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Results for “Taste Perception”

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PubMed2005

Aging and eating in the rural, southern United States: beliefs about salt and its effect on health.

This paper draws upon qualitative research conducted among older adults in the rural, southern United States in which they articulated their beliefs and experiences with nutrition and foods, and lay models of the connection of diet with chronic disease. Salt emerged as a focus of contention. The goals of the paper are to (1) present the culturally constructed meaning of salt, (2) contrast the cultural meaning with biomedical views, and (3) discuss how these findings can be applied to health education and better doctor-patient communication. Data were collected in two rural communities characterized by high rates of poverty and a high proportion of minority residents. A total of 116 African American, Native American and white adults aged 60 years and older participated in 55 in-depth interviews or seven focus groups. A systematic analysis of text showed that salt was a highly contested component of food. While valued for its role in traditional foods and cuisine, it also held negative connotations because of biomedical links to chronic diseases prevalent in the population. We suggest that attempts to control salt intake are made difficult by the changes in taste perceptions that accompany aging. Respondents' articulation of salt's role in health and disease shows cross-over among different chronic diseases and a lay interpretation of blood as the medium through which salt affects disease. These older adults' narratives demonstrate their attempts to reconcile the important role of traditional foods in their identity as Southerners with their attempts to meet medical recommendations for healthy eating.

Black or African American↗

PubMed1991

Taste of glutamate salts in young and elderly subjects: role of inosine 5'-monophosphate and ions.

Taste sensitivity to five glutamate salts (sodium glutamate, potassium glutamate, ammonium glutamate, calcium diglutamate, and magnesium diglutamate) were determined in sixteen young (mean age 25.58 years) and eighteen elderly (mean age 86.89 years) subjects. The effect of inosine 5'-monophosphate (IMP) and ions on taste perception of glutamate compounds was also investigated. The detection thresholds for glutamate salts were 5.04 times higher in elderly subjects than in young subjects; the recognition thresholds were 3.84 times higher. For young subjects, 0.1 mM IMP lowered detection and recognition thresholds for all 5 salts. A stronger concentration of IMP (1 mM) had this effect in both young and elderly groups. Elderly subjects perceived suprathreshold concentrations as less intense than young subjects. Chloride and acetate salts of sodium, potassium, and calcium reduced the detection and recognition thresholds of L-glutamic acid but had no effect sodium glutamate thresholds.

Adult↗

PubMedDate not supplied

Fluid replacement preferences in heat-exposed workers.

This study examined fluid intake, weight changes, and palatability of water and a carbohydrate-electrolyte (ECHO) beverage in two groups of eight subjects performing 4 hours of simulated industrial work while wearing impermeable protective clothing. Subjects also rated the palatability of a flavorless orange-colored water and four commercially available orange-flavored fluid-replacement drinks. Subjects worked 30 min at 300 Kcal/hour (moderate work rate), followed by 30 min of rest for a total of 4 hours in each of three environments: 18, 23, 27 degrees C wet bulb globe temperature (WBGT). Eight subjects drank water and eight drank an ECHO beverage (Drink 1). Mean sweat production was similar between groups at each WBGT, (p > 0.05). Mean weight changes expressed as percentage of total body weight for the water-drinking group were -0.25 (+/- 0.16) kg in 18 degrees C, -0.55 (+/- 0.09) kg in 23 degrees C, and -0.93 (+/- 0.13) kg in 27 degrees C. Mean weight changes for the ECHO-drinking group were 0.49 (+/- 0.12) kg in 18 degrees C, 0.13 (+/- 0.12) kg in 23 degrees C, and -0.02 (+/- 0.14) kg in 27 degrees C. Each change was significantly different from that of the water-drinking group at the same temperatures (p < 0.05). Mean pre- to post-trial palatability rating results for all temperatures revealed differences in taste perception with strong preferences for Drinks 1 and 2 (pre to post): Drink 1, 3.8 to 3.6; Drink 2, 3.8 to 3.7; Drink 3, 3.0 to 2.7, Drink 4 (water), 3.2 to 3.0, and Drink 5, 2.1 to 1.6. Drinks 1 and 2 were rated significantly more palatable (p < 0.05) than Drink 3. All drinks had a reduced flavor appeal from 3.18 (+0.96) preratings to 2.92 (+1.01) postratings (p < 0.05). Mean voluntary consumption during work across the three temperatures was 1561.5 mL (+/- 720.1) for ECHO versus 1062.7 mL (+/- 666.4) for water (p = 0.054). The water group experienced greater weight loss than the ECHO group, suggesting a greater rate of dehydration when water was used for fluid replacement.

