dementias, and cerebrovascular diseases such as strokes (1).

There is a close relationship between neurological disorders and nutrition. Patients with neurological diseases, both acute and chronic, have a high nutritional risk as a result of various factors, such as: decreased intake, cognitive impairment, apraxia, dysphagia, variations in energy expenditure and gastrointestinal alterations (nausea, vomiting, constipation) due to the side effects of the pharmacological treatment of the disease itself (2).

Malnutrition complicates the evolution of these patients, increases muscle atrophy (affecting respiratory and dysphagia), alters immune function, increases the risk of disability, and increases the possibility of developing pressure ulcers and fractures(3). In short, it increases the risk of morbidity and mortality and significantly worsens the patient’s quality of life.

For all these reasons, the correct assessment of the nutritional status of neurological patients, and the provision of adequate nutritional support should be part of the diagnostic and therapeutic process of these diseases (4). Based on the available scientific evidence, the ESPEN guidelines recommend the use of nutritional supplements to improve nutritional status in patients with dementia with a high degree of evidence (5).

At Persan Farma we are committed to offering a range of products that meet the nutritional requirements of this type of patient, in order to avoid the consequences of malnutrition and improve the quality of life of patients.

Bibliography

• OMS. ¿Qué son los trastornos neurológicos? [Internet]. 2018 [cited 218 Mar 30]. Available from: http://www.who.int/features/qa/55/es.
• Bretón Lesmes I, Burgos Peláez R. Nutrición en las enfermedades neurológicas. En: Gil Hernández Á, director. Tratado de Nutrición Nutrición y enfermedad. Tomo V; 3ª Edición. Madrid: Editorial Médica Panamericana; 2017. p. 991-1008.
• Planas Vilà M. Aspectos metabólico-nutricionales en las enfermedades neurológicas. Nutr Hosp. 2014; 29 (supl 2): 3-12.
• De Luis D A, Izaola O, de la Fuente B, Muñoz-Calero P, Franco-Lopez A. Enfermedades neurodegenerativas, aspectos nutricionales. Nutr Hosp. 2015; 32(2) 946-951.
• Volkert D, Chourdakis M, Faxen-Irving G et al. ESPEN guidelines on nutrition in dementia. Clin. Nutr 2015: 1-22

Diabetes mellitus is currently one of the main health problems worldwide. In Spain, the Di@bet.es study showed that the prevalence of diabetes mellitus in people over 18 years of age was around 13.8% (95% CI, 12.8 – 14.7%) (1).

Diabetes mellitus is a chronic endocrine-metabolic disorder, in which there is an alteration of metabolism; especially carbohydrates, although protein and lipid metabolism are also affected. It is due to a deficit in insulin secretion and/or activity and, as a consequence, persistent hyperglycemia occurs that in the long term is associated with the appearance of vascular complications, which determine the high morbidity and mortality of this disease. In addition, patients in a situation of metabolic stress who present metabolic alterations may develop a condition similar to diabetes mellitus, which is known as stress hyperglycemia (2).

There is a close relationship between nutritional status and diabetes mellitus. Thus, overweight or obesity are risk factors for the development of type 2 diabetes mellitus (3). In addition, on the other hand, the results of the sub-analysis of the PREDyCES study in diabetic patients revealed that 29.3% of patients were malnourished at the time of hospital discharge and, compared to normal-nourished, had a longer hospital stay (12.3 ± 8.3 vs 8.4 ± 5.5 days)

Nutritional intervention in patients with diabetes mellitus has the following objectives (2):

• Contribute to acceptable glycemic control
• Provide adequate calories, while maintaining a body weight close to the ideal
• Monitor and control plasma lipid levels and blood pressure
• Prevent and treat the development of complications of the disease

Persan Farma offers specific enteral nutrition formulas to meet the nutritional requirements of diabetic patients, in order to maintain and improve nutritional status, avoid complications associated with malnutrition and improve quality of life.

