Nutritional Issues and Self-care Measures Adopted by Cancer Patients Attending a University Hospital in Turkey A B S T R A C T

Abstract

Objective
This study aimed to assess the nutritional status of cancer patients and the self-care measures they adopted as a response to nutritional problems.

Methods
This descriptive study included seventy cancer patients staying in the oncology and internal disease clinics of a university hospital in Turkey. Data were collected using a questionnaire with 29 questions.

Results
The mean age of participants was 40.2 ± 1.82 years. Approximately, 62.9% of the patients ate only half of the meals offered to them, 65.7% experienced weight loss, and 45.7% had difficulty eating their meals on their own. Moreover, 47.1% of the patients received nutritional support and nutritional problems were observed in 71.4% of the patients; 80% were unable to eat hospital food, 54.3% had an eating disorder related to a special diet, 30% suffered from loss of appetite, 27% had nausea, and 14.3% had difficulty swallowing. Furthermore, 48.5% of patients responded that they ate home-cooked food or ordered food from outside when questioned about the self-care measures taken to avoid the aforementioned nutritional problems.

Conclusions
Most of the cancer patients had serious nutritional problems and ate home-cooked food and used nutritional supplements to overcome these problems. Oncology nurses are responsible for evaluating the nutritional status of cancer patients and eliminating nutritional problems.

