Article 5_homescience

7/27/2019 Article 5_homescience

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EFFECT OF RADIATION AND CHEMORADIATION ONNUTRITIONAL STATUS AND FUNCTIONAL WELL BEING OF

SELECTED ORAL CANCER PATIENTS

N.KOKILA a, REGI RAYMON SHARMELEE FERNANDO b

(Department of Home science, Queen Marys college, Chennai-600 004)

Abstract ______________________________________________________________________

Oral cancer is a major health problem in India commonly occurring in men dependingupon the extent and type of tobacco habits. Radiation and chemoradiation are provided tocontrol or minimize the neoplastic process. Therefore pre and post treatment assessment of the oral cancer patients nutritional status and functional well being becomes a valuablemeasure to improve their quality of life. Thirty six male patients confirmed with stage III oral

cancer in the age group of 30 to 60 years were selected by purposive random sampling from acancer hospital at Chennai. An interview schedule was administered on the selected patientswho were to receive radiotherapy (n=18) and chemoradiation (n=18) at the onset of treatment, during and by the end of treatment. At baseline majority of subjects were in theage group of 50 to 60 years with the habit of chewing tobacco, drinking alcohol and or smoking. Decrease in the body weight, hemoglobin, WBC levels and grade I mild energydeficiency was significant after treatment in both the groups. Toxicity was at higher

percentage in subjects receiving chemoradiation leading to cachexia which deteriorates thealready fragile nutritional status. The mean nutrient intake and functional well beingdecreased significantly in both the groups before and after the treatment. Oral cancer patientsundergoing treatment limit intake, due to toxicity which would aggravate their degree of

malnutrition. Therefore individualized nutritional support is necessary for all patients to promote preservation of lean body mass and maintain quality of life. ________________________________________________________________________________________________________

Introduction

O ral cancer is used to describe any malignancy that arises from the oral cavity and is

classified as lip, tongue, gingival, floor of mouth and other parts of mouth. Globally oral

cancer is one of the eleventh most common cancers mainly afflicting men and is typically

caused by smoking, together with alcohol abuse and tobacco chewing 1. A generally

impoverished diet, particularly lacking in vegetables and fruits is another risk factor for oral

cancer 2. Symptoms of oral cancer include pain, bleeding, and difficulty in opening the mouth,

chewing, swallowing, speech and a swelling in the neck 3. More advanced stages causes large

ulcerative proliferative mass extending to neighboring structures such as bones, muscles and

skin may be evident. Surgery and radiotherapy has been the mainstay of treatment for oral


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cancer, while those with advanced diseases are treated with definitive radiation therapy and

chemoradiation 4. Cancer patients either due to the disease itself or its treatment have

significant nutritional problems related to localized or systemic side effects like anorexia,

cachexia, mucosal inflammation, loss of taste, and dry mouth that interfere with the intake

resulting in malnutrition which in turn also affect the functional well being. Therefore the

present study was undertaken to highlight the effect of radiation and chemo radiation on the

nutritional status and functional well being of the oral cancer patients.

Materials and methods

Thirty six male patients with histologically confirmed stage III oral cancer within the

age group of 30-60 years were selected by purposive random sampling from a cancer hospital

in Chennai. Out of these, 18 patients who were to receive radiotherapy as treatment were put

together as Group I and the remaining 18 who were to receive chemo radiation were put

together as group 2. An interview schedule was administered on the chosen subjects and

information pertaining to their anthropometric, biochemical, toxicity levels and dietary data

were obtained at onset of treatment, during (III week) and after treatment to know their

baseline and post treatment nutritional status. A separate functional well being schedule was

used to assess information regarding the impact of treatment on the affected area. The

functioning of the oral cancer site such as changes in taste, smell, swallowing, chewing and

speaking problems were scored and total score >56 ,56 - 44 and


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In the study it was found that at baseline majority of subjects were in the age group of 50 to

60 years, belonging to low income group with the habit of chewing tobacco, drinking alcohol

or smoking and about 44.44 and 66.66 percent in group I & II were diagnosed to have cancer

of cheek.

Anthropometric measurements

Information regarding the body weight (Table 1) revealed that there was a significant

decrease in the mean body weight of the subjects from 49 and 53.50 kg in group I & II to

44.22 and 47.16 kgs after treatment. This reduction in the body weight was due to the toxic

effect of treatment which interferes with the patients ability to taste, ingest, and absorb food.

The consequence of significant weight loss predisposes the patient to malnutrition. De wys et

al (1980) 5 reported that patients who presented without weight loss had a significantly

prolonged survival following therapy than similarly treated patients who had weight loss at

presentation.

