1. PYHSICAL ACTIVITY, NUTRITIONAL STATUS AND QUALITY OF LIFE AMONG GASTROINTESTINAL CANCER SURVIVORS
Zalina AZ1,2, Lee VC1 and Kandiah M1
1Department of Nutrition and Dietetics, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia.
2Nutrition and Dietetics Department, School of Medicine, Faculty of Health Sciences, Flinders University, Australia.
METHODOLOGY
Study Design: Cross-Sectional study & purposive sampling with inclusion and exclusion criteria.
The study was approved by the Ethics Committee of the Faculty of Medicine & Health Sciences, UPM and the Ministry of Health National Medical Research Registry (NMRR).
Study Location: Oncology Outpatient Clinic, Hospital Selayang, Selangor.
Subjects: 70 GI patients who have completed primary treatments were recruited into this study with informed consent.
INTRODUCTION
Cancer survivors are individuals with a diagnosis of cancer and who have completed primary treatments for cancer (Aziz, 2002).
Gastrointestinal (GI) cancer encompasses a group of cancers that affects the GI tract (Kelson et al. 2008).
Studies show a significant relationship between quality of life (QOL) and nutritional status among cancer survivors, where depletion of nutritional reserves and significant weight loss subsequently leads to decreased QOL (Isenring et al. 2003; Caro et al. 2007; Ang & Kandiah 2009).
Assessment of nutritional status is important to identify malnutrition in gastrointestinal cancer survivors as good nutritional status will improve QOL and avoid cancer recurrence in the future.
Interviewer-administered questionnaire was used in this study, comprising:
Socio-demographic profile & Cancer characteristics.
International Physical Activity Questionnaire (IPAQ), to assess physical activity level of the patients.
The scored Patient Generated-Subjective Global Assessment (PG-SGA) questionnaire to determine the nutritional status of the patients, with higher score indicating lower nutritional status.
Gastrointestinal Quality of Life Index (GIQLI) questionnaire to assess the QOL of the patients, with higher score indicating better QOL.
Data
Collection
Physical activity level: Classification of physical activity level (low, moderate or high) depend on the total physical activity calculated in MET-minutes/week) (Craig et al., 2003).
Nutritional status assessment: Scoring and classification of total PG-SGA score as recommended by Ottery (2000).
Quality of life assessment: Scoring of total GIQLI score based on Eypasch et al., (1995).
Statistical analysis: The Statistical Package for the Social Sciences (SPSS) version 17.0; (One Way ANOVA & Pearson’s Correlation), p<0.05 set as level of significance
Data Analysis
OBJECTIVES OF STUDY
To determine the relationship between physical activity, nutritional status and QOL among GI cancer survivors
Specific
General
To assess the socio-economic and demographic profile and cancer characteristics of GI patients
To determine nutritional status, physical activity and QOL in GI patients
To determine the relationship between nutritional status and physical activity; QOL among GI cancer survivors
RESULTS
Table 1: Baseline characteristics of the subjects (n=70)
Characteristics
n (%)
Sex
Male
Female
39 (55.7)
31 (44.3)
Age Group (years)
< 65
> 65
35 (50.0)
Ethnic Group
Malay
Chinese
Indian
Other
12 (17.1)
48 (68.6)
9 (12.9)
1 (1.4)
Education Level
No schooling
Primary school
Secondary school
Tertiary
14 (20.0)
27 (38.6)
23 (32.9)
6 (8.6)
Occupation
Government
Private
Jobless
Retired
Self-employed
4 (5.7)
44 (62.9)
11 (15.7)
5 (7.1)
Marital Status
Single/divorce
Married
Widow/widower
9 (11.1)
70 (86.4)
2 (2.5)
Income (RM)
< 1000
> 1000
51 (72.8)
19 (27.2)
Mean GIQL score =
Table 3: PG-SGA nutritional status categories of the subjects (n=70)
Categories
Male (n=39)
Female (n=31)
Total (n=70) t p
n(%)
Mean ± SD
Stage A
(well-nourished)
11 (28.2)
2.82 ± 0.982
7 (22.6)
2.86 ± 0.690
18 (25.7)
2.83 ± 0.857
-0.091
0.928
Stage B
(moderately malnourished)
13 (33.3)
6.77 ± 1.235
5 (16.1)
7.60 ± 0.548
7.00 ± 1.138
-1.430
0.172
Stage C
(severely malnourished
15 (38.5)
15.67 ± 6.737
19 (61.3)
16.16 ± 6.635
34 (48.6)
15.94 ± 6.583
-0.213
0.833
Table 2: Clinical characteristics of the subjects (n=70)
Cancer Characteristics
n (%)
GI cancer type
Upper GI cancer
Lower GI cancer
8 (11.5)
62 (88.6)
Stage of Cancer
Stage I
Stage II
Stage III
Stage IV
18 (25.7)
15 (21.4)
33 (47.1)
4 (5.7)
Treatment Received
Surgery
Chemotherapy
Radiotherapy
Follow-up
64 (91.4)
14 (20.0)
70 (100.0)
Table 4: Correlation between PG-SGA total mean score and independent variables (n=70)
Independent variables
Relationship
(r)
Significance
(p)
Physical Activity, MET-mins/week
-0.309
0.009**
GIQLI total score
-0.661
0.000***
** Significant (p<0.01)
*** Significant (p<0.001)
RESULTS & DISCUSSION
Mean age of the subjects was years ; majority were males and Chinese (Table 1).
