Anorexia

Overview                               

Appetite loss and reduced caloric intake (anorexia) are common among patients with advanced cancer and other advanced illness. Anorexia is multifactorial, in part related to changes in pro-inflammatory upregulation and appetite mediators. The involuntary loss of more than 10% of pre-morbid weight resulting in loss of muscle, without fat (cachexia) is a common syndrome that effects people in the late stages of serious disease. Anorexia and cachexia often occur together. 

  • Consider importance of food in the social context and impact on quality of life, cultural issues, patient's accessibility to food
  • Screen, assess and manage potential causes of secondary cachexia (anti-cancer treatment, other medication and psychosocial factors)
  • Consider stage of disease, progression of disease and Palliative Performance Scale (PPS), or functional status when determining goals of care and treatment plans
  • Consider contributing causes and treat if appropriate according to goals of care
  • Provide emotional support to patient and family
  • Referral to other health care professionals where appropriate
  1. Poor palatability of prescribed diets (e.g. dietary restriction of sodium ± other restrictions based on clinical diagnoses)
  2. Early satiety (e.g. gastroparesis medications, physical limitations such as ascites)
  3. Dysgeusia (e.g. zinc deficiency)
  4. Medications (e.g. antihistamines, opioids, certain antibiotics, antidepressants)
  5. Hypogonadism (e.g. hypothyroidism, adrenal insufficiency)  
  6. Poorly controlled symptoms (e.g. See patient handouts in Helpful Links below)
  7. Anxiety & Depression

General Principles

Consider interdisciplinary consultation as appropriate:

  • A Dietitian or Nutrition Specialist can help evaluate and improve a patient’s nutrition
  • Early consultation with the palliative or supportive care team should be considered

Encourage the following behaviour:

  • Suggest smaller, more frequent meals and snacks high in calories and protein (every 3 to 4 hourly)
  • Consider relaxing previous dietary restrictions except for allergies to encourage increased oral intake
  • Recommend oral nutritional supplements as needed to augment diet; particularly if patient has symptoms that interfere with nutritional intake or absorption, e.g. Boost, Ensure
  • If nausea is an issue, recommend cold foods which may cause less aversion
  • Focusing on enjoyment of food within the limits of the patient’s ability
  • Encourage exercise, as tolerated by patient. Walking fifteen minutes a day can help regulate appetite
  • Reserving room for food by limiting fluid intake to 30 min prior to meals to avoid feeling full
  • Avoiding drinks that reduce appetite and provide little nutrition such as coffee, tea and water
  • Avoiding spicy, acidic, or overly sweet foods
  • Sitting upright for 30-60 min after eating to facilitate digestion
  • Consider setting alarms as reminders to eat

General Principles

  • There is no data to support the routine use of appetite supplements in the setting of cirrhosis
  • In cancer patients, appetite stimulants such as Megesterone acetate have not shown benefits on sarcopenia, physical function or survival. Use is associated with a risk of thrombosis

One:carepath Patient Handout Lack of Appetite

One:carepath Patient Handout Taste Changes

One:carepath Patient Handout Pain

One:carepath Patient Handout Dehydration

One:carepath Patient Handout Swallowing Difficulties

One:carepath Patient Handout Depression & Anxiety

AHS Adding Protein & Calories To Your Diet

AHS Eating Well When You Have Taste & Smell Changes

AHS Eating Well With Cirrhosis