Bibliography

1. Soriguer F, Goday A, Bosch-Comas A, Bordiú E, Calle-Pascual A, Carmena R, et al. Prevalence of diabetes mellitus and impaired glucose regulation in Spain: The Di@bet.es Study. Diabetologia. 2012;55(1):88–93.
2. Valero M, León-Sanz M. Nutrición en la diabetes mellitus. In: Gil A, director. Tratado de Nutrición Nutrición y enfermedad. Tomo V, 3^a Edición. Madrid: Editorial Medica Panamericana; 2017. p. 533–50.
3. National Institute of Diabetes and Digestive and Kidney Diseases. [Internet]. U.S. Department of Health and Human Services. Factores de riesgo para la diabetes tipo 2, 2016 Nov [cited 2018 March 20]. Available on: https://www.niddk.nih.gov/health-information/informacion-de-la-salud/diabetes/informacion-general/factores-riesgo-tipo-2. 2016.
4. León-Sanz M, Álvarez J, Planas M, García A, Araujo K, Celaya-Pérez S. Prevalence of Hospital Malnutrition in SM Journal of Public Health and Patients with Diabetes Mellitus : A Sub- Analysis of the PREDyCES ® Study Epidemiology. SM J Public Heal Epidemiol. 2015;1(4):1–6.

Kidney disease, also known as nephropathy, can appear abruptly and be reversible, as in acute kidney disease, or progressively and irreversibly, as in chronic kidney disease. In both cases, there is a decrease in the kidney’s ability to carry out its main functions (1).

In the patient with kidney disease, several factors contribute to the deterioration of nutritional status, including: (i) poor intake or anorexia, (ii) intercurrent illnesses and (iii) nutrient losses on dialysis. Considering that the term “renal disease” encompasses a variety of clinical situations, the establishment of common nutritional recommendations is challenging. In addition, these patients have limitations in terms of macro- and micronutrient intake and volume intake (2).

Therefore, nutritional intervention in renal patients should be individualised according to the aetiology, stage of the disease and the therapy they are undergoing.

Persan Farma offers enteral nutrition formulas adapted to the nutritional needs of patients with renal pathology, in order to maintain or improve their nutritional status, prevent complications associated with malnutrition and improve their quality of life.

Bibliography

1. ALCER National Federation. What is kidney disease [Internet]. [cited 2018 Mar 21]. Available from: http://alcer.org/federacionalcer/que-es-la-enfermedad-renal/
2. Riobó P, Ortiz A, Barril G. Nutrition in renal diseases. In: Gil A, editor. Treatise on Nutrition, Nutrition and Disease. Volume V, 3rd Edition. Madrid: Editorial Medica Panamericana; 2017. p. 935-56.

Respiratory diseases are diseases that affect the airways and other structures of the lung. Among the most common are asthma, respiratory allergies, pulmonary hypertension, occupational lung diseases, chronic obstructive pulmonary disease (COPD) and cystic fibrosis (1).

COPD is a condition in which airflow to the lungs is obstructed. This may be due to narrowing of the airways, in the case of chronic bronchitis, or to loss of elastic tissue and destruction of the alveolar walls in emphysema. This results in airflow limitation together with trapping of non-expelled air leading to an abnormal inflammatory response (2).

Cystic fibrosis is an inherited genetic disease, characterised by an accumulation of mucus that obstructs different organs, especially the lungs and pancreas (3).

The lungs play a key role in the body’s digestive, metabolic and endocrine functions, as they are an organ of elimination through the excretion of water and CO2. Therefore, any involvement of the respiratory system, whether acute or chronic, can have an impact on the patient’s nutritional status (4). Malnutrition associated with advanced stage pulmonary pathology has been termed Pulmonary Cachexia Syndrome and is characterised by loss of fat-free mass (5). This syndrome is associated with accelerated decline in functional status and can affect any patient with lung disease, such as patients with COPD and cystic fibrosis (5-7).

For all these reasons, it is necessary to carry out a nutritional assessment of patients with respiratory disease in order to identify those who are at greater nutritional risk or are already malnourished and to establish the appropriate nutritional strategy for the patient’s clinical situation.

Persan Farma offers enteral nutrition formulas adapted to the nutritional needs of patients with respiratory pathology, in order to maintain or improve their nutritional status, prevent complications associated with malnutrition and improve their quality of life.

