The National Ribat University
Faculty of Graduate Studies and Scientific Research
Dietary Adequacy and Patient Meal Satisfaction in
Liver Cirrhosis Patients, in Ibn-sina Hospital,
Khartoum.
A thesis submitted in partial fulfillment for the Requirements of M.
Sc. In Human Nutrition and Dietetics
By: Nafisa Abdurahman Mohammed Zain Ahmed
Supervisor: Dr. Nadia Abdalrahiam khogaly
December 2015
اآلية
قال تعالى
الذين ضل سعيهم (301قل هل ننبئكم باألخسرين أعماال ) )
نيا وهم يحسبون أنهم يحسنون صنعا )في ( 301الحياة الد
الذين كفروا بآيات ربهم ولقائه فحبطت أعمالهم فال أولئك
( ذلك جزاؤهم جهنم بما 301نقيم لهم يوم القيامة وزنا )
((301كفروا واتخذوا آياتي ورسلي هزوا )
صدق هللا العظيم
الكهف سورة 301-301اآليات
3
Dedication
It is a source of pride and pleasure for me to dedicate the
outcome of my continuous hard work to
My Lovely parents
Who taught me the meaning of forgiveness…and to
be there when one needs us …
I wish them health, happiness and peace
Beloved my sister and brothers
To my husband
My lovely teacher Uz.Safa Almusharf
My lovely friend Rania
All those helped and supported me.
Nafisa
I
Acknowledgements
My gratitude first and last goes to Allah for accompanying and
supporting me throughout this research.
There is no single word that is enough to express my appreciation and
gratefulness to my supervisor Dr. Nadia Abdalrahiam khogaly for the
continuous support of my study and research, for her patience,
motivation, enthusiasm, and immense knowledge. Her guidance helped
me at all the time of research and writing of this thesis. I could not have
imagined having a better advisor and mentor for my thesis. My sincere thanks also go to the staff of IBN-SINA Hospital in
Khartoum State, for offering me the opportunity to collect the required
data for my thesis. Last but not the least; I would like to thank my
family: my parents, husband, brothers and sisters, for supporting me
spiritually throughout my life.
II
Abstract Objectives: This study aimed to determine the dietary management of liver
cirrhosis patient in IBN-SINA hospital. Methods: Descriptive, cross – sectional Hospital based study, conducted in IBN-
SINA hospital during the period from September to November 2015. Thirty
patients were case –findings as sampling technique from medical wards. Primary
data was obtained using questionnaire. Weights and heights were measured to
calculate the BMI. The food intake data were collected by 24 hour record method.
Hb, albumin, ALP, ALT and AST were taken from patients' files. Data were
analyzed using statistical packages for sciences (SPSS) version 20, significant
considered at P. value less than (0.05). Results: Males were 20(66.7%), females 10(33.3%). Seven (23.3%) of the patients
received dietary advises in the hospital. Most of the patients in this study regarded
the food services provided to them in the hospital as good in terms of taste and
flavor, variety, temperature, and portion size, cleanness and quality of food
services. The majority of the patients 19(63.3%) consumed hospital diet and
11(36.7%) consumed liquid diet. The majority of patients 21(70%) agreed that the
hospital food quality is better than other states hospitals. Underweight BMI (< 18.5)
was reported in 18(60%) of the patients and normal BMI (18.5 – 24.9) was reported
in 12(40%) of the patients. Significant differences were found between the four age
groups (P < 0.05). Significant differences in the values of BMI, ALP and AST were
found between males and females (P < 0.05) and no significant differences between
the two groups in Hb, albumin and ALT values (P > 0.05). There were no
significant differences between males and females in 24 hour recall of total energy,
carbohydrate, protein and fat intake (P > 0.05) (both males and female intake fall
with limits of intake lower than recommended). Conclusion: Patients satisfaction towards meal services in the hospital was found
to be relatively good; in addition dietary change caused improvement in health for
most of the patients. Patients should be advised to increase their intake of energy,
protein, carbohydrate and fat to recommended levels suitable for liver cirrhosis.
III
ة البحثخالص
لمرضى تليف الكبد في الرضاء في الخدمات هدفت هذه الدراسة الى تحديداألهداف:
مستشفى ابن سينا.