Adult↗

PubMed2005

The role of taste in food selection by African apes: implications for niche separation and overlap in tropical forests.

Ripe fruit eating shapes the behavior of most of the apes. Gorillas (Gorilla gorilla) and chimpanzees (Pan troglodytes) are very different sizes and, consequently, have been traditionally viewed as ecologically distinct, but few studies have explored the behavioral and physiological foundations of their diets. Debate continues on the extent that large-bodied gorillas may be less selective and more opportunistic fruit eaters than chimpanzees. Taste responses have been predicted to relate to body size and digestive strategies. This study employs laboratory research on taste perception and discrimination among captive zoo-housed chimpanzees and relates it to previous work on gorillas to better characterize diets and niche separation among these apes. During the captive trials, differences were recorded in consumption patterns of water and varying concentrations of dilute aqueous fructose (sweet) and tannic acid solutions (astringent), compounds commonly found in wild foods. The chimpanzees exhibited similar preference thresholds for fructose (50 mM) to other primates studied. They exhibited slightly lower inhibition thresholds for tannic acid solutions than gorillas, but higher than smaller primates studied to date. These preliminary findings suggest that tannin tolerance may well be mediated by body size, though possible species differences in salivary proteins or other sensory differences remain to be explored. This research furthers our efforts to understand the roles of body size and physiological adaptations in shaping diet and niche separation of chimpanzees and gorillas.

Animals↗

PubMed1996

Water and electrolyte replenishment in the exercising child.

This article reviews studies, mostly from the authors' laboratory, on children's sweating rates and composition, voluntary drinking patterns during prolonged exercise in the heat, taste perception of beverages, and the importance of fluid flavor and composition in preventing voluntary dehydration. Subjects were children, exposed for 90 to 180 min to intermittent bouts of cycling (45-50% maximal O2 uptake) in a climatic chamber (mostly at 35 degrees C, 40-50% relative humidity). There were five main findings: When given unflavored water ad libitum, children dehydrated progressively and their core temperature increased faster than in adults. When offered drinks with various flavors, children preferred grape to other flavors. When given grape-flavored water during intermittent exercise in the heat, children voluntarily drank 44.5% more than with unflavored water. When given grape-flavored carbohydrate-electrolyte solution, they voluntarily drank 91% more than with unflavored water. Finally, such consumption of carbohydrate-electrolyte solution was sufficient to prevent voluntary dehydration during 180-min intermittent exercise in the heat.

Adolescent↗

PubMed1990

A search for the cortical gustatory area in the hamster.

The gustatory area was searched in the cerebral cortex of the hamster by means of a combined approach using electrophysiological, behavioral, and histological experiments. The chorda tympani (CT), which innervates taste buds on the anterior part of the tongue, projected to a confined area anterior to the middle cerebral artery and just dorsal to the rhinal fissure. The trigeminal component of the lingual nerve (LN) area was located anterodorsal to the CT area, and the glossopharyngeal nerve (GN), which innervates taste buds on the posterior part of the tongue, was posterior to the CT area. The center of the CT and GN areas belonged to the dorsal part of the dysgranular insular cortex, and the LN area was within the primary somatosensory granular cortex. Bilateral symmetrical ablations of the CT and GN areas abolished the conditioned taste aversion (to sodium saccharin) that had been acquired before ablations, indicating a role of these areas in some cognitive processes of taste perception. Injections of horseradish peroxidase conjugated with wheat germ agglutinin (WGA-HRP) in the CT and GN areas, centered in the dysgranular insular cortex, revealed that this cortical region had major fiber connections with the contralateral homotypical cortical area, ipsilateral amygdala (central, lateral and basolateral nuclei), ipsilateral parvicellular part of the posteromedial ventral nucleus of the thalamus, bilateral parabrachial nucleus, contralateral nucleus of the solitary tract, raphe nuclei, and the locus ceruleus. Conversely, injections of WGA-HRP in these target areas showed anterograde and/or retrograde transport in the similar dysgranular insular cortex and additionally in the ventral part of the granular insular cortex. The present results suggest that the cortical gustatory area of the hamster is about 1.5 X 1.5 mm in size with the topographic organization between anterior and posterior parts of the tongue, and is located mainly in the dysgranular insular cortex around the middle cerebral artery.

