欧洲肠外肠内营养学会癌症患者营养指南（二）
前情提要
第二章、癌症患者治疗总论
B1、筛查和评定
B1-1、筛查
为早期发现营养紊乱，我们推荐从癌症确诊开始常规评估营养摄入、体重变化和体重指数，重复评估取决于其临床病情的稳定情况。
推荐强度：强
证据级别：非常低
研究问题：筛查与评定、干预和临床结局的关系
高度共识
B1-2、评定
对筛查异常的患者，我们推荐客观、定量评定其营养摄入、受营养影响的表现、肌肉含量、身体活动能力和全身炎症反应程度。
推荐强度：强
证据级别：非常低
有待研究：将当前和今后干预试验的结局与合适的筛查和评定工具联系起来
共识
B2、能量和底物需求
B2-1、能量需求
我们推荐癌症患者总能量消耗，如果无单独测定，假设与健康人群相似，一般为25～30kcal/kg/d。
推荐强度：强
证据级别：低
有待研究：提高对每个患者能量需求的预测
共识
B2-2蛋白质需求
我们推荐蛋白质摄入量应高于1g/kg/d，如果可能，应达到1.5g/kg/d。
推荐强度：强
证据级别：中
有待研究：增加蛋白质/氨基酸供给（1～2g/kg/d）和组成对临床结局的影响
高度共识
B2-3、供能底物的选择
对合并胰岛素抵抗、体重下降的癌症患者，我们推荐增加脂肪供能与碳水化合物供能的比值。这是为了提高膳食的能量密度，并降低血糖负荷。
推荐强度：强
证据级别：低
有待研究：高脂饮食对全身炎症反应/胰岛素抵抗患者的影响，不同脂肪成分的影响
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B2-4、维生素和微量元素
我们推荐维生素和矿物质供给量应接近推荐的每日膳食营养素供给量（RDA），在无特定缺乏情况不鼓励使用高剂量微量营养素。
推荐强度：强
证据级别：低
有待研究：评定癌症患者的微量营养素状况及补充效果
高度共识
B3、营养干预
B3-1、营养干预效果
我们推荐对能摄食但存在营养不良或营养不良风险的癌症患者进行营养干预以增加其经口摄入。这包括饮食建议、治疗影响食物摄入的症状和紊乱（受营养影响的表现）及提供口服营养补充剂（ONS）。
推荐强度：强
证据级别：低
有待研究：饮食建议和ONS对临床结局的影响
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B3-2、潜在有害的饮食
我们推荐不要给有营养不良或营养不良风险的患者提供限制能量摄入的饮食。
推荐强度：强
证据级别：低
有待研究：禁食或禁食模拟饮食对抗癌药物想要和不想要作用的影响
高度共识
B3-3、营养供给方式：何时调整
如果已决定对患者进行喂养，若尽管有营养干预（咨询建议、ONS），但经口营养仍不足，我们推荐肠内营养，若肠内营养不足或不可行，推荐使用肠外营养。
推荐强度：强
证据级别：中
有待研究：EN或PN或二者联合对食物摄入不足患者临床结局的影响
高度共识
B3-4、再喂养综合征
如果经口摄食量严重减少已经很长一段时间，我们推荐在数天内只能慢慢增加（口服、肠内或肠外）营养，并采取额外的预防措施以防止再喂养综合征。
推荐强度：强
证据级别：低
有待研究：评定营养不良的癌症患者磷、钾和镁水平及其对人工喂养的反应
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B3-5、家庭人工营养
对长期饮食摄入不足和/或存在不可控的吸收不良患者，我们推荐合适的患者采用家庭人工营养（肠内或肠外）。
推荐强度：强
证据级别：低
有待研究：长期EN或PN对临床结局的影响
高度共识
B4、运动
B4-1、运动联合营养
我们推荐癌症患者维持或增加身体活动以保持肌肉含量、身体功能和代谢模式。
推荐强度：强
证据级别：高
有待研究：抗癌治疗前、中、后的身体活动对临床结局的影响，在治愈性和姑息性治疗时运动联合营养支持的效果
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B4-2、推荐的运动类型
