Cancer-related anorexia is a common concomitant symptom in patients with malignant tumors, characterized by persistent loss of appetite, early satiety, and insufficient nutrient intake. Its incidence rate is as high as 50%–80%.1,2 This symptom not only easily accelerates the cachexia process of patients but is also closely related to the decline in chemotherapy tolerance, immune function suppression, and deterioration of the quality of life of patients. At present, Western medical intervention mainly focuses on nutritional support and drug treatment. However, long-term use of certain drugs can easily lead to thrombosis risks and hormonal disorders. In recent years, the theory of “treating the spleen and kidney simultaneously” in traditional Chinese medicine (TCM) has demonstrated its advantages in the supportive treatment of tumors. By harmonizing the synergistic relationship between the acquired root (spleen) and the innate root (kidney), it has provided a new approach for the integrated intervention of cancerrelated anorexia.
From the perspective of the pathogenesis in TCM, cancer-related anorexia falls within the category of “poor appetite” and “debility,” with the main pathogenesis being “spleen failure to function properly and kidney essence deficiency.”3–5 The tumor itself and the damage caused by radiotherapy and chemotherapy can lead to weakness of the spleen qi and dysfunction in transformation and transportation, which in turn affects the kidney Yang, forming a vicious cycle of “deficiency of both spleen and kidney.” The characteristic nursing of TCM, based on the simultaneous treatment of the spleen and kidney, emphasizes multi-dimensional intervention. This study aims to explore the impact of TCM characteristic nursing based on the theory of treating the spleen and kidney simultaneously (including syndrome differentiation, dietary therapy, acupoint application, and emotional regulation) on the gastrointestinal function and quality of life of patients with cancer-related anorexia, in order to provide a reference for tumor supportive treatment.
Two hundred patients who received medical treatment in a tertiary grade-A TCM hospital in Zhejiang Province from July 2023 to January 2025 were selected as the research subjects. The patients were divided into the experimental group and the control group by the random number table method, with 100 cases in each group. Inclusion criteria: (1) Patients with malignant tumors other than those in the digestive system; (2) Conform to the criteria of the “Chinese Expert Consensus on Diagnosis and Treatment of Cancer-related anorexia,” and the total score of the anorexia/cachexia Function Assessment scale (A/CS-12 scale) is ≤37 points; (3) TCM syndrome differentiation: It conforms to the syndrome of deficiency of both spleen and kidney; (4) No drugs that affect appetite have been used, such as glucocorticoids, progesterone. (5) In a nonterminal stage, with an expected survival period of ≥1 year, receiving tertiary care; and (6) ≥18 years old. Exclusion criteria: (1) Digestive system diseases; (2) Insufficiency of liver and kidney functions; (3) Has a history of digestive system diseases or has undergone digestive system surgery; (4) Critically ill patient; and (5) A history of cognitive dysfunction or a mini-mental state examination (MMSE) score of no more than 24 points. This study was approved by the ethics department of the institution.
Routine nursing services are provided to the patients in the control group. According to the patient’s condition, provide high-protein liquid food (such as Ansu nutritional supplements) as prescribed by the doctor, with a daily calorie intake of ≥25 kcal/kg and ensure basic nutritional support. For those who vomit, Glaisetron should be administered intravenously as directed by a doctor. For those with constipation, oral lactulose should be given as directed by a doctor. Distribute the hospital-made “Dietary Guidelines for Cancer Patients” to patients and ensure dietary education.