وهي دراسة وصفية عبر دراسة مقطعية في مستشفى ابن سينا ، والتي اجريت :األساليب
. وقد كانوا ثالثين 5102في نفس المستشفى خالل الفتره من سبتمبر الى نوفمبر عام
مريضا أخذت من عنابر المستشفى . وتم الحصول على البيانات األولية بإستخدام اإلستبيان
( وقد تم جمع IMB) ساب مؤشر كتلة الجسم . وكذالك تم أخذ الوزن والطول لح
(52الطعام )الوجبات( التي يتناولها المرضى خالل معدل التناول الغذائى اليومى )
أخذت من Pia,PLa,PLA,TLH,TSA(، bHى. اما بالنسبة للهيموقلوبين )للمرض
علوم والتي تعرف ب ) ملفات المرضى .وتم تحليل البيانات بإستخدام الحزمة األحصائيه لل
iAii )
( من %5363)6(. و%3363) 01( و اإلناث %66..) 51كانت نسبة الذكورالنتائج :
المرضى تلقوا ارشادات غذائية في المستشفى. معظم المرضى في هذه الدراسة اعتبروا
الخدمات الغذائية المقدمة لهم في المستشفى بأنها جيدة من حيث الطعم والنكهة ودرجة
( يتناولون %363.)01العظمى من المرضى الحرارة والنظافة وجودة الخدمات. الغالبية
( بان جودة الغذاء المقدم %61)50عن طريق تعديل النظام الغذائى .ووافقت غالبيه الرضى
لهم من قبل المستشفى، هو افضل مقارنه بمستشفيات اخرى .ونقص الوزن لمؤشر كتله
الجسم
(IMB لوحظ او اظهر عن اقل من )وأفادة التقارير (من المرضى .% 1.) .0فى 0.62
( من المرضى ووجدت %21) 05( في 5261 – 0.62الطبيعي كان ) IMBبأن
) جموعات الألربعه المذكورة اعالهفروقات ذات دالئل احصائية بين الم
1612>Aروق ذات دالالت احصائية في كل من(.وتم العثور على ف IMB وPLA
( ولم توجد فروق ذات دالالت احصائية بين A<1612واإلناث )بين الذكور Piaو
كانت PLa( وقيمة الPLH,TSA(و الزالل )bHالمجموعتين في الهيموقلوبين )
(1612<A وام يكن هناك فرق كبير بين الذكور و اإلناث خالل معدل التناول الغذائى . )
(.) لوحظ في A>1612ات والدهون )لكل من الطاقة والكربوهيرات والبروتين (52اليومى )
كل من الذكور واإلناث انخفاض كمية الوجبات التي تم تناولها اقل من الموصى بها.(
وجد رضا المرضى نحو خدمات الوجبات الغذائية في المستشفى ان تكون جيدة الخاتمة :
معظم نسبيا ، باإلضافة الى ذالك تسبب تغير النظام الغذائي تحسين الصحة بالنسبة ل
للطاقة والكربوهيدرات والبروتينات ’المرضى. ينبغي ارشاد المرضى الى زيادة تناولهم لل
.الى المستويات المطلوبة أو الموصى بها لتليف الكبد
IV
Table of Contents
Content Page
Dedication I
Acknowledgements II
Abstract III
IV خالصه البحث
Table of Contents V
List of Tables VII
List of Figures IX
List of Abbreviations X
Chapter One
1. Introduction
1.1 Introduction 1
1.2 Statement 0f problem 1
1.3 Justification 2
1.4 Objectives 2
Chapter Two
2. Literature Review
2.1 The liver 3
2.2 Liver cirrhosis 4
2.3 Complications of liver cirrhosis 7
2.4 Treatment of liver cirrhosis 10
2.5 Nutritional support 10
2.6 Nutrition of liver cirrhosis patients 11
2.7 Nutritional assessment of patients with liver cirrhosis 12
2.8 Dietary modification in patients with liver cirrhosis 13
2.9 Medical management 15
2.10 Meal satisfaction 15
V
2.11 Previous studies 16
Chapter Three
3. Subjects and Methods
3.1 Type of research 18
3.2 Study area 18
3.3 Sample population 18
3.4 Study Sample and method of selection 18
3.5 Data collection 18
3.6 Data analysis 19
Chapter Four
4. Results 20
Chapter Five
5. Discussion 38
Chapter Six
6. Conclusion and Recommendations
6.1 Conclusion 41
6.2 Recommendations 42
References 43
Appendix 1
Appendix 2
VI
List of Tables
No Table Page
1 General information of patients 20
2 Distribution of patients according to other chronic diseases 21
3 Distribution of the patients according to presenting 21
symptoms of liver cirrhosis
4 Distribution of the patients according to number of meal per 22
Day
5
Distribution of the patients according to type food cooking at
home 22
6 Distribution of the patients according to reception of dietary 23
Advices
7 Distribution of the patients according to drinking of alcohol 23
8 Distribution of the patients according to smoking 24
9 Distribution of the patients according to eating served meals 24
10 Distribution of the patients according to satisfaction towards 25
meal services provided in the hospital
11 Distribution of the patients according to consumption of 26
hospital diet
12 Distribution of the patients according to meeting his/her 26
Cultural food preferences by the hospital
13 Distribution of the patients according to frequency of visits 26
by dietitian in the hospital
VII
14 Distribution of the patients according to their opinions 27
towards the quality of food services compared to other t
States Hospitals
15 Distribution of the patients according to improvement in 27