Table I

Comparison of mean body weight of the subjects as assessed before, during and after treatment

Assessment Mean bodyweight (kg)Group I

Comparison between

tValue

Mean bodyweight (kg)Group II

Comparison between

tValue

Beforetreatment 49.008.19(A) A vs B

7.023** 53.507.83(D) D vs E 11.368**

Duringtreatment 46.117.20(B) B vs C

5.239** 49.447.92(E) E vs F 4.644**

After treatment 44.227.30(C) A vs C 7.188** 47.167.48(F) D vs F 15.991**

** -significant at 1% level

From table II it was seen that only 44.44 percent and 77.78 percent of subjects in group I&II

had a normal body mass index at the start of treatment which dropped to 16.76 percent and

27.70 percent after treatment. Mild and moderate energy deficiency was more obvious among

group II (27.74 percent) and group I (27.70 percent) subjects after treatment. Galvan (2000) 6


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observed that there was significant change in the body mass index particularly after the

treatment which was mainly due to the dry mouth, difficulty in masticating and swallowing

food.

Table II

Percentage of subjects based on body mass index classification

# BMI

Radiotherapy

(Group I)

Chemoradiation

(Group II)

Before During After Before During After

Normal 44.44 27.70 16.76 77.78 33.30 27.70

Low weight Normal 33.33 22.21 22.22 11.12 38.85 16.66

Grade I mild energy deficiency 12.11 22.22 16.72 5.55 16.65 27.74

Grade II Moderate energydeficiency

5.11 16.66 27.70 5.55 5.65 16.66

Grade III Severe energydeficiency

5.11 11.21 16.60 - 5.55 11.24

# Source: Bamji M.S: Textbook of human nutrition 1996.

Biochemical data

Hemoglobin and WBC levels

The mean haemoglobin and WBC values (TableIII)of the subjects in group I and II as

assessed before, during and after treatment, indicated a fluctuation in the mean hemoglobin

and WBC values which was not significant and this could be due to the type of

chemotherapeutic or radiotherapeutic agents used, which must have been more site specific

and does not affect the bone marrow.

Table III

Comparison of mean haemoglobin values and mean white blood cell count of the subjects as

assessed before, during and after treatment

Assessment MeanHb (g/dl)Group I

Comparison between

tValue

Mean Hb(g/dl)Group II

Comparison between

tValue

Beforetreatment 10.992.59(A) A vs B 0.253

NS 12.602.20(D) D vs E 0.384 NS


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Duringtreatment 10.911.69(B) B vs C 0.236

NS 12.752.17(E) E vs F 0.452 NS

After treatment 10.861.42(C) A vs C 0.273 NS 12.612.17(F) D vs F 0.015 NS

NS- non significantTable V

Comparison of mean white blood cell count levels of the subjects as assessed before, during and

after treatment

Assessment Mean WBCGroup I

Comparison between

tValue

Mean WBCGroup II

Comparison between

tValue


NS 7022.22870.16(D) D vs E 0.641 NS

During

treatment7138.881040.44(B) B vs C 1.917 NS 7172.22890.34(E) E vs F 0.096 NS

After treatment 7388.88938.01(C) A vs C 0.463 NS 7161.111092.83(F) D vs F 0,493 NS

NS- non significant

Toxicity levels

Although tumor themselves initiate or potentate anorexia many chemo therapeutic and radio

therapeutic agents can also produce profound nausea and vomiting , mucositis , gastro

intestinal dysfunction leading to different grades of toxicity. When a higher grade of toxicity

is seen on a patient the treatment is stopped until the toxicity subsides. Toxicity level was

assessed during (3rd week) and end of treatment (7 th week) some of the common toxicity

criteria for chemotherapeutic agents and radiotherapuetic agents observed among the subjects

are graded and given in percentage in the table IV

Table IV

Percentage of subjects in different grades of toxicity

ToxicityRadiotherapy (Group I) # Chemoradiation (Group II) #During

treatmentEnd of

treatmentDuring

treatmentEnd of

treatmentHaemoglobinGrade I (normal -10g/dl)Grade II (10 - 8g/dl)

72.2227.78

72.2227.78

94.455.55

88.8911.12

MucositisGrade I (soreness) 50.00 50.00 61.11 33.33


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NauseaGrade I ( reduced butreasonable intake)

44 16.6 50.44 27.77

ConstipationGrade I (mild) 33.33 22.22 38.88 5.55

# Percentage less than 100 since grading is done only for the subjects having toxicity, the rest areconsidered to be normal.