我们建议除了有氧运动外进行个体化抗阻运动以维持肌肉力量和肌肉含量。
推荐强度：弱
证据级别：低
有待研究：在癌症治疗过程中抗阻和耐力运动作为支持和姑息治疗的组成部分对存活者临床结局的不同影响和联合作用
高度共识
B5、药理营养素和具有药理作用的物质
B5-1、使用糖皮质激素增加食欲
我们建议考虑在限定时间（1-3周）内使用糖皮质激素增加晚期癌症厌食患者的食欲，但要注意其潜在的严重副作用（如血栓栓塞）。
推荐强度：弱
证据级别：高
有待研究：更好地确定使用糖皮质激素获得有益效果的条件
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B5-2、使用孕激素增加食欲
我们建议考虑使用孕激素增加晚期癌症厌食患者的食欲，但要注意其副作用（如肌肉萎缩、胰岛素抵抗、感染）。
推荐强度：弱
证据级别：高
有待研究：进行前瞻性研究评估恰当的营养支持与孕激素的联合作用
共识
B5-3、使用大麻酚类改善食欲
尚无足够一致的临床数据资料推荐使用大麻酚类改善癌症患者的味觉异常或厌食。
推荐强度：—
证据级别：低
有待研究：大麻酚类对发生味觉改变的厌食癌症患者营养状况的影响
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B5-4、使用雄激素增加肌肉含量
目前尚无足够一致的临床数据资料推荐赞成使用雄激素类固醇增加肌肉含量。
推荐强度：—
证据级别：低
有待研究：选择性雄激素受体调节剂（SARM）对恶病质患者的作用机制及长期效果
共识
B5-5、使用氨基酸增加去脂体重
尚无足够一致的临床数据资料推荐补充支链氨基酸或其他氨基酸或其代谢产物以改善去脂体重。
推荐强度：—
证据级别：低
有待研究：在大规模随机试验中亮氨酸或HMB（羟基丁酸甲酯）对体重下降患者的影响
高度共识
B5-6、使用非甾体抗炎药物（NSAID）增加体重
尚无足够一致的临床数据资料推荐使用非甾体抗炎药物以增加体重下降患者的体重。
推荐强度：—
证据级别：低
有待研究：NSAID对合并全身炎症反应的癌症患者体成分和临床结局的影响
高度共识
B5-7、使用脂肪酸改善食欲和体重
对接受化疗并存在体重下降或营养不良风险的癌症晚期患者，我们建议补充N-3长链脂肪酸或鱼油以稳定或改善食欲、进食量、瘦体重和体重。
推荐强度：弱
证据级别：低
有待研究：N-3长链脂肪酸对接受抗肿瘤治疗的癌症患者的体成分和临床结局的影响，N-3长链脂肪酸对癌症恶病质患者的生活质量和临床结局的影响。
高度共识
B5-8、使用促胃动力药物改善早饱
对主诉早饱的患者，在诊断和治疗便秘后，我们建议考虑使用促胃动力药，但要注意甲氧氯普胺对中枢神经系统、多潘立酮对心律的潜在不良作用。
推荐强度：弱
证据级别：中
有待研究：在最佳营养咨询建议下促胃动力药对经口营养摄入的影响
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翻译：肖慧娟（天津市第三中心医院营养科）
Chapter B: General Concepts of Treatment Relevant to All Cancer Patients
Section B1: Screening and Assessment
B1-1 Screening
To detect nutritional disturbances at an early stage, we recommend to regularly evaluate nutritional intake, weight change and BMI, beginning with cancer diagnosis and repeated depending on the stability of the clinical situation.
