The effect of individual nutrition counseling on the life quality and weight in patients with gastric cancer following total gastrectomy

Abstract

The primary objective of this research is to investigate the influence of individual nutritional counseling (INC) on the quality of life (QOL) of gastric cancer patients who have undergone total gastrectomy. This prospective randomized controlled trial included 59 patients who were randomly assigned to either an intervention group, which received INC, or a control group. QOL data were collected by using the EORTC QOL-C30 and QOL-STO22 questionnaire. Weight and BMI were measured at discharge and two-month follow-up. The intervention group demonstrated significant improvements in several dimensions compared to the control group, including global health score and reduction in weight and BMI loss (all p < 0.01). This study highlights INC as an essential aspect of comprehensive care provided for patients following total gastrectomy. The intervention has been proven to be highly effective in enhancing QOL, physical function, and psychological well-being, as well as in mitigating the adverse effects of post-surgical complications. QOL was measured using the EORTC QLQ-C30 and QLQ-STO22 questionnaires, and weight and BMI were assessed at discharge and two months postoperatively. Patients in the intervention group showed significant improvements in overall health, physical functioning, fatigue, anorexia, and dysphagia (all p < 0.01), as well as in nausea and vomiting, reflux, and eating restrictions (all p < 0.05). The intervention group also had significantly less reduction in body weight and BMI (p < 0.001). These findings support the integration of INC as a vital component of postoperative care to improve physical, psychological, and nutritional outcomes in patients undergoing total gastrectomy.

Supplementary Information

The online version contains supplementary material available at 10.1038/s41598-025-18177-6.

Introduction

Gastric cancer (GC) is a prevalent malignancy that is widely observed across the globe. It ranks fifth in incidence and is the fourth cause of cancer-related deaths worldwide. Furthermore, it is the main cause of cancer related death in several South-Central Asian countries, including Iran¹. The clinical stage which includes radiation therapy, chemotherapy, or surgery is the most important indicators for stomach cancer treatment. Gastrectomy is the most effective treatment method for both the early and advanced stages of stomach cancer^2,3. However, surgery is associated with significant gastrointestinal complications, it causes a decrease in the volume of food storage, and threatens the nutritional status of patients^4–6. GC, especially following total gastrectomy, poses substantial challenges for nutritional status and quality. Home rehabilitation after gastrectomy is crucial as patients continue to experience post-surgery syndromes and the risk of re-hospitalization⁷. During this period, their diet is inevitably restricted⁸. Following gastrectomy, patients usually experience weight loss due to reduced food intake, malabsorption, or metabolic changes that lead to insufficient caloric and protein intake⁹. A significant percentage of patients, specifically 98.3%, reported weight reduction following gastrectomy. It has also been shown that malnutrition and weight loss adversely affect patients’ quality of life (QoL)^10–13. The importance of proper assessment of QoL in cancer patients is Firmly established; however, strategies to enhance this important outcome are relatively rare, particularly in Iran^14–16. The available solutions to improve cancer patients’ quality of life are limited and include physical activity, education, personal care protocols, and psychosocial support^17–19.

This study specifically targets patients who have undergone total gastrectomy—a group that faces distinct and more severe nutritional and metabolic challenges compared to those who have had partial gastric resections. Unlike previous studies that grouped different types of gastric surgeries, our exclusive focus on total gastrectomy allows for a more precise evaluation of nutritional needs and responses to intervention. In this context, individualized nutrition counseling, tailored to each patient’s unique physiological status, tolerances, and eating limitations, emerges as a promising strategy to manage post-surgical nutritional complications. The primary aim of this intervention is to promote better dietary habits, enhance symptom management, and ultimately improve the overall quality of life and chemotherapy tolerance in this vulnerable population.

Methods

Study design

This randomized controlled trial was conducted in the Cancer Institute of Imam Khomeini Hospital and Firouzgar Hospital (Tehran, Iran) from Feb 2023 to April 2024. The sample size was calculated based on the primary outcome measure for quality of life (QoL), used by Gao et al.²⁰. Assuming a type I error (α) of 0.05 and a type II error (β) of 0.20 (i.e., 80% power), the required sample size was determined using the following formula:

Based on the expected means and standard deviations reported in the Gao study, and using STATA software version 15 (MP), the minimum sample size required for each group was estimated to be 30 participants. Considering a potential dropout rate of 10%, the final sample size was increased to 33 participants per group (total of 66 participants).

