Nutritional Status and Its Determinants among Adult Cancer Patients Undergoing Chemotherapy Treatment at Hawassa University Comprehensive Specialized Hospital, Hawassa, Southern Ethiopia

Background Malnutrition is a common problem in cancer patients. It has an impact on all aspects of the patient's life such as increasing the risk of infection, treatment toxicity, hospital stay, and health-care costs. Factors influencing the nutritional status of adult cancer patients undertaking chemotherapy treatment in Ethiopia have not been thoroughly investigated. As a result, the purpose of this study is to assess the nutritional status and its determinants among adult cancer patients undergoing chemotherapy treatment at Hawassa University Comprehensive Specialized Hospital. Objectives The objective of this study is to determine the nutritional status and its determinants among adult cancer patients undergoing chemotherapy treatment at Hawassa University Comprehensive Specialized Hospital. Methods A cross-sectional study was conducted among adult cancer patients undergoing chemotherapy treatment at Hawassa University Comprehensive Specialized Hospital Oncology Treatment Center, from January to May 2021. The data were gathered through a face-to-face interview and chart review method. Epi Data 4.6 was used to enter the data, which was then exported to SPSS version 25 for statistical analysis. Multivariable logistic regression analysis was used to determine the association between nutritional status and potential risk factors. A P value less than 0.05 was used to determine statistical significance. Result This study revealed that 48.1% of participants have some level of malnutrition. Lowest wealth index AOR 0.06 (0.016–0.2), food insecurity AOR 0.1 (0.05–0.24), vomiting AOR 0.2 (0.110–.444), poor appetite AOR 0.2 (0.11–0.44), no diarrhea AOR 2.6 (1.34–5.00), and poor functioning AOR 0.3 (0.2–0.54) were significantly associated with good nutritional status. Conclusion and Recommendation. The prevalence of malnutrition among adult cancer patients undergoing chemotherapy treatment at HUCSH was high. Wealth index, food security, poor appetite, diarrhea, and performance status were significantly correlated with the nutritional status of the patients. To improve the patient's nutritional status, economic support, early nutritional screening, and assessment, management of chemotherapy-induced symptoms should be considered.


Introduction
Cancer is a disease in which abnormal cells develop without control, these cells develop and invade other cells and spread to diferent sites in the body causing disease and, if left income countries [3]. In Ethiopia, cancer is responsible for 77,352 new cases and 51,865 cancer deaths in 2020 [4].
Cancer patients are vulnerable to nutritional defciency as a result of the combined efects of the disease and its treatment [5]. Nutrition has a positive role in improving patients' overall health. On the other hand, malnutrition afects all aspects of a patient's life by increasing the risk of infection, delayed wound healing, increasing treatment toxicity, extending hospital stay, and increasing health-care costs [6].
Malnutrition is defned as an acute or chronic nutritional condition characterized by nutrient excess or defciency, energy imbalance, and infammatory activity that results in a change in body composition, impairment of function, and clinical outcome [6].
Cancer and its treatment have an impact on the nutritional status by altering the metabolic system, altered food taste, and reducing food intake [7]. It causes changes in physiological and psychological functions [7], which may have an impact on quality of life [7]. Indeed, acute and chronic symptoms associated with antineoplastic treatments frequently have a negative impact on the nutritional status of the patients [8][9][10].
Chemotherapy has a number of side efects, including nausea, vomiting, anorexia, diarrhea, and constipation, all of have an efect on the patient's life [6]. Patients are more likely to become malnourished in these circumstances, especially if chemotherapy treatment is given more often and for long periods [6,11].
Even though cancer and its treatment raise the risk of malnutrition, early assessment of nutritional status is crucial for early nutritional management and thus increasing the patient's survival [10]. Despite the high prevalence of malnutrition in cancer patients, only a few studies have examined the nutritional condition of adult cancer patients in Ethiopia, with all previous studies took place in Addis Ababa (the capital city of Ethiopia). Furthermore, there are key issues that afect cancer patients' nutritional health that have yet to be addressed, particularly in our country's setting, such as length of sickness [10], food security [12], anxiety [13,14], and depression [13,15].
Tis study aims to examine the nutritional status of adult cancer patients who are undergoing chemotherapy treatment at Hawassa University Comprehensive Specialized Hospital (HUCSH). As a result, this research will help researchers to better understand the incidence of malnutrition and the factors that contribute to it. It will also aid healthcare workers to emphasize the prevention of malnutrition. As a result, early detection and management of malnutrition will reduce mortality, morbidity, and length of stay in the hospital, improve healing, and reduce costs.

