Background: Malnutrition is common among patients with cancer, but little attention is given to its risks and consequences.
Objectives: The aim of this study is to assess the nutritional status and identify the factors associated with malnutrition among newly diagnosed patients with cancer.
Methods: Patients admitted with newly diagnosed cancer at a teaching hospital in Malaysia were recruited from January to April 2015. Nutritional status was assessed before treatment initiation, and patients were classified into three categories: well nourished, mild to moderately malnourished, and severely malnourished. Clinical parameters and disease characteristics were also assessed.
Findings: A total of 132 pretreatment patients were recruited into the study. About half were severely malnourished. Patients with stage III cancer had the highest prevalence of severe malnourishment. Clinical parameters and disease characteristics were significantly associated with nutritional status. Demographic variables were also statistically significantly associated with severe nutritional status.
Malnutrition is a significant challenge among patients with cancer worldwide, and it may lead to clinical and economic consequences, which are associated with alteration in survival rates (Nitenberg & Raynard, 2000). The National Cancer Control Programme in Malaysia has been established to improve the quality of life of patients through early diagnosis, appropriate cancer treatments, alternative therapies, and rehabilitation facilities. However, less attention is focused on disease-related malnutrition.
Nutrition and diet have been widely recognized to play vital roles throughout the course of cancer care. In a study by Davies (2005), 85% of patients with cancer developed some form of dietary deficiency, with about half losing 5% of their weight at presentation and more in subsequent treatments.
Many studies have found that the presence of malnutrition not only increases length of stay, but also may lead to deterioration in clinical outcomes, increased cost and use of hospital resources, and increased number of complications (Sorenson et al., 2008). The risks of malnutrition and its severity depend on the type of cancer, stage of the disease, and the patient’s pre-illness weight. The consequences of malnutrition among patients with cancer can lead to weight loss, muscle weakness, apathy, immune deficiencies, frequent infections, and higher mortality. Because of its deleterious effects on morbidity and mortality, early identification of patients at nutritional risk would help to improve the expected outcome.
Ravasco, Monteiro-Grillo, Vidal, and Camilo (2005) emphasized the importance of nutrition screening to help identify existing malnutrition; however, it is not routinely performed with the initial assessment. Patients are most commonly referred to dietitians or nutritionists for severe malnourishment. Timely intervention could prevent the patient from going into a cachexic state.
Malnutrition in patients with cancer is strongly associated with poor prognosis. Paccagnella, Morassutti, and Rosti (2011) found that weight loss of 50% was commonly found in patients with aggressive forms of lymphoma, as well as colon, prostate, and lung cancers. Higher incidence (85%) of weight loss was found in patients with upper gastrointestinal cancers. Weight loss has been found to be an important predictor of mortality and affects nutritional status. Malnutrition in hospitalized patients is the result of many factors associated with the disease and treatment (Aquino Rde & Philippi, 2011). One of the major causes of malnutrition is inadequate dietary intake.
Nutritional screening, assessment, and intervention in patients with malnutrition are key components of nutrition care. The American Society for Parenteral and Enteral Nutrition (2012) defined nutritional screening as “a process to identify an individual who may be malnourished or at risk for malnutrition to determine if a detailed nutrition assessment is indicated” (p. 8). The Joint Commission in the United States mandates nutrition screening within 24 hours of admission to an acute care center (Mueller, Compher, & Druyan, 2011). The goal of nutrition assessment is to identify any specific nutritional risks or clear existence of malnutrition that may lead to recommendations for improving nutritional status, such as interventions for change in diet, enteral or parenteral nutrition, further medical assessment, or rescreening (Ukleja et al., 2010).
Nutrition screening tools are designed to effectively identify patients who are at risk for malnutrition or already malnourished (Lim, Lee, & Chan, 2014). An effective screening tool encompasses subjective and objective factors for assessment (Aydin & Karaoz, 2007). Although several nutrition screening tools exist, there is no gold standard. The choice of screening tool could be based on setting, preference of the nurses, or nurse knowledge and skill.
This study used a quantitative cross-sectional study design. Newly diagnosed patients with cancer in the outpatient setting or admitted to the teaching hospital were recruited from January to April 2015. Patients aged 18 years or older who were newly diagnosed with cancer and had not yet started treatment were included.
A two-part, structured, self-administered questionnaire was used in this study. Part A consisted of questions related to patients’ sociodemographic characteristics, medical information (clinical diagnosis, type of cancer, cancer stage), nutritional data on food consumptions (food practices, food taboos, consumption of oral supplements), evaluation of anthropometric measurements (height, weight, body mass index), and laboratory parameters (hemoglobin, serum albumin, creatinine, urea). Part B consisted of the Subjective Global Assessment (SGA), a simple and realistic tool that can predict patients’ outcomes and be performed by the nurses in a short amount of time.