Following the acquisition of informed consent, patients were randomly assigned to two groups: individual nutritional counseling group (INCG) and control group (CG) through a randomization process, using the minimization method, stratified by gender, and in balanced blocks. To implement this, the study’s statistical consultant used six slips of paper—three labeled with the letter “I” for Intervention and three with the letter “C” for Control. These slips were placed into a container and randomly drawn one by one until all six were selected. Then, the slips were returned to the container, and the process was repeated until the entire sample was allocated. Participants were then assigned to the corresponding blocks in a balanced manner, taking gender into account. Allocation concealment was not implemented.

Patients who understood the purpose of the study and expressed their willingness to participate were included in the study provided that they met specified inclusion criteria, that is a diagnosis of stomach cancer, an age between 20 and 65 years, and having undergone total gastrectomy surgery. Exclusion criteria included patients with chronic diseases, such as cardiovascular diseases or diabetes, that may affect their nutritional status, prolonged hospitalization after surgery or rehospitalization. A total of 66 Qualified subjects were enrolled in this intervention. The participants were divided into two groups: the intervention group consisting of patients who received individual nutritional counseling immediately after discharge for eight weeks, and the control group including patients who received only standard nutritional care prior to discharge from the hospital.

During the follow-up period, a total of seven participants were excluded from the study. In the control group, five patients were lost: three due to lack of response during follow-up, one due to a stroke, and one due to loss of communication channels. In the intervention group, two participants were excluded because of lost contact. These dropouts resulted in unequal attrition between the groups. To ensure the robustness of the findings despite this imbalance, an intention-to-treat (ITT) analysis was performed. Ultimately, data from 59 participants (28 in the control group and 31 in the intervention group) were included in the final analysis. A detailed flowchart of participant recruitment and retention is presented in Fig. 1.

Fig. 1.

CONSORT flow diagram.

The current study was registered with the Iranian Registry of Clinical Trials (IRCT) under the registration number IRCT20150902023861N9. The trial was first registered on 13/02/2023. All methods were carried out in accordance with relevant guidelines and regulations. The study protocol was approved by the Ethics Committee of Iran University of Medical Sciences (Approval Number: IR.IUMS.REC.1401.087). Informed written consent was obtained from all participants prior to their discharge and inclusion in the study. All participant data were kept confidential and the study was conducted in accordance with the Declaration of Helsinki.

Study protocol

A nutrition support team, comprising surgeons and nutritionists, was established. Comprehensive data were collected, including general characteristics and disease-related factors, such as age, gender, education level, length of hospitalization (days), medical history, morning weight, preoperative complications, and symptom evaluations through interviews. Moreover, a 24-hour food diary was maintained. Prior to discharge, both groups received a standard single-session nutritional counseling session, which focused on increasing awareness of the disease and introducing the principles of post-surgery dietary progression. This included guidance for transitioning from liquid to semi-solid and solid diets over the first 2 months post-discharge, in line with typical post-gastrectomy recovery phases.

The intervention group received an innovative eight-session individualized nutritional counseling program, delivered at weekly intervals over two months, designed based on a structured protocol that considered individual patient needs, symptoms, treatment progress, and recovery pace.

Given that patients undergo chemotherapy as an adjuvant treatment to surgery, nutrition counseling interventions were tailored based on the American Cancer Society nutrition guidelines and adjusted according to each patient’s treatment phase and side effect profile. The intervention also included ongoing management of nutrition impact symptoms (e.g., appetite loss, early satiety, dysgeusia) and individualized meal planning strategies aimed at improving food tolerance and promoting nutritional adequacy.

A multidisciplinary coordination model was employed, ensuring continuous communication between the clinical dietitian and oncology team, which enabled dynamic adjustments to the intervention based on evolving clinical conditions and patient feedback.

Nutrition counseling program:

Each nutrition counseling session included four assessment stages: evaluation, identification, intervention, and follow-up. The evaluation phase initiated with an assessment of nutritional state and determination of any problems using PG-SGA-SF outcomes and anthropometric data. In the identification phase, we determined and described specialized feeding problems, their causes, and associated symptoms. To address these nutritional problems, a nutritionist provided consultation and a tailored meal plan to each patient’s individual needs^21,22. The monitoring stage involved discussions about current weight, and assessment of nutritional intake based on patient reports. No significant adverse events were observed, and participants reported no major negative effects from the nutritional counseling.