Full text

© 2016 Ann & Joshua Medical Publishing Co. Ltd | Published by Wolters Kluwer - Medknow
390
Nutritional Issues and Self-care Measures
Adopted by Cancer Patients Attending a
University Hospital in Turkey
Sevgisun Kapucu
Nursing Faculty, Hacettepe Universitesi, Ankara, Turkey
Corresponding author: Sevgisun Kapucu, PhD, RN
Associate Professor, Faculty of Nursing
Hacettepe University, Ankara, Turkey
Tel: 00903123051580; Fax: 00903123127085
E‑mail: sevgisunkapucu@gmail.com
Received: June 23, 2016, Accepted: August 24, 2016
ABSTRACT
Objective: This study aimed to assess the nutritional status of
cancer patients and the self‑care measures they adopted as a
response to nutritional problems. Methods: This descriptive
study included seventy cancer patients staying in the oncology
and internal disease clinics of a university hospital in Turkey.
Data were collected using a questionnaire with 29 questions.
Results: The mean age of participants was 40.2 ± 1.82 years.
Approximately, 62.9% of the patients ate only half of the meals
oered to them, 65.7% experienced weight loss, and 45.7%
had diculty eating their meals on their own. Moreover, 47.1%
of the patients received nutritional support and nutritional
problems were observed in 71.4% of the patients; 80% were
unable to eat hospital food, 54.3% had an eating disorder
related to a special diet, 30% suered from loss of appetite, 27%
had nausea, and 14.3% had diculty swallowing. Furthermore,
48.5% of patients responded that they ate home‑cooked
food or ordered food from outside when questioned about
the self‑care measures taken to avoid the aforementioned
nutritional problems. Conclusions: Most of the cancer patients
had serious nutritional problems and ate home‑cooked
food and used nutritional supplements to overcome these
problems. Oncology nurses are responsible for evaluating the
nutritional status of cancer patients and eliminating nutritional
problems.
Key words: Cancer, malnutrition, nurse, nutrition, precaution
Introduction
Malnutrition is common among cancer patients. It is a
condition resulting from the consumption of a diet that is
either deficient or excessive in nutrients, thereby causing
health problems.[1] Cancer patients usually suffer from
malnutrition because of the side effects of cancer treatment
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Cite this article as: Kapucu S. Nutritional issues and self-care
measures adopted by cancer patients attending a university hospital
in Turkey. Asia Pac J Oncol Nurs 2016;3:390-5.
Original Article
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Kapucu: Nutritional Problems in Cancer Patients
Asia‑Pacic Journal of Oncology Nursing • Oct‑Dec 2016 • Vol 3 • Issue 4 391
and deleterious effects of the disease itself. Chemotherapy
and radiotherapy are the most common methods for
cancer treatment. Given that these methods damage cells
in the gastrointestinal tract, food intake decrease because
of nausea and vomiting, mucositis, absence of appetite,
diarrhea, constipation, and taste changes.[2,3] Malnutrition
is the result of chemotherapy‑ and radiotherapy‑related
diffusive systemic side effects in cancer patients. The
incidence of malnutrition in cancer patients is between 40%
and 80%.[4,5] Moreover, malnutrition in these patients is
responsible for 20% of cancer‑related deaths.[5] Malnutrition
can be described as inadequate food intake or absorption
because of cancer.[6] It can cause ineffective therapy, long
hospitalization, decreased the quality of life, and increased
mortality and morbidity.[7‑9]
The most common nutritional problems in cancer
patients are nausea, vomiting, difficulty in swallowing,
mucositis‑related decrease in food intake, loss of appetite,
inadequate food consumption, difficulty in eating hospital
food, special diet‑related inadequate food consumption
such as neutropenic diet and inadequate liquid intake. If
these nutritional problems are not handled efficiently by a
healthcare team, malnutrition, and cachexia may develop.
In both cases, the general health condition of patients
worsens, and treatment success decreases. The mortality
rate may even increase.[8,10] Previous studies have shown
that malnutrition rates of cancer patients, especially those
undergoing cancer treatment, are higher than those of
normal patients. Therefore, the nutritional status of patients
should be evaluated. Kara[11] reported that patients in his
study showed higher average energy consumption at 3 days
before cancer treatment than after treatment because of
chemotherapy side effects. Data in the literature regarding
cancer patient malnutrition related to nutrition in Turkey
are limited. Medical treatment of cancer patients usually
focuses on the administration of cytotoxic agents and/
or radiation therapy, and the prevalence of malnutrition
among cancer patients has been very high.
Oncology nurses help patients deal with cancer treatment
and its side effects, as well as take care of these patients
using an integrated approach. Evaluating and providing
nutritional support are the responsibilities of these nurses.
An oncology nurse detects nutritional problems of patients
in cooperation with a physician and dietitian and attempts
to solve such problems.[4,11,12] This study aimed to assess
the nutritional status of cancer patients and the self‑care
measures they adopted as a response to nutritional
problems. This manuscript also aimed to increase awareness
of professional healthcare providers and encourage further
studies into this topic.
Methods
Study design
This study was performed to describe the nutritional
problems in cancer patients and self‑care measures adopted
by these patients.
Study questions
1. Are there any nutritional problems in cancer patients?
2. What are the factors causing nutritional problems in
cancer patients?
3. What kind of precautions does cancer patients take for
