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Table of Contents
Year : 2021  |  Volume : 4  |  Issue : 2  |  Page : 170-174

Malnutrition in cancer patients receiving chemotherapy in a single oncology center

1 Department of Oncology, King Khaled University Hospital, Riyadh, Saudi Arabia
2 College of Medicine Research Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia

Date of Submission19-Aug-2020
Date of Decision20-Sep-2020
Date of Acceptance16-Nov-2020
Date of Web Publication13-Apr-2021

Correspondence Address:
Firas A Almomen
College of Medicine Research Center, College of Medicine, King Saud University, Riyadh
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jnsm.jnsm_99_20

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Background: Cancer patients face a high risk of developing malnutrition due to cancer itself and as an adverse effect of receiving chemotherapy rounds. Objectives: The aim of this study is to estimate the prevalence of malnourishment in cancer patients receiving chemotherapy in an oncology center in Riyadh, to identify the biometric characteristics that are associated with changes due to receiving chemotherapy, and to identify possible associated risk factors affecting nutritional status. Methodology: A cross-sectional study was conducted at an oncology center in Riyadh, Saudi Arabia, in 2018. The scored patient-generated subjective global assessment (PG-SGA), which is a global tool used to assess the nutritional status in cancer patients, was distributed among 126 patients, with 116 (92.1%) patients responding, and of which 110 (87.3%) were ultimately selected for participation. We assessed the associated risk factors of malnutrition, and inquired about cancer type, location, age, current residence, and social support. Past laboratory results (albumin, hemoglobin, mean corpuscular volume, and creatinine) were obtained from the patients' records. Results: Fifty-seven of the participants (51.8%) were malnourished according to the PG-SGA scoring system (Class B and C PG-SGA), and the other 53 participants (48.2%) were well-nourished (Class A PG-SGA). Out of the 57 malnourished patients, 39 (68.42%) were moderately malnourished (Class B PG-SGA), and 18 (31.58%) were severely malnourished (Class C PG-SGA). Conclusion: There is a statistically significant correlation between chemotherapy, cancer, and malnourishment. Intervention is required to improve the detection of the condition and increase both awareness and nutritional status of the affected patients.

Keywords: Cancer, chemotherapy, malnutrition, oncology, patient-generated subjective global assessment, Saudi Arabia

How to cite this article:
Alsaleh K, Almomen FA, Altaweel A, Barasain O, Alqoblan A, Binsalamah A, Almashham A. Malnutrition in cancer patients receiving chemotherapy in a single oncology center. J Nat Sci Med 2021;4:170-4

How to cite this URL:
Alsaleh K, Almomen FA, Altaweel A, Barasain O, Alqoblan A, Binsalamah A, Almashham A. Malnutrition in cancer patients receiving chemotherapy in a single oncology center. J Nat Sci Med [serial online] 2021 [cited 2021 Jun 13];4:170-4. Available from: https://www.jnsmonline.org/text.asp?2021/4/2/170/313653

  Introduction Top

Malnourishment is already a major health issue which is further complicated in cancer patients. A study which took place in South Korea assessed the nutritional status of 8895 cancer patients and found that approximately 61% of the participants suffered from some form of malnutrition.[1] Moreover, it is a well-known fact that chemotherapy has a negative impact on the nutritional status of cancer patients.[2] A Chinese study observed 310 Colon cancer patients who had received chemotherapy and found a general increase in the percentage of malnourished patients already at high risk of developing malnourishment (from 83.8% to 92.3%).[3] There are currently no known screening protocols to monitor nutritional status in patients undergoing chemotherapy in Saudi Arabia. Cancer is associated with weight loss and impaired nutritional status, in addition to biometric changes as a side effect of chemotherapy. This cascade of events has a documented effect on the morbidity and mortality of chemotherapy patients, and that makes research on the subject significant. Supporting this claim is a study conducted in Australia in 2014, whereof 1913 cancer patients, 26% had malnutrition. Malnourished patients had higher 30-day mortality (7.7%) and higher morbidity (18.2%) compared to well-nourished patients (1.3% and 10.1%, respectively).[4] Another study conducted in France showed that 39% of the study participants receiving chemotherapy were malnourished.[5]

There is no single cause for the decline in the nutritional status in chemotherapy recipients, for there are many factors which may predispose to, or directly cause decreased nutritional status. Risk factors include type and location of tumor, duration of hospital stay, immunodeficiency, and most importantly, the chemotherapy course itself. This information, coupled with knowledge about screening procedures in Saudi hospitals, serve as definitive evidence that current nutritional screening procedures in Saudi Arabia are insufficient since there is already an established relationship between malnutrition and increased morbidity/mortality in chemotherapy patients.

