Sarcopenic obesity, a dual condition in which patients lose muscle mass but gain fat mass, can both be caused by and complicate cancer and its treatment. Aging is a factor in its development, and some studies have found that weight gain during chemotherapy for breast cancer has a sarcopenic obesity pattern. Additionally, it can increase risks of toxicity, morbidity, and mortality in cancer survivors. Oncology nurses need to be aware of the condition, screen for it, and educate their patients to ensure best outcomes.
In their article in the October 2016 issue of the Clinical Journal of Oncology Nursing, Lindsey, Astroth, and Kumar discussed the issue of sarcopenic obesity in patients with cancer and provided a toolbox strategy for oncology nurses to increase their awareness and confidence in identifying, educating, and managing patients with the condition.
Understanding Sarcopenic Obesity
According to Lindsey et al., the dual nature of sarcopenic obesity can “synergistically exacerbate functional decline and negatively affect health and quality of life more so than obesity or sarcopenia alone.” However, despite its clinical implications, the condition is underrecognized.
One reason is that no specific criteria are available to clinically diagnose it. Body mass index alone is not sensitive enough to estimate muscle versus fat mass; tests such as dual-energy x-ray absorptiometry, computed tomography, or magnetic resonance imaging are able to estimate muscle mass, but they are costly and time-consuming to schedule.
An instrument called SARC-F was developed to use in the community setting to quickly screen patients at risk for sarcopenia using a rating system for five questions about a patient’s strength, functional abilities, and number of falls in the past year. Lindsey et al., included the SARC-F in their study toolbox.
Combined, sarcopenia and obesity have a significant impact on wellness and healthcare resources. An estimated $18.5 billion was spent in the United States on sarcopenia-associated health care in 2000, and an estimated $147 billion was spent on obesity-associated health care in 2008.
Managing Sarcopenic Obesity
Educating patients on exercise and nutrition strategies to preserve muscle mass and mitigate increased fat mass can be beneficial. Studies have shown that exercise during chemotherapy not only manages cancer-related fatigue, but it decreases muscle wasting. Other studies support including resistance training three days per week as well. Nutritionally, the National Comprehensive Cancer Network’s (NCCN’s) recommendations for cancer survivorship include a high-quality, plant-based diet with 20–30 grams of protein three times per day.
Building an Oncology Nursing Toolbox
Lindsey et al.’s project provided an educational intervention and corresponding toolbox for advanced practice nurses (APNs) to increase their knowledge and self-confidence in identifying and managing patients at risk for sarcopenic obesity. Although the study focused on APNs, the tactics can be translated for oncology nurses and healthcare providers at any level who assess and educate patients with cancer.
The researchers developed a 10-minute in-service presentation and paper and electronic toolbox containing educational materials related to sarcopenic obesity. Included in the toolbox were the following.
- Paper/electronic copy of the in-service educational presentation on sarcopenic obesity (i.e., definition, clinical importance, expert recommendations for identification and management)
- Expert recommendations for nutrition, weight management, and physical activity
- Evidence-based guidelines on healthy lifestyles adapted from NCCN’s survivorship guidelines
- The SARC-F rapid scoring tool
- Referral resources for expert management of functional impairment, physical disability, and nutritional counseling in the community
- Template for documenting assessments and interventions in a patient’s electronic record
- Educational handout for patients
Lindsey et al. presented the in-service and toolbox individually to each of the 12 APNs participating in the project; the APNs were told to use the tools in their practice as they saw fit. The researchers asked them to track their documentation, interventions, and referrals to supportive care, and participants completed pre- and postintervention surveys about their confidence with assessing and managing sarcopenic obesity.
The researchers found a significant increase in confidence scores on the nurses’ ability to identify and manage patients with cancer at risk for sarcopenic obesity. Documentation, education, and referrals also increased, but the numbers were not statistically significant. Anecdotally, participants commented that the toolbox was a complete and informative resource manual.
Lindsey et al. noted that the study was limited by a small convenience sample and short duration; they recommended that a future project should expand the in-service and toolbox to other oncology professionals who provide care to cancer survivors and to multiple oncology practices.
As the frontline healthcare professionals for patients with cancer, oncology nurses must understand the signs, symptoms, and risk factors of sarcopenia and sarcopenic obesity. Lindsey et al. noted that the conditions should be considered for any “patients who cannot rise from a chair unassisted, walk without assistance, fatigue when climbing stairs, have decreased strength, or are a fall risk.” Such patients should be educated about exercise and rehabilitation programs and nutritionally balanced diets that include high-quality protein.
Five-Minute In-Service is a monthly feature that offers readers a concise recap of full-length articles published in the Clinical Journal of Oncology Nursing (CJON) or Oncology Nursing Forum. This edition summarizes “Improving Awareness, Identification, and Management of Sarcopenic Obesity in Cancer Survivors: An Evidence-Based Toolbox,” by Sarah Lindsey, DNP, APN, ACNS-BC, AOCNS®, Kim Schafer Astroth, PhD, RN, and Pankaj Kumar, MD, which was featured in the October 2016 issue of CJON. Questions regarding the information presented in this Five-Minute In-Service should be directed to the CJON editor at CJONEditor@ons.org. Photocopying of this article for educational purposes and group discussion is permitted.