For the patients in the experimental group, on the basis of the intervention methods in the control group, the following TCM nursing services were provided. (1) Dietary therapy based on syndrome differentiation. 1) For spleen and kidney Yang deficiency-type (linked to cold manifestations) medicinal diet plan: warming Yang and Strengthening Kidney porridge (5 g aconite, 3 g cinnamon, 15 g coix seed, 30 g yam, and 50 g glutinous rice), Eucommia and Lamb soup (100 g lamb, 10 g Eucommia, 20 g walnut kernel, and 5 red dates); 2) spleen and kidney Yin deficiency-type (linked to dry manifestations) medicinal diet plan: Nourishing Yin and moistening dryness soup (20 g fresh dendrobium, 10 g Ophiopogon, 15 g tremella, 10 g lily, and a little rock sugar), mulberry parasitic egg tea (15 g mulberry parasitic, 10 g wolfberry, and 1 egg); 3) For liver depression and spleen deficiency-type medicinal diet plan: liversoothing and stomach-harmonizing drink (Buddha’s hand 10 g, dried tangerine peel 5 g, coix seed 30 g, and millet 50 g), rose and Poria cocos cake (Poria cocos powder 30 g, rose jam 10 g, and yam puree 50 g); 4) Damp-heat accumulation in the spleen-type medicinal diet plan: heat-clearing and damp-removing soup (200 g winter melon, 30 g red adzuki beans, and 15 g Poria cocos), Portulaca oleracea and lotus root porridge (50 g fresh Portulaca oleracea, 20 g lotus root starch, 50 g glutinous rice); 5) For the type of deficiency of both qi and blood, medicinal diet plan: Steamed pigeon with Angelica sinensis and Astragalus membranaceus (6 g of Angelica sinensis, 15 g of Astragalus membranaceus, and half a pigeon with its skin peeled), 5-red blood-nourishing drink (30 g of red-skinned peanuts, 10 g of wolfberries, 5 red dates, 15 g red beans, and 5 g brown sugar). (2) Meridian intervention. 1) Umbilical moxibustion: Once every other day, mix Evodia rutaecarpa powder and galangal powder (1:1) with yellow wine and apply it to the Shenque point. Then, moxibustion for 20 min can stimulate the Yang qi of the spleen and kidneys. 2) Acupuncture at acupoints: Three times a week; select the Zusanli (on stomach meridian, aiding digestion), Sanyinjiao (on spleen meridian, regulating gynecology), and Guanyuan (on conception vessel, tonifying yang) acupoints. Perform the tonifying method and retain the needles for 30 min to regulate the secretion of gastrointestinal hormones. (3) Emotional regulation. Five Elements Music Therapy: Play 30 min of palace tune music (such as a clip from “Ambush on All Sides”) every day, combined with breathing exercises, to soothe the liver and strengthen the spleen. 2) Mindful Eating training: Guide patients to observe the color and smell of food 5 min before meals to reduce eating anxiety. (4) Exercise guidance. Improve the “Baduanjin” and practice the movements of “one hand lifting to regulate the spleen and stomach” and “holding the feet with both hands to strengthen the kidneys and waist” every morning for 15 min each time to enhance the qi transformation function of the spleen and kidneys.
The appetite, gastrointestinal symptoms, quality of life, and body mass index (BMI) of the patients were evaluated respectively before the intervention, 1 month after the intervention, 3 months after the intervention, and 6 months after the intervention.
Appetite: It was evaluated using the Anorexia/Cachexia Subscale-12 (A/CS-12) for cancer patients.6,7 The scale consists of 12 appetite-related questions. Points are scored either positively or negatively based on the content of the questions (each item is scored on a scale of 0-4), with a total score ranging from 0 to 48. A total score of no more than 37 points can confirm the diagnosis of cancerous anorexia. The lower the score, the more significant the improvement in appetite.
Gastrointestinal symptoms: The Gastrointestinal Symptom Scale (GIS) was used for assessment.8 The scale includes 7 symptoms: abdominal pain, heartburn, abdominal distension, nausea/vomiting, acid reflux, abnormal bowel sounds, and abnormal defecation. Each symptom is scored on a scale of 0-3 points (from asymptomatic to severe, with 0 indicating asymptomatic and 3 indicating severe), and the total score ranges from 0 to 21 points. The higher the total score, the more severe the gastrointestinal symptoms. A total score of ≥8 points is determined as gastrointestinal dysfunction.
Quality of life: It is evaluated using the quality of life scale for cancer patients (QOL-CP).9,10 The scale includes 12 aspects: appetite, spirit, sleep, fatigue, pain, family understanding and cooperation, colleagues’ understanding and cooperation, awareness of cancer, treatment attitude, daily life, treatment side effects, and facial expressions. Each aspect is divided into 5 grades (on a scale of 1-5, with 1 indicating the worst state and 5 indicating the best state), and the total score ranges from 0 to 60 points. The higher the total score, the better the quality of life. The specific classification is as follows: 51–60 points is good, 41–50 points is relatively good, 31–40 points is average, 21–30 points is poor, and ≤20 points is extremely poor.
