Different Quantities of Two Commercial Liquid Diets Consumed by Weight-Losing Cancer Patients LARS OVESEN, MD; From Medical Department
AND
LENE ALLINGSTRUP, RD
C, Division of Oncology, Bispebjerg University Hospital, Copenhagen, Denmark
ABSTRACT. Twenty ambulatory, weight-losing patients with advanced cancer of the lung, breast, or ovary were randomized
supplement their diet for 2 months with either of two commercial complete liquid diets, one containing intact milk proteins and the other partially hydrolyzed soy proteins. Both products were prescribed as sip feeds in addition to normal food. The patients consumed more of the hydrolysate-containing product than of that with intact (milk) protein. The differ-
to
Cancer, especially if advanced, is often accompanied by poor appetite and insufficient food intake leading to progressive weight loss and decreased well-being.l°2 In these situations it is common to recommend some kind of sip feed supplementation. To find the most acceptable supplement for cancer patients some studies have evaluated taste preferences for different commercial productS.3-7 However, such taste preference testing does not
imply
high acceptability through longer periods. investigated long-term intake of two commercially manufactured, nutritionally complete liquid products used as sip feeds in ambulatory cancer patients with progressive weight loss, and evaluated the effect of nutrition supplementation on nutrition status. a
This study
METHODS
Twenty-six patients with advanced cancer of the lung (small cell), ovary, or breast were randomized to supplement their diet with either
one of two commercial liquid diets. One diet was based on intact milk protein (Salvimulsin MCT, Ercopharm, Copenhagen, Denmark). The other product supplied partially hydrolyzed soy protein as a source of nitrogen (Standard Top Up, Novo-Nordisk, Copenhagen, Denmark). Inclusion criteria were (1) an unintentional and continuous weight loss of more than 5% of body weight despite at least 2 months’ efforts by the dietitian to increase weight by increasing intake of ordinary foods (during this period patients consulted the dietitian whenever they needed, but at least twice monthly), (2) a performance status of not more than 3 on the Eastern Cooperative Oncology Group scale (the scale quantifies performance in this way: 0 asymptomatic ; 1 symptomatic, full activity; 2 symptomatic, =
=
=
Reprint requests: Lars Ovesen, MD, Clinical Nutrition Service. Department of Medicine, Albany Medical College, 214 Hun A-23, Albany, NY 12208.
significant and was maintained during both months of the study. An increase in total energy and protein was obtained in both groups, but was significant only with the hydrolysate product. At the end of the study there was no group difference in measures of nutritional status, but weight loss was halted in both groups. (Journal of Parenteral and Enteral Nutrition 16:275-278, 1992)
ence was
less than 50% of time in bed; 3 symptomatic, spends more than 50% of time in bed; 4 bedridden), (3) no evidence of ascites or metastatic disease to the brain, and (4) a life expectancy of more than 2 months. The two liquid diets used in this study are popular as dietary supplements and both are nutritionally complete, lactose-free, and contain almost the same amounts of macro- and micronutrients (Table I). However, their basic tastes are distinctly different: the peptide product has a weakly sour taste (pH 4.2), and the intact protein product has a characteristic milky taste (neutral, pH 6.5). Similar products had received high palatability ratings in a prior study.’ The patients were offered free choice between two different flavor varieties: pineapple or lemon for the hydrolyzed protein product and chocolate or nut/vanilla for the intact protein product. Supplements were delivered at regular intervals to the patients’ addresses. It was recommended that they be consumed cold from the refrigerator, primarily between meals. Patients came on a regular basis (twice monthly) to the oncology outpatient clinic. In conjunction with these visits all patients in the study were also seen by the dietitian, who continued the nutrition counseling on an individual basis according to lines of instructions generally employed.’ The supplementation period lasted for 2 months. The patients were asked to drink at least 500 mL of the product daily but were encouraged to drink as much as possible. All nutrition measurements were performed before start of supplementation and after 1 and ’? months. A 3day dietary record was used to calculate energy and protein intake using a computer-based program based on Danish food composition tables. The dietitian gave each patient detailed instructions on how to weigh and measure food using scales and measuring cups. In patients receiving chemotherapy, dietary intake recordings were performed during the week before (monthly) cyclical therapy was planned. The volume of the commercial
