The present study provides the first data on the nutrient intake and status of newly diagnosed patients with cancer from the East Coast of Peninsular Malaysia prior to the initiation of any therapeutic interventions. The current study suggests that about 40% of newly diagnosed patients with cancer were underweight, one-third were undernourished and two-thirds were anaemic. The older women (i.e. age 51-70 years) had a poor macro and micro nutrient intakes compared to young and older men. In addition, one-third of the study participants had inadequate intakes for protein, and the majority consumed diets poor in micronutrients.
The present study showed a high prevalence of pre-existing malnutrition in newly diagnosed patients with cancer, even prior to the initiation of cancer treatments. Malnutrition in the study participants may have been due to the systemic effects of the undiagnosed cancer, such as altered appetite and sensory functions, anorexia, cancer related discomforts that decrease the food intake leading to weight loss . The prevalence of malnutrition in the current study participants were lower than that reported in cancer patients from other countries [30, 31]; the prevalence rates reported in these studies were estimated in cancer patients undergoing clinical interventions in the hospitals. Furthermore, the study participants were newly diagnosed with cancer and three-quarters of them were in the early stages (i.e. stage 1 & 2) of cancer. A high prevalence of malnutrition in patients with cancer undergoing therapy is unsurprising as cancer treatments have implications on the patient food intakes due to the associated side effects such as nausea, vomiting, loss of appetite, taste and smell alterations and anorexia . Moreover, cancer treatments may develop or aggravate the anorexia, and without adequate nutritional support may trigger a series of catabolic changes that lead to weight loss and early cancer cachexia .
The median energy intakes of participants from the East Coast Malaysia were below the RNI for normal young and older Malaysians; the intake of energy was significantly lower in women than men of the same age group. There are several reasons that may have contributed to the lower energy intakes in patients with cancer: Firstly, the cancer-related pathophysiological changes lead to the onset of anorexia and taste changes that compromise the food intake . Secondly, the physical activity levels are altered due to disease-related discomforts, pain and malignancy, which may reduce the appetite . Thirdly, the psychological stress and trauma associated with disease diagnosis might lead to depression that influences the food intake of patients with cancer . The older women may have lower food intakes than men of the same age, which may precipitate in lower energy intakes, especially when they have less access to nutritious foods, living alone or have poor socio-economic background . The energy requirements of patients with cancer are determined by the stage of cancer, the primary location of the cancer, physical activity levels including whether ambulatory or bed ridden .
The macronutrient intakes of newly diagnosed young adult patients with cancer (i.e. 20-50 years) were just within the range set for normal healthy individuals [26, 28]. Conversely, the energy derived from carbohydrates (i.e. 55-75% of energy) and the protein intake (i.e. <60% of RNI) in older adults was below the adequate levels of intakes , probably due to the implications of undiagnosed cancer. The nutrient requirements (i.e. marco and micro nutrients) of patients with cancer are higher than for normal healthy individuals to meet the increased metabolic turnover and to prevent disease-related wasting and malnutrition leading to cancer cachexia . In addition, young adults with cancer should consume micronutrient dense diets to improve their intakes of vitamin C, iron, riboflavin and vitamin A. In older adults, the lower nutrient intakes could be attributed the dual burden of cancer-induced and age-related physiological changes that decrease the appetite and food intakes [36, 37]. The factors that contribute to decreased nutrient intake in these older participants may include low physical activity levels, poor appetite, apathy, altered taste and sensory functions, poor memory, co-morbidities, local tumor effects, discomforts, and altered metabolic changes . The poor macro and micronutrient intakes of older women strongly indicate the need for special nutritional interventions, support and care prior to the initiation of cancer treatments. A third of undernourished participants in the current study at the time of diagnosis require higher intakes of energy and protein; and specific personalized nutritional interventions to improve their body weight and lean muscle mass.
The prevalence of inadequate micronutrient intakes was higher (>50%) in the study participants for many of the micronutrients investigated; consequently, a greater proportion had anaemia. In the current study, we have used an EAR cut-off point (i.e. <77% of RNI) to assess the risk of inadequate intakes of nutrients, which is lower than the recommended nutrient intake (RNI), however, the proportion of participants with inadequate intakes of micronutrients remained high. The use of RNI as cut-off point to estimate the prevalence of inadequate intakes of nutrients may overestimate the proportion of participants with inadequate intakes [23, 27]. Furthermore, with such poor micronutrient intakes it is likely that many of the study participants may have co-existing micronutrient deficiencies that may adversely influence cancer treatments and associated clinical outcomes .
Cancer-related pathophysiological processes together with reduced intakes of micronutrient dense foods might potentially induce a poor micronutrient status in patients with cancer. Evidence suggests that the patients with cancer in general have a lower micronutrient status of vitamin A, B, C, D, E, selenium and zinc, otherwise known as antioxidants compared to healthy individuals [6, 39]. Unless addressed prior to the initiation of cancer treatments, the micronutrient deficits may exacerbate the risk of complications after surgery, depression, and compromised immune competence that influence the clinical outcomes and quality of life of cancer patients . The poor micronutrient intakes among the majority of the study participants mandate improvements in their diet quality with micronutrient dense foods; in cases where the food intake is compromised micronutrient supplementation through enteral or parenteral route is warranted.
Although recommendations for systematic evaluation of nutritional status of cancer patients using standardized protocols exist, in routine clinical practice it is widely neglected [8, 34]. The current study findings were surprising, as often a high prevalence of malnutrition was reported in hospitalized inpatients  or inpatients undergoing cancer treatments. Evidence suggests that nutrition interventions and nutrition counseling of patients with cancer improved response and tolerance to treatments, nutritional status, and quality of life . We suggest a nutritional screening of cancer patients on their first visit to the Oncology clinic for treatments after diagnosis. In addition, we recommend regular nutritional interventions in malnourished cancer patients with systematic nutritional surveillance during treatments be made mandatory in Malaysia to reduce the risk of preventable morbidity and mortality due to cancer cachexia. Furthermore, vulnerable groups including older women should be given additional nutritional support, as they have the dual burden of the disease and ageing that may exacerbate the risk of malnutrition.
The limitations of the current study include the use of a single interactive 24-hour dietary recall, as an additional food recall would increase the respondent burden, thus, less precise estimates of nutrient intakes. Secondly, the 24-hour recall method of dietary intake data collection is subjective and dependent on the memory of the participants; however, we used a modified interactive dietary recall method to elicit more reliable dietary information. The use of single modified interactive 24 hour dietary recall is adequate to estimate the mean nutrient intakes of groups . Thirdly, day-to-day variations in the nutrient intakes were unadjusted as the dietary intake data was collected in a single day. Nevertheless, the poor nutrient intakes reported in the current study participants were also reflected in their anthropometric and biochemical parameters. Fourthly, the Malaysian food composition database used for the dietary data analyses is out-of-date and thus, the changes in nutrient composition of foods over the time (i.e. post 1997) may not have adequately captured. However, the recent food composition databases developed with nutrient information on Malaysian foods continued to rely on the same Malaysian food composition database ; the use of this database for nutrient analysis was inevitable.