Case Study – Nutritional Management in Cancer

(The original language of this article is French, and the graphs are shown from actual screenshots in the original language)

Numerous recent studies have highlighted that cancer can be associated with the onset of cachexia, which is characterized by a pathological decrease in skeletal muscle mass and fat mass¹. In addition to the consequences on quality of life, cachexia is also responsible for a drastic reduction in the chances of patient survival², making it necessary to prevent and detect its onset as early as possible. The causes of cachexia are multiple and include, among others, cancerous pathophysiological mechanisms, side effects of treatments, particularly chemotherapy, and/or a decrease in nutritional intake. In this context, it is crucial that cancer patients have appropriate nutritional management to 1) avoid the onset of cachexia, 2) improve treatment quality, and 3) maintain quality of life. In this case study, we will present the nutritional management of a woman during her breast cancer and how bioimpedance analysis can be used to perform this monitoring.

Sex	Female
Age	54 years
Height	164 cm
Weight	68 kg
BMI	28,67 kg/m2
Pathologies	Breast cancer
Remarks	Unbalanced lifestyle but no medical history

Quick Analysis – First Visit (January 2022)

The patient’s first visit to the nutritionist took place at the time of her breast cancer diagnosis. Her quick analysis shows an excess fat mass of 6.71 kg associated with a muscle mass 2.59 kg higher than health references and slight dehydration of 1.16 L at the time of measurement. Muscle load and total load indices suggest good capacity of the musculoskeletal system to support the excess body mass, especially during exercise.

Although the values of the phase angle and the impedance ratio are within normal ranges, they remain close to the thresholds of 6.12 for the phase angle and 0.82, suggesting a moderate inflammatory and pro-oxidant state associated with the cancer.

Fat-Free Mass, Skeletal Muscle Mass, and Fat-Free Dry Mass

Cachexia is considered a form of cancer-associated malnutrition, so it is important to control the parameters associated with malnutrition, which are fat-free mass, fat-free dry mass, and skeletal muscle mass, to verify if they are sufficient at the start of care to compensate for potential cachexia. In this patient’s case, these three parameters are above health references. Indeed, we can observe that the fat-free mass index (FFMI) is equal to 18.01 kg/m², well above the limit of 15 kg/m², and that skeletal muscle mass is 2.59 kg higher than the health reference. These data suggest that the patient has sufficient fat-free mass and skeletal muscle mass to 1) compensate for a pathological decrease associated with the onset of cachexia and 2) engage in physical activity without too many physiological limitations. This observation is reinforced by the fat-free dry mass value, which is 330 g higher than the reference, confirming a significant amount of proteins and minerals in this patient, considering her lifestyle.

Fat mass

As shown in the quick analysis, the patient has a fat mass 6.71 kg higher than the reference, corresponding to a fat mass percentage approximately 9% higher than the reference. Given this result and her BMI, this patient is significantly overweight, nearing obesity, which is explained by her unbalanced lifestyle.

Hydration and Fat-Free Balance

Considering the high percentage of fat mass in this patient, it is more relevant to use fat-free hydration measures to limit the effects of excess fat mass on hydration measurement. Indeed, body compartment modeling divides the body into fat mass, containing only the lipids of adipose tissue, and fat-free mass, composed of all body water, proteins, and minerals. Thus, the water in adipose tissue is included in total water, fat-free mass hydration, and total water balance. Adipose tissue has a hydration rate of approximately 15%, with a water distribution of 20% intracellular and 80% extracellular. The main consequence of these differences is that an excess of adipose tissue can artificially mask dehydration and/or water imbalance of the fat-free mass. Additionally, water exchange and regulation mainly occur in the fat-free mass, so these two measures aim to study the water movements within this compartment precisely, where the organs ensuring normal body function are located.

In this patient’s case, we can observe that she is dehydrated (-1.16 L), but intracellular hydration is maintained, and the dehydration is extracellular.

Bone Mineral Content

In this context, it is also interesting to monitor bone mass, as skeletal demineralization can occur due to the pro-inflammatory and pro-oxidant state induced by cancer and/or chemotherapy and/or a decrease in daily food intake.

