Development and validation of nutrition knowledge questionnaire for cancer-related anorexia and cachexia syndrome in Taiwanese patients with cancer

Drugs in development for treatment of patients with cancer-related anorexia and cachexia syndrome [Retraction] The Editor-in-Chief, Dr Pilch, of Drug Design, Development and Therapy has been alerted to unacceptable levels of duplication between a previously published paper: Macciò A, Madeddu C, Mantovani G. Current pharmacotherapy options for cancer anorexia and cachexia. Expert Opin. Pharmacotherapy 2012 13(17) 2453–2472 and one published subsequently in Drug Design, Development and Therapy: Mantovani G, Madeddu C, Macciò A. Drugs in development for treatment of patients with cancer-related anorexia and cachexia syndrome. Drug Design, Development and Therapy 2013:7 645–656.

Cancer-related anorexia and cachexia syndrome (CACS) is a complex multifactorial condition, with loss of lean body mass, chronic inflammation, severe metabolic derangements, reduced food intake, reduced physical activity, and poor quality of life as key symptoms. Cachexia recognizes different phases or stages, moving from precachexia through overt cachexia to advanced or refractory cachexia. The purpose of this review is to describe currently effective approaches for the treatment of cachexia, moving forward to drugs and treatments already shown to be effective but needing further clinical trials to confirm their efficacy. We then introduce novel promising investigational drugs and approaches which, based on a strong rationale from the most recent data on the molecular targets/pathways driving the pathophysiology of cachexia, need to be tested either in currently ongoing or appropriate future clinical trials to confirm their clinical potential. Although different drugs and treatments have been tested, we can speculate that a single therapy may not be completely successful. Indeed, considering the complex clinical picture and the multifactorial pathogenesis of CACS, we believe that its clinical management requires a multidisciplinary and multitargeted approach. In our opinion, appropriate treatment for cachexia should target the following conditions: inflammatory status, oxidative stress, nutritional disorders, muscle catabolism, immunosuppression, quality of life, and above all, fatigue. A comprehensive list of the most interesting and effective multitargeted treatments is reported and discussed, with the aim of suggesting the most promising with regard to clinical outcome. A critical issue is that of testing therapies at the earliest stages of cachexia, possibly at the precachexia stage, with the aim of preventing or delaying the development of overt cachexia and thereby obtaining the best possible clinical outcome for patients.

Introduction: Anorexia and cachexia syndrome represents a complex clinical picture that occurs in the late stage of several chronic inflammatory diseases, including cancer. Unless counteracted cancer-related anorexia and cachexia syndrome affects quality of life (QL) and survival. However, to date a standard effective treatment is lacking.Areas covered: The aim of this review is to describe the current pharmacological approaches for anorexia and cachexia syndrome, focusing on cancer-related syndrome. The several pharmacological agents tested so far are discussed, distinguishing them in unproven drugs, effective drugs, and drugs under investigation. Moreover, a section is devoted to the promising use of nutritional supplements and nutraceuticals. The emerging role of a multitargeted combined treatment approach is exhaustively reviewed.Expert opinion: Considering the complex clinical picture and the multifactorial pathogenesis of anorexia and cachexia syndrome, we believe that its clinical management requires a multidisciplinary and multipharmacological approach. In our opinion the anorexia and cachexia syndrome treatment should include drugs that target the following conditions: inflammatory status, oxidative stress, nutritional disorders, muscle catabolism, anemia, immunosuppression, and fatigue. The multidimensional therapies for anorexia and cachexia syndrome should ideally be introduced within a context of the “best supportive care,” which includes optimal symptom management and careful psychosocial counseling.