Bibliography

1. OMS. About chronic respiratory diseases [Internet]. 2018 [cited 2018 Mar 21]. Available from: http://www.who.int/respiratory/about_topic/es/
2. Bordejé-Laguna ML. Our great forgotten ones, the chronically ill respiratory patients. Nutr Hosp. 2017;34(1):38-45.
3. National Center for Advancing Translational Sciences. Genetic and Rare Diseases Information Center. Cystic fibrosis [Internet]. 2017 [cited 2018 Mar 21]. Available from: https://rarediseases.info.nih.gov/espanol/12467/fibrosis-quistica
4. Bordejé-Laguna ML, Sánchez C, Pérez A. Nutrition in respiratory tract diseases. In: Gil A, director. Tratado de Nutrición Nutrición y enfermedad. Volume V, 3rd Edition. Madrid: Editorial Medica Panamericana; 2017. p. 689-703.
5. Wagner PD. Possible mechanisms underlying the development of cachexia in COPD. Eur Respir J. 2008;31(3):492-501.
6. Schols AMWJ. Pulmonary cachexia. Int J Cardiol. 2002;85:101-10.
7. King SJ, Nyulasi IB, Strauss BJG, Kotsimbos T, Bailey M, Wilson JW. Fat-free mass depletion in cystic fibrosis: Associated with lung disease severity but poorly detected by body mass index. Nutrition. 2010;26(7-8):753-9.

Dysphagia is a symptom characterised by difficulty or inability to swallow liquids and/or solids from the oral cavity to the stomach. It should be noted that it is a geriatric syndrome that has a major impact on the lives of those who suffer from it (1).

There are multiple causes of dysphagia, such as tumours, injuries, neurological diseases, and surgical or oncological treatments. Depending on the type of dysphagia presented by the patient, there will be different clinical effects and a specific therapeutic approach, as dysphagia can be permanent or temporary (2).

There are multiple classifications of dysphagia according to:

• Swallowing phase affected: oesophageal dysphagia or oropharyngeal dysphagia.
• Cause: mechanical dysphagia (narrowing of the lumen) or motor dysphagia (neuromuscular).
• Sudden or gradual onset.
• Consistency of the item to be swallowed: dysphagia to liquids, solids or both (2).

Oropharyngeal dysphagia is the most prevalent in the elderly population (more than 60% of institutionalised elderly people), in people suffering from neurological diseases (more than 30% of patients who have suffered a stroke have dysphagia in acute phases), and in people suffering from neurodegenerative diseases (in Parkinson’s disease around 35-45%, 100% of patients with bulbar amyotrophic lateral sclerosis, and 84% of patients with Alzheimer’s disease)(3).

The most serious consequences of dysphagia are due to alterations in swallowing efficiency and safety:

• Malnutrition.
• Dehydration.
• Respiratory complications (which can lead to death of the patient).
• Significant decrease in quality of life (4).

For all of the above reasons, it is very important to make an early diagnosis and establish appropriate treatment according to the degree of dysphagia, with the aim of preventing and reversing the situation. Based on scientific evidence, the ESPEN (European Society for Clinical Nutrition and Metabolism), with a grade A recommendation, “indicates the use of enteral nutrition in geriatric patients with severe neurological dysphagia to ensure the supply of energy and nutrients, and thus maintain or improve nutritional status” (5).

At Persan Farma, we are committed to offering a range of products that cover the nutritional requirements of these patients, in order to avoid the consequences of malnutrition and improve their quality of life.

