“He’s Losing Weight…What Are You Doing to Help Him?”: How to Better Assess Your Patients’ Nutrition

Imagine entering an exam room and your patient’s significant other asking how their loved one can prevent further weight loss. How would you respond? Many clinicians would not feel confident in what to say. Clinicians caring for people living with a serious illness regularly encounter patients with a variety of nutritional needs that stem from illness progression and side effects of treatment. This is especially true with cancer, where most of the relevant palliative care/nutrition research is concentrated.

Fortunately, clinicians can partner with registered dietitians (RD) to help patients and their families work through this complex issue. Knowing when and how to loop your nutrition colleagues into the conversation can help you focus your time assessing and managing your patient’s medical needs while allowing RDs to use their expert training to address complex nutritional needs.

While a complicated topic, a crucial starting point is an accurate assessment of the patient’s goals of care and trajectory of disease, which you have likely already completed.

The focus of palliative care is the whole patient—and everything that contributes to improving their quality of life. A key part is the patient’s nutrition, which unfortunately doesn’t always get the attention it desperately needs due to time constraints or limited guidance on how to approach these topics.

A number of factors can influence one’s ability to take in food:

• Medication side effects (e.g., mouth sores, altered sense of taste)
• Anorexia or low appetite
• Presence and severity of gastrointestinal (GI) symptoms (e.g., nausea, vomiting, diarrhea, or constipation)
• Pain
• Hospitalizations, which might be prolonged

Additionally, the patient’s function must be considered. Can they participate in their activities of daily living (ADLs) at a level that aligns with their ideal quality of life? The aforementioned factors can all influence this question, so they must be addressed.

Any clinician can get the screening process started. Currently, we don’t have a screening tool that’s designed specifically for assessing nutritional risk in the palliative care setting, but other validated tools can help you decide if a full nutrition assessment from an RD is warranted. These include:

• Malnutrition Screening Tool (MST), a two-step questionnaire that asks the patient about recent weight loss and appetite. The MST is validated for outpatient use and is most often used in oncology.
• Malnutrition Universal Screening Tool (MUST), a five-step tool used to assess malnutrition in adults.
• Mini Nutritional Assessment Short Form (MNA-SF), which is most commonly used in older adults in institutional settings.

Check with your organization to see what’s already in place—a validated malnutrition screening tool (e.g., the MST) may already be integrated into the electronic health record.

Starting with a screening tool can uncover some useful information, prompting you to consult your nutrition colleagues. But it may only scratch the surface. It can confirm that a patient isn’t eating as much as they should, or that they’re losing weight, but it will not tell you why. Including the RD can help uncover how and why the patient isn’t eating—or why they’re losing weight.

But where can you start if your RD colleague isn’t available during the outpatient visit? A few questions that you, as the clinician, may ask include:

• Are you experiencing any side effects from your meds? What have you noticed?
• Tell me about the timing of the nausea/vomiting/diarrhea you’ve been having.
• Are you having any difficulties chewing or swallowing?
• Have you noticed any changes in your abilities to carry out your activities of daily living.
• What is a typical day’s intake of food and drink recently?
• Are you having any issues getting enough food to eat?
• Has your appetite changed?
• Does food taste different?

The answers may be illuminating. You might find out that a patient isn’t eating because they have developed thrush or dry mouth as the result of their chemotherapy regimen, or they’re experiencing GI dysmotility from taking their antidepressant. You may discover that they’ve developed dysphagia, or perhaps they don’t want to eat because of the metallic taste left behind after a new zinc deficiency related to chronic diarrhea following radiation therapy. You may uncover that a patient cannot afford nutritious food because of the other costs associated with their illness.

Every answer will give you a better sense of their current nutritional status and uncover more information you can use to help. There’s usually more than one root cause, so the more questions, the better.

After you’ve screened your patient and have a clear understanding of their trajectory and goals, consult with your organization’s nutrition team.

If your patient is in the hospital, there is usually a built-in team. If in an outpatient clinic, you may need to develop relationships with RDs in private practice for referral (but consider the cost and logistical implications for your patient in this case). If you have practicing privileges at your local hospital, the inpatient nutrition team may know which local services are available to meet outpatient needs. You can also reach out to your state or local nutrition associations or RDs who may provide telehealth services through nationwide telehealth services. Together, you, the RD, and the rest of the palliative care team can ensure the nutritional plans align with the patient’s goals of care.

We recently had a patient with advanced cervical cancer who had no GI symptoms but continued to lose weight despite saying that she was following her physician’s nutrition orders. One of our RDs initiated a conversation and discovered that she was drinking four oral nutrition supplements (equaling 1400 calories) per day, which was recommended by her oncologist.

She shared that she was still hungry and wanted to know when she could add food back into her diet. She wasn’t at her calorie goal of 2,000 as she had stopped eating and was only drinking supplements. She had misunderstood her oncologist’s directions and thought supplements were a better source of nutrition. Through conversations, the RD helped her reintroduce food, complementing meals with oral nutrition supplements. This critical change helped her meet her nutritional needs—so she could be discharged and go home feeling stronger.

We hope you can see how a few simple questions can open the door to a deeper understanding of how your patient’s nutritional status might be (negatively) impacting their quality of life and medical progression. By quickly screening your patients using a validated tool, you may uncover that they are at high risk for malnutrition—and you can do something about it (consult with an RD). Ultimately, finding ways to help your patients overcome nutritional barriers can relieve unnecessary stress and anxiety.

• The Academy of Nutrition and Dietetics, a reputable source with educational resources, which can help bridge the gap between the clinical visit and when the patient sees the RD
• American Society for Parenteral and Enteral Nutrition, which provides evidence-based resources for the appropriate use of nutrition support therapies and important considerations for patients and their families

Edited by Melissa Baron. Clinical review by Andrew Esch, MD, MBA.