Each counseling session was conducted in the presence of a family member, and a supportive approach that may enhance adherence and patient motivation. Routine follow-up confirmed no complications or health risks. Individual nutrition counseling was offered to enhance dietary intake as necessary. An initial face-to-face training session was conducted at the beginning of the study, followed by seven weekly non-face-to-face training sessions with the patient, preferably with family participation. The first in-person educational session, conducted prior to discharge, comprised a comprehensive program covering the disease description, principles of the post-gastrectomy diet, necessary precautions, and management of potential complications. Subsequent sessions included training on recommended dietary choices and cooking techniques, physical activity guidelines, and foods to avoid. These recommendations were customized to meet the specific needs of patients after gastrectomy and were adjusted according to the occurrence of complications and disorders. During these meetings, patient adherence to the instructions was ensured, and any concerns or problems were addressed. A personalized meal plan was developed for each patient at the beginning of each week based on the post-gastrectomy treatment protocol²². To monitor adherence to the individualized nutritional counseling (INC), repeated 24-hour dietary recalls were conducted throughout the intervention period.

The CG did not receive individual nutrition counseling after discharge. To evaluate the effectiveness of the counseling program, patients were invited to the hospital for a follow-up examination eight weeks post-discharge. The evaluation included weight measurement and comple tion of relevant questionnaires. For patients unable to attend in person, alternative assessments were conducted via telephone.

Patient and public involvement

The design, conduct, and reporting phases of this trial did not include patient or public engagement. Notwithstanding this, prior to enrollment, participants were provided with detailed information about the study’s rationale, and their informed agreement to participate was documented.

Data collection

To obtain a comprehensive insight into the QOL of a patient with GC, the European Organization for Research and Treatment of Cancer (EORTC) recommends the QLQ-C30, a 30-question core questionnaire that includes nine multiple-item scales (five functional scales (physical, role, cognitive, emotional, and social); three symptom scales (fatigue, pain, and nausea/vomiting); and a global health status. Additionally, the 22-item STO22 module for GC is conceptualized into five distinct scales alongside four individual variables related to disease symptoms. The GC module (QLQ-STO22) complements the QLQ-C30 by addressing treatment-related adverse effects and emotional issues unique to GC^23,24. For overall quality of life assessment, a higher score indicates better QOL, while for the symptom scale, a lower score reflects better QOL.

To assess nutritional status, the Patient-Generated Subjective Global Assessment Short Form (PG-SGA SF) questionnaire was employed. The PG-SGA SF comprises four distinct categories: weight change, changes in food consumption, symptoms related to nutritional impact, and activity and performance. In this study, the PG-SGA was exclusively utilized to evaluate gastrointestinal symptoms and provide nutritional recommendations for patients. The symptom score obtained from the PG-SGA was not employed as an outcome measure.

Statistical analysis

The Statistical Package for the Social Sciences (SPSS) version 23 was employed to conduct a comprehensive analysis of the collected data. Descriptive statistics, encompassing measures such as means and standard deviations for quantitative variables, as well as frequencies and percentages for categorical variables, were used to describe the data. To test the research hypotheses, both parametric and nonparametric tests were applied. An independent samples t-test was performed to analyze the differences in the means of two independent groups (intervention and control) for quantitative variables. A chi-square test was employed to compare the frequencies of two groups for categorical variables. Given the importance of controlling for the effects of covariates on the dependent variable, an analysis of covariance (ANCOVA) was performed to assess differences between groups after controlling for these effects. In cases where the assumptions for parametric tests were not met, appropriate nonparametric tests were used. Additionally, to evaluate the effectiveness of the treatment in real-world conditions, an intention-to-treat (ITT) analysis was conducted employing the expected maximum (EM) calculation method.

Result

Patients’ characteristics

The disease characteristics and demographic of the study participants are presented in Table 1. There were no statistically significant disparities between the intervention group receiving individual nutrition counseling and the control group regarding sex, age, weight, body mass index (BMI) and length of hospitalization after surgery.

Table 1.

General characteristics of participants at baseline.