The SGA tool was developed by Allan Detsky in 1987 to determine the nutritional status of patients. The tool is comprised of clinical techniques (physical examination and patient history) and subjective elements to assess patients’ nutritional status (Ottery, 2000). The tool is focused on weight change, dietary intake change, gastrointestinal symptoms, and changes in functional capacity in relation to malnutrition, as well as assessment of fat and muscle stores and the presence of edema and ascites (Detsky et al., 1987). A version of the SGA can be accessed online at http://bit.ly/2gPuXnB. Patients were interviewed using the questionnaire, which allowed capture of subtle patterns of change in clinical variables, such as weight loss pattern rather than absolute weight loss. Patients were also physically examined. Based on scores, the patients were classified into three categories: well nourished, mild to moderately malnourished, and severely malnourished.
Validity and Reliability
The questionnaire used in this study has been validated in previous studies. However, a pilot study with 20 patients was conducted to test the reliability and validity of the SGA in a surgical ward of a teaching hospital. The Cronbach alpha was 0.96. Inter-rater reliability and intra-rater reliability were assessed using Cohen’s kappa statistic to determine the agreement of measurement. In the test for inter-rater agreement, 10 patients were selected, and they were assessed by the researcher and a dietitian. The findings showed a perfect agreement between the two raters. In the test for intra-rater agreement, 10 patients were selected, and the patients were assessed by the researcher. The same 10 patients were assessed again after two to three days, and perfect agreement was found at two different time points, with a kappa coefficient of 1.
Data Collection and Analysis
Data were collected from January to April 2015, with a total of 152 patients assessed for eligibility. Fifteen were excluded because they were too sick to participate in the study, had been discharged home, were ventilated, or had a language barrier. Of the 137 patients who met the criteria, five declined to participate because they were in pain or too tired to respond to the questions. Data from the final sample of 132 patients were analyzed using SPSS®, version 16.0. Pearson’s chi-square test was used to determine the associations between the variables.
Ethical approval was obtained from the research ethical committee at the University Malaya Medical Centre in Kuala Lumpur, Malaysia. Permission to conduct the study was given by nursing administration, the nursing officer, and the director of the University Malaya Medical Centre.
Of the 132 participants, 53 (40%) were male and 79 (60%) were female. Mean age of the patients was 47.9 years (SD = 14.7, range = 28–78). Patients were 49% Chinese, 28% Malaysian, and 23% Indian. Of the participants, 77% were married and 24% were single. In terms of educational level, 24% of patients had only a primary level of education, 33% had secondary education, and 43% had tertiary education. Seventeen percent of patients had a monthly income of less than RM3,000 (about 669 U.S. dollars), 51% had a monthly income of RM3,000 or greater, and 32% of the patients responded that they did not have any income. The majority (96%) of patients were taken care of by family members. Two percent of patients were in a nursing home, and 2% were cared for by friends. Eight percent of respondents were vegetarian, and the rest were not.
Body mass index, stage of disease, type of cancer, food taboos, and oral supplement consumption were explored in this study. None of the patients had food taboos, and the majority of patients (98%) were not taking oral supplements. Based on the World Health Organization (2017) standard for body mass index, about half of the patients were underweight, and half were a healthy weight. In terms of disease stage, 41% of the patients were stage I, 21% were stage II, 24% were stage III, and 15% were stage IV. The distribution of the types of cancer included gastrointestinal (33%), breast (15%), sarcoma (15%), head and neck (11%), lung (11%) hematologic (5%), thyroid (4%), genitourinary (3%), and gynecologic (2%) cancers.
Nutritional Status and Demographic Variables
Of the participants in the current study, 64 (48%) were severely malnourished, 23 (17%) were mild to moderately malnourished, and only 45 (34%) were well nourished. Results from the tests of association between patients’ characteristics and nutritional status are presented in Table 1. Nutritional status (p < 0.001), education level (p < 0.04), and ethnicity (p < 0.001) were all significantly associated with gender. Among the men, 75% (n = 40) were severely malnourished, compared to only 30% (n = 24) of women. A relatively lower percentage of those with primary education (23%, n = 7) were well nourished, compared to those with secondary (36%, n = 16) or tertiary education (39%, n = 22). By ethnicity, 83% (n = 25) of Indians were severely malnourished, compared to 45% (n = 29) of Chinese and 27% (n = 10) of Malaysians. All 11 vegetarians in the sample were severely malnourished; among the remaining non-vegetarian participants, 53 were severely malnourished.. Based on these findings, nurses should to ensure that all patients, particularly vegetarians, receive proper counseling on maintaining a balanced diet to help with nutritional status.
Nutritional Status and Disease Characteristics
The results from the tests of association between patients’ disease stage and cancer type with nutritional status are presented in Table 2. In this study, all patients with stage IV disease were severely malnourished. The more advanced the disease, the higher the proportion of severe malnourishment (p < 0.001). Among those with gastrointestinal cancers (esophageal, pancreatic, gastric, and colorectal), 33 were severely malnourished. In this study, 44 patients had gastrointestinal cancer.