Based on Second National Cancer Registry (2004), Chinese have the highest incidence of lower GI cancer (colon and rectal cancers) compared to other ethnic groups.
Majority of the subjects have primary education, unemployed, married, total income of RM<1000, had lower GI cancer (colorectal cancer), in Stage III, and obtained follow-up treatment. (Table 1
In Malaysia, colorectal cancer is the most common GI cancer regardless of sex (NCR, 2008).
More male survivors than females were in the highest quartile of GIQLI scores distribution while more females than males were in the lowest quartile (Figure 1).
Most of the subjects were classified as having low physical activity level and were severely malnourished (Figure 2 & Table 3).
Pearson’s correlation test showed a strong significant relationship between nutritional status and QOL (r=-0.661, p<0.001) indicating better nutritional status (low total mean score of PG-SGA), with better QOL of the respondents (high mean score of GIQLI) (Table 4).
This study showed similar outcome with a study done by Hill et al. (2010) where GI cancer survivors who scored higher in PG-SGA experienced greater weight loss and malnutrition which led to lower QOL.
There was a weak but significant negative relationship between physical activity level and nutritional status score (r=-0.309, p<0.01); the higher the physical activity level performed by the patients (high MET-min/week), the better nutritional status of the patients (low total mean score of PG-SGA) (Table 4).
These result support a study done by Copland et al. (2010) which found a significant 5% or more weight loss in GI cancer survivors for those who reduced their exercise capacity after major upper GI surgery.
CONCLUSION
GI cancer survivors in this study have shown a relationship between nutritional status, QOL and physical activity level where those who had low nutritional status have low QOL as well and survivors with higher physical activity have better QOL and nutritional status.
Therefore, a diet and lifestyle intervention is recommended to improve physical activity , nutritional status and QOL which may reduce risk of cancer recurrence in the future.
REFERENCES
Aziz NM Cancer survivorship research: Challenge and opportunity. Journal of Nutrition. 132:
Kelson DP, Daly JM, Kern SE, Levin B, Tepper JE & Custem EV Principles and practice of gastrointestinal oncology. 2nd Ed. Philadelphia: Lippincott Williams & Wilkins.
Isenring EA, Bauer J & Capra S The scored Patient-Generated Subjective Global Assessment and its association with quality of life in ambulatory patients receiving radiotherapy. European Journal of Clinical Nutrition. 57:
Caro MMM, Laviano A & Pichard C Impact of nutrition on quality of life during cancer. Current Opinion in Clinical Nutrition and Metabolic Care. 10:
Kwang AY & Kandiah M Objective and Subjective Nutritional Assessment of Patients With Cancer in Palliative Care. Am J Hosp Palliat Care. 27(2):
Craig CL, Marshall AL, Sjostrom M, Bauman AE, Booth ML, Ainsworth BL et al International physical activity questionnaire: 12 country reliability an validity. Medicine & Science in Sports & Exercise. 35:
Ottery F (2000). Patient-Generated Subjective Global Assessment. In: The Clinical Guide to Oncology Nutrition, ed. P McCallum & C Polisena. Chicago, IL: American Dietetic Association: pp11–23.
Eypasch E, Williams JI, Wood-Dauphinee S, Ure BM, Schmulling C, Neugebauer E & Troidl H Gastrointestinal Quality of Life Index: development, validation and application of a new instrument. British Journal of Surgery. 82(2):
National Cancer Registry (2008). Cancer Incidence in Peninsular Malaysia Lim GCC, Halimah Y, & Sanjay R. National Cancer Registry: Kuala Lumpur.
National Cancer Registry (2004). Second Report on the National Registery Cancer Incidence in Malaysia Lim GCC, Halimah Y, & Sanjay R. National Cancer Registry: Kuala Lumpur.
Hill A, Kiss N, Hodgson B, Crowe TC & Walsh AD Associations between nutritional status, weight loss, radiotherapy treatment toxicity and treatment outcomes in gastrointestinal cancer patients. Clinical Journal. 30(1):
Copland L, Rothenberg E, Ellegard L, Hyltander A & Bosaeus I Muscle mass and exercise capacity in cancer patients after major upper GI surgery. The European e-Journal of Clinical Nutrition and Metabolism. 5, e265-e271. Doi: /j.eclnm
Acknowledgement
The author wish a sincere gratitude to all enthusiastic and cooperative participants extended during the study. We are also grateful to the hospital staff for their cooperation and assistance.