Characteristics	INC group(n = 31)	Control (n = 28)	p-value
Gender			0.90
Males	15 (48.4%)	14 (50%)
Females	16 (51.6%)	14 (50%)
Weight (kg)	62.24 ± 9.9	61.51 ± 5.15	0.63
BMI (kg/m2)	22.14 ± 4.43	21.46 ± 2.44	0.59
Age, years	54.9 ± 9.32	55.79 ± 6.52	0.53
Marital status			0.55
Married	29 (93.5%)	25 (89.3%)
Others (unmarried/divorced/widowed)	2 (6.5%)	3 (10.7%)
Hospitalization period, day	10.16 ± 1.15	10.00 ± 1.33	0.62
Chemotherapy, sessions	2.71 ± 1.88	3.0 ± 1.82	0.55

Values are presented as mean ± standard deviation or number (%). T- test and chi-square test.

INC, Individual Nutritional Counseling group; *P < 0.05.

Nutritional intake data

The average daily intake of energy, protein, carbohydrate, fat, Vit E, Vit C, Vit D, calcium, zinc, and iron at baseline was not statistically different between the two groups (p > 0.05). However, by the end of the study, the mean protein intake in the INCG was significantly higher than that in the CG (p < 0.001), while there were no statistically significant differences in other daily nutritional intakes. This may be related to the greater emphasis on protein during the counseling sessions, and the fact that post-gastrectomy patients often tolerate limited food volumes, which can restrict significant changes in total energy and micronutrient intake in both groups. (Details of nutritional intakes analysis are provided in Supplementary Table S1).

Evaluating the effectiveness of the program on the QLQ-C30

At the end of the study, the INCG showed significantly greater mean differences (MD) compared to the CG in global health status (p < 0.001), physical functions (p < 0.01), fatigue (p < 0.01), nausea and vomiting(N/V) (p < 0.05), appetite loss (p < 0.01), and financial problems (p < 0.05). The effect size, which indicates the magnitude of the difference between the groups, were as follows: large for global health status (SMD = 1.84), physical function (SMD = 0.82), fatigue (SMD = − 1.02), and appetite loss (SMD = − 1.27); moderate for financial problems (SMD = − 0.57) and nausea and vomiting (SMD = − 0.56). These findings indicate that nutritional counseling had a large positive impact on patients’ overall well-being and several key symptoms. However, the intervention showed minimal or no effect on other aspects such as role, cognitive, and social functioning, pain, dyspnea, insomnia, constipation, and diarrhea (Table 2). Comparison of baseline scores for the Global health, Functional and Symptom scales of the QLQ-C30 were not statistically different between the two groups (p > 0.05); full details are provided in Supplementary Table S2.

Table 2.

Comparison scores for the global health, functional and symptom scales of the QLQ-C30 between INC group (n = 31) and control (n = 28).

Variable	Mean difference			SMD (95%CI)
	INC group	Control	95%CI
Global health status/QoL a	33.87 ± 12.71	18.45 ± 10.72	9.25, 21.58***	1.84 (1.22, 2.44)
Functional scalesa
Physical functioning	47.74 ± 11.81	36.90 ± 14.57	3.95, 17.7**	0.82 (0.28, 1.35)
Role functioning	52.15 ± 15.95	45.23 ± 15.61	− 1.33, 15.15	0.44 (− 0.08, 0.95)
Emotional functioning	24.19 ± 13.66	19.64 ± 14.02	− 2.26, 11.77	0.32 (− 0.19, 0.84)
Cognitive functioning	15.59 ± 21.05	13.09 ± 19.43	− 8/10, 13.09	0.38 (− 0.13, 0.89)
Social functioning	20.43 ± 12.70	13.69 ± 17.00	− 1.03, 14.51	0.45 (− 0.06, 0.63)
Symptom scales/itemsb
Fatigue	− 52.68 ± 15.96	− 39.28 ± 16.13	− 21.87, − 5.02**	− 1.02 (− 1.56, − 0.47)
Nausea and vomiting	− 18.81 ± 19.12	− 5.35 ± 28.70	− 26.38, − 5.02*	− 0.56 (− 1.07, − 0.03)
Pain	− 69.89 ± 14.54	− 64.88 ± 16.56	− 13.12, 3.09	− 0.23 (− 0.83, 0.19)
Dyspnea	− 5.37 ± 21.25	− 7.14 ± 20.99	− 9.26, 12.79	0.08 (− 0.43, 0.59)
Insomnia	− 13.97 ± 26.90	− 14.28 ± 27.85	− 13.97, 14.59	− 0.48 (− 0.99, 0.04)
Appetite loss	− 54.83 ± 23.64	− 33.33 ± 28.68	− 35.16, − 7.84**	− 1.27 (− 1.83, − 0.71)
Constipation	− 31.18 ± 30.95	− 28.57 ± 31.05	− 18.79, 13.57	− 0.08 (− 0.59, 0.42)
Diarrhea	− 6.45 ± 20.03	− 1.19 ± 14.29	− 14.28, 3.75	− 0.30 (− 0.81, 0.21)
Financial difficulties	− 30.10 ± 27.69	− 14.28 ± 29.29	− 30.68, − 0.96*	− 0.53 (− 1.07, − 0.005)