Background: Cancer-related cachexia and anorexia syndrome (CACS) is a common phenomenon in cancer patients. Cannabis has been suggested to stimulate appetite but research on this issue has yielded mixed results. The current study aimed to evaluate the effect of dosage-controlled cannabis capsules on CACS in advanced cancer patients. Methods: The cannabis capsules used in this study contained two fractions of oil-based compounds. The planned treatment was 2 × 10 mg per 24 hours for six months of tetrahydrocannabinol (THC) 9.5 mg and cannabidiol (CBD) 0.5 mg. If patients suffered from side effects, dosage was reduced to 5 mg × 2 per day (THC 4.75 mg, CBD 0.25 mg). Participants were weighed on every physician visit. The primary objective of the study was a weight gain of ≥10% from baseline. Results: Of 24 patients who signed the consent form, 17 started the cannabis capsules treatment, but only 11 received the capsules for more than two weeks. Three of six patients who completed the study period met the primary end-point. The remaining three patients had stable weights. In quality of life quaternaries, patients reported less appetite loss after the cannabis treatment (p=0.05). Tumor necrosis factor-α (TNF-α) levels decreased after the cannabis treatment but without statistical significance. According to patients’ self-reports, improvement in appetite and mood as well as a reduction in pain and fatigue was demonstrated. Conclusions: Despite various limitations, this preliminary study demonstrated a weight increase of ≥10% in 3/17 (17.6%) patients with doses of 5mgx1 or 5mgx2 capsules daily, without significant side effects. The results justify a larger study with dosage-controlled cannabis capsules in CACS.

Increasing evidence suggests that many adipokines are involved in cancer-related anorexia and cachexia syndrome (CACS), although the underlying mechanism remains to be clarify. Asprosin is a new peptide hormone mainly secreted by white adipose tissues that can increase appetite and body weight. In this cross-sectional study, we tested whether asprosin may intervene in the development of CACS. The fasting plasma asprosin levels were determined via enzyme-linked immune-sorbent assay. Anorexia was determined using the anorexia/cachexia subscale (A/CS) of the functional assessment of anorexia/cachexia therapy (FAACT) questionnaire. The body composition was assessed using bioelectrical impedance analysis. The association of plasma asprosin with anorexia, cachexia, and nutritional status was analyzed. One hundred twenty treatment-naïve patients with pathological confirmed gastrointestinal or lung cancer and 14 mild gastritis patients were recruited. We found no significant difference in asprosin levels between subgroups of patients by age, sex, cancer types or stage. Correlation analysis suggested that asprosin levels were positively associated with body fat mass (r = 0.248, p = 0.043). No correlations were found between asprosin levels and hemoglobin, white blood cell count, blood platelet count, albumin, C-reactive protein, glucose, cholesterol, triglyceride, high density lipoprotein, low density lipoprotein, body mass index, body fat percentage, protein, skeletal muscle, muscle mass, lean body mass, and basal metabolic rate. Furthermore, asprosin levels were not significantly different between patients with or without cachexia. However, patients with anorexia had significantly lower asprosin levels compared with patients without anorexia. No significant difference in asprosin levels between gastritis and gastric cancer patients. Similarly, no significant change of asprosin levels occurred postoperatively in 10 gastric cancer patients. Patients with anorexia had significantly lower asprosin levels compared with patients without anorexia. We therefore speculated that asprosin might intervene in the development of cancer anorexia and serve as a potential therapeutic target.

Nutrition knowledge is one of the factors that affect nutritional status and nutritional habits of individuals, families, and societies. Nutrition knowledge is an important tool in assessing the nutritional status of an individual, group or community. Researchers have been trying to design and develop reliable and valid questionnaires that distinguish and measure nutrition knowledge and its impact on dietary behavior and diet-health awareness. Many studies have shown that nutrition knowledge can affect someone to follow dietary recommendations. The aim of this study was to assess the nutrition knowledge of Syrian university students and to find out if there was any relationship between anthropometric measurements, socioeconomic status, type of university and nutrition knowledge of the students. Nutritional knowledge was assessed using valid nutrition knowledge questionnaire, which covered six main sections. The questionnaire was designed for this study and was adapted from Parameter and Wardle. The number of students participated in the study was 998 students and were selected from four universities) in Syria. They were asked to complete the nutrition knowledge questionnaire under supervision of trained nutritionist. Anthropometric measurements were taken for all participants by trained professional. The results were statistically analyzed and P 30 had the highest points in TNK. Females had higher TNK score as compared with males. Furthermore, students enrolled in the private university and in health-related programs showed typically better TNK scores than those enrolled in public universities and in nonhealth-related programs. The highest TNK score based on BMI was found among students with BMI >30. The results support the likely value of including nutrition knowledge as a target for health education campaigns aimed at promoting healthy eating.