spends
=
=
=
=
275
Downloaded from pen.sagepub.com at MOUNT ALLISON UNIV on June 24, 2015
276 TABLE I
TABLE II
Composition and nutrient values of the protein hydrolysate supplement (Standard Top Up) and the intact protein supplement
Performance status,
cancer
disease, and
treatment
of the patients
(Saluimulsin MCT) ___
product consumed was recorded daily by the patients. Indicators of nutrition status included height, habitual and actual weights, midarm circumference, and triceps skinfold thickness. Body weight was measured by a calibrated physician’s scale. Arm circumference was meas-
* CM, breast cancer; CO, ovarian cancer; CP, lung cancer. ured using a nonstretchable tape. Triceps skinfold thick- t Cis, cisplatin; CY, cyclophosphamide; EP, epirubicin; FU, fluracil; ME, methotrexate; TP, tenoposide; VCR, vincristine. ness was measured using the Harpenden caliper, and the average of three readings was used. Midarm muscle area Figure 1. In patients offered the soy protein hydrolysate (&dquo;bone-free&dquo; arm muscle area) was calculated from arm total intakes of energy and protein increased significircumference and triceps skinfold according to the equacantly during both supplementation months compared tion by Heymsfield et al. 10 with the presupplementation intakes. Although intakes Of the 26 patients who fulfilled the inclusion criteria, of energy and protein, especially during the first month, 3 patients died in the first month of supplementation (2 also were higher in patients randomized to the intact patients receiving the intact protein supplement, 1 re- milk protein product, the increase was not significant. ceiving the protein hydrolysate), and 3 patients (2 re- The mean (±SD) volumes of the protein hydrolysate and ceiving intact protein, 1 receiving protein hydrolysate) of the intact protein product consumed daily were 610 declined further participation because of side effects mL and 419 (± 172) mL (p < .05), respectively, (±189) 20 the (abdominal cramps). Thus, patients completed 222 (± trial. Twelve of these patients (8 women, 4 men; median during the first month, and 558 (±219) mL and < .05) during the second month. mL 53) (p [range] age, 66 [29 to 76] years) took the protein hydrolThere were no significant differences in nutrition staysate and 8 (7 women, 1 man; median [range] age, 61 [44 tus between groups at the beginning or at the end of the to 70] years) the intact protein diet. Of those patients period, but the progressive weight loss supplementation the 12 intact 7 trial, (5 completing protein, protein hyobserved in the presupplementation period stopped in drolysate) received cyclical chemotherapeutic therapy both groups in the supplementation period (Table III). during the supplementation period (Table II). All patients had advanced disease (TNM classification: M1 in In fact, in the protein hydrolysate group, weight loss was breast and ovarian cancer patients, and disease outside reduced by 1.6%, resulting in a mean increase in body weight of 1.0 kg, whereas in the intact protein group, one hemithorax in small cell lung cancer). None received antineoplastic endocrine therapy including corticoster- weight loss increased by 0.2%, resulting in a mean decrease in body weight of 0.9 kg after 2 months of suppleoids or progestogens. The protocol was approved by the local ethics com- mentation. mittee, and the study was conducted according to the DISCUSSION Helsinki II declaration. Group means were compared and differences were Commercial liquid feeds are frequently offered to paassessed by the unpaired Student’s t test. Changes within tients with cancer who complain of poor appetite, early groups with time were assessed by the paired t test. satiety, and weight loss. Several studies have been made Where changes over more than two periods were being of the of commercial products, and on the compared, analysis of variance followed by the paired t basis ofpalatability such studies one or more products are usually test was used. Only two-sided p values of less than .05 recommended to the patient with cancer.3-’ However, it were considered statistically significant. has been shown that an initial good palatability rating does not predict high intake of the products in question.’ RESULTS Poor compliance frequently secondary to gastrointestinal Mean daily intakes of energy and protein before and symptoms seems to be the most difficult problem in during the 2 months of supplementation are shown in patients offered liquid diet supplements. Poor compliDownloaded from pen.sagepub.com at MOUNT ALLISON UNIV on June 24, 2015
277 Nutrition status
All values
FIG. 1. Energy and protein intake in the presupplementary period, and after 1 and 2 months of supplementation with the protein hydrolysate product (open bars) and the intact protein product (hatched bars). Shading indicates the intake from supplements. * p < .05 compared with presupplementary intakes.