Values are presented as mean difference ± standard deviation (95% CI). CI, Confidence Interval; INC, Individual Nutritional Counseling group; SMD, Standard Mean Difference; QoL, quality of life.

^aA higher score represents a better QoL.

^bA higher score represents a worse QoL. *P < 0.05; **P < 0.01; ***P < 0.001.

Evaluating the effectiveness of the program on the QLQ-STO22

Compared to the CG, the INCG experienced significantly greater MD in several domains of the QLQ-STO22, including dysphagia (p < 0.01), abdominal pain (p < 0.05), reflux (p < 0.05), eating restriction (p < 0.01), anxiety (p < 0.05), and body image (p < 0.05). Effect size analysis revealed a large effect of the intervention on dysphagia (SMD = -0.91) and eating restriction (SMD = -1.14). Moderate effects were observed for abdominal pain (SMD = -0.57), reflux (SMD = -0.60), anxiety (SMD = -0.56), and body image (SMD = -0.56). In contrast, the intervention had small or negligible effects on dry mouth, food taste problems, and hair loss (Table 3). Comparison of baseline scores for the Symptom scales of the QLQ-STO22 showed no statistically significant differences between the two groups (p > 0.05); full details are provided in Supplementary Table S3.

Table 3.

Comparison scores for the subscales of the QLQ-STO22 between INC group (n = 31) and control (n = 28).

Variable	Mean difference			SMD (95%CI)
	INC group	Control	95%CI
Dysphagia	− 52.32 ± 11.54	− 39.68 ± 16.12	− 20.05, − 5.23**	− 0.91 (− 1.44, − 0.37)
Abdominal pain	− 35.75 ± 15.98	− 31.25 ± 18.74	− 13.57, 4.56	− 0.57 (− 0.77, 0.25)
Reflux	− 8.24 ± 10.72	− 1.98 ± 10.05	− 11.69, − 0.82*	− 0.60 (− 1.12, − 0.07)
Eating restrictions	− 44.35 ± 10.62	− 34.82 ± 9.36	− 12.77, − 4.28*	− 1.14 (− 1.68, − 0.58)
Anxiety	− 30.46 ± 20.27	− 19.44 ± 19.03	− 21.30, − 0.73*	− 0.56 (− 1.07, − 0.03)
Having a dry mouth	− 18.27 ± 34.25	− 5.95 ± 18.26	− 26.52, 1.76	− 0.34 (− 0.96, 0.07)
Taste problem	− 4.30 ± 16.64	− 2.38 ± 8.74	− 8.79, 4.95	− 0.14 (− 0.64, 0.36)
Body image	− 31.18 ± 29.73	− 14.28 ± 30.66	− 32.65, − 1.14*	− 0.56 (− 1.07, − 0.03)
Hair loss	− 7.14 ± 18.89	− 16.66 ± 16.66	− 19.70, 38.74	0.12 (− 0.87, 1.88)

Values are presented as mean difference ± standard deviation (95% CI). CI, Confidence Interval; SMD, Standard Mean Difference; INC, Individual Nutritional Counseling group. A higher score represents a worse QoL. *P < 0.05; **P < 0.01; ***P < 0.001.

Comparison of changes in weight and BMI

When comparing the INCG and CG, significant mean differences were observed for both weight (p < 0.001) and BMI (p < 0.001), with the intervention group experiencing substantially less reduction in these measures. The intervention demonstrated a large effect size, with a standardized mean difference (SMD) of -1.24 for weight and − 1.38 for BMI, indicating that nutritional counseling had a strong and clinically meaningful impact on preserving weight and BMI in the intervention group compared to the control (Table 4).