Body mass index: It is evaluated using BMI.11 BMI = Weight (kg)/Height (m).2 The BMI classification includes 4 grades: low weight (<18.5kg/m2), normal range (18.5–24kg/m2), overweight (24–28kg/m2), and obese (≥28kg/m2).
Statistical analysis was conducted using Statistical Product and Service Solutions (SPSS). The measurement data conforming to the normal distribution were expressed as mean and standard deviation. The independent sample t-test was used for comparison between the two groups, the paired sample t-test was used for comparison before and after within the group, and repeated measures analysis of variance was used for comparison at different time points. The measurement data that did not conform to the normal distribution were expressed as the median and quartile, and the rank sum test was used for comparison between groups. Counting data were expressed as frequency, percentage, or percentage rate, and the χ2 test was used for comparison between groups. A P value <0.05 was considered statistically significant.
There were no significant differences in the baseline data of age, gender, appetite, gastrointestinal symptoms, quality of life, and BMI between the experimental group and the control group (P > 0.05), as shown in Table 1.
Comparison of baseline data of patients.
| Indicators | Experimental group (n = 100) | Control group (n = 100) | Statistical value | P |
|---|---|---|---|---|
| Age (years) | 56.3 ± 8.7 | 55.8 ± 9.2 | t = 0.426 | 0.670 |
| Gender | ||||
| Male | 52 | 54 | χ2 = 0.124 | 0.724 |
| Female | 48 | 46 | ||
| Appetite (A/CS-12, points) | 32.6 ± 4.2 | 33.1 ± 3.9 | t = 0.862 | 0.389 |
| (GIS, points) | 10.2 ± 2.8 | 10.5 ± 3.1 | t = 0.715 | 0.475 |
| Quality of life (QOL-CP points) | 35.6 ± 6.8 | 34.9 ± 7.2 | t = 0.683 | 0.495 |
| BMI (kg/m2) | 17.8 ± 1.2 | 17.6 ± 1.3 | t = 1.082 | 0.280 |
Note: A/CS-12, Anorexia/Cachexia Subscale-12; BMI, body mass index; GIS, gastrointestinal symptom scale; QOL-CP, quality of life scale for cancer patients.
The appetite, gastrointestinal symptoms, quality of life, and BMI scores of the patients in the experimental group and the control group before the intervention, 1 month after the intervention, 3 months after the intervention, and 6 months after the intervention are shown in Table 2. The appetite and gastrointestinal symptom scores of the patients in the experimental group were lower than those in the control group (P < 0.05), while the quality of life score and BMI were higher than those in the control group (P < 0.05).
Comparison of various indicators between the two groups of patients at different intervention times (x ± s).
| Indicators | Time point | Experimental group (n = 100) | Control group (n = 100) | t | P |
|---|---|---|---|---|---|
| Appetite (A/CS-12, points) | Before intervention | 32.6 ± 4.2 | 33.1 ± 3.9 | 0.862 | 0.389 |
| 1 month after intervention | 28.5 ± 3.6 | 32.8 ± 4.1 | 6.489 | 0.004* | |
| 3 months after intervention | 22.3 ± 3.1 | 32.5 ± 3.8 | 17.753 | 0.011* | |
| 6 months after intervention | 18.6 ± 2.8 | 32.3 ± 3.6 | 24.891 | 0.023* | |
| GIS, points | Before intervention | 10.2 ± 2.8 | 10.5 ± 3.1 | 0.715 | 0.475 |
| 1 month after intervention | 8.5 ± 2.3 | 10.3 ± 2.9 | 4.592 | 0.008* | |
| 3 months after intervention | 6.2 ± 1.8 | 10.1 ± 2.7 | 11.483 | 0.019* | |
| 6 months after intervention | 4.3 ± 1.5 | 9.8 ± 2.5 | 17.396 | 0.031* | |
| Quality of life (QOL-CP points) | Before intervention | 35.6 ± 6.8 | 34.9 ± 7.2 | 0.683 | 0.495 |
| 1 month after intervention | 41.2 ± 5.9 | 35.2 ± 6.7 | 6.127 | 0.016* | |
| 3 months after intervention | 48.5 ± 5.2 | 35.1 ± 6.5 | 14.812 | 0.029* | |
| 6 months after intervention | 53.6 ± 4.8 | 34.9 ± 6.3 | 22.287 | 0.043* | |
| BMI (kg/m2) | Before intervention | 17.8 ± 1.2 | 17.6 ± 1.3 | 1.082 | 0.280 |
| 1 month after intervention | 18.3 ± 1.1 | 17.7 ± 1.2 | 3.115 | 0.006* | |
| 3 months after intervention | 19.5 ± 1.0 | 17.8 ± 1.3 | 9.472 | 0.017* | |
| 6 months after intervention | 21.2 ± 1.2 | 17.9 ± 1.4 | 14.158 | 0.037* |
Note: A/CS-12, Anorexia/Cachexia Subscale-12; BMI, body mass index; GIS, gastrointestinal symptom scale; QOL-CP, quality of life scale for cancer patients;
indicates P < 0.05.
