What Patients Know About Nutrition May Shape Malnutrition Risk in Head and Neck Cancer Surgery

For patients facing surgery on the head or neck, eating is never a simple matter. Tumors in the mouth, throat, larynx, and nasal passages can make chewing and swallowing painful or physically impossible, and the operations used to remove them often make things worse before they get better. Against this backdrop, a new study from China adds a surprising twist to the story of cancer-related malnutrition: what patients actually know about nutrition, and what they do with that knowledge, appears to be independently linked to whether they arrive at the operating table malnourished.

The research, published in the journal Supportive Care in Cancer, was conducted by a team from the Nutritional Department of the Eye & ENT Hospital of Fudan University in Shanghai. Between April 2023 and January 2025, the investigators enrolled 626 hospitalized patients who were scheduled to receive surgical treatment for head and neck cancer. Using a single-center, cross-sectional design with consecutive sampling, they set out to answer two intertwined questions: how much do these patients know, believe, and practice when it comes to nutrition, and how do those cognitive and behavioral factors relate to objectively diagnosed malnutrition?

To diagnose malnutrition, the team followed a two-step protocol that mirrors international best practice. Every participant first underwent routine nutritional risk screening with the Nutritional Risk Screening 2002 tool, known as NRS-2002, which weighs body mass index, recent weight loss, dietary intake, disease severity, and age. Patients whose scores reached three or higher, indicating significant nutritional risk, then underwent a full diagnostic assessment using the criteria of the Global Leadership Initiative on Malnutrition, or GLIM. The GLIM framework, established by a global consensus of clinical nutrition societies, requires the combination of a phenotypic criterion, such as unintentional weight loss or low body mass index, with an etiologic criterion, such as reduced food intake or inflammation, to formally diagnose malnutrition.

The headline number from the study is sobering but perhaps not shocking for clinicians in the field: 14.9 percent of the 626 patients, or 93 individuals, met the GLIM criteria for malnutrition. That figure sits within the range reported by other research groups using the same diagnostic framework in head and neck cancer populations, where prevalence estimates have varied widely depending on disease stage, treatment setting, and timing of assessment. What distinguishes the new study is not the prevalence count itself but the parallel investigation of the patients’ nutritional knowledge, attitudes, and practices, a triad that researchers abbreviate as KAP.

Each participant completed a structured KAP questionnaire probing three domains: what they understood about nutrition in the context of their disease, how they felt about the importance of nutritional care, and what they actually did day to day to manage their intake. The analysis revealed weak to moderate positive correlations among the three domains, with correlation coefficients ranging from 0.229 to 0.326, all statistically significant. In plain terms, knowing more about nutrition was associated with more favorable attitudes, and both were associated with better practices, but the links were far from airtight. Knowledge alone does not automatically translate into behavior, a gap that has frustrated health educators for decades and one that this data quantifies in a cancer population.

The comparison between nourished and malnourished patients was striking. Those who met the GLIM criteria scored significantly lower across the KAP dimensions than their well-nourished counterparts, with differences reaching statistical significance. But the researchers went further than simple group comparisons. Recognizing that sick patients differ in countless ways beyond their nutritional literacy, they built a multivariable regression model that adjusted for treatment burden and a battery of clinical confounders, allowing each factor’s independent contribution to malnutrition odds to be estimated.

What emerged from that model was a hierarchy of risk. The single strongest driver of malnutrition was cumulative treatment burden. Patients undergoing reoperation for recurrent nasopharyngeal carcinoma after prior radiotherapy and surgery faced the highest odds of all, with an odds ratio of 5.45, meaning their odds of malnutrition were more than five times higher than the reference group. This makes biological sense: repeat surgery in a previously irradiated field compounds tissue damage, impairs swallowing mechanics, and stacks the metabolic demands of healing on top of an already depleted reserve. Comorbidities told a similar dose-dependent story, with patients carrying two or more additional chronic conditions facing roughly 3.6 times the odds of malnutrition compared with those without such burdens.

Yet even after the statistical machinery had accounted for these powerful clinical forces, the cognitive-behavioral pathway remained visible. Every five-point increase in the knowledge score was associated with a 10 percent reduction in the odds of malnutrition, with an odds ratio of 0.90 and a confidence interval that excluded the null value. Every five-point increase in the practice score carried an even stronger association, an odds ratio of 0.86, corresponding to a 14 percent reduction in odds. Attitude scores, by contrast, did not remain independently significant after adjustment, suggesting that positive feelings about nutrition matter mainly insofar as they are converted into concrete dietary practices. The knowledge-practice gap, long a staple of health psychology, thus appears to have real clinical consequences in this population.

The authors are careful, appropriately, to frame these findings as associations rather than causal relationships. A cross-sectional study captures a single moment in time, so it cannot determine whether poor nutritional knowledge and practice lead to malnutrition, whether malnourished patients simply have less energy and capacity to learn and implement good dietary habits, or whether some unmeasured factor, such as social support or socioeconomic status, drives both. Longitudinal and interventional studies would be needed to establish that teaching patients about nutrition actually prevents malnutrition. Still, the consistency of the association after rigorous adjustment, and its alignment with a growing international literature linking KAP scores to malnutrition risk in tumor patients undergoing radiotherapy, lends the finding credibility.

The practical implications are where the study earns its keep. The authors argue for risk-stratified nutritional management: patients with heavy treatment burdens or multiple comorbidities need intensive, often clinical, nutritional support and aggressive symptom management, because education alone cannot overcome a surgically altered swallowing apparatus or the catabolic fire of recurrent disease. For patients at medium or low risk, however, the data suggest a different lever. Educational and behavioral interventions designed to close the gap between knowing and doing, teaching not just what good nutrition is but how to shop for it, prepare it, and sustain it through treatment, may meaningfully reduce malnutrition risk. In an era when head and neck cancer affects hundreds of thousands of people worldwide each year, and when malnutrition is known to worsen surgical outcomes, wound healing, and survival, the idea that a well-designed nutrition education program could shift the odds, even modestly, is a finding worth taking seriously. The Shanghai team’s work does not prove that it will, but it makes a compelling case that the question deserves a proper trial.

Subject of Research: Nutritional knowledge, attitudes, and practices and GLIM-defined malnutrition in hospitalized head and neck cancer surgery patients

Article Title: Nutritional knowledge, attitudes, and practices (KAP) and GLIM-defined malnutrition in hospitalized head and neck cancer patients receiving surgical treatment: A cross-sectional study in china

Article References: Jiang, J., Shi, Q., Xu, Q., Wu, R., & Ma, J. (2026). Nutritional knowledge, attitudes, and practices (KAP) and GLIM-defined malnutrition in hospitalized head and neck cancer patients receiving surgical treatment: A cross-sectional study in china. Supportive Care in Cancer, 34(10), Article 996. https://doi.org/10.1007/s00520-026-11257-x

Image Credits: AI Generated

DOI: 10.1007/s00520-026-11257-x

Keywords: head and neck cancer, malnutrition, GLIM criteria, nutritional KAP, NRS-2002, surgical patients, nasopharyngeal carcinoma, nutritional risk screening, comorbidities, nutrition education, supportive care, cross-sectional study