Prevalence and Factors Associated with Undernutrition on Cancer Patients at Tikur Anbessa Specialized Hospital, Ethiopia: A cross-sectional study

8 Background: Cancer is one of the leading causes of death in the world and it is considered that 9 every fourth person dies of it. Under-nutrition is most commonly seen in cancer patients with 10 some types of solid tumors, various chronic diseases, as well as in older persons and young 11 children. This can result in longer hospital stay, reduced response to therapies, increased 12 complications to therapy and surgery proceedings, poor survival and higher care costs. This 13 study aimed to assess the prevalence and factors associated with under-nutrition on cancer 14 patients. 15 Methods: Cross-sectional study was conducted from September to October 2018 among 347 16 cancer patients in Tikur Anbessa Specialized hospital Addis Ababa, Ethiopia. Quantitative data 17 was collected using questionnaires and the Patient Generated-Subjective Global Assessment 18 (PG-SGA) score. Data was entered into Epi-Info version 7 and exported and analyzed by SPSS 19 version 20. Both bivariate and multivariate logistic regression analyses were employed to 20 identify the associated factors. Variables with 𝑃 value of less than 0.05 were considered as 21 significant predictors. Results: The prevalence of under-nutrition according to PG-SGA score result 202 (63.1%) and 23 88(27.5%) of the participants were moderately and severely undernourished, respectively. BMI 24 of the participants also showed that 206 (64.4%) and 89 (27.8%) were normal and underweight, 25 respectively. Two hundred seventy-six (86.3%) of the patients needed critical nutrition 26 intervention. Performance status of ≥2 and cancer stage II, III & IV were significantly associated 27 with malnutrition on cancer patients at a P-value <0.05. 28 Conclusion: The prevalence of under-nutrition is prevalent in the study area. Performance status 29 of ≥2 and cancer stages were important factors associated with malnutrition in cancer patients. 30 Screening and evaluation of nutritional status of the patients and planning nutritional therapy 31 such as dietary supplements or enteral nutrition to counteract malnutrition on cancer patients 32 should be implemented. 33


Results:
The prevalence of under-nutrition according to PG-SGA score result 202 (63.1%) and 23 88(27.5%) of the participants were moderately and severely undernourished, respectively. BMI 24 of the participants also showed that 206 (64.4%) and 89 (27.8%) were normal and underweight, 25 respectively. Two hundred seventy-six (86.3%) of the patients needed critical nutrition 26 intervention. Performance status of ≥2 and cancer stage II, III & IV were significantly associated 27 with malnutrition on cancer patients at a P-value <0.05.  Cancer is one of the causes of death in high and lower-income countries of the world and it is 36 considered that every fourth person dies of it. Malnutrition and cachexia are most commonly 37 seen in cancer patients with some types of solid tumors, various chronic diseases, in older 38 persons and young children [1]. However, the nutritional aspect of cancer management has not 39 always been given priority. Cancer patients suffer from protein-energy malnutrition throughout 40 the evolution of their disease, with elevated basal energy requirements, due to their inherent 41 illness and decreased oral intake due to reduced gustatory senses [2]. 42 Under-nutrition is a possible complication in patients with cancer and can be the first 43 symptom to reveal the presence of the disease. It is a major cause of morbidity and mortality. 44 Even before starting anticancer treatment patients can experience profound metabolic and 45 physiological alterations with increased needs of macro and micronutrients. Malnutrition impairs 46 the immune status and reduces the body's defense against infectious diseases [3]. 47 Malnutrition in cancer patients has been also associated with several clinical 48 consequences, including quality of life impairment, decreased treatment response, increases in 49 the risk of infections, high risk of chemotherapy-induced toxicity, length of hospital stay, 50 hospitalization costs, and increased morbidity and mortality [4]. The prevalence of under-51 nutrition in people with cancer is estimated up to 40% to 80%, which is higher than in the 52 general patient population due not only to the illness but also to the treatment involved [5].   The sample size of the study was determined by considering the expected prevalence rates of 90 undernutrition among cancer as 71.1% [9]. The sample size was calculated with 5% marginal error 91 and 95% CI and none response rate of 10%. Based on the above assumption, the sample size for the 92 study was determined using the formula for a single population proportion as follows. 93 n = (Zɑ/2) 2 * p (1-q)] Simple random sampling method was used to select samples from the sample frame. Confidence interval was calculated. For all statistical significance tests between each 143 independent and dependent variable, the significance level was fixed at P < 0.05. were married and 69.7% live in urban areas. More than half (57.8%) of individuals had a 151 monthly income of greater than1500 Ethiopian birr. (Table 1) 152

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The most common types of cancer identified in this study classified by the organic system were  Table   165 2) 166  Availability of data and materials 287 Data will be available upon request from the corresponding authors. 288

Authors' contributions 289
Eyerusalem Worku has involved in study design, data collection, supervision and analysis, and 290 interpretation of data and wrote the first draft of the manuscript. Hayat Aragaw and Damte Kebede were 291 involved in study design, reviewing data analysis findings, and revised the draft and final manuscript. All 292 authors read and approved the final manuscript. 293 Ethics approval and consent to participate 294 Ethical clearance was obtained from the Institutional Ethical Review Board of Faculty of 295 Chemical and Food Engineering, Bahir Dar University. Supportive letters were obtained from 296 Amhara public Health institute wrote a letter to the Tikur Anbessa Specialized Hospital.

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Respondents were given assurances about the privacy and confidentiality of their responses.

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Informed oral consent was obtained from each participant to ensure their willingness to 299 participate, and all were informed that they had the right to not participate or could withdraw 300 from the study at any time. Confidentiality of the data was assured and kept in secret; code 301 number was assigned to the study participants without mentioning the name, the information that 302 was collected by the study was kept in a file and locked with a key.