Afferent Pathways↗

PubMed2004

Identification and characterization of a specific sensory epithelium in the rat larynx.

A specific laryngeal sensory epithelium (SLSE), which includes arrays of solitary chemoreceptor cells, is described in the supraglottic region of the rat. Two plates of SLSE were found, one on each side of the larynx. The first plate was located in the ventrolateral wall of the larynx, and the second was located in the interarytenoidal region. In SLSE, immunoblotting showed the presence of alpha-gustducin and phospholipase C beta2 (PLCbeta2), which are two markers of chemoreceptor cells. At immunocytochemistry, laryngeal immunoreactivity for alpha-gustducin was localized mainly in solitary chemosensory cells. Double-label immunocytochemistry using confocal microscopy demonstrated that alpha-gustducin-expressing cells in large part colocalize type III IP3 receptor (IP3R3), another key molecule in bitter taste perception. However, some IP3R3-expressing cells do not colocalize alpha-gustducin. At ultrastructural immunocytochemistry, these cells showed packed apical microvilli, clear cytoplasmic vesicles, and cytoneural junctions. SLSE was characterized by high permeability to a tracer due to poorly developed junctional contacts between superficial cells. Junctions were short in length and showed little contact with the terminal web. Ultrastructural analysis showed deep pits among the superficial cells. In SLSE, high density of intraepithelial nerve fibers was found. The lamina propria of the SLSE appeared thicker than that in other supraglottic regions. It was characterized by the presence of a well-developed subepithelial nerve plexus. The immunocytochemical and ultrastructural data suggested that SLSE is a chemoreceptor located in an optimal position for detecting substances entering the larynx from the pharynx or the trachea.

Animals↗

PubMed1996

Retention of conditioned taste aversion to NaCl after chorda tympani transection in Fischer 344 and Wistar rats.

Fischer 344 (F344) rats fail to prefer sodium chloride (NaCl) solution to water, and this behavior is dramatically altered by bilateral transection of the chorda tympani nerve (CTX). Tests of retention and generalization of a conditioned taste aversion (CTA) to 0.15 M NaCl were used to assess alterations in salt taste perception after CTX. A CTA was established to 0.15 M NaCl in groups of F344 and Wistar rats after two pairings with LiCl (IP, 2% body weight; 0.15 M). After conditioning, animals received bilateral CTX or sham operations. Approximately 2 weeks after surgery animals were tested for retention of the CTA. Aversion to 0.15 M NaCl was evident in CTX and SHAM rats that had been conditioned prior to surgery, with no apparent difference in magnitude as a function of surgical condition. Thus, although CTX profoundly alters F344 rats' hedonic response to NaCl, it does not alter perceptual characteristics so markedly that NaCl is no longer recognized as the stimulus presented during aversion conditioning. Rather these studies suggest that in both the F344 and Wistar strains the chorda tympani nerve is not necessary for retention of a presurgical CTA to NaCl. These studies, therefore, do not provide evidence of changes in NaCl perceptual "quality" as a consequence of CTX either in F344 rats, where such changes were indicated by the preference data, or in the Wistar rat, where they were not.

Afferent Pathways↗

PubMed1987

Propafenone versus disopyramide: a double-blind randomized crossover trial in patients presenting chronic ventricular arrhythmias.

In vitro and in vivo electrophysiological studies have shown that propafenone could be classified as a class I antiarrhythmic agent. The aim of this study was to investigate the short-term antiarrhythmic efficacy and safety of propafenone in 10 patients compared to disopyramide in a double-blind randomized protocol. Included patients suffered from ventricular arrhythmias with at least 60 ventricular premature beats (VPB) per hour refractory to at least two other antiarrhythmic agents. At the end of the control period and of the two treatment periods during which patients received either propafenone (300 mg three times a day) or disopyramide (200 mg three times a day), clinical examination, Holter recordings, electrocardiogram, and clinical laboratory tests were performed. The PR interval and the QRS interval were significantly increased with propafenone, but not with disopyramide. The cQT interval was not significantly changed by either propafenone or disopyramide. Heart rate was decreased with propafenone (p less than 0.05) with no change in the diurnal/nocturnal circadian ratio variation. Heart rate was significantly decreased with disopyramide only during the day. Five of nine patients in the propafenone group and two of nine patients in the disopyramide group showed a reduction in ventricular premature beats greater than 80%. Total resolution of severe arrhythmias (repetitive events) was seen in 5 of 8 patients with propafenone; 2 of 8 with disopyramide. Adverse events, when they occurred, were mild (visual disturbances, epigastric discomfort, changes in taste perception, transient atrioventricular block with propafenone, and photophobia with disopyramide), and did not require reduction or discontinuation of study drug.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