their nutritional problems?
Samples of the study
This study included seventy cancer patients staying in the
oncology and internal medicine clinics of the Hacettepe
University Hospital between January 2010 and June 2011.
Selection criteria of the sample area
The inclusion criteria were as follows:
• Age above 18 years
• Cancer diagnosed at least 6 months ago
• Under chemotherapy or radiotherapy
• Treated by staying in a hospital
• Able to communicate.
Exclusion criteria of the sample area
• Terminally ill cancer patients.
Materials used for data collection
A questionnaire prepared in accordance with previous
studies was used by the researcher to collect data.[1,11] This
form had the following three parts:
• The first part contained 13 questions to learn the
sociodemographic characteristics of the patients
• The second part contained 16 questions. These
questions were prepared for detecting the nutritional
status, nutritional problems, and reasons behind these
problems.
Situations defined as nutritional problems are as
follows
• Low body mass index (BMI)
• Consuming less than half of the food provided
• Not eating hospital food
• Weight loss during the stay in the hospital
• The last part contained a table to detect the problems
and precautions that affect the nutritional status of the
patients.
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Kapucu: Nutritional Problems in Cancer Patients
Asia‑Pacic Journal of Oncology Nursing • Oct‑Dec 2016 • Vol 3 • Issue 4
392
Procedure of the study
This study included seventy volunteer cancer patients
staying in the oncology and internal medicine clinics of a
university hospital between January 2010 and June 2011.
The questionnaire was filled out by the nurses in charge of
these patients. Filling out these forms took almost 30 min.
Statistical analysis
Data collected at the end of the study were analyzed using
Statistical Package for the Social Sciences Windows 20.0.
Descriptive measures were used to summarize the data.
Ethical perspective of the study
Written permission was obtained from the institution, and
oral permission was acquired from the patients who were
able to accomplish these forms.
Results
The mean age of the participants was 40.2 ± 1.82 years, of
whom 37% were female, 71.4% were married, 37.1% were
primary school graduates, 37.1% were homemakers, and
77% were unemployed. Regarding their caregivers, 34.3%
received care from their husbands/wives, and 34.3% received
care from their parents. The results are shown in Table 1.
When the diagnoses were analyzed, 20% of the patients
had acute myeloid leukemia, 18.6% had multiple myeloma,
and 18.6% had non‑Hodgkin lymphoma. Moreover,
11.4% of the patients had metastasis; 27% underwent
cyclophosphamide, doxorubicin, oncovin, and prednisone
treatment (mean dosage of 2.7 ± 0.20); 55.7% used steroids;
30% used antidepressants; and 15.7% had edema [Table 2].
The mean BMI of the patients was 23.5 ± 0.06 (daily
medical report). Of the patients studied, 62.9% ate half of
all their meals, 65.7% lost weight (between 2 and 12 kg; the
process of treatment), and 45.7% had difficulty eating their
meal. Furthermore, 47.1% of the patients took nutritional
supplements, and 35.7% took Ensure. Nutritional
supplementation‑related complications were observed in
27.7% of the patients [10% had constipation, and 8.6%
had nausea, vomiting, and diarrhea Table 3]. As indicated
in the table, 94.3% of the patients had a special diet, and
77.1% of this diet was neutropenic. Moreover, 62.95% of
the patients followed their diets and were informed about
their diets by their physicians and nurses.
In this study, 71.4% of the patients indicated they had
nutritional problems. Of these problems, 80% were
difficulty in eating hospital food, 54.3% were special
diet‑dependent eating problems, 30% were a loss of appetite,
27% were nausea and 14.3% were difficulty in swallowing.
When the patients were asked about the precautions they
took to overcome these problems, 48.5% of the patients
said they brought their foods from either outside or home,
and 34.2% of the patients said they have been using oral
solutions [mouthwash Table 4].
Discussion
Most of the cancer patients had nutritional problems.
Of the patients included in this study, 80% had difficulty
eating hospital foods, 54.3% had a special diet‑dependent
decrease in food intake, 30% had loss of appetite, 27%
had nausea, and 14% had difficulty in swallowing. Among
the patients with nutritional problems, anorexia and
malnutrition could dysregulate their general condition.
According to previous studies, malnutrition is observed in
40%–80% of cancer patients.[4,5] Numerous factors can cause
malnutrition in cancer patients, such as treatment‑related
Table 1: Descriptive characteristics of patients (n=70)
Characteristics n%
Age (minimum: 18, maximum: 68,
mean: 40.2±1.82), year
18-34 25 35.7
35-55 29 41.4
≥55 16 22.9
Gender
Male 37 52.9
Female 33 47.1
Marital status
Married 52 74.3
Single 18 25.7
Education
Elementary school 26 37.1
High school 23 32.9
University 21 30.0
Career
Officer 4 5.7
Worker 17 24.2
Retired 10 14.3
Homemaker 26 37.1
Students 13 18.6
Working status
Unemployed 54 77.1
Full time 16 22.9
Caregiver
Wife or husband 24 34.3
Children 18 25.7
Parents 19 27.1
Sister or brother 9 12.9
Total 70 100.0
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Kapucu: Nutritional Problems in Cancer Patients
Asia‑Pacic Journal of Oncology Nursing • Oct‑Dec 2016 • Vol 3 • Issue 4 393
side effects (e.g., mucositis, loss of appetite, taste alterations,
difficulty in swallowing, constipation, and diarrhea),
infection, functional weakness, hospital environment,
and depression.[4,8,12] Oncology nurses are responsible for
evaluating the nutritional status of the patients using an
integrated approach. Early detection of malnutrition and
timely administration of nutritional requirements can