in one third of the patients and is often evident during the first week of supplementation, despite an enthusiastic approach and offerings of several choices of flavor.8,1l It is claimed that the continued daily use of a liquid diet soon provokes taste fatigue and decreasing intake in many patients, but the few studies of long-term intake (>1 month) that have been performed have not found taste fatigue to be a significant problem. Brown et al. 12 asked 51 patients undergoing radiation therapy for intraabdominal malignancy to supplement their diet witch an ance occurs
before
are means
TABLE III and after 2 months of supplementation
(±SD). No differences
are
significant.
amino acid product for 4 to 5 weeks. Seventeen patients acted as control subjects. No difference was found in weight loss between supplemented and nonsupplemented groups. However, 21 patients dropped out because of intolerance. The authors did not examine actual intake from food and supplement. Moloney et ap3 investigated 97 patients receiving abdominal irradiation. Forty-two patients were given dietary counseling and supplements of a commercial product based on milk protein, the other 42 patients were control subjects. A significantly higher energy and protein intake was found in the supplemented group. At the end of the supplementation period lasting 5 weeks, daily energy and protein intakes were 8.2 MJ and 88 g compared with 6.3 MJ and 53 g in the control group. No distinction was made between intake from usual diet and from the supplement. Finally, Arnold and Richter&dquo; examined 50 patients with cancers of the head and neck who received radiation therapy. Twenty-three patients were randomized to supplement their diet with a milk-based commercial liquid product and 27 patients were control subjects. Intensive nutrition counseling was given to all patients during the 10-week trial. Nutrition supplementation increased total energy and protein intake. The daily energy and protein contribution from the supplement at week 10 were about 1.6 MJ and 30 g, respectively, and not significantly different from the intakes at week 1. Equal weight loss occurred in the two groups during the supplementation period. The two commercial liquid diets used in our study were chosen because (1) both have the reputation of being highly palatable and are popular as sip feeds, (2) they have distinctly different basic taste qualities, and (3) both products contain the same amounts of macro- and micronutrients. Our study showed that intake from sip feeds was higher with the soy protein hydrolysate product than with the intact milk protein product when offered to weight-losing patients with advanced cancer. In the second month the soy protein supplement provided 2.3 MJ and 28 g of protein daily, and the milk protein supplement 0.9 MJ and 11 g of protein. Eight of the 12 patients randomized to the protein hydrolysate had a daily intake of more than 500 mL during the second month of supplementa-
Downloaded from pen.sagepub.com at MOUNT ALLISON UNIV on June 24, 2015
278
tion, whereas
none of the 8 patients randomized to the intact milk protein product took the recommended volume. There was no difference in nutrition status between the two groups, but in both groups, further nutrition deterioration was halted through the combined effect of nutrition counseling and liquid supplementation. From our study we conclude that a partially hydrolyzed and slightly acidic product may be a better choice for long-term supplementation in weight-losing cancer patients than a neutral product based on intact milk protein.
ACKNOWLEDGMENTS
The authors wish to thank Novo-Nordisk and Erco-
pharm, the makers of Top Up and Salvimulsin MCT, for supplying the patients with the products. This work was supported by grant 89-402 from the Danish Cancer Society.