Therefore, the main objective of this study became to identify the prevalence of malnourishment and its associated factors in cancer patients receiving chemotherapy in an oncology center in Saudi Arabia. We hypothesized that the percentage of malnourished cancer patients would be higher than 25%. An approved nutritional assessment scoring system called the patient-generated subjective global assessment (PG-SGA) was used to determine the degree of malnourishment among patients, and a self-constructed questionnaire assessing sociodemographic status was used to determine any relevant associated factors.[6],[7] Specific laboratory test results were extracted from the patient medical records on e-SiHi Electronic Medical Record software. The outcome of this research is that with adequate screening and risk factor assessment, we may raise patient and clinical awareness of the problem and contribute to the ongoing effort of improving the nutritional status of cancer patients, ultimately enhancing the quality of care provided.

  Methodology Top

Study design and study population

A cross-sectional study design was chosen as the main aim of the study was to estimate the prevalence of malnutrition among cancer patients receiving chemotherapy. The study was conducted over a period of 3 weeks in 2018 on cancer patients receiving chemotherapy in the oncology center in Riyadh, Saudi Arabia. A questionnaire was distributed among 126 participants after obtaining their informed consent. Selected participants were both males and females of different age groups (under 18/18–49/50 and above).

Sample size and sampling

A sample size of 126 was calculated using the single proportion equation (n = Z2αP(1 − P)/d2 (Z = 1.81, P = 0.25, d = 0.07)] with a selected confidence interval of 93% ± 1.81%.

Convenience sampling technique was used.

Study subject: Selection, definitions

Subjects were selected after receiving their informed consent. They were selected based on receiving chemotherapy, to estimate their degree of malnourishment, identify biometric characteristics as well as possible associated factors. Receiving chemotherapy at the time of the study was the inclusion criteria. A Zubrod performance status score >2.0 (patient is ambulatory <50% of the day) was the exclusion criteria.

Study questionnaires and formats

Nutritional status and malnutrition risk factors were assessed using the PG-SGA nutritional scoring system. This scoring system has two sections. The first section classifies the nutritional status of the patient into three classes, Class A (well-nourished), Class B (moderately malnourished), and Class C (severely malnourished). Class B is the nutritional triage of recommendations, which has four categories: No intervention needed (score ranging from 0 to 1), education by a dietitian (score ranging from 2 to 3), intervention by a dietitian is required (score ranging from 4 to 8), and intervention and symptom management required (score equal to 9 or above). In addition, a self-constructed questionnaire was used to identify the patient's demographic characteristics and socioeconomic status to recognize any associated factors with malnutrition.

Data collection methods

A consent form, the PG-SGA nutritional status scoring form, and a socioeconomic and demographic questionnaire were distributed for each patient, after which laboratory test results were obtained from the e-SiHi system. PG-SGA scores were calculated, and PG-SGA classes were determined for each patient, then the PG-SGA scores and classes, demographic and socioeconomic information and laboratory tests were organized into excel sheets along with the date of submission. Afterward the participants' identities and provided biometric measurements were confirmed for accuracy using the e-SiHi system.

We collected the following biochemical laboratory measurements: Mean corpuscular volume, erythrocyte sedimentation rate, serum creatinine (SCr), hemoglobin (Hgb), and albumin. Other information collected was participants' tumor location, subtype, and any steroid use.

Ethical considerations

The hospital's Institutional Review Board (IRB) has approved our study and signed an IRB form to enable us to conduct the study was obtained from the was received from the ethical participation in the study required informed consent, and as such consent forms detailing the study, nature were distributed alongside the data collection forms. Patients' confidentiality was maintained by omitting any identifying personal information from the data collection forms.

Data management and statistical analysis

Data were then entered and analyzed using SPSS version 22.0 (Armonk, NY, USA: IBM Corp). Statistics 21 software. Participants' PG-SGA score and class, age, sex, tumor subtype and location, social support, financial status, and residence (Riyadh/Other, Urban/Rural) were recorded.