The appetite, gastrointestinal symptoms, quality of life, and BMI scores of the patients in the experimental group before the intervention, 1 month after the intervention, 3 months after the intervention, and 6 months after the intervention are shown in Table 3. Compared with before the intervention, the appetite and gastrointestinal symptom scores of the patients in the experimental group were lower (P < 0.05), while the quality of life score and BMI were higher(P < 0.05).
Intra-group comparison of various indicators at different time points in the experimental group (x ± s) (n = 100).
| Indicators | Before intervention | 1 month after intervention | 3 months after intervention | 6 months after intervention | F | P |
|---|---|---|---|---|---|---|
| Appetite (A/CS-12, points) | 32.6 ± 4.2 | 28.5 ± 3.6 | 22.3 ± 3.1 | 18.6 ± 2.8 | 181.932 | 0.009* |
| GIS, points | 10.2 ± 2.8 | 8.5 ± 2.3 | 6.2 ± 1.8 | 4.3 ± 1.5 | 120.315 | 0.025* |
| Quality of life (QOL-CP points) | 35.6 ± 6.8 | 41.2 ± 5.9 | 48.5 ± 5.2 | 53.6 ± 4.8 | 209.874 | 0.035* |
| BMI (kg/m2) | 17.8 ± 1.2 | 18.3 ± 1.1 | 19.5 ± 1.0 | 21.2 ± 1.2 | 152.146 | 0.048* |
Note: A/CS-12, Anorexia/Cachexia Subscale-12; BMI, body mass index; GIS, gastrointestinal symptom scale; QOL-CP, quality of life scale for cancer patients.
indicates P < 0.05.
The scores of appetite, gastrointestinal symptoms, quality of life, and BMI of patients in the control group before the intervention, 1 month, 3 months, and 6 months after the intervention are shown in Table 4. Compared with the baseline (before the intervention), there were no significant differences in the scores of appetite, gastrointestinal symptoms, quality of life, or BMI of patients in the control group (P > 0.05).
Intra-group comparison of various indicators at different time points in the control group (x ± s) (n = 100).
| Indicators | Before intervention | 1 month after intervention | 3 months after intervention | 6 months after intervention | F | P |
|---|---|---|---|---|---|---|
| Appetite (A/CS-12, points) | 33.1 ± 3.9 | 32.8 ± 4.1 | 32.5 ± 3.8 | 32.3 ± 3.6 | 0.982 | 0.405 |
| GIS, points | 10.5 ± 3.1 | 10.3 ± 2.9 | 10.1 ± 2.7 | 9.8 ± 2.5 | 0.896 | 0.459 |
| Quality of life (QOL-CP, points) | 34.9 ± 7.2 | 35.2 ± 6.7 | 35.1 ± 6.5 | 34.9 ± 6.3 | 0.035 | 0.998 |
| BMI (kg/m2) | 17.6 ± 1.3 | 17.7 ± 1.2 | 17.8 ± 1.3 | 17.9 ± 1.4 | 0.737 | 0.533 |
Note: A/CS-12, Anorexia/Cachexia Subscale-12; BMI, body mass index; GIS, gastrointestinal symptom scale; QOL-CP, quality of life scale for cancer patients.