ment of the cancer patient. Cancer Res 37:2429-2431, 1977 4. Harrah JD, Stephens ND, Hawes MC: Prospective sensory evaluation of preparatory methods of elemental diets. JPEN 4:303-306, 1980 5. Gallagher P, Tweedle DE: Taste threshold and acceptability of commercial diets in cancer patients. JPEN 7:361-363, 1983 6. Brown RO, Schlegel K, Hall NH, et al: Taste preferences for nutritional supplements: Comparison of cancer patients and healthy controls using a wine-tasting scale. JPEN 10:490-493,1986 7. Parkinson SA, Lewis J, Morris R, et al: Oral protein and energy supplements in cancer patients. Hum Nutr: Appl Nutr 41A:233-
243, 1987 8. Ovesen L. Palatability and intake of two commercial liquid diets in patients with poor appetite. Eur J Clin Nutr 45:273-275, 1991 9. Eating hints. Recipes and tips for better nutrition during cancer treatment. US Department of Health and Human Services. National Institute of Health Publication No. 87-2079. Bethesda, Md, National Cancer Institute, 1986 10. Heymsfield SB, McManus C, Smith J, et al: Anthropometric measurement of muscle mass: Revised equations for calculating bonefree arm muscle area. Am J Clin Nutr 36:680-690, 1982 11. Williams CM, Driver LT, Older J, et al: A controlled trial of sipfeed supplements in elderly orthopaedic patients. Eur J Clin Nutr
43:267-274, 1989 MS, Buchanan RB, Karran SJ: Clinical observations on the effects of elemental diet supplementation during irradiation. Clin Radiol 31:19-20, 1980 Moloney M, Moriarty M, Daly L: Controlled studies of nutritional intake in patients with malignant disease undergoing treatment. Hum Nutr: Appl Nutr 37A:30-35, 1983 Arnold C, Richter MP: The effect of oral nutritional supplements on head and neck cancer. Int J Radiat Oncol Biol Phys 16:15951599, 1989
12. Brown
REFERENCES 13.
1. Kern KA, Norton JA: Cancer cachexia. JPEN 12:286-298, 1988 2. DeWys WD, Begg C, Lavin PT, et al: Prognostic effect of weightloss prior to chemotherapy in cancer patients. Am J Med 69:4913.
497, 1980 DeWys WD, Herbst SH: Oral feeding in the nutritional
manage-
14.
Downloaded from pen.sagepub.com at MOUNT ALLISON UNIV on June 24, 2015
AND
LENE ALLINGSTRUP, RD
C, Division of Oncology, Bispebjerg University Hospital, Copenhagen, Denmark
ABSTRACT. Twenty ambulatory, weight-losing patients with advanced cancer of the lung, breast, or ovary were randomized
supplement their diet for 2 months with either of two commercial complete liquid diets, one containing intact milk proteins and the other partially hydrolyzed soy proteins. Both products were prescribed as sip feeds in addition to normal food. The patients consumed more of the hydrolysate-containing product than of that with intact (milk) protein. The differ-
to
Cancer, especially if advanced, is often accompanied by poor appetite and insufficient food intake leading to progressive weight loss and decreased well-being.l°2 In these situations it is common to recommend some kind of sip feed supplementation. To find the most acceptable supplement for cancer patients some studies have evaluated taste preferences for different commercial productS.3-7 However, such taste preference testing does not
imply
high acceptability through longer periods. investigated long-term intake of two commercially manufactured, nutritionally complete liquid products used as sip feeds in ambulatory cancer patients with progressive weight loss, and evaluated the effect of nutrition supplementation on nutrition status. a
This study
METHODS
Twenty-six patients with advanced cancer of the lung (small cell), ovary, or breast were randomized to supplement their diet with either
one of two commercial liquid diets. One diet was based on intact milk protein (Salvimulsin MCT, Ercopharm, Copenhagen, Denmark). The other product supplied partially hydrolyzed soy protein as a source of nitrogen (Standard Top Up, Novo-Nordisk, Copenhagen, Denmark). Inclusion criteria were (1) an unintentional and continuous weight loss of more than 5% of body weight despite at least 2 months’ efforts by the dietitian to increase weight by increasing intake of ordinary foods (during this period patients consulted the dietitian whenever they needed, but at least twice monthly), (2) a performance status of not more than 3 on the Eastern Cooperative Oncology Group scale (the scale quantifies performance in this way: 0 asymptomatic ; 1 symptomatic, full activity; 2 symptomatic, =
=
=
Reprint requests: Lars Ovesen, MD, Clinical Nutrition Service. Department of Medicine, Albany Medical College, 214 Hun A-23, Albany, NY 12208.