A pilot study was conducted at an oncology center in Riyadh, Saudi Arabia. Ten participants were included in the pilot study. Ten surveys, which included PG-SGA nutritional status assessment forms, as well as socioeconomic and demographic questions, were distributed to the participants, with all ten participants responding. Afterward, specific laboratory test results, measurements, and cancer locations were collected from the e-SiHi system. All participants meeting inclusion and lacking exclusion criteria were included. Afterward, over the course of 3 weeks, investigators distributed the questionnaires and collected the data from the e-SiHi system, after which nutritional score was calculated using the PG-SGA scoring system, and PG-SGA class served as a recommendation guideline for intervention. Participants with missing critical data were excluded from the study, and data were checked after the conclusion of the collection process to eliminate redundant entries.

  Results Top

One-hundred and twenty-six questionnaires were distributed in this study, with 116 patients agreeing to participate, arriving at a response rate of 92.1%. Six participants were later excluded from the study due to meeting exclusion criteria, bringing the final sample size down to 110 (87.3%). Following the retrieval of the participant's collection forms, laboratory results were collected from the participant's medical records with their consent. 53 (48.2%) male and 57 (51.8%) female participants were divided into three age groups: Under 18 years, 23 participants (20.9%), 18–49 years old, 27 participants (24.5%), 50 and above, 60 participants (54.5%). The PG-SGA scoring system categorizes patient nutritional status into three categories: A (well-nourished), B (moderately malnourished), and C (severely malnourished). Assessment of PG-SGA scores revealed that 57 (51.9%) were malnourished in some capacity, with 18 (16.4%) of all participants showing suggesting severe malnourishment [Table 1].
Table 1: Prevalence of Malnutrition

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Body mass index (BMI) measurements showed that 26 participants (23.6%) had normal BMI (18.5–24.9), and of those participants, 15 (57.7%) were malnourished. Sixty-six participants (60%) had a BMI over 24.9 (overweight/obese), and 30 (45.5%) of those participants were malnourished. Eighteen participants (16.4%) had a BMI <18.5 (underweight), and of those participants, 12 (66.6%) were malnourished. Sociodemographic information was provided by participants through the constructed questionnaire [Table 2]. Inquiry about family income revealed that of all participants with a monthly family income of <5000 SR (1333.3$), 63.2% were malnourished. In comparison to 56.7% and 27.6% of participants with incomes 5000–1000 SR and more than 10,000 SR, respectively. Fourteen participants refused to provide information regarding their income. Ninety-three participants (86.9%) reported having a caretaker at home, and of those participants 48 (50.5%) were malnourished.
Table 2: Sociodemographic Characteristics

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Participant cancer type and location were obtained through the e-SiHi system. Cancer subtypes/locations were later categorized into four major categories: breast, colon, leukemia/lymphoma, and other. “Other” refers to cancers which individually occurred no more than three times in the sample, and as such were grouped with other similarly occurring cancers. The analysis showed the most frequent cancer type was lymphoma/leukemia at 29 participants (26.6%), and of those participants, 16 (55.2%) were malnourished. One participant had an unclear origin of their primary tumor location.

As for laboratory results, two metrics were marginally lower in the case of malnourished participants: sCr and Hgb. Reference ranges for sCr and Hgb are 0.6–1.2 mg/dL (0.5-1.1 mg/dL in females) for sCr and 13.5–17.5 g/dL (12–15.5 g/dL for females) for Hgb. Participants were again divided into three categories according to the results of their SCr or Hgb: Normal, low, or high. It was found that of the 42 participants (39.6%) who had low sCr, 24 (57.1% of 42) were malnourished. In contrast, of the 64 participants (60.4%) who had normal or high sCr, 31 (56.4% of 64) were malnourished. As for Hgb, 78 (72.9%) participants had low Hgb, according to their most recent laboratory results (usually on the day of recruitment). Of those participants, 55.1% were malnourished. This is in comparison to 44.8% malnourished participants with normal Hgb. Three participants had outdated results for their lab measurements and as such their results were not included in this segment of the analysis process.

