EFFECT OF RADIATION AND CHEMORADIATION ON NUTRITIONAL STATUS AND FUNCTIONAL WELL BEING OF SELECTED ORAL CANCER PATIENTS

N.KOKILAa, REGI RAYMON SHARMELEE FERNANDOb (Department of Home science, Queen Marys college, Chennai-600 004)

Abstract ______________________________________________________________________ Oral cancer is a major health problem in India commonly occurring in men depending upon the extent and type of tobacco habits. Radiation and chemoradiation are provided to control or minimize the neoplastic process. Therefore pre and post treatment assessment of the oral cancer patients nutritional status and functional well being becomes a valuable measure 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 a cancer hospital at Chennai. An interview schedule was administered on the selected patients who 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 the age 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 energy deficiency was significant after treatment in both the groups. Toxicity was at higher percentage in subjects receiving chemoradiation leading to cachexia which deteriorates the already fragile nutritional status. The mean nutrient intake and functional well being decreased significantly in both the groups before and after the treatment. Oral cancer patients undergoing 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.
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Introduction

Oral 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 chewing1. A generally

impoverished diet, particularly lacking in vegetables and fruits is another risk factor for oral cancer2. 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

cancer, while those with advanced diseases are treated with definitive radiation therapy and chemoradiation4. 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 <44 was graded as high, average and low functional well being. The study was conducted for a period of 4 months.

Results and discussion General and baseline characteristics

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 Before treatment During treatment After treatment Mean body Comparison weight (kg) between Group I 49.008.19(A) 46.117.20(B) 44.227.30(C) A vs B B vs C A vs C t Value 7.023* * 5.239* * 7.188* * Mean body Comparison weight (kg) between Group II 53.507.83(D) 49.447.92(E) 47.167.48(F) D vs E E vs F D vs F t Value 11.368** 4.644** 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

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 Radiotherapy # BMI Before Normal Low weight Normal Grade I mild energy deficiency Grade II Moderate energy deficiency Grade III Severe energy deficiency 44.44 33.33 12.11 5.11 5.11 (Group I) During 27.70 22.21 22.22 16.66 11.21 After 16.76 22.22 16.72 27.70 16.60 Before 77.78 11.12 5.55 5.55 Chemoradiation (Group II) During 33.30 38.85 16.65 5.65 5.55 After 27.70 16.66 27.74 16.66 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 Before treatment Mean Hb (g/dl) Group I 10.992.59(A) Comparison between A vs B t Value 0.253NS Mean Hb(g/dl) Group II 12.602.20(D) Comparison between D vs E t Value 0.384 NS

During treatment After treatment

10.911.69(B) 10.861.42(C)

B vs C A vs C

0.236 NS 0.273 NS

12.752.17(E) 12.612.17(F)

E vs F D vs F

0.452 NS 0.015 NS

NS- non significant

Table V
Comparison of mean white blood cell count levels of the subjects as assessed before, during and after treatment Assessment Before treatment During treatment After treatment Mean WBC Group I 7488.881271.35(A) 7138.881040.44(B) 7388.88938.01(C) Comparison between A vs B B vs C A vs C t Value 1.338NS 1.917NS 0.463NS Mean WBC Group II 7022.22870.16(D) 7172.22890.34(E) 7161.111092.83(F) Comparison between D vs E E vs F D vs F t Value 0.641NS 0.096NS 0,493NS

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 Toxicity Haemoglobin Grade I (normal -10g/dl) Grade II (10 - 8g/dl) Mucositis Grade I (soreness) Radiotherapy (Group I) # During End of treatment treatment 72.22 27.78 50.00 72.22 27.78 50.00 Chemoradiation (Group II) # During End of treatment treatment 94.45 5.55 61.11 88.89 11.12 33.33

Nausea Grade I ( reduced reasonable intake) Constipation Grade I (mild)

but

44

16.6

50.44

27.77

33.33

22.22

38.88

5.55

# Percentage less than 100 since grading is done only for the subjects having toxicity, the rest are considered 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 Matarese8 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.

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 Assessmen t Before treatment During treatment After treatment Mean energy Comparison t intake(kcal) between Value Group I 5.154* 1496.16268.21(A) A vs B * 9.392* 1234.27111.21(B) B vs C * 1000.7742.86(C) A vs C 7.772* * Mean energy Comparison t intake(kcal) between Value Group II 1627.27252.47(D) 1183.83179.62(E) 894.6155.95(F) D vs E E vs F D vs F 13.447** 9.038** 14.499**

** -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 Matarese8 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 Before treatment During treatment After treatment Mean protein Comparison intake(g) between Group I 36.777.15(A) 34.613.85(B) 29.162.79(C) A vs B B vs C A vs C t Value 1.444NS 4.528* * 4.028* * Mean protein Comparison intake(g) between Group II 40.777.33(D) 33.775.64(E) 25.223.88(F) D vs E E vs F D vs F t Value 6.741** 7.442** 9.920**

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. Marcy10 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 Mean functional well being Group I 48.773.07(A) 43.222.92(B) 36.612.83(C) Comparison t between Value Mean Comparison functional well between being Group II 45.552.06(D) 40.002.249(E) 33.272.44(F) D vs E E vs F D vs F t Value

Before treatment During treatment After treatment

A vs B B vs C A vs C

13.171* * 9.835** 16.299* *

14.577** 29.333** 13.896**

**- 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,

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 communitybased ,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.

9. Ravasco (2003) nutritional deterioration in cancer- the role of disease and diet AJCM pp 272-82. 10.Marcy (2004) evaluations of quality of life and organ function semin Oncol . 31: 82735.

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

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

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.

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.

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 Variables Age (in Years) 20 30 30 40 Educational Status Primary School High School Marital Status Married Unmarried Family Type Nuclear Joint Family *Family Income Low Income (Rs.15000 Rs.31,800) Middle Income Rs. 31800 to Rs.53,400 High Income (Above Rs. 53,000) 24 40 36 60 43 17 71 29 46 14 77 33 51 9 85 15 Number 30 30 Percentage 50 50

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 Anthropometric Measurements Body weight (kg) Standing Height (CM) Body Mass Index Waist Hip Ration NCHS Standard 50 156 20 25 0.8 Mean SD 47.47 4.02 158.77 5.12 18.61 1.57 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.

Table 3 Mean Nutrient intake of the subjects Nutrients Energy (Kcal) Protein (g) Fat (g) RDA* 1875 50 20 Mean Intake 1377 169 35 4 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

Table 4 Health Problems of the subjects Health Problem Back pain Joint Pain Low Blood pressure Nervousness Giddiness Dust related respiratory Problems Number 42 44 14 16 38 28 Percentage 70 73 23 26 63 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 and Unwin. Joseph et al., (2003). Health and Population: poor Intake of selected Nutrients by Women Workers in a Garment Factory. pp: 23. Mukopadhyay, S. (1996). Working Status and Health. Indian Journal of Social Work. pp: 36, 96 - 107.

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: World Health Organisation Head Office.