Table 4.

Comparison of weight and BMI changes in INC group (n = 31) and control (n = 28).

Variable	Mean difference			SMD (95%CI)
	INC group	Control	95%CI
Weight	− 5.41 ± 2.43	− 8.19 ± 1.97	− 3.94, − 1.61***	− 1.24 (0.68, 1.80)
BMI	− 2.03 ± 0.52	− 2.92 ± 0.72	− 1.22, − 0.56***	− 1.38 (0.80, 1.95)

SD, Standard Deviation; CI, Confidence Interval; INC, Individual Nutritional Counseling group; SMD, Standard Mean Difference; BMI, Body Mass Index.

*P < 0.05; **P < 0.01; ***P < 0.001.

Intention-to-treat analysis

By conducting an intention-to-treat (ITT) analysis, which includes all randomized participants regardless of their adherence to treatment, we obtained a conservative estimate of the intervention’s overall impact. Although some participants dropped out of the study, the results remained robust, and the primary findings did not change.

Discussion

Despite significant advancements in GC treatment, post-surgical malnutrition remains a persistent challenge that significantly affects patients’ quality of life. Metabolic abnormalities, decreased appetite, and gastrointestinal symptoms resulting from the disease and its treatment contribute to severe weight loss, muscle wasting, and chronic inflammation²⁵. While individual nutritional counseling is a crucial part of post-operative management, effective strategies for improving long-term dietary adherence are still limited²⁶. The heterogeneity of patients’ individual characteristics necessitates personalized approaches. Although complete prevention of malnutrition and weight loss after surgery may not be feasible, proactive patient management and tailored nutritional interventions can significantly improve quality of life. Nutritional counseling can play a pivotal role in both physical and psychological rehabilitation²⁰. By addressing the physiological changes induced by the disease and its treatment, as well as the psychological impact, nutritional counseling can empower patients to make informed food choices and adopt healthier lifestyle habits²⁷.

The findings of this study demonstrated that nutritional counseling interventions significantly reduced weight and BMI (p < 0.001) in post-surgical GC patients compared to the CG. The effect sizes for both outcomes were large, indicating a strong and clinically meaningful impact of the intervention.

These results are consistent with previous research highlighting the benefits of ongoing nutritional counseling after gastrectomy²⁸. Studies have also shown that the frequency and continuity of counseling sessions play an important role in weight maintenance²⁹.

Yang et al.³⁰ reported that individualized dietary counseling tailored to calorie and protein needs helped reduce BMI loss following gastrectomy, with significant differences between intervention and control groups. Conversely, Moon Bae et al.³¹, did not find similar results, likely due to a shorter intervention period and less comprehensive educational content.

In this While baseline QOL scores did not differ significantly between groups, post-intervention analysis showed a marked improvement in several QOL domains in the intervention group, especially global health status (p < 0.001). This aligns with Yu et al.³², who linked similar improvements to better weight management and reduced symptoms such as fatigue and nausea. Likewise, Davoudi et al.³³ found that self-care education positively influenced global health status. Conversely, Lee et al.³⁴ suggested that group education alone might be insufficient for enhancing QOL.

Notably, the intervention group also experienced significant improvements in physical functioning (p < 0.01). This suggests that beyond addressing nutritional status, individualized counseling may directly enhance physical performance post-surgery. These findings are consistent with prior research emphasizing the role of tailored nutritional support and increased physical activity in functional recovery after gastrectomy^35,36.

In contrast, Davoudi et al., did not report any significant difference in patients’ physical function which may be due to differences in study design, population characteristics, or other confounding variables.

It seems that functional scales, compared to symptom scales or QLQ-STO22, are more influenced by emotional and psychological issues and environmental conditions rather than being directly related to nutrition and dietetics. Individual nutritional counseling, by providing dietary interventions tailored to the needs of each patient, can improve nutritional status, and ultimately enhance physical functioning.

Numerous studies have demonstrated that nutritional counseling significantly improves swallowing function in post-surgical patients. Dysphagia management, determining appropriate food textures, teaching swallowing techniques, and modifying dietary patterns, seems to account for the great effect of individual nutritional counseling on reducing dysphagia in the INCG compared to the CG.