PubMed1998

Molecular cloning of a DEG/ENaC sodium channel cDNA from human testis.

The number of members of the recently defined DEG/ENaC sodium channel superfamily is increasing. Their importance in Na transport, taste perception, acid sensing, and mechanotransduction has been implicated. We have cloned a new member of this superfamily from human testis, which was named hTNaC1 (for human testis sodium channel 1). The hTNaC1 has 532 amino acid residues with two hydrophobic transmembrane domains. It has the highest identity (82%) with a rat H(+)-gated Na channel specific for sensory neurons (DRASIC) and a low identity (29%) with an epithelial isoform (alpha-ENaC) of this superfamily. Northern blot of human tissues revealed its selective expression in testis (7 kb) and absence in other tissues. The identification of a new member of Na channel specifically expressed in testis will expand the role of this channel family to the reproduction physiology.

Acid Sensing Ion Channels↗

PubMed1997

[Microneural reconstruction after iatrogenic lesions of the lingual nerve and the inferior alveolar nerve. Critical evaluation].

As microneural repair techniques of the sensory mandibular branches enter the third decade of their clinical use, there are but a few long-term investigations into the value of these procedures in the treatment of iatrogenic injury to the lingual (LN), inferior alveolar (IAN) or mental (MN) nerve. To establish the efficacy of microneural repair in lesions of the LN, IAN or MN with loss of continuity, the outcome of sensory recovery was evaluated in a series of 92 patients (LN: direct coaptation n = 39, coaptation + sural nerve grafting n = 23; IAN: direct coaptation n = 11 coaptation + sural nerve grafting n = 10; MN: direct coaptation n = 11). The minimum duration of follow-up was 14 months postoperatively. The persistent sensory deficit was assessed using standardized neurosensory testing and gustometric stimuli. In addition the patients answered a multiple-choice questionnaire containing a list of complaints. To obtain a numeric estimate for interindividual and intergroup comparison the information from clinical measurements and patient reports was condensed into a 'neurological score' and a 'complaint score', respectively. Furthermore, adequate items from both scores were combined to affirm or deny the return of sensory function in terms of protective and discriminative sensation. The overall results show a broad range of variation in the scores, sometimes reflecting severe degrees of persistent sensory impairment. The lowest scores, corresponding to the best regeneration, were found after direct coaptation of the LN, IAN and NM, but even the best results did not provide sensory recovery to a preinjury level. After direct coaptation of LN 69% of the patients exhibited protective sensation and 41% regained discriminative function. In contrast, LN grafting was ensued from restoration of protective function in 39% and discriminative function in 17% of the patients. More striking differences were found between coaptation and grafting of the IAN (IAN coaptation: 91% protective function; 18% discriminative function; IAN grafting: 60% protective function, 0% discriminative function). In the LN coaptation group low scores and improved taste perception were convincingly associated with short periods since injury (i.e. timing of repair). In conclusion, we feel there is sufficient justification to optimize the potential results of microneural repair by immediate (LN/MN) or early (IAN) reexposure of the injured site in order to clarify the precise nature of the underlying nerve damage and prevent delay, if patients present with complete loss of sensory function subsequent to dentoalveolar or oral surgery. However, clinical and electrophysiologic findings suggesting impairment or partial loss of sensory function are considered a contraindication to microneural intervention, in view of the limited prospects of sensory recovery after surgical repair.

Adolescent↗

PubMed1992

Smoking status and dietary fats.

