Changes in Dietary Intake, Body Weight, Nutritional Status, and Metabolic Rate in a Pancreatic Cancer Patient
A 42-year-old man diagnosed with pancreatic head cancer at another hospital was referred to our hospital for a second opinion. For further evaluation, the patient underwent a biopsy that yielded positive results for malignant cells. The patient was in good health except for hypercholesterolemia. However, the patient complained of fatigue, dyspepsia, and nausea and developed jaundice. The patient's total bilirubin level was 10.6 mg/dL. Other blood test indices were as follows: albumin, 4.0 g/dL; total cholesterol, 288 mg/dL; and glycosylated hemoglobin (HbA1c), 6.1% ().\nNutrition consultation was regularly provided by a registered dietitian. Nutritional status was assessed using the scored Patient-Generated Subjective Global Assessment (PG-SGA) at diagnosis, as well as at 2 and 3 months after the diagnosis. Dietary intake was evaluated using 3-day food records. Measured resting energy expenditure (measured REE) was assessed using indirect calorimetry (TrueOne2400; Parvo Medics, Utah, USA), while predicted resting energy expenditure (predicted REE) was calculated using the Harris-Benedict equation at the time of diagnosis and 2 months later. To increase the accuracy of the food records, a trained registered dietitian confirmed all of the records written by the caregiver using face-to-face interviews. The daily intakes of energy and nutrients were calculated using the CAN-pro 3.0 (Korean Nutrition Society, Korea). The main caregiver was a family member (a sister) who assisted with the nutritional assessment by recording the patient's dietary intake.\nThe patient's height was 161 cm and usual body weight was 70 kg. At diagnosis, the patient's measured REE was 1,707 kcal/day (24.4 kcal/kg/day), while the predicted REE was 1,545 kcal/day (22.1 kcal/kg/day). The patient usually consumed 3 meals a day and sometimes had constipation, but this had no effect on the patient's dietary intake. The mean energy intake was 1,887 kcal/day (27.0 kcal/kg/day), and the mean protein intake was 56 g/day (0.8 g/kg/day). Because the patient was an outpatient at this time, no parenteral nutrition was provided. The ratio of carbohydrates to proteins to lipids was 70:12:18. The patient's weight was stable at 70 kg. According to the PG-SGA, the patient was classified as well nourished (SGA-A) with a PG-SGA score of 2. Physical examination of the subcutaneous fat, muscle mass, and fluid balance did not reveal any depletion in the subcutaneous fat or muscle ().\nThe patient was encouraged to divide his daily energy intake over 6 meals: 3 main meals and 3 snacks between meals that included various food items for a well-balanced diet. No strict rules or prohibitions with respect to dietary intake were imposed. The patient received pancreatic enzyme replacement therapy in combination with dietary counseling to maintain his weight and improve the QOL. The patient received concurrent chemo-radiation therapy (CCRT) with 5-fluorouracil (5-FU) after he recovered from hyperbilirubinemia. The patient's weight was stable during the first CCRT.\nAt the 2-month follow-up after diagnosis, the patient's weight was almost stable at 69 kg. However, the patient reported having a poor appetite and epigastric pain. At this time, the patient intended to reduce his food intake as a result of decreased physical activity. The patient's energy intake decreased to 1,060 kcal/day (15.4 kcal/kg/day), and the protein intake also decreased to 30 g/day (0.44 g/kg/day). Because the patient was an out-patient at this time, no parenteral nutrition was provided. The ratio of carbohydrates to proteins to lipids was 78:11:11. Conversely, the measured REE of the patient increased to 2,416 kcal/day (35.0 kcal/kg/day), while the predicted REE remained stable (1,531 kcal/day). There was no depletion in the subcutaneous fat or muscle. The patient's daily functioning was also good, and the patient was still considered as well nourished (SGA-A), but the PG-SGA score increased to 8. Nutritional education was conducted to encourage dietary intake in order to prevent further deterioration of his nutritional status.\nAt the 3-month follow-up after diagnosis, the patient was readmitted for a pancreatectomy and was classified as being moderately malnourished or with suspected malnutrition (SGA-B). The PG-SGA score was 8. The patient's weight decreased to 68 kg, and the serum albumin level was 4.1 g/dL. After the total pancreatectomy, the patient was diagnosed with diabetes mellitus and received insulin therapy along with diet education for blood glucose control. The patient reported symptoms such as constipation, poor appetite, and abdominal pain. The frequency of the patient's dyspepsia also increased, which contributed to a decrease in food intake to 500-1,000 kcal/day. A dietitian advised the patient and his caregiver to consume frequent small meals and provided tips for the treatment and prevention of hypoglycemia.\nWhen the patient was discharged, the patient could only consume a very minimal amount of solid food, as the patient was experiencing severe pain and dyspepsia. The patient had several hypoglycemic events; hence, the insulin dosage was reduced. Dietary intake, especially of solid food, continued to decrease. A dietitian provided detailed explanations on food preparation skills to the caregiver in order to increase the nutrition density in food and to prepare a balanced liquid diet.\nAt the 8-month follow-up after diagnosis, positron emission tomography (PET) findings suggested a recurrence around the superior mesenteric artery with aortocaval lymph node metastasis. While chemotherapy commenced, the patient continued to have poor oral intake, and a dietitian met the patient's caregiver to introduce an oral nutrition supplement. However, the patient's weight was 55 kg and continuously decreased to 49 kg at the last chemotherapy treatment.\nAt the 11-month follow-up after diagnosis, the patient could not meet the dietitian due to his poor health. Medical care for the patient focused on supportive care due to the advanced stage of the disease and treatment-refractory disease progression. The last weight measurement showed a 15 kg weight increase over a 2-week period due to the accumulation of ascites. The patient was referred to a hospice for end-of-life care.