help manage dysregulation of the general condition of
the patient and decrease morbidity and mortality rates.
Given the difficulty faced by most of the patients in eating
hospital food and restrictions in neutropenic diet, nutritional
deficiency and malnutrition may develop.[13] In the 2014
consensus results of oncology nurses, some decisions were
Table 2: Patients and disease characteristics (n=70)
Feature of diseases n%
Time taken to diagnose (3.9±0.27)
0-11 months 44 62.9
1-3 years 22 31.4
4-6 years 4 5.7
Diagnosis of disease
AML 14 20
MM 13 18.6
NHL 13 18.6
ALL 12 17.1
Lymphoma 7 10
Breast cancer 6 8.6
CML 3 4.3
CLL 2 2.9
Metastasis
Yes* 8 11.4
No 62 88.6
Type of therapy
Chemotherapy 65 92.8
Radiotherapy 5 7.2
Protocol of chemotherapy (n=65) - mean of cure: 2.7±0.20
CHOP 19 29.2
VAD 14 21.5
CVAD 14 21.5
ARA-C 12 18.4
AC 4 6.2
Taxol 2 3.2
Steroid receiving status
Ye s 39 55.7
No 31 44.3
Antidepressant receiving status
Ye s 21 30
No 49 70
Edema
Yes* 11 15.7
No 59 84.3
Total 70 100
*Colon, legs and face. CHOP: Cyclophosphamide, doxorubicin, oncovin, prednisone,
VAD: Vincristine, adriamycin and dexamethasone, C‑VAD: Cyclophosphamide, vincristine,
adriamycin and dexamethasone, ARA‑C: Cytosine arabinoside, AC: Adriamycin
and cyclophosphamide, AML: Acute myeloid leukemia, MM: Multiple myeloma,
NHL: Non‑Hodgkin lymphoma, ALL: Acute lymphocytic leukemia, CML: Chronic myeloid
leukemia, CLL: Chronic lymphocyte leukemia
Table 3: Nutritional features of the patients (n=70)
Nutritional features n%
BMI* (23.5±0.06)
≤18 2 2.9
19-24 36 51.4
25-33 32 45.7
Meal consumption status
Complete 22 31.4
Half 44 62.9
Less than half 4 5.7
Weight loss
Yes* 46 65.7
No 24 34.3
Status of independence from eating the meal
Eat with help 12 17.1
Hardly eat by themselves 32 45.7
Do not need help 26 37.1
Nutritional supplement status
Ye s 33 47.1
No 37 52.9
Nutritional supplement types
Ensure 25 35.7
Biyosorb 4 5.7
Glukerna 2 2.9
Total parenteral nutrition 2 2.9
Problems due to nutritional supplements
Ye s 19 27.7
No 51 72.9
Nutritional supplement problems (n=19)
Constipation 7 10.0
Diarrhea 6 8.6
Nausea and vomiting 6 8.6
Total 70 100.0
*BMI: Body mass index
Table 4: Nutritional problems and measures taken by cancer
patients (n=70)
Nutritional problems and measures n%
Nutritional problems
Ye s 50 71.4
No 20 28.6
Type of nutritional problems*
Inability to eat hospital food 56 80.0
Eating problem due to a special diet 38 54.3
Anorexia nervosa 21 30.0
Nausea 19 27.1
Mucositis 17 24.3
Constipation 12 17.1
Difficulty swallowing 10 14.3
Vomiting 8 11.4
Diarrhea 7 10.0
Taste changes 4 5.7
Measures taken by the patients* (n=60)
Eating from outside or bringing lunch from home 34 56.6
Nutritional supplements + mouthwash 24 40.0
Mouthwash 24 40.0
Total 70 100.0
*n‑folded
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Kapucu: Nutritional Problems in Cancer Patients
Asia‑Pacic Journal of Oncology Nursing • Oct‑Dec 2016 • Vol 3 • Issue 4
394
made to this effect, such as evaluating appetite loss of
patients with different tools by a nurse, inhibiting mucositis,
and providing nutritional support.[15]
The present study found that more than half of the patients
staying in the study hospital consumed only half of their
meal and had lost weight. Almost half of these patients
took nutritional supplements; however, they had nausea and
vomiting, diarrhea, and constipation in response to these
supplementations. Nutritional supplements maintain the
body weight of the patients, inhibit dysregulations in general
conditions, and inhibit the generation of life‑threatening
complications in patients.[14] If food intake is insufficient for
compensating energy expenditure in an oncology patient,
enteral nutritional supplementation should be given.[15,16] In
the study of Lee et al., prophylactic enteral feeding during
radiotherapy decreased weight loss, dehydration, and
mucositis‑related rate of admission to hospital.[17] However,
if this enteral feeding supplementation is not evaluated
carefully, some product‑dependent complications, such as
diarrhea, nausea and vomiting, swelling in the stomach,
and gas can occur.[14] Oncology nurses should evaluate the
adequacy of nutritional supplementation and its effects on
patients.[13]
When patients were asked about the kind of precautions they
took to overcome these problems, almost half brought their
food from either their home or outside. Furthermore, they
used antiemetics (sourced from nutritional supplements)
to deal with nausea and mouthwash to block mucositis
formation as recommended by their physician. The methods
used by patients to control nausea and mucositis were
compatible with previous studies,[4,12,14,15,17‑20] but the most
interesting result was bringing their food from outside.
This situation also matched with the observations of the
present study, and oncology nurses were also included in
this discussion. In the 2014 consensus meeting of oncology
nurses, the participants decided to support the idea of
bringing fresh food (consumed the same day) that should
be cooked in a pressure cooker for the patients who do not
have severe neutropenia.
Limitations
Data of this study were limited as the study was conducted
in one hospital.
Conclusion
Cancer patients face certain nutritional problems caused
either by the side effects of cancer treatments or hospital
food‑related problems. Oncology nurses who are in charge
of these cancer patients are also responsible for evaluating
their nutritional status and eliminating malnutrition.
Individual and institutional responsibilities need to be
taken.
Acknowledgments
The author would like to thank Nurse Filiz Bek, Attending
Nurse Gulizar Avci, and Nurse Sevgi Erdal for their
contribution to this study.
Financial support and sponsorship
Nil.
Conicts of interest
There are no conflicts of interest.
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