From the table VI it was seen that 94.45 percent of the subjects receiving chemoradiation had

grade I levels of heamoglobin toxicity during treatment which was higher when compared to

the subjects on radiotherapy,which was only 72.22 percent. It was observed that the

percentage of mucositis, nausea and constipation (61.11, 50.4and 38.88 percent) was higher

during treatment among group II subjects.

The results of the present study are in tune with that of Bozzetti 7 (1992) who observed that

nausea, vomiting, mucositis was grade II or less in most of the patients which was due to the

intensity of the treatment.

Dietary data of subject

Using a 24 hour dietary recall method the mean nutrient intake of the subjects were assessed

before, during and after the treatment.

Energy intake

It was seen from the table that the mean energy intake of the subjects in group I and group II

showed a significant decrease before and after treatment. The actual energy requirement for

cancer patients as per Matarese 8 is 35 kcal/kg body weight. The mean body weight of the

subjects in group I and group II before treatment is 49 and 53 kg for which 1715 and 1855

kcal is the actual requirement but the intake is only 1496 and 1627 kcal which further

reduces, during and after the treatment.


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The result of the present study coincides with Ravasco (2003) 9 who observed that with a

significant decrease in the current energy and protein intake, malnutrition was more

prevalent.

Table V

Comparison of mean energy and mean protein intake of the subjects as assessed before, during

and after treatment

Assessment

Mean energyintake(kcal)Group I

Comparison between

tValue

Mean energyintake(kcal)Group II

Comparison between

tValue


5.154** 1627.27252.47(D) D vs E 13.447**

Duringtreatment

1234.27111.21(B) B vs C 9.392**

1183.83179.62(E) E vs F 9.038**


** -significant at 1% level

Protein intake

It was seen from the table that the mean protein intake of the subjects in group I and group II

showed a significant decrease before and after treatment. The actual protein requirement for

cancer patients as per Matarese 8 is 1.5g/kg body weight. The mean body weight of the

subjects in group I and group II before treatment is 49 and 53 kg for which 73.5g and 79.5g

of protein has to be given to meet the replenishment of tissues but the actual intake is only

36g and 40g which further decreases, during and after the treatment.

Table VIII

Comparison of mean protein intake of the subjects as assessed before, during and after

treatment

Assessment Mean proteinintake(g)Group I

Comparison between

tValue

Mean proteinintake(g)Group II

Comparison between

tValue


NS 40.777.33(D) D vs E 6.741**

Duringtreatment

34.613.85(B) B vs C 4.528**

33.775.64(E) E vs F 7.442**



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NS- Not significant**- Significant at 1% level

Functional well being

The table showed that the mean functional well being of group I and II subjects significantly

decreased from 48.77 and 45.55 to 36.61 and 33.27 after treatment.

Marcy 10 similarly reports that there was a significant deterioration in the overall functional

well being of the subjects receiving radiation or chemoradiation due to the toxic effect of

treatment leading to profound nausea,constipation,mucositis and weight loss.

Table VI

Comparison of mean functional well being of the subjects as assessed before, during and after

treatment

Assessment Meanfunctionalwell beingGroup I

Comparison between

tValue

Meanfunctional well

beingGroup II

Comparison between

tValue


13.171** 45.552.06(D) D vs E 14.577**

Duringtreatment 43.222.92(B) B vs C 9.835** 40.002.249(E) E vs F 29.333**


**- Significant at 1% level

Summary and Conclusion

The results revealed that there was a significant decrease in the bodyweight, energy

,protein intake and functional well being of the subjects by the end of treatment. The

haemoglobin levels and WBC counts decreased in both the groups and the toxicity levels

were more pronounced among patients receiving chemoradiation making the patient more

cachetic. Malnutrition was more obvious among both the groups due to the different grades

of toxicity. Toxicity leading to cachexia and malnutrition, decreased the nutritional status,


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increased the medical complication, diminished the quality of life after antineoplastic

therapy. Therefore the adverse effects of cancer treatment along with the state of exhaustion

that results from the prolonged excessive challenge,necessitates nutritional support,whether it

is in the form of individualized nutritional councelling for better dietary choices or

supplemental nutrients or to provide low cost parenteral feeds for those unable to feed by

mouth.

Reference

1. Bernard.W. (2003) world cancer report, world health organization: 232-236.

2. Steinmetz.KA,PotterJD (1991) vegetables, fruits and cancer I.epidemology. Cancer

causes control, 2:325-357.

3.Sankaranarayanan.R,Mathew B,Jacob B.J(2000) early findings from a community-

based ,cluster randomized,controlled oral cancer screening trial in kerala,India.The

trivandrum oral cancer screening study group.Cancer ,88:664-673

4. Schwartz JL (2000) Biomarkers and molecular epidemoplogy and chemoprevention of

oral cancer.Crit Rev Oral Bio Med, 11:92-122.