Strength of recommendation: STRONG
Level of evidence: Very low
Questions for research: relationship of screening to assessment, Interventions and clinical outcomes
Strong consensus
B1-2 Assessment
In patients with abnormal screening, we recommend objective and quantitative assessment of nutritional intake, nutrition impact symptoms, muscle mass, physical performance and the degree of systemic inflammation.
Strength of recommendation: STRONG
Level of evidence: Very low
Questions for research: Linking outcomes from current and future intervention trials with appropriate screening and assessment tools
Consensus
Section B2: Energy and substrate requirements
B2-1 Energy requirements
We recommend, that total energy expenditure of cancer patients, if not measured individually, be assumed to be similar to healthy subjects and generally ranging between 25 and 30 kcal/kg/day.
Strength of recommendation: STRONG
Level of evidence: Low
Questions for research: improve prediction of energy requirements in the individual patient
Consensus
B2-2 Protein requirement
We recommend that protein intake should be above 1 g/kg/day and, if possible up to 1.5 g/kg/day
Strength of recommendation: STRONG
Level of evidence: Moderate
Questions for research: effect on clinical outcome of increased supply (1-2 g/kg/day) and composition of protein/amino acids
Strong consensus
B2-3 Choice of energy substrates
In weight-losing cancer patients with insulin resistance we recommend to increase the ratio of energy from fat to energy from carbohydrates. This is intended to increase the energy density of the diet and to reduce the glycemic load.
Strength of recommendation: STRONG
Level of evidence: Low
Questions for research: effect of a high fat diet on clinical outcome in patients with systemic inflammation/insulin resistance effect of varying the fat composition
Consensus
B2-4 Vitamins and trace elements
We recommend that vitamins and minerals be supplied in amounts approximately equal to the RDA and discourage the use of high-dose micronutrients in the absence of specific deficiencies.
Strength of recommendation: STRONG
Level of evidence: Low
Questions for research: Assessment of micronutrient status in cancer patients and effect of supplementation
Strong consensus
Section B3: Nutrition Interventions
B3-1 Efficacy of nutritional intervention
We recommend nutritional intervention to increase oral intake in cancer patients who are able to eat but are malnourished or at risk of malnutrition. This includes dietary advice, the treatment of symptoms and derangements impairing food intake (nutrition impact symptoms), and offering oral nutritional supplements.
Strength of recommendation: STRONG
Level of evidence: Moderate
Questions for research: effect of dietary advice and ONS on clinical outcome
Consensus
B3-2 Potentially harmful diets
We recommend to not use dietary provisions that restrict energy intake in patients with or at risk of malnutrition.
Strength of recommendation: STRONG
Level of evidence: Low
Questions for research: Effects of fasting or fasting mimicking diets on wanted and unwanted effects of anticancer agents
Strong consensus
B3-3 Modes of nutrition: when to escalate
If a decision has been made to feed a patient, we recommend enteral nutrition if oral nutrition remains inadequate despite nutritional interventions (counselling, ONS), and parenteral nutrition if enteral nutrition is not sufficient or feasible.
Strength of recommendation: STRONG
Level of evidence: Moderate
Questions for research: effect of EN or PN or combinations on clinical outcome in patients with inadequate food intake
Strong consensus
B3-4 Refeeding syndrome
If oral food intake has been decreased severely for a prolonged period of time, we recommend to increase (oral, enteral or parenteral) nutrition only slowly over several days and to take additional precautions to prevent a refeeding syndrome.
Strength of recommendation: STRONG
Level of evidence: Low
Questions for research: Assessment of phosphate, potassium and magnesium levels in malnourished cancer patients and response to artificial feeding
Consensus
B3-5 Home artificial nutrition
In patients with chronic insufficient dietary intake and/or uncontrollable malabsorption, we recommend home artificial nutrition (either enteral or parenteral) in suitable patients
Strength of recommendation: STRONG
Level of evidence: Low
Questions for research: Effect of long-term EN and PN on clinical outcome
Strong consensus
Section B4: Exercise
B4-1 Exercise in combination with nutrition
We recommend maintenance or an increased level of physical activity in cancer patients to support muscle mass, physical function and metabolic pattern.