Here, the patient has a bone mass 160 g higher than the health reference, which means she can compensate for the onset of cachexia and maintain sufficient bone mineral content.

Management

Before her first visit, the patient had an unbalanced lifestyle that could worsen her pathological condition during treatment. Therefore, a secondary management plan focused on improving her lifestyle was proposed. More specifically, the patient has:

• adopted a Mediterranean diet associated with stopping the consumption of foods containing simple/quick sugars.
• started and maintained regular physical activity.
• followed hypnosis sessions alongside her chemotherapy and then her radiotherapy.

The objective of this management was to provide a healthy physiological environment to 1) limit the pathophysiological consequences of cancer, 2) promote the therapeutic effects of treatments, and 3) limit their side effects.

Quick Analysis – Last Visit (September 2023)

The patient’s last visit took place just after her cancer went into remission. Over these two years, the patient lost 7.2 kg of body mass, and the quick analysis suggests that she mainly lost fat mass and gained muscle mass with better hydration.

Fat-Free Mass, Skeletal Muscle Mass, and Fat-Free Dry Mass

For these three parameters, we can observe that the fat-free mass varies little (+80 g), with a gain of 700 g in muscle mass associated with a decrease of 1 kg in fat-free dry mass, including a loss of 1.13 kg of proteins and a gain of 120 g of minerals. It seems counterintuitive to observe the maintenance of fat-free mass and a gain in skeletal muscle mass associated with a decrease in proteins in fat-free dry mass, but this can be explained by two things:

• Fat-free mass and skeletal muscle mass have hydration rates of 73% and 75%, respectively. It is possible that these tissues are better hydrated, which is strongly suggested by the results of the quick analysis. These results could therefore be explained by a larger volume of water in these two tissues.
• Physiologically, skeletal muscle adapts its mass according to body weight to ensure locomotion and posture. This is why it is possible to observe very high muscle masses in obese people, even if they are not active: the excess body mass causes an increase in the mechanical tension applied to the skeletal muscle, stimulating muscle protein synthesis. The patient has lost a significant body mass (≈ 8 kg), mostly fat mass, which decreases the mechanical tension applied and thus the stimulation of protein synthesis. It is therefore normal for her to have lost protein mass over time.

However, it is interesting to note that the theoretical gap is 620 g, compared to 330 g at the first visit, suggesting that the patient has a higher fat-free dry mass relative to her weight, indicating an improvement in her body composition.

Fat Mass

Between the two measurements, the patient lost 7.30 kg of fat mass, representing a 6.87% decrease in fat mass percentage. This result shows that the lifestyle-focused management caused a significant fat mass loss in the patient, confirming the improvement in her body composition.

Hydration and Fat-Free Balance

Compared to the first measurement, we can observe an improvement in the patient’s hydration level with a slight water surplus of 180 mL. However, she presents a significant water imbalance with intracellular overhydration associated with extracellular dehydration. This indicates a physiological environment favoring intracellular water retention, e.g., a low-salt diet, and it seems necessary to address this situation.

Bone Mineral Content

Between the two measurements, the patient’s bone mineral content increased by 100 g over 2 years, which is a significant gain considering the patient’s health status and age. This gain is attributed to both an improved diet and increased physical activity.

Conclusion

The various data obtained show an improvement in overall health status during management, characterized by an improvement in phase angle and impedance ratio, maintenance of fat-free mass, better hydration, and fat mass loss. Considering that these results were achieved in the context of breast cancer, and thus cachexia was avoided, they confirm the importance of appropriate nutritional management in chronic diseases.

References

1. Fearon K, Arends J, Baracos V. Understanding the mechanisms and treatment options in cancer cachexia. Nat Rev Clin Oncol. févr 2013;10(2):90‑9.
2. Kurk SA, Peeters PHM, Dorresteijn B, de Jong PA, Jourdan M, Creemers GM, et al. Loss of skeletal muscle index and survival in patients with metastatic colorectal cancer: Secondary analysis of the phase 3 CAIRO3 trial. Cancer Med. 18 déc 2019;9(3):1033‑43.