Study Area and Period.
Te study was conducted at the Cancer Treatment Center of HUCSH from January to May 2021. Hawassa University Comprehensive Specialized Hospital is one of the teaching and referral hospitals providing cancer treatment for the southern nation's nationalities peoples and Sidama National Regional State of Ethiopia and is under Hawassa University.
Hawassa University Comprehensive Specialized Hospital is located in Hawassa city which is 275 km far from Addis Ababa. Te oncology unit of the hospital provides diagnostic, surgical, and chemotherapy treatment services. Te Oncology Treatment Center contains a total of 12 beds for inpatient treatment, and the treatment was given in three days per week.

Study
Design. An institutional-based cross-sectional study design was conducted.

Inclusion and Exclusion Criteria. Inclusion Criteria
Patients were included in the study if they were 18 years or older, had no hospitalization in the month before the study (except for routine chemotherapy), and had received at least one cycle of chemotherapy treatment, regardless of the site of cancer.
(2) Life Style Factors. Tey are consumption of alcohol, cigarette smoking, and chat chewing.
(3) Clinical Information. It includes type of cancer, duration of illness, number of chemotherapy cycles, stage of cancer, performance status, comorbidities, anxiety, and depression.

Operational Defnition
(1) Subjective global assessment score of nutritional status: according to the sum score of points assigned to each item, patients were classifed as well nourished: <17 points, and malnourished (moderate and severe): ≥17 points [14]. (2) Performance status: this is the assessment of the level of function and ability of self-care using the World Health Organization Performance Status measuring scale ranging from 0 (fully active) to 4 (bedridden) [16]. (3) Food insecurity is a state that exists when people do not have adequate physical, social, or economic access to sufcient, safe, and nutritious food to meet their dietary needs for an active and healthy lifestyle [17]. (4) Te Household Food Insecurity Access Scale is a set of questions about food access that are used to distinguish food-secure from food-insecure households in various cultural contexts [18].

Sample Size Determination.
All adult cancer patients who visited the HUCSH Cancer Treatment Center for chemotherapy treatment during the data collection period were included consequently. Te sample size was calculated using a single population proportion formula with a 5% margin of error (d) and a 95% confdence interval (alpha � 0.05), and the proportion of malnutrition in cancer patients in Ethiopia at TASH was 27.5 percent (P � 0.275) [17].
where ni � initial sample size. Zα/2 � 1.96 (Z � score corresponds to 95% confdence level). P � proportion of afected quality of life of cancer patients. q � proportion of not affected quality of life of cancer patients. d2 � margin of error (0.05) Considering 10% of contingency for nonresponses, the fnal sample size will be 338.