Research has shown that combining nutritional counseling with swallowing therapy, especially in patients who have undergone surgical procedures, such as laryngectomy, is effective in improving swallowing function³⁷. This dual approach not only improves nutritional status but also leads to a significant increase in QOL^37,38. However, the effectiveness of nutritional counseling may be influenced by individual patient factors, such as the severity of dysphagia and the type of surgical intervention. Therefore, there is an increasing need for personalized approaches in treatment programs.

The fatigue scale revealed a significant reduction in the INCG compared to the CG (p < 0.01), indicating the greater effectiveness of individual nutritional counseling. This result is consistent with prior studies demonstrating that targeted nutritional interventions can lower fatigue levels. According to Chen et al., patients receiving nutritional counseling reported lower levels of fatigue³⁰.

Furthermore, continuous nutritional care (CNC) has been shown to improve food intake and prevent excessive weight loss, both of which are crucial for maintaining energy levels and reducing fatigue²⁸. Promoting healthy eating habits, such as increasing protein intake and meal frequency, is associated with improved quality of life. This underscores a direct connection between nutrition and fatigue management³⁹.

The present study’s results revealed that INC can effectively reduce symptoms of nausea and vomiting following gastrectomy (p < 0.05), particularly in managing dumping syndrome. Controlling food components (reducing fat and sugar intake), increasing meal frequency, and decreasing portion sizes, may help prevent rapid gastric emptying and lessen stress on the gastrointestinal system, thereby alleviating nausea and vomiting. Additionally, educating patients on recognizing symptoms and managing them can significantly improve patient outcomes⁴⁰.

The study also indicated an improvement in the nutritional status of patients in the intervention group. While no statistically significant difference was observed in nutrient intake between the two groups, the trend was more favorable in the INCG. This improvement may be attributed to the provision of personalized dietary plans tailored to each patient’s preferences, tolerance, and nutritional needs^25,41.

Post-gastrectomy patients commonly experience a decreased appetite, a complication that significantly affects their nutritional status and recovery^40,42–45. This condition is primarily due to physiological changes resulting from total gastrectomy, including disruptions in gastric acid and intestinal hormone production, impaired digestion, altered satiety signaling, and symptoms such as dumping syndrome, all of which may contribute to eating disorders and reduced food intake.

The findings of this study demonstrate that individualized nutritional counseling can play a pivotal role in mitigating these complications. Patients in the intervention group (INCG) showed a significantly greater reduction in appetite loss compared to the control group (CG) (p < 0.01), underscoring the positive impact of tailored dietary strategies on appetite management. These strategies typically involve dietary plans emphasizing small, frequent meals that are rich in protein and essential nutrients, which help patients meet their nutritional needs more effectively and prevent undesirable weight loss.

Consistent with previous research³⁰, this study further showed that personalized nutritional counseling led to improved intake of target calories and proteins. Moreover, it significantly alleviated dietary restrictions in patients who underwent total gastrectomy, as evidenced by the marked difference between the INCG and CG groups in terms of dietary limitations (p < 0.01). These results suggest that individualized interventions can not only improve nutritional status but also reduce fear of eating and correct irregular eating behaviors by incorporating nutrition education, post-meal symptom management, and guidance on constructing a balanced diet.

Moreover, the INCG showed a statistically significant improvement in reflux symptoms compared to the CG (p < 0.05), further supporting the overall benefit of dietary counseling. This reduction can be attributed to both improved eating behaviors and key dietary modifications, such as decreasing intake of fatty, acidic, and spicy foods-known to compromise the lower esophageal sphincter and exacerbate acid reflux^46–48.

The findings of this study indicate that individual nutritional counseling can effectively enhance the psychological status of patients following total gastrectomy, particularly in reducing anxiety (p < 0.05) and improving body image (p < 0.05). By providing accurate nutritional information, making appropriate dietary adjustments, and developing personalized dietary plans patients can better adapt to bodily changes and fulfill their nutritional requirements. This leads to an improved quality of life and reduced fear of eating.

In our study, individualized nutritional counseling did not lead to a significant reduction in dry mouth and hair loss compared to the control group. This finding aligns with existing literature and may be attributed to the complex and multifactorial nature of post-gastrectomy nutritional challenges. Total gastrectomy results in physiological alterations such as malabsorption, early satiety, and decreased food tolerance, which contribute to deficiencies in nutrients essential for skin and hair health, including iron and vitamin B12^49,50. Although counseling aims to improve oral intake, its efficacy is limited by impaired digestion and absorption^41,51,52. Furthermore, concurrent chemotherapy exacerbates these nutritional disruptions and related symptoms, making them less responsive to dietary strategies alone.