Nutritional Status and Biochemical Measures
Biochemical measures are laboratory markers used to indicate nutrient level in the blood, and they help healthcare providers plan nutritional supplements. In the results from the tests of association between patients’ biochemical measures and nutritional status among the severely malnourished, 67 (51%) were underweight, and 89 (67%), 90 (68%), 55 (42%), and 16 (12%) had low hemoglobin, albumin, creatinine, and urea, respectively (see Table 3). According to Davies (2005), nutritional screening can assist in early identification of patients at risk or experiencing nutritional deficits prior to progression and can help to prevent the onset of malnourishment. For those with advanced disease, nutritional intervention may help stabilize weight and improve quality of life. Improving nutritional status may help with immunity, survival rate, and quality of life.
The high level of severe malnutrition (48%, n = 64) among the patients in this study is similar to studies by Bauer, Capra, and Ferguson (2002), Vellas et al. (2000), and Zulian, Gold, Herrmann, and Michel (1999), which supports the assertion that the prevalence of malnutrition is high. Consequences of malnutrition include increased hospital length of stay, complications, and hospital costs.
Results of this study showed that the male patients were at higher risk of malnutrition (75% versus 30%). A study by Aquino Rde and Philippi (2011) demonstrated that hospitalized patients and men aged 65 years or older were at higher risk for malnutrition. Based on the findings of that study, men seek healthcare services much later when compared to women. This behavior could be because men do not go for preventive health care as often and are much less attentive to changes in weight and food consumption than women.
The association between disease characteristics and nutritional status revealed that patients with esophageal, pancreatic, gastric, and colorectal cancers are more likely to be severely malnourished. Findings by Aydin and Karaoz (2007) also indicated that patients with malignant gastrointestinal disease have a higher prevalence of malnutrition. This finding is also consistent with a study by Hill, Kiss, Hodgson, Crowe, and Walsh (2011). Treatment effects during therapy may worsen nutritional status of patients who are already malnourished and may lead to other complications. Maintaining nutritional status and implementing dietary intervention could improve patient outcomes. The benefits will reduce healthcare expenditure through prevention of unplanned admissions and interruptions in treatments.
Hughmann and Cunningham (2005) suggested that 31%–80% of malnutrition depends on the tumor site and disease stage. The highest level of malnutrition was observed in cancers of the digestive tract and in those with advanced disease stages. Findings of this study also showed an association between disease stages and nutritional status. Wie et al. (2010) also reported that cancer stage was related to the risk of malnutrition. The results from the current study and previous research suggest that nutritional interventions should be individualized on the basis of patient characteristics, such as gender, cancer stage, and type of cancer, to maintain adequate nutritional status.
The SGA has been accepted as one assessment method to evaluate nutritional status. It focuses on patient-centered care and incorporates clinical history and physical examination. It is easy to use by healthcare providers and can accurately identify malnourished patients (Wu et al., 2010). However, because the respondents in this study were from one center, the findings may not be generalizable to other settings. Further research in different settings is needed to make generalizations in the cancer population in Malaysia.
Implications for Nursing
The findings showed that about half of the patients in this study were severely malnourished. In developing countries like Malaysia, the number of patients with cancer is escalating annually. With screening and proper assessment, it may be possible to reduce the number of malnourished patients with cancer and subsequently reduce the length of hospital stay, which can benefit patients and healthcare institutions.
Nursing staff need to be trained to improve patients’ nutritional assessment and management. Pradignac et al. (2011) recommended that training nurses in early screening and assessment would improve the nutritional status in patients at risk of malnutrition. By detecting malnourishment and providing proper guidance, nurses can help to improve treatment outcomes.
Based on recommendations given by Prevost, Joubert, Heutte, and Babin (2014), simple screenings must be performed routinely and systematically in the early course of the disease, preferably at the first visit where the diagnosis is confirmed and then repeated regularly. Because weight loss and the SGA were the most appropriate nutritional markers, weight loss should be evaluated routinely in the preoperative setting, and the SGA should be used by healthcare providers regularly. Monitoring for early warning signs of malnutrition may help to detect weight loss, which would indicate the need for an appropriate management by dietitians. Delaying interventions until excessive weight loss has occurred will make treatment modalities more difficult and result in poorer patient outcomes.
The authors gratefully acknowledge the contribution of all patients who participated in this study, as well as the doctors, dietitians, and nurses in the surgical department at the University Malaya Medical Centre for their time in helping to complete this research.
About the Author(s)
Karthikayini Krishnasamy, MNSc, is a nurse manager, Tang Li Yoong, PhD, is a lecturer, and Chong Mei Chan, PhD, is a senior lecturer, all in the Department of Nursing Science; Lau Peng Choong, MD, MS, is a consultant and general surgeon in the Department of Surgery; and Karuthan Chinna, PhD, is an associate professor in the Department of Social and Preventive Medicine, all at the University of Malaya in Kuala Lumpur, Malaysia. Krishnasamy can be reached at firstname.lastname@example.org, with copy to CJONEditor@ons.org. (Submitted May 2015. Accepted April 13, 2016.). The authors take full responsibility for this content. This study was supported by an incentive grant (No. PO030-2014B) from the University of Malaya. The article has been reviewed by independent peer reviewers to ensure that it is objective and free from bias.
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