Statistical analysis by ANOVA revealed statistical significance between primary cancer origin and PG-SGA score (P < 0.037), as well as between PG-SGA score and reported family income (P < 0.017) where P < 0.07 is considered significant [Table 3].
Table 3: Associations with PG-SGA

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  Discussion Top

There is a high prevalence rate of malnutrition (51.8%) among sampled chemotherapy recipients at the oncology center, which confirms our first hypothesis. Most participants were aged 50 and above, which is in line with expectations from cited studies and is representative of the general cancer population in the oncology center. Gender bias was not observed to affect nutritional status, with results being split down the middle with regard to gender distribution. BMI was not a reliable measure of nutritional status, as most participants were within normal BMI ranges and some were overweight, which rejects our second hypothesis. During the analysis of sociodemographic variables, family income was especially notable. Participants with a family income of <5000 SAR were 2.33 more likely (P < 0.0475) to be malnourished in comparison to other groups. Consultation of the nutritional triage scoring system suggests that participants with a triage score of more than 4 (100, 90.9% of all participants) would benefit from intervention guided by a dietitian.[8] Intervention would be for the purposes of managing chemotherapy-induced side effects and/or nutritional intervention. Participants with triage scores of 2 or 3 (8, 7.2% of all participants) only needed educational counseling. Participants with triage scores of 0 or 1 did not require any intervention.

Our study shows a comparable prevalence rate of malnutrition among our study sample, in line with similar studies in the past.[9],[10]

With regard to cancer location, lymphoma/leukemia was the cancer subtype with the highest in-category prevalence rate (26.6%), which differs from other studies conducted in other regions of the world.[11],[12]

The clinical relevance of these results lies in the implication that there is a valid need to implement appropriate screening tools, other than routine body weight, height, and BMI measurement, for the detection of malnourishment in cancer patients, especially those receiving chemotherapy. This should be done to accurately assess and monitor nutritional status among these at-risk patients and offer intervention if needed.

The main limitations of this study were the small sample size of 110 participants after exclusion. This was partly due to a limited data collection period of 1 month and the inconsistent nature of the sampling technique. Chemotherapy cycles were repeated during the final week of data collection, resulting in a few redundant entries and effectively restricting the collection period to 3 weeks. Another limitation was missing data in the patient medical records, which resulted in the gaps in some participants' results during data analysis. If follow-up studies are conducted, the inclusion of multiple cancer clinics citywide or nationwide and extended data collection period, along with better documentation of patient information, could help overcome some of the limitations faced in this study.


The limitations include incomplete patient medical records, a small sample size selected from one hospital cancer clinic, so an extension of the study to include other cancer clinics in Riyadh or other provinces in Saudi Arabia is highly recommended. In addition, the PG-SGA criteria should be modified to accurately assess the nutritional status of pediatric patients, as it fails to appreciate pediatric physiological differences in its current form.

  Conclusion Top

Malnutrition is a general problem and can affect anyone, but physicians must be diligent in detecting and monitoring nutritional deficiencies in at-risk participants such as cancer participants receiving chemotherapy. These patients are more susceptible, and their altered nutritional status may significantly affect their morbidity and mortality if left unresolved. Even if the malnourishment is not so severe as to associate with mortality, it can still impact continued response to therapy as well as patients physical and psychological well-being.


Approximately half the participants in the study were found to be malnourished. As such there is a need for more effective screening and reporting protocols. Awareness should also be raised in clinical settings in order to promptly detect cases of malnourishment. An interventional clinical trial should be considered, as to qualitatively asses the differences in mortality and response to therapy between chemotherapy patients who receive dietary intervention versus those who only receive nutritional counseling.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Wie GA, Cho YA, Kim SY, Kim SM, Bae JM, Joung H. Prevalence and risk factors of malnutrition among cancer patients according to tumor location and stage in the National Cancer Center in Korea. Nutrition 2010;26:263-8. doi: 10.1016/j.nut.2009.04.013.  Back to cited text no. 1
Custódio ID, Marinho Eda C, Gontijo CA, Pereira TS, Paiva CE, Maia YC. Impact of chemotherapy on diet and nutritional status of women with breast cancer: A prospective study. PLoS One 2016;11:e0157113. doi.org/10.1371/journal.pone.0157113.  Back to cited text no. 2
Fu K, Pan H. “Nutritional status and risk factors for malnutrition in CRC patients undergoing neoadjuvant therapy.” Biomedical Research 2017;28:2017.  Back to cited text no. 3
Loeliger J, Kiss N. Phase II Malnutrition in Victorian Cancer Services: Summary Report. Department of Health and Human Services, State Government of Victoria, Melbourne; 2015.  Back to cited text no. 4
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  [Table 1], [Table 2], [Table 3]


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