Supportive Care in Cancer

, Volume 27, Issue 5, pp 1853–1860 | Cite as

Exploring reasons behind patient compliance with nutrition supplements before pelvic exenteration surgery

  • Sophie E. HoganEmail author
  • Michael J. Solomon
  • Sharon K. Carey
Original Article



Compliance with oral nutrition support (ONS) is poorly reported in the literature. Many factors influence compliance, which could mask the true benefits of preoperative ONS. Surgical oncology patients, including pelvic exenteration patients, are often requested by healthcare workers to consume nutrition supplements before surgery. Exploration of barriers and enablers to compliance with nutrition supplements is needed to improve patient compliance and understand the real impact of preoperative ONS.


A qualitative study using semi-structured interviews was performed to investigate enablers and barriers to preoperative nutrition supplement compliance. Twenty participants who had been asked to consume 15 nutrition supplements, either immunonutrition or standard polymeric supplements, were interviewed. Inductive thematic analysis was used to determine major themes associated with compliance.


Twelve out of 20 participants were not compliant with recommended dosing. Well-nourished participants were more compliant than malnourished participants. Major themes associated with compliance were flavour, volume, texture, impact on dietary intake and motivation to consume supplements. Flavour differed between the two groups, negatively impacting compliance in the immunonutrition group. Volume, texture and impact on dietary intake also negatively impacted compliance whereas motivation positively impacted compliance.


To overcome barriers and enforce enablers with nutrition supplement compliance, it is essential healthcare workers implement individualised interventions, taking into account nutritional status. A range of flavours, minimal volume and low viscosity supplements should be provided to address individual preference and minimise poor compliance. Better-targeted education and regular motivation are needed to improve compliance.


Preoperative period Patient compliance Enteral nutrition Qualitative research Elective surgical procedures 



The authors acknowledge the patients who participated in the study and the host institution, Royal Prince Alfred Hospital, Sydney, Australia, where recruitment was performed.

Compliance with ethical standards

Ethics approval to conduct this research was obtained from the Sydney Local Health District Human Ethics Review Committee.

Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    Bruns ERJ, Argillander TE, Van Den Heuvel B, Buskens CJ, Van Duijvendijk P, Winkels RM, Kalf A, Van Der Zaag ES, Wassenaar EB, Bemelman WA, Van Munster BC (2018) Oral nutrition as a form of pre-operative enhancement in patients undergoing surgery for colorectal cancer: a systematic review. Surg Infect 19(1):1–10. CrossRefGoogle Scholar
  2. 2.
    Darmon P, Karsegard VL, Nardo P, Dupertuis YM, Pichard C (2008) Oral nutritional supplements and taste preferences: 545 days of clinical testing in malnourished in-patients. Clin Nutr 27(4):660–665. CrossRefGoogle Scholar
  3. 3.
    Kabata P, Jastrzebski T, Kakol M, Krol K, Bobowicz M, Kosowska A, Jaskiewicz J (2015) Preoperative nutritional support in cancer patients with no clinical signs of malnutrition--prospective randomized controlled trial. Support Care Cancer 23(2):365–370. CrossRefGoogle Scholar
  4. 4.
    Nieuwenhuizen WF, Weenen H, Rigby P, Hetherington MM (2010) Older adults and patients in need of nutritional support: review of current treatment options and factors influencing nutritional intake. Clin Nutr 29(2):160–169. CrossRefGoogle Scholar
  5. 5.
    Gupta D, Lis CG, Granick J, Grutsch JF, Vashi PG, Lammersfeld CA (2006) Malnutrition was associated with poor quality of life in colorectal cancer: a retrospective analysis. J Clin Epidemiol 59(7):704–709CrossRefGoogle Scholar
  6. 6.
    I IJ, Renken RJ, Ter Horst GJ, Reyners AK (2016) The palatability of oral nutritional supplements: before, during, and after chemotherapy. Support Care Cancer 24(10):4301–4308. CrossRefGoogle Scholar
  7. 7.
    Tueros I, Uriarte M (2018) Innovative food products for cancer patients: future directions. J Sci Food Agric 98(5):1647–1652. CrossRefGoogle Scholar
  8. 8.
    Barker LA, Gray C, Wilson L, Thomson BN, Shedda S, Crowe TC (2013) Preoperative immunonutrition and its effect on postoperative outcomes in well-nourished and malnourished gastrointestinal surgery patients: a randomised controlled trial. Eur J Clin Nutr 67(8):802–807. CrossRefGoogle Scholar
  9. 9.
    Burden S, Todd C, Hill J, Lal S (2012) Pre-operative nutrition support in patients undergoing gastrointestinal surgery. Cochrane Database Syst Rev 11:CD008879. Google Scholar
  10. 10.
    Hegazi RA, Hustead DS, Evans DC (2014) Preoperative standard oral nutrition supplements vs immunonutrition: results of a systematic review and meta-analysis. J Am Coll Surg 219(5):1078–1087CrossRefGoogle Scholar
  11. 11.
    Thornblade LW, Varghese TK Jr, Shi X, Johnson EK, Bastawrous A, Billingham RP, Thirlby R, Fichera A, Flum DR (2017) Preoperative immunonutrition and elective colorectal resection outcomes. Dis Colon Rectum 60(1):68–75CrossRefGoogle Scholar
  12. 12.
    Drover JW, Dhaliwal R, Weitzel L, Wischmeyer PE, Ochoa JB, Heyland DK (2011) Perioperative use of arginine-supplemented diets: a systematic review of the evidence. J Am Coll Surg 212(3):385–399.e381. CrossRefGoogle Scholar
  13. 13.
    Brown KGM, Solomon MJ, Koh CE (2017) Pelvic exenteration surgery: the evolution of radical surgical techniques for advanced and recurrent pelvic malignancy. Dis Colon Rectum 60(7):745–754. CrossRefGoogle Scholar
  14. 14.
    Young JM, Badgery-Parker T, Masya LM, King M, Koh C, Lynch AC, Heriot AG, Solomon MJ (2014) Quality of life and other patient-reported outcomes following exenteration for pelvic malignancy. Br J Surg 101(3):277–287. CrossRefGoogle Scholar
  15. 15.
    Yang TX, Morris DL, Chua TC (2013) Pelvic exenteration for rectal cancer: a systematic review. Dis Colon Rectum 56(4):519–531. CrossRefGoogle Scholar
  16. 16.
    Funder JA, Tolstrup R, Jepsen BN, Iversen LH (2017) Postoperative paralytic ileus remains a problem following surgery for advanced pelvic cancers. J Surg Res 218:167–173CrossRefGoogle Scholar
  17. 17.
    Rausa E, Kelly ME, Bonavina L, O’Connell PR, Winter DC (2017) A systematic review examining quality of life following pelvic exenteration for locally advanced and recurrent rectal cancer. Color Dis 19(5):430–436. CrossRefGoogle Scholar
  18. 18.
    Austin KK, Young JM, Solomon MJ (2010) Quality of life of survivors after pelvic exenteration for rectal cancer. Dis Colon Rectum 53(8):1121–1126. CrossRefGoogle Scholar
  19. 19.
    Beaton J, Carey S, Solomon M, Young J (2013) Preoperative and postoperative nutritional status of patients following pelvic exenteration surgery for rectal cancer. e-SPEN J 8(4):e164–e168CrossRefGoogle Scholar
  20. 20.
    Schwegler I, von Holzen A, Gutzwiller JP, Schlumpf R, Muhlebach S, Stanga Z (2010) Nutritional risk is a clinical predictor of postoperative mortality and morbidity in surgery for colorectal cancer. Br J Surg 97(1):92–97. CrossRefGoogle Scholar
  21. 21.
    Braun V, Clarke V (2006) Using thematic analysis in psychology. Qual Res Psychol 3(2):77–101CrossRefGoogle Scholar
  22. 22.
    Patton MQ (1999) Enhancing the quality and credibility of qualitative analysis. Health Serv Res 34(5 Pt 2):1189–1208Google Scholar
  23. 23.
    Hubbard GP, Elia M, Holdoway A, Stratton RJ (2012) A systematic review of compliance to oral nutritional supplements. Clin Nutr (Edinburgh, Scotland) 31(3):293–312. CrossRefGoogle Scholar
  24. 24.
    Jin J, Sklar GE, Min Sen OV, Chuen Li S (2008) Factors affecting therapeutic compliance: a review from the patient’s perspective. Ther Clin Risk Manag 4(1):269–286Google Scholar
  25. 25.
    Ritter JC, Budge SM (2012) Key lipid oxidation products can be used to predict sensory quality of fish oils with different levels of EPA and DHA. Lipids 47(12):1169–1179. CrossRefGoogle Scholar
  26. 26.
    Gerstein DE, Woodward-Lopez G, Evans AE, Kelsey K, Drewnowski A (2004) Clarifying concepts about macronutrients’ effects on satiation and satiety. J Am Diet Assoc 104(7):1151–1153. CrossRefGoogle Scholar
  27. 27.
    Mattes RD, Rothacker D (2001) Beverage viscosity is inversely related to postprandial hunger in humans. Physiol Behav 74(4–5):551–557CrossRefGoogle Scholar
  28. 28.
    Vecchi T, Richardson JT, Cavallini E (2005) Passive storage versus active processing in working memory: evidence from age-related variations in performance. Eur J Cogn Psychol 17(4):521–539CrossRefGoogle Scholar
  29. 29.
    Sorensen J, Kondrup J, Prokopowicz J, Schiesser M, Krahenbuhl L, Meier R, Liberda M (2008) EuroOOPS: an international, multicentre study to implement nutritional risk screening and evaluate clinical outcome. Clin Nutr (Edinburgh, Scotland) 27(3):340–349. CrossRefGoogle Scholar
  30. 30.
    Sungurtekin H, Sungurtekin U, Balci C, Zencir M, Erdem E (2004) The influence of nutritional status on complications after major intraabdominal surgery. J Am Coll Nutr 23(3):227–232CrossRefGoogle Scholar
  31. 31.
    Arends J, Bachmann P, Baracos V, Barthelemy N, Bertz H, Bozzetti F, Fearon K, Hütterer E, Isenring E, Kaasa S, Krznaric Z, Laird B, Larsson M, Laviano A, Mühlebach S, Muscaritoli M, Oldervoll L, Ravasco P, Solheim T, Strasser F (2017) ESPEN guidelines on nutrition in cancer patients. Clin Nutr 36(1):11–48. CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Royal Prince Alfred HospitalSydneyAustralia
  2. 2.University of SydneySydneyAustralia

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