BACKGROUND: There have been several recent reports of differences in the diet of smokers versus that of nonsmokers. This has broad implications for assessment of disease risk associated with diet or smoking. METHODS: We examined dietary fats for several categories of smoking status in a large cross-sectional data set. The annual risk factor survey of a cardiovascular disease prevention trial in three pairs of upper Midwest communities includes 3,495 subjects ranging in age from 24 to 75. Smoking was assessed by self-report and thiocyanate, and diet by the Willett questionnaire. Dietary comparisons of smokers, recent quitters, long-term (over 1 year) quitters, and never-smokers were conducted. RESULTS: Previous findings of lower polyunsaturated fat intake in smokers were confirmed and extended by finding significantly elevated polyunsaturate intake among those who had quit smoking within the last year. The source of these differences is unclear, but the differences are large enough to constitute a significant contribution to disease risk for smokers or a protective effect for recent quitters. CONCLUSIONS: Future research examining risks associated with smoking or diet should control for the interaction of the two factors. The dietary differences in recent quitters, whether caused by a conscious decision to improve diet, a change in taste perception as a result of quitting, or simply the habits of those smokers who are able to quit, need further exploration.

Adult↗

PubMed1993

Molecular cloning of human von Ebner's gland protein, a member of the lipocalin superfamily highly expressed in lingual salivary glands.

Von Ebner's glands (VEG) are small lingual salivary glands. Their ducts open into trenches of circumvallate and foliate papillae, thus influencing the milieu where the interaction between taste receptor cells and sapid molecules takes place. The major secretions of human VEG is a protein with a molecular mass of 18 kDa. The human VEG protein crossreacts with antibodies raised against the rat VEG protein, indicating sequence similarity between the rat and human VEG proteins. This was subsequently confirmed by N-terminal protein sequencing. A cDNA clone, isolated from a human VEG library, contained an insert of 735 bp including an open reading frame that encodes the human VEG protein of 176 amino acids. Comparison of the human and rat VEG proteins revealed an overall identity of 60%. Immunocytochemistry, in situ hybridization and in vitro translation studies demonstrated the human VEG protein to be highly and exclusively expressed in VEG. The VEG proteins are members of the lipocalin protein superfamily and, together with the rat odorant binding protein II, they constitute a new subfamily. Sequence similarity to proteins such as the retinol binding protein and the odorant binding protein which are lipophilic ligand carriers, suggests a possible function for the human VEG protein in taste perception.

Amino Acid Sequence↗

PubMed2004

Morphology of parasympathetic neurons innervating rat lingual salivary glands.

Saliva is essential for taste function and not only does saliva influence taste reception, but also taste perception initiates salivation. As a first step in investigating circuits involved in gustatory-salivary reflexes, we have studied the morphology of the rat inferior salivatory nucleus (ISN), which contains parasympathetic secretomotor neurons that control the parotid and lingual (von Ebner) salivary glands. By applying the fluorescent label Fluorogold to the cut end of the glossopharyngeal nerve, the neurons supplying only the lingual salivary glands were labeled. Confocal microscopy and three-dimensional reconstruction were used to analyze the labeled neurons in the horizontal plane to determine their morphological characteristics. Additional neurons were studied in the coronal plane to determine the influence of the plane of section on neuron morphology. Reconstructions indicated that inferior salivatory neurons extend in a rostral-caudal distribution just adjacent to the medial border of the nucleus of the solitary tract (NST). There is considerable morphological variability among neurons, with neurons having up to 6 primary dendrites and 17 dendritic segments that extend a maximum of 834 microm from the soma. However, although ISN neurons vary in the size and complexity of their dendritic trees, distributions of all measures of neuron morphology are unimodal, indicating that distinct groups of neurons are not revealed based on these measures. There is, however, variability in the orientation pattern of the dendritic trees that is not represented in either the population or mean measures. Individual neurons can be categorized with either mediolateral, rostro-caudal or no apparent preferred orientation. Comparisons of neurons in rostral, intermediate or caudal third of the ISN revealed regional differences in neuron morphology; neurons in the caudal third have significantly longer dendrites than those in the intermediate or rostral third. Thus, while ISN neurons belong to a single morphological grouping, they vary in the size and complexity of their dendritic trees, as well as having different dendritic orientations within the salivary nucleus.

Animals↗

PubMed2006

FMRFamide-gated sodium channel and ASIC channels: a new class of ionotropic receptors for FMRFamide and related peptides.