The theory of treating the spleen and kidney simultaneously holds that the spleen is the foundation of the body after birth and is in charge of transforming and transporting the essence of food and water. The kidney is the foundation of the body’s innate constitution, storing essence and governing water and qi transformation. The two organs work in synergy through a mechanism where “the innate constitution nourishes the acquired constitution and the acquired constitution supplements the innate constitution.” The syndrome differentiation diet plan proposed in this study, by targeting and regulating the “spleen–kidney–gastrointestinal” axis, embodies the core idea of “seeking the root cause in treating diseases” in TCM. Modern research shows that cinnamaldehyde in cinnamon can promote gastric motility by activating the Transient Receptor Potential Vanilloid 1 channel,12 while sarcandin in Eucommia ulmoides can regulate the secretion of ghrelin.13 This is in line with the phenomenon of improved appetite that we have observed at the molecular level. It is worth noting that the synergistic effect of yam and japonica rice in the medicinal diet combination may improve digestion and absorption by regulating the β diversity of intestinal flora.14–16 This “food and medicine sharing the same origin” microecological regulation mechanism provides a modern medical interpretation for traditional Chinese medical theory.
The therapeutic effect of meridian intervention may be closely related to the regulation of the vagus nervegut-brain axis. Recent functional magnetic resonance studies have shown that stimulation of the Shenzhuo acupoint can activate the neural pathways between the nucleus solitus and the hypothalamus,17’18 while acupuncture at the Zusanli acupoint can increase the level of motilin in plasma.19’20 This bidirectional regulatory effect precisely explains why the patients in the experimental group not only showed relief of early satiety symptoms but also experienced an increase in food intake, presenting a contradictory and unified phenomenon.
The dual intervention of “audition-cognition,” composed of the Five Elements Music Therapy and mindful eating, has created a special window period for neuroendocrine regulation. Research has confirmed that Gong tune music can enhance the functional connection between the default mode network and the insular lobe,21’22 which is directly related to the reduction of eating anxiety we have observed. Cancer patients are prone to liver qi stagnation (associated with “wood” in the Five Elements) or kidney qi deficiency (associated with “water” in the 5 Elements) due to fear and anxiety. The Five Elements music soothes the liver and relieves depression through the Jiao tune (the “wood” in the Five Elements) and calms the mind and stabilizes the will through the Yu tune (the “water” in the Five Elements), alleviating the suppression of negative emotions on the immune system.
Gong Diao music (the “earth” element in the Five Elements theory) can strengthen the spleen and stomach and improve loss of appetite after chemotherapy. Shangtiao (the “metal” in the Five Elements) tonifies lung qi, alleviates shortness of breath and wheezing after radiotherapy, and regulates the ascending and descending of spleen and kidney qi through the resonance of the 5 tones. More notably, mindfulness training may improve stress-induced gastrointestinal dysfunction by downregulating the expression of corticotropin-releasing hormone in the amygdala.23’24 This transmembrane regulation provides a molecular target for emotional care.
The “co-nourishment of body and spirit” feature of the improved Baduanjin demonstrates a unique advantage in metabolic regulation. Research in exercise physiology has revealed that the movement “to regulate the spleen and stomach, one must hold” can promote blood flow in the hepatic portal veins through the rhythmic contraction of the intercostal muscles,25 while “holding feet with both hands to strengthen the kidneys and waist” can activate the expression of uncoupling proteins in brown adipose tissue.26 This surface-visceral reflex mechanism perfectly interprets the scientific connotation of “external movement and internal effect” in traditional guiding exercises.
The most significant theoretical breakthrough of this study lies in establishing the potential association between dialectical classification and metabolomics characteristics. The abnormal metabolism of branched-chain amino acids in patients with spleen and kidney Yang deficiency type27’28 precisely explains why the Wen Yang Gu Shen Porridge can significantly improve their protein metabolism. The activation of the tryptophan-kynurenine pathway in patients with spleen and kidney Yin deficiency type29 confirms the inhibitory effect of dendrobium polysaccharides in the Nourishing Yin and Moistening Dryness Decoction on indoleamine 2, 3-dioxygenase. Thi+s precise correspondence model of “syndrome-metabolism-intervention” provides a new classification strategy for tumor nutritional support.