Cancer cachexia is defined as a multifactorial syndrome characterized by an ongoing loss of skeletal muscle mass (with or without loss of fat mass) that cannot be fully reversed by conventional nutritional support and leads to progressive functional impairment. The prominent clinical feature of cachexia is weight loss in adults. Anorexia, inflammation, insulin resistance, and increased muscle protein breakdown frequently are associated with cachexia. One single therapy may not be completely successful in the treatment of cachexia because of the complexity of the pathogenesis and symptoms of the cachexia syndrome. Among effective treatments, progestogens currently are considered the best available treatment option and are the only approved drugs in Europe for the treatment of cancer- and AIDS-related cachexia. However, they have limited efficacy in treating cancer cachexia. However, thalidomide, selective COX-2 inhibitors, ghrelin mimetics, and selective androgen receptor modulators showed promising results but should be defined further and confirmed in clinical trials. Therefore, to date, despite several years of coordinated efforts in basic and clinical research, the practice guidelines for the prevention and treatment of cancer-related anorexia cachexia syndrome (CACS) are lacking. The management of CACS is a complex challenge that should address the different causes underlying this clinical event. Recent studies showed that integrated, multitargeted approaches are more effective than single-agent approaches for the treatment of CACS. Further clinical trials to improve and refine current strategies to counteract cancer cachexia using multimodal interventions, including nutritional supplementation, anabolic agents, and antiinflammatory drugs along with an appropriate physical exercise program, are warranted.

Foodbot Factory is a serious game developed to teach children about the 2019 Canada's Food Guide (CFG) healthy eating principles. Because no measurement tools existed to assess changes in children's knowledge of the CFG, the Nutrition Attitudes and Knowledge (NAK) questionnaire was developed for this purpose. The NAK is based on the 2019 CFG nutrition content and aligned with the Foodbot Factory modules (Drinks, Whole Grain foods, Vegetables and Fruit, Protein foods). Seven experts assessed face and content validity of the draft NAK questionnaire. Three sections were deemed valid, while the remaining 2 required minor revisions. The NAK was pilot tested for changes in nutrition attitudes and knowledge among children aged 9-10 years-old (n= 23), who answered the NAK questionnaire before and after using Foodbot Factory. Significant increases were found in overall nutrition knowledge, and knowledge of Whole Grain foods, Vegetables and Fruit and Protein foods. Knowledge of Drinks and nutrition attitudes remained unchanged. The NAK showed a moderate reliability when tested among a group of children (n= 23). While the NAK questionnaire is a promising tool for assessing changes nutrition knowledge related to the 2019 CFG guidelines in children, further research is required to test construct validity of this instrument. Novelty: The Nutrition Attitudes and Knowledge (NAK) questionnaire was developed by educators and dietitians. The NAK underwent face and content validity assessments and was pilot tested among children. The NAK questionnaire is a potential tool to detect changes in children's knowledge of the 2019 Canada's Food Guide.

Cancer, being in fact a generalized disease involving the whole organism, is most frequently associated with metabolic deregulation, a latent inflammatory state and anorexia of various degrees. The pathogenesis of this disorder is complex, with multiple dilemmas remaining unsolved. The clinical consequences of the above-mentioned disturbances include cancer-related cachexia and anorexia-cachexia syndrome. These complex clinical entities worsen the prognosis, and lead to deterioration of the quality of life and performance status, and thus require multimodal treatment. Optimal therapy should include nutritional support coupled with pharmacotherapy targeted at underlying pathomechanisms of cachexia. Nevertheless, many issues still need explanation, and efficacious and comprehensive therapy of cancer-related cachexia remains a future objective.