Strength of recommendation: STRONG
Level of evidence: High
Questions for research: effect of physical activity before, during and after anticancer treatment on clinical outcome, effect of combining an exercise program with nutritional support in curative and palliative settings
Consensus
B4-2 Type of exercise recommended
We suggest individualized resistance exercise in addition to aerobic exercise to maintain muscle strength and muscle mass.
Strength of recommendation: WEAK
Level of evidence: Low
Questions for research: Differential and combined effects of resistance and endurance exercise on clinical outcome during anticancer therapy, in survivors and as a component of supportive and palliative care
Strong consensus
Section B5: Pharmaconutrients and Pharmacological Agents
B5-1 Corticosteroids to increase appetite
We suggest considering corticosteroids to increase the appetite of anorectic cancer patients with advanced disease for a restricted period of time (1-3 weeks) but to be aware of side effects (e.g. muscle wasting, insulin resistance, infections).
Strength of recommendation: WEAK
Level of evidence: High
Questions for research: Better define settings for a beneficial effect of corticosteroids
Consensus
B5-2 Progestins to increase appetite
Strength of recommendation: WEAK
We suggest considering progestins to increase the appetite of anorectic cancer patients with advanced disease but to be aware of potential serious side effects (e.g. thromboembolism).
Level of evidence: High
Questions for research: Prospective studies to evaluate the combined effects of appropriate nutritional support and progestins
Consensus
B5-3 Cannabinoids to improve appetite
Strength of recommendation: -
There are insufficient consistent clinical data to recommend cannabinoids to improve taste disorders or anorexia in cancer patients
Level of evidence: Low
Questions for research: Effects of cannabinoids on nutritional state in anorectic cancer patients with taste alterations
Consensus
B5-4 Androgens to increase muscle mass
Strength of recommendation: -
There are insufficient consistent clinical data to recommend currently approved androgenic steroids to increase muscle mass
Level of evidence: Low
Questions for research: Mechanism and long term effects of SARMs in patients with cachexia.
Consensus
B5-5 Amino acids to increase fat free mass
Strength of recommendation: -
There are insufficient consistent clinical data to recommend the supplementation with branched-chain or other amino acids or metabolites to improve fat free mass.
Level of evidence: Low
Questions for research: Effects of leucine or HMB (hydroxy methylbutyrate) in weight losing patients studied in large randomized trials
Strong consensus
B5-6 Non steroidal antiinflammatory drugs (NSAID) to increase body weight
Strength of recommendation: -
There are insufficient consistent clinical data to recommend nonsteroidal antiinflammatory drugs to improve body weight in weight losing cancer patients.
Level of evidence: Low
Questions for research: Effect of NSAID on body composition and clinical outcome in cancer patients with systemic inflammation
Strong consensus
B5-7 N-3 fatty acids to improve appetite and body weight
Strength of recommendation: WEAK
In patients with advanced cancer undergoing chemotherapy and at risk of weight loss or malnourished, we suggest to use supplementation with long-chain N-3 fatty acids or fish oil to stabilize or improve appetite, food intake, lean body mass and body weight.
Level of evidence: Low
Questions for research: Effect of long chain N-3 fatty acids on body composition and clinical outcome in cancer patients undergoing antineoplastic treatment. Effect of long chain N-3 fatty acids on quality of life and clinical outcome in patients with cancer cachexia.
Strong consensus
B5-8 Prokinetic drugs to improve early satiety
Strength of recommendation: WEAK
In patients complaining about early satiety, after diagnosing and treating constipation, we suggest to consider prokinetic agents, but to be aware of potential adverse effects of metoclopramide on the central nervous system and of domperidone on cardiac rhythm
Level of evidence: Moderate
Questions for research: Effect of prokinetics on oral nutritional intake in the context of optimal nutritional counselling
Consensus