The impact of personalized nutritional counseling on patients’ psychological state was found to be moderate when compared to those who did not receive such counseling. Moreover, efforts in weight management to reduce weight loss may explain the significant differences in anxiety and body image observes between the two groups. The intervention group also experienced improved management of complications after total gastrectomy, likely due to effective strategies provided through nutritional counseling. By addressing essential nutritional factors and modifying dietary patterns, healthcare professionals can significantly improve the QOL for patients after complete stomach removal.

Although existing evidence suggests that nutritional counseling can improve the quality of life for GC patients after gastrectomy, a more comprehensive and multidisciplinary approach is needed to achieve optimal outcomes. Collaboration among nutritionists, psychologists, nurses, oncologists, and other members of the care team can significantly improve these patients’ quality of life. Previous research has shown that psychological interventions, such as cognitive-behavioral therapies, can be effective in reducing emotional distress and increasing coping skills in GC patients^53,54. Therefore, incorporating psychological services into care programs especially for patients experiencing emotional and psychological challenges after surgery, would be very beneficial.

A multidisciplinary approach can significantly help patients cope with the various challenges they face following gastrectomy, including nutritional issues, treatment side effects, changes in body image, and psychological disorders. This approach can encompass nutritional counseling, psychotherapy, social support, and patient education.

While nutritional counseling in oncology is not a novel concept, this study introduces several methodological and practical innovations. These include a focus on total gastrectomy patients, implementation of a four-phase counseling model, dynamic dietary adjustments, family involvement in sessions, and symptom-oriented individualized plans. Together, these features enhance the applicability and effectiveness of the intervention in real-world clinical practice and distinguish the present work from previous studies in the field.

To improve the quality of life for GC patients, further research is essential to develop and evaluate multidisciplinary interventions. Such research can help identify factors affecting the QOL of these patients and establish the most effective combination of services tailored to each patient.

While this study enhanced the credibility of its findings by employing standardized and validated tools to measure quality of life and other variables, as well as by focusing on an individual nutrition program and assessing its impact, the short duration of the study may not have adequately captured the long-term effects of the intervention. Furthermore, the lack of objective indicators, such as blood test results to assess patients’ nutritional status, may have reduced the accuracy of the results. Additionally, the absence of a suitable tool to assess patient adherence to dietary recommendations may have affected the interpretation of the results.

Specifically, while we attempted to control for key patient confounders, we were unable to directly collect data on factors such as socioeconomic status and the level of postoperative support available at home. Although these unmeasured variables could act as residual confounders by influencing nutritional intake, adherence to recommendations, and overall quality of life, we utilized marital status as an indirect indicator of a home-based supportive network. For future research, it is crucial to directly measure these important social determinants of health, including socioeconomic status, the level of domestic support, and health literacy, to provide a more comprehensive understanding of the factors affecting patient outcomes.

For future studies, it is recommended to extend the study duration to better assess the long-term effects of the intervention, develop adherence assessment tools, and use a multidisciplinary approach. Future studies should consider the limitations of this study and employ more comprehensive approaches and precise tools to examine the effectiveness of nutritional interventions in improving the quality of life for GC patients. Such research will deepen our understanding of these patients’ needs and enable us to develop more effective treatment plans.

Conclusion

The findings of this study, highlight individual nutritional counseling as a critical component in the comprehensive management of gastric cancer patients following total gastrectomy. The intervention proved to be effective in improving quality of life, addressing issues related to appetite and weight loss, and alleviating common post-surgical symptoms. These results not only emphasize the necessity of tailored nutritional strategies to optimize patient outcomes, but also advocate for the broader integration of nutritional care into standard treatment guidelines for gastric cancer survivors.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contributions

N. K.: Study design, data collection, statistical analysis, drafting the manuscript. F. Sh.: (Corresponding author) Project supervision, scientific review and editing of the manuscript. S. R. M.: Clinical supervision, participation in data collection, scientific review of the manuscript. F. S. H. B.: Statistical consultation, methodology design, data analysis. R. B.: Language and grammatical editing and review of the manuscript. S. M. Gh.: Participation in statistical analysis.All authors reviewed the manuscript.

Declarations

Competing interests

The authors declare no competing interests.