In a female patient with colon cancer scheduled for colectomy who has lost 10% of body weight, has poor appetite, and inadequate protein and caloric intake, what is the most appropriate first-line nutritional intervention?

Oral Protein Supplements (Option A)

For this malnourished colon cancer patient with 10% weight loss and poor oral intake scheduled for colectomy, oral protein supplements (ONS) are the best first-line action, as she can swallow and has a functioning gastrointestinal tract. 1, 2

Rationale for Oral Nutritional Supplements

• ONS is the primary recommended route for preoperative nutrition in malnourished colorectal cancer patients who can swallow and have functional GI tracts, according to the American Society for Parenteral and Enteral Nutrition and ESPEN guidelines 1, 2
• The patient's 10% weight loss indicates moderate malnutrition requiring immediate preoperative nutritional intervention 1
• Nutrition counseling combined with ONS is regarded as first-line therapy and can improve nutritional intake, stabilize body weight, and reduce postoperative complications 3

Specific ONS Protocol

• Provide 400-600 kcal/day of standard balanced ONS formula that can serve as a sole nutrition source if needed 1, 2
• Target total protein intake of 1.2-1.5 g/kg ideal body weight daily plus adequate calories to prevent further weight loss 3, 1, 4
• Include standard multivitamin/mineral supplementation to ensure adequate micronutrients (zinc, vitamin C, vitamin D) critical for wound healing 1, 2
• Implement for 7-10 days preoperatively to reduce infectious complications and anastomotic leaks 1, 2

Why Not the Other Options

TPN (Option C) is Inappropriate

• Parenteral nutrition is only indicated when the patient cannot meet energy requirements through oral/enteral routes, typically in severe malnutrition (>15% weight loss) or complete bowel obstruction 1, 2
• This patient has no indication she cannot eat orally—she simply has poor appetite and inadequate intake 3
• Both ASPEN and the American Dietetic Association recommend that TPN should be used selectively and with caution due to associated risks for complications 3
• There is no place for indiscriminate use of artificial nutrition in all cancer patients as a "routine" adjunct 3

NG Tube Feeding (Option D) is Premature

• Nasogastric tube feeding is indicated when oral nutrition cannot be started and oral intake will be inadequate (<50%) for more than 7 days 1
• This adds unnecessary procedural risk when the patient can swallow 2
• The patient should first attempt ONS before escalating to tube feeding 3

Fluid Restriction (Option B) is Contraindicated

• Restricting fluids provides no nutritional benefit and could worsen the patient's nutritional status 2
• This option has no basis in evidence-based preoperative nutritional management 3

Implementation and Monitoring

• Start ONS immediately rather than waiting until hospital admission to avoid nosocomial infections 1
• Consider immunonutrition formulas containing arginine, omega-3 fatty acids, and nucleotides for 5-7 days preoperatively, which reduce infectious complications in malnourished cancer patients 1, 2
• Monitor compliance carefully, as patient motivation affects ONS effectiveness 1, 2
• Continue ONS postoperatively for at least 3 months after discharge to reduce skeletal muscle loss 1, 4

Common Pitfall to Avoid

The major pitfall is jumping directly to TPN or tube feeding without first attempting the least invasive approach of oral supplementation 2. The evidence clearly shows that oral nutrition counseling combined with ONS is effective for patients who can swallow, and more aggressive interventions should only be considered if this approach fails after adequate trial 3.