Data Collection and Quality Control.
Tere were six parts to the data collection: initially, after evaluating the literature, the authors constructed questionnaires to collect socio-demographic data, and clinical information about the disorders and treatments was collected from the medical chart.
Second, a wealth index questionnaire consists of 21 questions that are used to measure housing conditions and household characteristics. Principal component analysis was used to compute and minimize the number of variables (PCA). Ten, using an Ethiopian demographic health survey, they were divided into fve quintiles [19].
To assess the patient's nutritional status, the patientgenerated subjective global assessment (PG-SGA) tool was used. Tis tool consists of a patient history emphasizing weight loss, gastrointestinal symptoms such as nausea and vomiting, and a physical examination emphasizing subcutaneous fat tissue loss and muscle wasting [20].
Fourth, the Household Food Insecurity Access Scale (HFIAS) was used to assess food insecurity in households.
It consists of nine questions about food insecurity, with response options of never, rarely, sometimes, or often. Te highest HFIAS score is 27, and the higher the score, the greater the food insecurity [15].
Fifth, the World Health Organization Performance Status (WHO-PS) questionnaire was used to assess the patient's performance status.
It is frequently used to assess how the condition afects the patient's ability to perform daily duties, which are graded on a scale of 0 (completely active) to 4 (bedridden), with a score of 0-1 indicating good status and 2-4 indicating poor status [16].
Sixth, the hospital anxiety and depression questionnaire was used to assess the patient's anxiety and depression levels. It is a valid and reliable questionnaire used to assess anxiety and depression in the general population [21]. Te HAD consists of 14 items divided into two subscales (anxiety and depression), each with seven items, and is scored on a fourpoint Likert scale ranging from 0 to 3, with 0 being the most pleasant response and 3 being the least pleasant. Each subscale's score is computed, and values of 11 or higher are considered to indicate depression or anxiety disorder. Scores of 7 or less indicate that the person should not be considered a case, while scores of 8 to 10 indicate that the fndings are questionable [21,22].

Data
Analysis. Data were entered into Epi Data 4.2 software, cleaned and coded, and then exported to SPSS version 25 for analysis (IBM SPSS, Chicago, IL, USA). SPSS Inc. was a software house headquartered in Chicago, USA. It is a foremost global manufacturer of software used in data analysis, data management, reporting, and modeling [23]. Categorical variables were expressed using descriptive statistics (frequency and percentages) and continuous variables using mean and standard deviation. Bivariable analyses were used to investigate the frst connection between each independent variable and the dependent variable. Ten, to account for cofounders and identify the predictors of nutritional status, those independent variables with a P value of less than 0.25 were entered into multivariable logistic regression. Te statistical signifcance was determined by a P value of less than 0.05, and the strength of the association was determined by an OR with a 95 percent confdence interval. Te Hosmer and Lemeshow goodness of ft test (P value � 0.223) was used to assess model ftness.

Determinants of Nutritional Status.
In this study, multiple factors were associated with nutritional status in adult cancer patients. Te bivariable logistic regression analysis shows that educational status, wealth index, food security, type of cancer, stage of cancer, the cycle of chemotherapy, the presence of comorbidities, anxiety, performance status, nausea, poor appetite, vomiting, and diarrhea were signifcantly correlated with nutritional status at P < 0.25 and entered into the multivariable analysis.
In the multivariable analysis, wealth index, food security, poor appetite, vomiting, diarrhea, and performance status had a signifcant association with nutritional status. Te multivariable analysis showed that adult cancer patients with vomiting were 80% less likely to have good nutritional status, AOR 0.2 (0.110-444).
Patients that have the lowest wealth index were 94% less likely to be well nourished AOR 0.06 (0.016-0.2) compared to patients with the highest wealth index. Patients with food insecurity were 90% less likely to be well nourished AOR 0.1 (0.05-0.24) than patients with secured food. Similarly, patients who have poor appetite are 80% less likely to be well nourished than patients without appetite loss with AOR 0.2 (0.11-0.44).

