恶性肿瘤患者康复期营养管理专家共识
中国营养学会肿瘤营养工作组
组长：于康
副组长：李增宁，丛明华，方玉，张片红
成员：李融融，李春微，崔敏，应捷
学术顾问：杨月欣，石汉平，薛长勇
评阅专家：杨月欣，翟凤英，程义勇，苏宜香，杨晓光，郭俊生，郭长江
序言
本共识适于目前未接受放疗、化疗或手术治疗，且未处于住院状态下的恶性肿瘤患者。包括恶性肿瘤完全缓解、部分缓解、无变化和/或无肿块的患者。目前，国内外仍缺乏针对恶性肿瘤康复期患者的营养管理共识，这在一定程度上影响这类患者的临床结局。中国营养学会委托北京协和医院营养科牵头，联合中国疾病预防控制中心、中国医学科学院肿瘤医院、北京大学肿瘤医院、河北医科大学第一医院、浙江大学医学院附属第二医院等单位，按照循证医学原则，选择当前最佳证据，经反复讨论修改，最终形成本共识。证据等级采用牛津循证医学中心分级系统。本共识可供各级医生、护士、营养（医）师、肿瘤营养教育和卫生管理专业人员参考。
第一部分 研究证据
1 营养筛查及评定
对恶性肿瘤康复期患者进行营养风险筛查有利于对营养不良进行早期识别及干预以改善临床的结局【1-3】。筛查工具应具备基于循证医学基础、简单易行、高敏感性和特异性的特点。可选用营养风险筛查2002（NRS-2002）等工具。经筛查存在营养风险者，应进行营养评定，包括膳食摄入、人体成分、体力活动及主要代谢指标和炎症指标测定【4】。
2 营养干预的循证基础
恶性肿瘤住院患者一般会接受手术、放化疗、生物靶向治疗等治疗手段【5】。对出院后患者的营养建议，既要结合肿瘤治疗及机体代谢状况，还要充分考虑患者基础疾病情况【6-9】。欧洲肠外肠内营养学会（ESPEN）等相关指南【10-12】，均建议恶性肿瘤患者康复期患者应定期至专业营养（医）师处寻求营养建议。经调整后患者仍不能通过日常膳食满足营养需求时，须加用较高能量密度的口服营养补充剂（ONS），必要时给予肠内营养或肠外营养。
3 能量及营养素供给
3.1 能量
恶性肿瘤康复期患者能量摄入可参考健康人群标准，以25～35kcal/kg/d为起始量【10】。如已存在营养风险，均应给予充足能量以避免进一步的体重下降。如患者存在摄入不足情况，需考虑增加膳食摄入的能量密度【11】。
3.2 碳水化合物
在体重下降并伴胰岛素抵抗者，若碳水化合物较高会加重血糖负荷，进而增加高血糖所致感染风险。故碳水化合物供能应占总能量的40%或更低【13-14】。对不存在胰岛素抵抗者，可参考一般人群标准，碳水化合物供能占总能量的50%～65%。碳水化合物应来源于全谷类食物、蔬菜、水果和豆类等，利于减低肿瘤复发风险及合并心脑血管疾病风险，对超重或肥胖患者利于降低体重【15-16】。添加糖可在一定程度上降低患者食欲，减少食物摄入量而导致营养风险。
3.3 蛋白质
增加蛋白质摄入可增强患者肌肉蛋白质合成代谢。恶性肿瘤患者蛋白质摄入应在1.0g/kg/d以上，若体力活动下降且存在系统炎症状态，蛋白质可增至1.2～1.5g/kg/d【17】。在肾功能正常者，给予1.5g/kg/d蛋白质是安全的【18】；但如存在急/慢性肾功能不全，蛋白质摄入不应超过1.0g/kg/d【19】。优质蛋白应占总蛋白量的50%以上。
3.4 脂肪
脂肪供能应占全日摄入能量的20～35%。恶性肿瘤患者可更多利用脂肪酸供能【20-27】。n-3脂肪酸降低炎症反应，减少免疫抑制【28-29】。如存在体重下降并伴胰岛素抵抗，可增加中链甘油三酯（MCT）供能比，减少碳水化合物的供能比，优化糖脂比例【30-34】。高饱和脂肪可能缩短生存时间【35-37】，而增加单不饱和脂肪可能延长生存时间【38-39】。
3.5 营养素补充剂
荟萃分析表明，营养素补充剂不能改善恶性肿瘤患者全因死亡率【40】，不能降低恶性肿瘤相关死亡率【41】，不能降低恶性肿瘤复发风险【42-43】。值得注意的是，营养素补充剂的临床研究难度较大，所得结论尚存在矛盾，需要高水平研究获得更高强度的证据。目前认为，在膳食摄入不足或经检查证实存在某类营养素缺乏或不足时，可经有资质的营养（医）师评估后使用营养素补充剂。
3.6 营养支持