5. DeWys .WD. (1980): Prognostic effect of weight loss before chemotherapy in cancer

patients. AM JMed, 469-491.

6. Galavan.O (2000)Cancer and patient outcome: - A prospective study on head and neck

patients undergoing treatment.Elsevier. 265-278.

7. Bozzetti (1992) Impact of cancer, type, site, stage and treatment on the nutritional status

of patients. Ann surg 196 , pp 170-79

8. Matarese, Gottschilch et al. (2003). Contemporary nutrition support practice - A clinical

guide , 2 nd edition , saunders , Philadelphia pp. : 484-508.


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9. Ravasco (2003) nutritional deterioration in cancer- the role of disease and diet AJCM pp272-82.

10.Marcy (2004) evaluations of quality of life and organ function semin Oncol . 31: 827-35.


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NUTRITIONAL STATUS OF ADULT WOMEN WORKING IN THE

GARMENT INDUSTRY

Ms.Regi Raymon Sharmelee Fernando Assistant Professor, Department of Home Science,Queen Marys College and Ms.B.Hima Bindhu

Background : Womens labour contribution has become the backbone of Indian economys

current growth path. Health and nutritional status of women, especially of working women

are inextricably bound up with social, cultural and economic factors that influence all aspects

of their lives, and has consequences not only for the women themselves but also for the well

being of their children, the functioning of households and society at large (WHO 2000).

Womens increased participation in the labour force overlaps with their extensive

involvement in care giving, adding considerable strain to their lives. Women in industry are

traditionally and economically a segment of the working population that suffer from many

disadvantages (Amita 1990).

Objectives: The present study assesses the nutritional status of adult women working in the

garment industries in Chennai and to identity the association of occupational hazards with

health status.

Materials & Methods : The research design adopted for the study was Expost facto research

design. Purposive sampling was used to select the subjects. Random sampling technique was

used to select a sub sample of 20 subjects for the biochemical test. The tool adopted for the

study was an interview schedule, whose reliability and validity was established and than

administered.

Results & Discussion: Using the prepared schedule details related to their nutritional,

occupational and health profile were gathered. It was found that 85 percent of the subjects

had completed only primary schooling 71 percent were from nuclear families and 60 percent

from low income group. Their mean body weight, body mass index and waist to hip ratio

were lower than the NCHS standard for Women. Given the socio-economic background it

was found that their mean calorie and protein intake were significantly lower than the

recommended allowance and that 60 percent were undernourished. The results highlighted

that Majority of the subjects were found to suffer from back pain, joint pain and dust related


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problems leading to upper respiratory infections. They were trapped in a cycle of ill health

and malnutrition.


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NUTRITIONAL STATUS OF ADULT WOMEN WORKING IN THE

GARMENT INDUSTRY

Introduction

You can tell the condition of a nation by looking at the status of its women.

- Jawharlal Nehru

Womens labour contribution has become the backbone of Indian economys current growth

path. Further the trends of jobless growth has pushed more women into earning for household

survival.

Health and nutritional factors play a vital role in the development of working women.

Working women appear to pay less attention to their health and food intake (Repette and

Mattews, 1990).

Women require healthy and balanced diet to perform effective and productive work. Good

food and good health go together. Optimum Nutrition is vital to maintain health and enhance

quality of life in physiological, psychological, social, economical and cultural issues that

influences individuals nutritional status (Crotty, 2000).

Womens increased participation in the labour force overlaps with their extensive

involvement in care giving adding considerable strain to their lives. By 1992 61.4% of

women were employed outside of home and 75% of mothers with children under 12 years

were working for pay.

However, research reveals that the division of home labour has remained virtually unchanged

over the years. Women continue to spend significantly more time than men on housework

and the care of children and relatives (Mukopadhyay 1996). The strenous physical tasks

allocated to women, combined with limited food intake, exacerbate malnutrition among

Indian Women.


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Background

This study was planned following recent studies that women in the garment factory, do not

consume adequate dietary requirement due to various factors like low socio-economic status,

dong distance between work place and home, low salary and other domestic problems

(Joseph, 2003).

Methodology

The study was conducted on 60 women subjects chosen from the garment industry in

Chennai. Purposive sampling was used to select the subjects. A subsample of 20 subjects

were chosen randomly for the haemoglobin estimation. The protocol for the study was

designed and its reliability and validity established before administration written informed

consent was obtained from the subjects. The tools for the study comprised of an interview

schedule comprising of details about personal & occupational profile, anthropometric

measurements, dietary recall and biochemical estimation. The dietary collection method was

a 3 day dietary recall followed by an interview to clarify un certainties and portion size.

