Wine for appetite loss: "how do you know?".

Patients often ask me, “How do I protect myself from unfounded medical recommendations?” My advice to them is to respond to any opinion, from any healer, no matter how seemingly reliable, with, “How do you know?” Should recommendations for palliating loss of appetite in cancer patients be subject to this same degree of questioning? We contend the answer is “yes.” Invariably, cancer patients list appetite loss as one of their five most common and distressing endof-life symptoms. Two other points further underscore its negative impact. First, appetite loss carries far-reaching negative social ramifications. Strife can occur at mealtime because of it. McClement et al followed the course of 13 cancer patients, 23 bereaved family members, and 11 health care providers in an inpatient hospice service and concluded that this symptom was often the nidus for negative interactions between patients, family members, and health care providers. Second, appetite loss predicts an early demise. In a North Central Cancer Treatment Group study, Loprinzi et al studied 1,115 patients with colorectal and lung cancer. Evaluating patient-reported quality of life data, these investigators observed that poor food intake was a powerful, independent predictor of compromised survival. Thus, undeniably, appetite loss is a major end-of-life symptom. Recommending palliative strategies— strategies that meet rigorous, scientifically proven thresholds of efficacy—should apply to its palliation, as they do to any other aspect of cancer care. What do major cancer organizations recommend? If one surveys patient-directed nonprescription recommendations for palliating loss of appetite from major cancer organizations around the world, one recommendation appears over and over. Simply paraphrased, it reads as follows, “With your doctor’s approval, enjoy a glass of wine before eating.” This recommendation crops up on multiple patient-oriented Web sites, including those from the American Cancer Society, the National Cancer Institute, the Oncology Nursing Society, and the American Society of Clinical Oncology (Table 1). Surprisingly, despite the near ubiquitous nature of this recommendation, to our knowledge, there has never been a clinical trial that has examined the use of alcoholic beverages, such as wine, for the palliation of appetite loss in patients with cancer. More importantly, to claim that wine stimulates appetite in patients with cancer suffering from poor appetite just because it seems do so in healthy individuals with healthy appetites (as discussed herein) represents a giant leap of faith to what, we believe, is an unproven conclusion. Admittedly, the hypothesis that wine boosts appetite among patients with cancer is not farfetched. First, for centuries, wine has been paired with food. Indeed, the French word “aperitif” refers to “appetite” and describes an alcoholic beverage that is thought to stimulate appetite at mealtime. Originally used for general medicinal purposes in the 1500s, many of these beverages became popular in the United States in the early 1900s and are now often served along with food, in part, because of their presumed orexigenic effects. This long cultural history that pairs the “aperitif” with food suggests that the former may in fact be valued for its original, less well-defined “medicinal purposes.” Of note, however, a history of resorting to wine to palliate appetite loss in cancer patients appears less well documented. Second, a sizable epidemiologic literature describes a direct relationship between alcohol consumption and weight gain or between alcohol consumption and increased caloric intake. Comprising a robust compilation of literature, these studies do not focus on patients with active cancer. Instead, they focus on data from the Nurses’ Health Study II, which included 49,324 women; the British Regional Heart Study, which included 7,735 men; the European Prospective Investigation into Cancer and Nutrition, which included 100,000 women; the National Health Interview Survey, which included 45,896 individuals; a Finnish study, which included 12,669 individuals; the Health Professionals Follow Up Study, which included 138,031 individuals; and the National Health and Nutrition Examination Survey, which included 10,428 individuals. Each of these studies shows that alcohol intake is associated with either increased caloric intake and/or weight gain in general populations. For example, the Health Professionals Follow Up Study found that average energy consumption was 7,575 kJ/d in From the Oncology Division, Washington University, St Louis, MO; and the Department of Oncology, Mayo Clinic, Rochester, MN.