Discussion
Cancer patients are vulnerable to nutritional defciency as a result of the combined efects of the disease and its treatment. Nutritional defciency has an impact on all spheres of the patient's life by increasing the risk of infection, increasing treatment toxicity, delaying wound healing, prolonging hospital stay, and increasing health-related costs. In Ethiopia, nutritional assessment is not performed routinely on cancer patients. An institution-based cross-sectional study was aimed to assess the nutritional status and associated factors among adult cancer patients undergoing chemotherapy treatment at Hawassa University Comprehensive Specialized Hospital, Ethiopia, 2021. Tis study has shown that the overall prevalence of malnutrition among adult cancer patients receiving chemotherapy was 48.1%. Tis fnding was in line with studies done in Malaysia (43.5%) [24], Oman (40.21%) [25], and Ethiopia at Addis Ababa (47.1%) [26]. However, the fnding of this study was higher than the study done in New Zealand (32%) [26], Vietnaam (34.1%) [27], Iran (6%) [5], and Japan (19%) [28]. A high level of malnutrition in this study could be explained by low socioeconomic status, diferences in the assessment method used, less resourced health facilities, and lack of integration of dieticians in the treatment protocol of cancer [13,14].
Te nutritional status found in this study was associated with the economic conditions of the patients, patient with the lowest economic status was 94 times less likely to be well nurished than patients with the highest economic status, AOR 0.06 (0.02-0.2). Tis fnding was in line with studies in the USA, Vietnam, and Kenya [25,27,29]. Tis can be explained by patients with a good fnancial status that can access a diversifed nutritional diet and special supportive treatments that can promote the health status of the patient.
In this study, patients with insecure food were 90% less likely to be well nourished than patients with secured food with AOR 0.1 (0.05-0.24). Tis fnding was in line with studies in Iran, Malaysia, Saudi Arabia, and Kenya [6,12,23,30]. Tis can be explained by food insecurity in households leading to a change in dietary practices and lack of adequate food that can lead to poor nutritional status, so this can increase the burden of symptoms, the length of hospital stay, and poor prognosis [29].
Appetite loss and diarrhea are signifcantly associated with the nutritional status of adult cancer patients. Tis fnding was consistent with studies reported from Libya, [31] India, [32] and Korea [33]. Tis may be due to cancer therapy afecting the nutritional status of the patient through altering the metabolic system and changes in food tests, resulting in damage to normal tissues [33].
In this study, a signifcant association was found between performance statuses with the nutritional status of participants. Functional performance activity is a factor that deserves attention, considering that individuals with limited functional capacity have difculties in the preparation of food, and basic life care [16]. Te results of this study support this statement because it was observed that patients with poor functional status were 60% less likely to have normal nutritional status than mobile patients. Tis fnding was in line with other studies [5,14]. Poor functional status is a known factor unfavorably afecting the physical, psychological, and social health of the patients [16].  Te potential limitation of this study was that food insecurity is assessed based on a one-month recall of occurrence, and social desirability bias may increase or decrease. Some variables like dietary diversity, family size of the patients, and treatment adherences were not determined which could be considered as a limitation. Tis study address anxiety and depression in relation to nutritional status.

Conclussion
Te prevalence of malnutrition among adult cancer patients receiving chemotherapy treatment was high. Wealth index, food security, appetite loss, presence of diarrhea, and performance status were found to be signifcant factors for nutritional status. To improve the nutritional status of adult cancer patients, regular nutritional assessment, economic support, improving food security, managing chemotherapyinduced symptoms, such as appetite loss and diarrhea, nutritional education mainly on food preference, energy, and nutrient balance, nutritional intervention, and further longitudinal studies are needed to explore the impact of malnutrition on survival and quality of life in cancer patients.

Recommendation.
Governmental and nongovernmental organizations should provide support to cancer patients that have an economic problem to improve food security so that

Data Availability
Te datasets analyzed during the current study are available from the corresponding author upon reasonable request.

Ethical Approval
Ethical clearance and approval letters were obtained from the Ethical Clearance Committee of Bahir Dar University College of Medicine and the Health Science Ethical Review Committee to conduct the research with protocol No. 051/ 2021. A formal letter was submitted to the HUCSH Oncology Treatment Center.

Consent
Informed consent was obtained from the study participants after clearly introducing the purpose, benefts, and risks of the study. Confdentiality was secured by coding each questionnaire and not sharing personal information to the third party.

Conflicts of Interest
Te authors declare no conficts of interest for this study.

Authors' Contributions
Ahmed Nuru conceived the study, prepared the proposal, analyzed the data, interpreted the fndings, and wrote the manuscript. Berihun Bante and Endalik Getasew were involved in data analysis and reviewing of the manuscript. Sahlu Shiferaw and Dessie Temesgen participated in editing and revising subsequent drafts of the paper. All authors read and approved the fnal manuscript.