对存在营养风险患者应早期启动营养支持，包括ONS、肠内或/和肠外营养【44-45】。荟萃分析显示，ONS可提高患者生活质量【46】并增加体重【47】。对加用ONS1周以上但营养摄入未获改善，或摄入量低于推荐量60%持续1～2周者，应予肠内或/和肠外营养。营养支持应遵循阶梯治疗原则，依次进行营养咨询、ONS、肠内营养、部分肠外营养＋肠内营养和全肠外营养【48】。
4 膳食模式
肥胖和代谢综合征是恶性肿瘤复发独立风险因素【49-50】。恶性肿瘤康复期患者同时也是出现第二肿瘤及其他慢性病的高风险人群【51】。大量摄入蔬菜和水果，减少红肉及加工肉类，选择低脂乳制品，经常食用全谷物食物，选用坚果或橄榄油，利于提高总体生存率【52-55】。大量摄入红肉可增加罹患结直肠癌、乳腺癌及其他恶性肿瘤风险【56-57】。荟萃分析明确，大量摄入蔬菜水果等平衡膳食可降低恶性肿瘤患者心血管疾病风险及全因死亡率【58】。
5 运动和心理治疗
在肿瘤患者康复过程中，规律性运动不可或缺【59】。高强度研究证据提示，规律性运动利于降低各类恶性肿瘤复发风险【60】。通过心理调控使恶性肿瘤患者获得良好心理状态对综合治疗有确定性效果【61】。
第二部分 推荐意见
1 营养筛查及评定
应对所有恶性肿瘤康复期患者定期进行营养筛查，判断是否存在营养风险和营养不良。（A，2a）
对可能存在营养风险者，应进行营养评定，对膳食状况、代谢指标、人体成分、肌肉状况、体能状况及系统性炎症的程度等进行定量评价。（B，2b）
2 循证基础上的营养干预
恶性肿瘤康复期患者应定期接受有资质的营养（医）师的建议。（A，1a）
恶性肿瘤康复期患者应在有资质的营养（医）师建议下，避免或减轻营养素缺乏或不足，逐渐达到并维持合理体重，保持机体适宜瘦体组织及肌肉量。（A，1a）
恶性肿瘤康复期患者接受营养支持可减少营养相关不良事件或疾病发生风险，最大程度提高生活质量。（A，1a）
3 能量及营养素供给
3.1 能量
恶性肿瘤康复期患者的能量推荐可参考健康人群标准及患者体力活动状况等，予以25～35kcal/kg/d，再根据患者实际能量需求进行调整。（C，4）
如存在摄入不足，需考虑提高膳食摄入的能量密度。（A，2a）
3.2 碳水化合物
恶性肿瘤康复期患者，如不存在胰岛素抵抗，其比例应为50%～65%；如存在胰岛素抵抗，碳水化合物供能应占总能量40%或更低（B，2b）。
在胃肠功能允许的条件下，应增加全谷物食物、蔬菜和水果摄入，限制添加糖摄入。（B，2b）
3.3 蛋白质
肝肾功能无明显异常者，应摄入充足蛋白质，达到1.0～1.5g/kg/d。优质蛋白质应占总蛋白量的50%以上。（B，2b）
3.4 脂肪
如不存在胰岛素抵抗，膳食脂肪供能应占全日总能量20%～35%。如存在胰岛素抵抗，可在保证必需脂肪酸供应的基础上，增加MCT供给；并减少碳水化合物的供能比，优化糖脂比例。（B，2b）
应限制饱和脂肪摄入，增加n-3多不饱和脂肪酸和单不饱和脂肪酸摄入。（B，2b）
3.5 营养素补充剂
经均衡膳食摄入必需的各类微量营养素，无必要时不盲目使用营养素补充剂。（B，2a）
在膳食摄入营养素不足，或经生化检查或临床表现证实存在某类营养素缺乏或不足时，可经有资质的营养（医）师评估后使用营养素补充剂。（D，5）
3.6 营养支持
存在营养风险的患者应及时就诊于有资质的营养（医）师，经营养咨询加强膳食营养供给，必要时加用口服营养补充（ONS）或特殊医学用途配方食品。如膳食摄入未改善营养状况，或未满足60%目标能量需求超过1周，可依次选择肠内或肠外营养。（B，2b）
4 膳食模式
恶性肿瘤完全缓解患者食物应多样化，多吃新鲜蔬果和全谷物食品，摄入充足的鱼、禽、蛋、乳和豆类，减少红肉，限制加工肉类摄入。（B，2b）
恶性肿瘤完全缓解患者如存在早饱、纳差等症状，建议少量多餐，减少餐时液体摄入。餐间补充水分。（B，2b）
5 运动和心理治疗
恶性肿瘤康复期患者可在专业人士指导下选择适合自身特点的规律性身体活动，并遵循循序渐进原则。（A，2a）
对恶性肿瘤康复期患者的心理问题应及时应用心理疗法进行干预。（A，2a）
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