significant and was maintained during both months of the study. An increase in total energy and protein was obtained in both groups, but was significant only with the hydrolysate product. At the end of the study there was no group difference in measures of nutritional status, but weight loss was halted in both groups. (Journal of Parenteral and Enteral Nutrition 16:275-278, 1992)
ence was
less than 50% of time in bed; 3 symptomatic, spends more than 50% of time in bed; 4 bedridden), (3) no evidence of ascites or metastatic disease to the brain, and (4) a life expectancy of more than 2 months. The two liquid diets used in this study are popular as dietary supplements and both are nutritionally complete, lactose-free, and contain almost the same amounts of macro- and micronutrients (Table I). However, their basic tastes are distinctly different: the peptide product has a weakly sour taste (pH 4.2), and the intact protein product has a characteristic milky taste (neutral, pH 6.5). Similar products had received high palatability ratings in a prior study.’ The patients were offered free choice between two different flavor varieties: pineapple or lemon for the hydrolyzed protein product and chocolate or nut/vanilla for the intact protein product. Supplements were delivered at regular intervals to the patients’ addresses. It was recommended that they be consumed cold from the refrigerator, primarily between meals. Patients came on a regular basis (twice monthly) to the oncology outpatient clinic. In conjunction with these visits all patients in the study were also seen by the dietitian, who continued the nutrition counseling on an individual basis according to lines of instructions generally employed.’ The supplementation period lasted for 2 months. The patients were asked to drink at least 500 mL of the product daily but were encouraged to drink as much as possible. All nutrition measurements were performed before start of supplementation and after 1 and ’? months. A 3day dietary record was used to calculate energy and protein intake using a computer-based program based on Danish food composition tables. The dietitian gave each patient detailed instructions on how to weigh and measure food using scales and measuring cups. In patients receiving chemotherapy, dietary intake recordings were performed during the week before (monthly) cyclical therapy was planned. The volume of the commercial
spends
=
=
=
=
275
Downloaded from pen.sagepub.com at MOUNT ALLISON UNIV on June 24, 2015
276 TABLE I
TABLE II
Composition and nutrient values of the protein hydrolysate supplement (Standard Top Up) and the intact protein supplement
Performance status,
cancer
disease, and
treatment
of the patients
(Saluimulsin MCT) ___
product consumed was recorded daily by the patients. Indicators of nutrition status included height, habitual and actual weights, midarm circumference, and triceps skinfold thickness. Body weight was measured by a calibrated physician’s scale. Arm circumference was meas-
* CM, breast cancer; CO, ovarian cancer; CP, lung cancer. ured using a nonstretchable tape. Triceps skinfold thick- t Cis, cisplatin; CY, cyclophosphamide; EP, epirubicin; FU, fluracil; ME, methotrexate; TP, tenoposide; VCR, vincristine. ness was measured using the Harpenden caliper, and the average of three readings was used. Midarm muscle area Figure 1. In patients offered the soy protein hydrolysate (&dquo;bone-free&dquo; arm muscle area) was calculated from arm total intakes of energy and protein increased significircumference and triceps skinfold according to the equacantly during both supplementation months compared tion by Heymsfield et al. 10 with the presupplementation intakes. Although intakes Of the 26 patients who fulfilled the inclusion criteria, of energy and protein, especially during the first month, 3 patients died in the first month of supplementation (2 also were higher in patients randomized to the intact patients receiving the intact protein supplement, 1 re- milk protein