Bibliography

1. Barroso J. Oropharyngeal dysphagia and bronchoaspiration. Rev Esp Geriatr Gerontol. 2009; 44(S2): 22-28.
2. Laborda González L, Gómez Enterría P. Nutritional treatment of oropharyngeal dysphagia. Endocrinol Nutr. 2006; 53(5): 309-14.
3. García-Peris P, Velasco C, Frías Soriano L. Nutr Hosp Supplements. 2012; 5(1): 33-40.
4. Ashbaugh R.A, Ferrero López I. Nutrition and dysphagia. In: Gil Hernández Á, director. Tratado de nutrición, tomo V; 3rd Edition. Madrid: Panamericana; 2017. p. 977-989.
5. Volkert D, Berner Y N, Berry E, et al. ESPEN Guidelines on Enteral Nutrition: Geriatrics. Clin Nutr 2006; 25: 330-360

Palliative care

Palliative care patients are a heterogeneous group of clinical situations mostly deriving from advanced oncological and other chronic pathologies with a marked prevalence of malnutrition due to the presence of anorexia-cachexia syndrome. This multifactorial syndrome leads to weight loss, loss of muscle mass and depression of the immune system (1-3).

Malnutrition in these patients is caused by a significant reduction in intake, impaired nutrient metabolism and/or absorption, and increased nutritional requirements that patients fail to meet (1). In addition, there is an increased nutritional risk as the palliative care situation progresses. The consequences of malnutrition are directly related to the duration of inadequate intake and the impact of the underlying chronic disease itself, leading to increased complications and hospital admissions, as well as reduced functional capacity (4,5).

Prevention and management of malnutrition in palliative care patients depends on early identification to correct nutritional deficiencies in order to preserve good nutritional status and improve quality of life (6), as malnutrition is an independent predictor of mortality in palliative care patients with advanced oncological processes (7).

Therefore, it is essential to perform a nutritional assessment to determine an appropriate nutritional approach to meet the needs of palliative care patients, in order to reduce the complications that derive directly from the state of malnutrition (2-3). The aim of this intervention is to increase intake, maintain and/or recover the patient’s nutritional status and functional capacity, as well as to improve their quality of life (2,5,6). To carry it out, the use of oral nutritional supplements or, in cases where required, enteral nutrition by tube is recommended (8,9).

Persan Farma offers formulas for both oral supplementation and enteral tube feeding adapted to the nutritional needs of palliative care patients, with the aim of maintaining or improving nutritional status, patient functionality and quality of life.

Bibliography

1. García-Luna PP, Parejo J, Pereira JL. Causes and clinical impact of malnutrition and cachexia in cancer patients. Nutr Hosp. 2006; 21(Suppl. 3):10-6.
2. Arends J, Bachmann P, Baracos V, Barthelemy N, Bertz H, Bozzetti F, et al. ESPEN guidelines on nutrition in cancer patients. Clin Nutr. 2017; 36(1):11-48.
3. Arends J et al. ESPEN expert group recommendations for action against cancer-related malnutrition. Clin Nutr. 2017; 36:1187-1196.
4. Maltoni M, Caraceni A, Brunelli C, Broeckaert B, Christakis N, Eychmueller S, et al. Prognostic factors in advanced cancer patients: evidence based clinical recommendations – a study by the steering committee of the European association for palliative care. J Clin Oncol. 2005; 23(25):6240-48.
5. Tan CS, Read JA, Phan VH, Beale PJ, Peat JK, Clarke SJ, et al. The relationship between nutritional status, inflammatory markers and survival in patients with advanced cancer: a prospective cohort study. Support Care Cancer 2015; 23:385-91.
6. de Oliveira LC, Abreu GT, Lima LC, Aredes MA, Wiegert EVM. Quality of life and its relation with nutritional status in patients with incurable cancer in palliative care. Support Care Cancer. 2020; Feb 7. doi:10.1007/s00520-020-05339-7.
7. Marcela C. Souza Jr, Emanuelly Varea Maria Wiegert, Larissa Calixto-Lima, Livia C. Oliveira. Relationship of nutritional status and inflammation with survival in patients with advanced cancer in palliative care. Nutrition 2018. doi: 10.1016/j.nut.2017.12.004.
8. Philipson TJ1, Snider JT, Lakdawalla DN, Stryckman B, Goldman DP. Impact of oral nutritional supplementation on hospital outcomes. Am J Manag Care. 2013; 19(2):121-8.
9. Gómez Candela C, Cantón Blanco A, Luengo Pérez LM, Fuster GO. Efficacy, cost- effectiveness, and effects on quality of life of nutritional supplementation. Nutr Hosp. 2010;25(5):781-92.