Little is known about the nutritional knowledge of children in Kuwait and school-based nutrition interventions are scarce. No validated tool to assess the nutrition knowledge of schoolchildren in Kuwait is available. This study determined the validity and reliability of a nutrition knowledge questionnaire in Kuwaiti primary-school children, and measured children's nutrition knowledge before and after a nutrition awareness intervention. The questionnaire included five questions to measure nutritional knowledge. The face and content validity were assessed by nutrition and paediatric experts. To assess questionnaire reliability and nutrition knowledge, 642 schoolchildren (8-12 years) were assigned to an intervention, control or reliability group. Each group completed the questionnaire twice, one or two weeks apart. Students in the intervention group attended a nutrition knowledge presentation before completing the questionnaire the second time. Independent and paired samples t-tests were used to assess score differences between and within the intervention and control groups for changes in nutrition knowledge. Pearson correlation coefficients were used to measure score consistency in the reliability group. Overall, the questionnaire had good content validity and moderate to strong reliability (r = 0.44, P < 0.001). Students in the intervention group had significantly higher mean nutritional knowledge scores after the intervention (from 3.65 (SD 1.03) to 4.20 (SD 1.02); P = 0.17). Control group scores were mostly unchanged. The Kuwait child nutrition knowledge questionnaire is a valid and reliable tool to assess nutritional knowledge in schoolchildren in Kuwait. Nutrition knowledge of Kuwaiti schoolchildren should be improved using age-appropriate interventions in school.

BackgroundWhile several validated sports nutrition knowledge questionnaires exist, none are specifically designed to assess the sports nutrition knowledge (SNK) of Sri Lankan track and field athletes. This study aims to validate the Sri Lankan Sports Nutrition Knowledge Questionnaire (SLn-SNKQ), tailored for this athlete group, to provide more accurate and meaningful insights for research and practice. This will enable health professionals and coaches to confidently assess athletes’ nutrition knowledge, which directly influences their food choices.MethodsThe validity of the questionnaire was established through a multi-step approach. Content validity was achieved via ratings from nutrition experts, all of whom had specialized training in human nutrition and experience of working with athletes. Face validity was evaluated through in-depth telephone interviews with elite or highly trained athletes, using a retrospective think-out-loud protocol to gather feedback on the clarity and relevance of the questions. Construct validity involved nutrition-trained doctors (NTG), non-nutrition-trained professionals (NNTG), and elite-level athletes’ groups (AG). Internal consistency was assessed using Cronbach’s alpha, and test-retest reliability was evaluated.ResultsThe final tool comprised 123 individual statements or prompts (items) that were organized into 32 broader questions, spanning 12 sub-sections. Content validity was confirmed by fully integrating 49 out of 70 comments and partially integrating four comments received from nutrition experts for each sub-section. Face validity was established by fully integrating 33 out of 40 comments received from 16 elite and highly trained athletes. Construct validity was confirmed, indicating significant differences in the total scores achieved as a percentage of the SLn-SNKQ among the NTG (462.5, 92.5%), NNTG (223.5, 44.7%), and AG (235, 47.0%; p < 0.001). Reproducibility was established by strong test-retest reliability between individuals’ scores on two test attempts, three weeks apart (spearman’s correlation; ρ = 0.99, p < 0.05). Internal reliability for each sub-section met psychometric reliability requirements (Cronbach’s α > 0.7).ConclusionsThe SLn-SNKQ has been validated and demonstrates robust psychometric properties, offering a reliable tool for assessing SNK among Sri Lankan track and field athletes.

BackgroundEstablishing an understanding of an athlete’s nutrition knowledge can inform the coach/practitioner and support the development of the athlete. Thus the purpose of the study was to develop a psychometrically valid and reliable tool to assess general and sport nutrition knowledge.MethodsAn 85 question questionnaire was developed in consultation with a panel of experts. Ninety-eight participants from the UK completed the questionnaire, and again 3 weeks later. The participants were classified into two groups: those with nutrition (NUT, n = 53) training (sport nutritionists and dietitians who were either practicing or undertaking a postgraduate qualification in the field), and those without (NONUT, n = 48) training (professionals and postgraduate students with no exposure to any form of nutrition training). The questionnaire was then administered to a pilot cohort of UK based track and field athletes (n = 59) who were requested to time how long it took to complete the questionnaire.ResultsPsychometric statistical analysis of the results was completed, resulting in the removal of 23 questions for a total of 62 questions in the final questionnaire. The validated questionnaire was then administered to 58 track and field athletes. Internal consistency was assessed using Chronbach’s alpha (α > 0.7), Pearson’s correlation (p < 0.05) was used to assess reliability. Construct validity was evaluated using a t-test (p < 0.05). A total test retest correlation of 0.95 was achieved (sub-section range: 0.87–0.97). Internal consistency was accepted in each sub-section (α = 0.78–0.92) and the nutrition-trained group scored significantly higher on the overall questionnaire (80.4 vs 49.6%). The overall score for the athletic group was 61.0%.ConclusionThe questionnaire satisfied all psychometric measures and provides a new valid and reliable tool to assess general and sport nutrition knowledge of track and field athlete.