Anthropometric measurements such as body weight, standing height, BMI and waist to hip

circumference were used to evaluate nutrition status. Data analysis was carried out using

SPSS version 10.


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Results

Personal Profile

Sixty women subjects completed all aspects of the survey. Table 1 summarizes the personal profile of the subjects.

Table 1

Personal profile of the subjects

VariablesAge (in Years)

Number Percentage

20 30 30 50

30 40 30 50

Educational Status

Primary School 51 85

High School 9 15

Marital Status

Married 46 77

Unmarried 14 33

Family Type

Nuclear 43 71

Joint Family 17 29

*Family Income

Low Income(Rs.15000 Rs.31,800)

36 60

Middle IncomeRs. 31800 to Rs.53,400

High Income(Above Rs. 53,000)

24 40


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It was observed that 50 percent of the subjects were in age group of 20 30 years and 85

percent completed only their primary schooling. Regarding their marital status it was seen

that 77 percent were unmarried most of them 71 percent were from nuclear families and 60

percent were from low income groups. The results of the study correlate with the study by

Joseph et al, 2003 who found that women in the garment industry do not consume adequate

dietary requirement due to factors like low socio economic status and low salary.

Anthropometric Measurements

The anthropometric measurements of the subjects such as body weight, standing height, body

mass index and waist to hip ration is given in Table 2.

Table 2

Anthropometric measurements of subjects

AnthropometricMeasurements

NCHSStandard

Mean SD

Body weight (kg) 50 47.47 4.02

Standing Height (CM) 156 158.77 5.12

Body Mass Index 20 25 18.61 1.57

Waist Hip Ration 0.8 0.752 0.02

The result show that the mean body weight, standing height, body mass index and waist to

hip ratio and lower than the NCHS standard for Indian Women, lower body weight is an

indication of present malnutrition.

Diet Profile

Diet is a vital determinant of nutritional status of people. Table 3 summarize the range of

mean nutrient intake of the subjects.


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Table 3

Mean Nutrient intake of the subjects

Nutrients RDA* Mean IntakeEnergy (Kcal) 1875 1377 169Protein (g) 50 35 4Fat (g) 20 25 4

* ICMR, 2000

The obtained mean values revealed that the intake of energy and protein were found to be

lower than the Recommended Dietary Allowance and intake of fat higher.

Frequency of food consumption of the subjects was also analyzed and it was found that only

10 percent of them included green leafy vegetables and fruits once a week while the

recommendations are to have them every day. The low purchasing capacity and lack of time

to cook green leafy vegetables were reported as the main causes.

Haemoglobin Levels

Blood Haemoglobin leves were estimated for 20 subjects and mean levels was found to be

10.46 1.18 g/dl which is lower than the standard for women as 12g / dl.

Health Problems

It was observed from Table 4 that 70 percent of the subjects suffered from back pain 73

percent had joint pain and 63 percent reported giddiness and 46.7 percent sufferent from

respiratory problems


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Table 4

Health Problems of the subjects

Health Problem Number Percentage

Back pain 42 70

Joint Pain 44 73

Low Blood pressure 14 23

Nervousness 16 26

Giddiness 38 63

Dust related respiratoryProblems

28 47

Discussion

This study has shown that low socio economic background of the women working in the

garment industry and the low salary has a great impact on their nutritional status and quality

of life. This finding indicates the vicious cycle of malnutrition and infection of the workers

and helps to make recommendations to the garment industries to increase their awareness &

knowledge about dietary practices and help put them to put it into practice by providing a

healthy snack or meal. Optimum nutritional status of the workers, will decrease infection

health problems and absenteeism, which will in turn enhance productivity.

BIBLIOGRAPHY

Crotty, P. (2000). Health Promotion and Nutrition: Food and Nutrition. Australia: Allen andUnwin.

Joseph et al., (2003). Health and Population: poor Intake of selected Nutrients by WomenWorkers in a Garment Factory. pp: 23.

Mukopadhyay, S. (1996). Working Status and Health. Indian Journal of Social Work. pp: 36,96 - 107.


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Repette, R. A. and Mathews, R. A. (1999). Employment and Womens Health: Effects of Paid Employment On Womens Mental and Physical Health. American Psychologist,Volume: 44, pp: 1384 - 1400.

World Health Organisation, (2000). Better Health and Nutrition for Women. Geneva: WorldHealth Organisation Head Office.

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