The intervention effect of damp-heat accumulation in the spleen type indicates the importance of regulating the “gut-liver axis.” The omega-3 fatty acids in Portulaca oleracea can reduce the resistance of fibroblast growth factor 21 in the liver,30’31 while the phylloside in Poria cocos can regulate the enterohepatic circulation of bile acids.32’33 This multi-target intervention feature is in line with the construction of networked pharmacology pursued by modern precision medicine.
Cancer patients often suffer from spleen deficiency, insufficient qi and blood production, and kidney essence deficiency due to the depletion of the disease and adverse reactions to treatment. The spleen and kidneys work together to maintain immune function and metabolic balance. When the spleen is weak, nutrient absorption is impaired, and when the kidneys are deficient, the bone marrow’s hematopoietic function is impaired. Deficiency of both the spleen and kidneys leads to the intermingling of phlegm and blood stasis, creating conditions for tumor recurrence. The combined treatment of the spleen and kidney blocks the pathological chain by resolving phlegm and promoting diuresis and warming the kidney to remove blood stasis, while regulating the immune microenvironment and reducing the risk of recurrence.
The 4-in-1 TCM nursing intervention system constructed in this study has essentially created a “TCM version guideline” for the management of tumor cachexia. Compared with simple nutritional support, TCM nursing shows unique advantages in improving leptin resistance,34 which may be attributed to the inducing effect of moxibustion on browning of white adipose tissue. What is more worthy of attention is that the feedback loop of the microbiota-gut-brain axis, regulated by acupuncture,35 provides an important breakthrough for disrupting the vicious cycle of cancerrelated anorexia.
At the level of translational medicine, the corresponding model of symptom clusters, syndrome groups, and intervention packages proposed in this study goes beyond the fragmented model of traditional symptom management. Recent system biology studies have confirmed that the combined intervention of TCM can simultaneously regulate the target protein of rapamycin and the adenylate-activated protein kinase signaling pathway.36 This multi-pathway synergistic effect is precisely what is needed to address the complex pathogenesis of cancer-related anorexia.
The sample source of this study is not rich enough, and there may be selection bias. In the future, multicenter studies can be conducted to improve the external validity of the results. The intervention period of this study was up to 6 months at most. The tracking of long-term efficacy was not very clear. Subsequent studies can appropriately extend the follow-up time to evaluate the sustained effect of TCM nursing. In the future, modern technologies such as “Internet + “ can be integrated to continue the nursing model, improve the accuracy of intervention, and develop standardized nursing plans for treating both the spleen and kidneys. In addition, metabolomics and related technologies can be used to explore the molecular mechanisms and reveal the biological basis for improving cancer-related anorexia based on the concept of treating both the spleen and kidneys.
From the perspective of theoretical innovation, this study breaks through the limitation of focusing solely on “spleen and stomach transportation and transformation” in traditional intervention for cancer anorexia. Its mechanism of action is not a simple superposition of TCM external treatment and Western nutritional support but through the synergistic effect of “strengthening the spleen and tonifying the kidney, benefiting qi and nourishing blood.” On the one hand, by means of TCM external treatment and TCM acupoint application, it directly stimulates the meridians and acupoints related to the spleen and kidney, enhancing the activity of spleen and kidney functions. On the other hand, it innovatively integrates the concept of modern nutritional support and formulates a personalized nutritional supplement plan according to the patients’ spleen and kidney function status and nutritional needs, realizing the organic integration of “TCM functional regulation” and “modern nutritional supply,” so as to fundamentally improve the patients’ gastrointestinal digestion and absorption function and alleviate anorexia symptoms.
The results of this study not only confirm the significant advantages of the TCM characteristic nursing plan for simultaneous treatment of the spleen and kidney in improving the gastrointestinal function and quality of life of patients with cancer anorexia but, more importantly, construct an integrated non-pharmaceutical intervention model of “TCM theory guidance, TCM external treatment intervention, modern nutritional support, and multi-dimensional efficacy evaluation.” It provides an innovative solution with Chinese characteristics for the field of tumor supportive treatment and also a reference research paradigm for the integrated traditional Chinese and Western medicine intervention in symptoms related to chronic diseases.