B-cell activating factor (BAFF) is a cytokine and adipokine of the TNF ligand superfamily. The main biological function of BAFF in maintaining the maturation of B-cells to plasma cells has recently made it a target of the first FDA-approved selective BAFF antibody, belimumab, for the therapy of systemic lupus erythematosus. Concomitantly, the role of BAFF in cancer has been a subject of research since its discovery. Here we review BAFF as a biomarker of malignant disease activity and prognostic factor in B-cell derived malignancies such as multiple myeloma. Moreover, anti-BAFF therapy seems to be a promising approach in treatment of B-cell derived leukemias/lymphomas. In nonhematologic solid tumors, BAFF may contribute to cancer progression by mechanisms both dependent on and independent of BAFF's proinflammatory role. We also describe ongoing research into the pathophysiological link between BAFF and cancer-related cachexia. BAFF has been shown to contribute to inflammation and insulin resistance which are known to worsen cancer cachexia syndrome. Taking all the above together, BAFF is emerging as a biomarker of several malignancies and a possible hallmark of cancer cachexia.

The aim of this study was to assess the validity and reliability of a self-administered nutrition knowledge (NK) questionnaire for Italian university students. The NK questionnaire included ninety questions on experts' nutritional recommendations, nutritional content of food, health aspects of food and diets, relationship between diet and diseases, and proper food choices. It was administered to the same population under the same conditions on two different occasions with a time interval of 3 weeks between the two administrations. The survey was carried out at the University of Parma (Italy) during the 2018-2019 academic year. Data were collected for 132 bachelor and master degree students attending the University of Parma, either attending or not nutrition classes during their studies (19-30 years, 29·5 % males, 57·6 % with an academic nutrition background). The questionnaire revealed high overall internal consistency reliability (Cronbach's α > 0·8) and a good temporal stability with high correlation of the total score (r = 0·835, P < 0·001). Moreover, it showed a good ability to discriminate between subjects with potentially different NK. This NK questionnaire proved to be a reliable, valid and easy-to-use tool for assessing the NK of Italian university students, either with or without nutrition background.

To outline key statistical considerations and detailed methodologies for the development and evaluation of a valid and reliable nutrition knowledge questionnaire. Literature on questionnaire development in a range of fields was reviewed and a set of evidence-based guidelines specific to the creation of a nutrition knowledge questionnaire have been developed. The recommendations describe key qualitative methods and statistical considerations, and include relevant examples from previous papers and existing nutrition knowledge questionnaires. Where details have been omitted for the sake of brevity, the reader has been directed to suitable references. We recommend an eight-step methodology for nutrition knowledge questionnaire development as follows: (i) definition of the construct and development of a test plan; (ii) generation of the item pool; (iii) choice of the scoring system and response format; (iv) assessment of content validity; (v) assessment of face validity; (vi) purification of the scale using item analysis, including item characteristics, difficulty and discrimination; (vii) evaluation of the scale including its factor structure and internal reliability, or Rasch analysis, including assessment of dimensionality and internal reliability; and (viii) gathering of data to re-examine the questionnaire's properties, assess temporal stability and confirm construct validity. Several of these methods have previously been overlooked. The measurement of nutrition knowledge is an important consideration for individuals working in the nutrition field. Improved methods in the development of nutrition knowledge questionnaires, such as the use of factor analysis or Rasch analysis, will enable more confidence in reported measures of nutrition knowledge.