FMRFamide and related peptides typically exert their action through G-protein coupled receptors. However, two ionotropic receptors for these peptides have recently been identified. They are both members of the epithelial amiloride-sensitive Na+ channel and degenerin (ENaC/DEG) family of ion channels. The invertebrate FMRFamide-gated Na+ channel (FaNaC) is a neuronal Na+-selective channel which is directly gated by micromolar concentrations of FMRFamide and related tetrapeptides. Its response is fast and partially desensitizing, and FaNaC has been proposed to participate in peptidergic neurotransmission. On the other hand, mammalian acid-sensing ion channels (ASICs) are not gated but are directly modulated by FMRFamide and related mammalian peptides like NPFF and NPSF. ASICs are activated by external protons and are therefore extracellular pH sensors. They are expressed both in the central and peripheral nervous system and appear to be involved in many physiological and pathophysiological processes such as hippocampal long-term potentiation and defects in learning and memory, acquired fear-related behavior, retinal function, brain ischemia, pain sensation in ischemia and inflammation, taste perception, hearing functions, and mechanoperception. The potentiation of ASIC activity by endogenous RFamide neuropeptides probably participates in the response to noxious acidosis in sensory and central neurons. Available data also raises the possibility of the existence of still unknown FMRFamide related endogenous peptides acting as direct agonists for ASICs.

Acid Sensing Ion Channels↗

PubMed1996

An evaluation of the efficacy and safety of azelastine in patients with chronic asthma. Azelastine-Asthma Study Group.

BACKGROUND: Azelastine, an oral nonsteroidal, antiinflammatory drug with a good safety profile, has demonstrated relief of symptoms in patients with asthma. OBJECTIVE: The study was designed to evaluate the efficacy and safety of azelastine, a novel antiallergy compound, in patients with asthma who required maintenance therapy. METHODS: During this 16-week, double-blind, randomized, parallel-group study, patients received orally administered azelastine (4 mg twice daily), albuterol sulfate (4 mg twice daily), or placebo. RESULTS: Overall, patients in the azelastine group used 2.5 times less backup medication (p = 0.024) for relief of their asthma symptoms than patients in the placebo group. Reductions in asthma symptoms in the azelastine group were also noted throughout the double-blind treatment period. Moreover, the azelastine group had statistically significant improvements in FEV1 after the first dose of medication. The only notable adverse experiences in the azelastine group were alterations in taste perception and a small mean increase in body weight. CONCLUSION: Oral administration of azelastine to patients with asthma resulted in overall improvement in airway function while reducing the requirement for adjunctive antiasthma medications.

Adolescent↗

PubMed2002

Exploiting expolysaccharides from lactic acid bacteria.

Microbial exopolysaccharides (EPSs) synthesized by lactic acid bacteria (LAB) play a major role in the manufacturing of fermented dairy products. EPS production is characterized by a large variety in terms of quantity, chemical composition, molecular size, charge, type of sidechains and rigidity of the molecules. Monosaccharide unit's composition, linkages, charge and size determine the EPS' intrinsic properties and their interactions with other milk constituents. EPSs contribute to texture, mouthfeel, taste perception and stability of the final product. Furthermore, it was reported that EPS from food grade organisms, particularly LAB, have potential as food additives and as functional food ingredients with both health and economic benefits. A better understanding of structure-function relationships of EPS in a dairy food matrix and of EPS biosynthesis remain two major challenges for further applications of EPS and the engineering of functional polysaccharides.

Animals↗

PubMed1999

Incidence of weight loss in head and neck cancer patients on commencing radiotherapy treatment at a regional oncology centre.

The aim of this prospective study was to investigate the incidence of weight loss in head and neck cancer patients on commencing radiotherapy treatment at a regional oncology centre. Of the 100 patients included in the study, 33% presented with carcinoma of the larynx. Fifty-seven per cent of patients had lost weight on commencing treatment. A mean weight loss of 6.5 kg, equating to approximately 10% of body weight, was reported. A significant number of patients experienced a dry and/or sore mouth, had difficulty masticating and swallowing food, had altered taste perception, were missing meals or had symptoms of uncontrollable nausea and constipation. Since radiotherapy treatment may further limit oral intake, it is essential that dietetic intervention is addressed for all head and neck cancer patients and incorporated into the treatment plan on diagnosis before definitive management commences.

Adult↗