product, the increase was not significant. ceiving the protein hydrolysate), and 3 patients (2 re- The mean (±SD) volumes of the protein hydrolysate and ceiving intact protein, 1 receiving protein hydrolysate) of the intact protein product consumed daily were 610 declined further participation because of side effects mL and 419 (± 172) mL (p < .05), respectively, (±189) 20 the (abdominal cramps). Thus, patients completed 222 (± trial. Twelve of these patients (8 women, 4 men; median during the first month, and 558 (±219) mL and < .05) during the second month. mL 53) (p [range] age, 66 [29 to 76] years) took the protein hydrolThere were no significant differences in nutrition staysate and 8 (7 women, 1 man; median [range] age, 61 [44 tus between groups at the beginning or at the end of the to 70] years) the intact protein diet. Of those patients period, but the progressive weight loss supplementation the 12 intact 7 trial, (5 completing protein, protein hyobserved in the presupplementation period stopped in drolysate) received cyclical chemotherapeutic therapy both groups in the supplementation period (Table III). during the supplementation period (Table II). All patients had advanced disease (TNM classification: M1 in In fact, in the protein hydrolysate group, weight loss was breast and ovarian cancer patients, and disease outside reduced by 1.6%, resulting in a mean increase in body weight of 1.0 kg, whereas in the intact protein group, one hemithorax in small cell lung cancer). None received antineoplastic endocrine therapy including corticoster- weight loss increased by 0.2%, resulting in a mean decrease in body weight of 0.9 kg after 2 months of suppleoids or progestogens. The protocol was approved by the local ethics com- mentation. mittee, and the study was conducted according to the DISCUSSION Helsinki II declaration. Group means were compared and differences were Commercial liquid feeds are frequently offered to paassessed by the unpaired Student’s t test. Changes within tients with cancer who complain of poor appetite, early groups with time were assessed by the paired t test. satiety, and weight loss. Several studies have been made Where changes over more than two periods were being of the of commercial products, and on the compared, analysis of variance followed by the paired t basis ofpalatability such studies one or more products are usually test was used. Only two-sided p values of less than .05 recommended to the patient with cancer.3-’ However, it were considered statistically significant. has been shown that an initial good palatability rating does not predict high intake of the products in question.’ RESULTS Poor compliance frequently secondary to gastrointestinal Mean daily intakes of energy and protein before and symptoms seems to be the most difficult problem in during the 2 months of supplementation are shown in patients offered liquid diet supplements. Poor compliDownloaded from pen.sagepub.com at MOUNT ALLISON UNIV on June 24, 2015
277 Nutrition status
All values
FIG. 1. Energy and protein intake in the presupplementary period, and after 1 and 2 months of supplementation with the protein hydrolysate product (open bars) and the intact protein product (hatched bars). Shading indicates the intake from supplements. * p < .05 compared with presupplementary intakes.
in one third of the patients and is often evident during the first week of supplementation, despite an enthusiastic approach and offerings of several choices of flavor.8,1l It is claimed that the continued daily use of a liquid diet soon provokes taste fatigue and decreasing intake in many patients, but the few studies of long-term intake (>1 month) that have been performed have not found taste fatigue to be a significant problem. Brown et al. 12 asked 51 patients undergoing radiation therapy for intraabdominal malignancy to supplement their diet witch an ance occurs
before
are means
TABLE III and after 2 months of supplementation
(±SD). No differences
are
significant.
amino acid product for 4 to 5 weeks. Seventeen patients acted as control subjects. No difference was found in weight loss between supplemented and nonsupplemented groups. However, 21 patients dropped out because of intolerance. The authors did not examine actual intake from food and supplement. Moloney et ap3 investigated 97 patients receiving abdominal irradiation. Forty-two patients were given dietary counseling and supplements of a commercial product based on milk protein, the other 42 patients were control subjects. A significantly higher energy and protein intake was found in the supplemented group. At the end of the supplementation period lasting 5 weeks, daily energy and protein intakes were 8.2 MJ and 88 g compared with 6.3 MJ and 53 g in the control group. No distinction was made between intake from usual diet and from the supplement. Finally, Arnold and Richter&dquo; examined 50 patients with cancers of the head and neck who received radiation therapy. Twenty-three patients were randomized to supplement their diet with a milk-based commercial liquid product and 27 patients were control subjects. Intensive nutrition counseling was given to all patients during the 10-week trial. Nutrition supplementation increased total energy and protein intake. The daily energy and protein contribution from the supplement at week 10 were about 1.6 MJ and 30 g, respectively, and not significantly different from the intakes at week 1. Equal weight loss occurred in the two groups during the supplementation period. The two commercial liquid diets used in our study were chosen because (1) both have the reputation of being highly palatable and are popular as sip feeds, (2) they have distinctly different basic taste qualities, and (3) both products contain the same amounts of macro- and micronutrients. Our study showed that intake from sip feeds was higher with the soy protein hydrolysate product than with the intact milk protein product when offered to weight-losing patients with advanced cancer. In the second month the soy protein supplement provided 2.3 MJ and 28 g of protein daily, and the milk protein supplement 0.9 MJ and 11 g of protein. Eight of the 12 patients randomized to the protein hydrolysate had a daily intake of more than 500 mL during the second month of supplementa-
Downloaded from pen.sagepub.com at MOUNT ALLISON UNIV on June 24, 2015
278
tion, whereas
none of the 8 patients randomized to the intact milk protein product took the recommended volume. There was no difference in nutrition status between the two groups, but in both groups, further nutrition deterioration was halted through the combined effect of nutrition counseling and liquid supplementation. From our study we conclude that a partially hydrolyzed and slightly acidic product may be a better choice for long-term supplementation in weight-losing cancer patients than a neutral product based on intact milk protein.
ACKNOWLEDGMENTS
The authors wish to thank Novo-Nordisk and Erco-
pharm, the makers of Top Up and Salvimulsin MCT, for supplying the patients with the products. This work was supported by grant 89-402 from the Danish Cancer Society.
ment of the cancer patient. Cancer Res 37:2429-2431, 1977 4. Harrah JD, Stephens ND, Hawes MC: Prospective sensory evaluation of preparatory methods of elemental diets. JPEN 4:303-306, 1980 5. Gallagher P, Tweedle DE: Taste threshold and acceptability of commercial diets in cancer patients. JPEN 7:361-363, 1983 6. Brown RO, Schlegel K, Hall NH, et al: Taste preferences for nutritional supplements: Comparison of cancer patients and healthy controls using a wine-tasting scale. JPEN 10:490-493,1986 7. Parkinson SA, Lewis J, Morris R, et al: Oral protein and energy supplements in cancer patients. Hum Nutr: Appl Nutr 41A:233-
243, 1987 8. Ovesen L. Palatability and intake of two commercial liquid diets in patients with poor appetite. Eur J Clin Nutr 45:273-275, 1991 9. Eating hints. Recipes and tips for better nutrition during cancer treatment. US Department of Health and Human Services. National Institute of Health Publication No. 87-2079. Bethesda, Md, National Cancer Institute, 1986 10. Heymsfield SB, McManus C, Smith J, et al: Anthropometric measurement of muscle mass: Revised equations for calculating bonefree arm muscle area. Am J Clin Nutr 36:680-690, 1982 11. Williams CM, Driver LT, Older J, et al: A controlled trial of sipfeed supplements in elderly orthopaedic patients. Eur J Clin Nutr
43:267-274, 1989 MS, Buchanan RB, Karran SJ: Clinical observations on the effects of elemental diet supplementation during irradiation. Clin Radiol 31:19-20, 1980 Moloney M, Moriarty M, Daly L: Controlled studies of nutritional intake in patients with malignant disease undergoing treatment. Hum Nutr: Appl Nutr 37A:30-35, 1983 Arnold C, Richter MP: The effect of oral nutritional supplements on head and neck cancer. Int J Radiat Oncol Biol Phys 16:15951599, 1989
12. Brown
REFERENCES 13.
1. Kern KA, Norton JA: Cancer cachexia. JPEN 12:286-298, 1988 2. DeWys WD, Begg C, Lavin PT, et al: Prognostic effect of weightloss prior to chemotherapy in cancer patients. Am J Med 69:4913.
497, 1980 DeWys WD, Herbst SH: Oral feeding in the nutritional
manage-
14.
Downloaded from pen.sagepub.com at MOUNT ALLISON UNIV on June 24, 2015