health due to change in diet
16 Distribution of the patients according to BMI and nutritional 28
Status
17 Differences between males and females in BMI and 29
nutritional status
18 Differences in nutritional status and BMI according to age 31
19 Differences of mean values in BMI, HB, albumin and liver 33
enzyme according to gender of the patients
20 Differences of mean values of 24 hour intake according to 34
gender patients
21 Differences in mean values in BMI and HB according to age 35
of the patient
22 Differences in mean values in albumin and liver enzyme 36
according to age of the patient
23 Differences in mean values in of 24 hour intake of patients 37
according to age of the patient
VIII
List of Figures
No Figure Page
1 Differences between males and females in BMI 29
2 Differences between males and females in nutritional status 30
3 Differences in BMI of the patients according to age group 31
4 Differences in nutritional status of the patients according to 32
age group
IX
List of Abbreviations
ALD: Alcoholic Liver Disease
ALP: Alkaline Phosphatase
ALT: Alanine Aminotransferase
AST: Aspartate Aminotransferase
BMI: Body Mass Index
DNA: Deoxyribonucleic Acid
EIA: Enzyme Immunoassay
HFE: Human Hemochromatosis Protein (High Iron Fe)
HIV: Human Immunovirus
IBD: Inflammatory Bowel Disease
IR: Insulin Resistance
IU: International Unit
MAMA: Mid arm muscle area
NAFLD: Non –alcoholic fatty liver disease NCTs: Number
Connection tests
n-3 PUFAs: Omega-3 Polyunsaturated Fatty Acids
NASH: Non-Alcoholic Steatohepatitis
PCM: Protein-Calorie Malnutrition
PPAR: Peroxisome Proliferator-Activated Receptor
QUOTE: Quality of Care Through the Patient's Eyes
RNA: Ribonucleic Acid
SPSS: Statistical Packages for social Sciences
TIPS: Transjugular Intrahepatic Portosystemic Shunting
TSF: Triceps Skin Fold Thickness
NCTs: number connection tests
Chapter One
Introduction
1
Chapter One
1. Introduction
1.1 Introduction
The liver weighs about 3 pounds and is the largest solid organ in the
body. It performs many important functions, such as: manufacturing
blood proteins that aid in clotting, oxygen transport, and immune
system function; storing excess nutrients and returning some of the
nutrients to the bloodstream; manufacturing bile, a substance needed to
help digest fats; helping the body store sugar (glucose) in the form of
glycogen; ridding the body of harmful substances in the bloodstream,
including drugs and alcohol; and breaking down saturated fat and
producing cholesterol (WebMD, 2015).
Cirrhosis is a slowly progressing disease in which healthy liver tissue is
replaced with scar tissue, eventually preventing the liver from
functioning properly. The scar tissue blocks the flow of blood through
the liver and slows the processing of nutrients, hormones, drugs, and
naturally produced toxins. It also slows the production of proteins and
other substances made by the liver (WebMD, 2015).
1.2 Statement 0f problem
In the private clinic of the physician, name Abdelrahaman AL sheikh
(1/1/2014 to 30/8/2014) have seen 24 patients liver cirrhosis and the
most common causes of liver cirrhosis were: Hepatitis C, alcohol abuse,
and parasitic (Schistosomosis) personal communication.
2
1.3 Justification
Statistics of IBN-SINA (2014) showed that in the year 2014 the
total patient with liver cirrhosis was 189 with 61 deaths .On the
other hand statistics in same hospital (2013) reported that the
total number of patients with liver cirrhosis was155 with 45
deaths .
This research focuses on the dietary management at IBN-SINA
hospital for patients with liver cirrhosis.
1.4 Objectives:
1.4.1 General objectives:
To assess the dietary management of liver cirrhosis patient in
IBN-SINA hospital.
1.4.2 Specific objectives:
To assess nutrition status, biochemical data.
To assess patient meal satisfaction.
To evaluate their dietary intake, using 24-hr recall.
To design educational pamphlets from local or staple diets.
Chapter Two
Literature Review
3
Chapter Two
2. Literature Review
2.1 The liver
The liver is a vital organ of vertebrates and some other animals. In
the human it is located in the upper right quadrant of the abdomen, below
the diaphragm. The liver has a wide range of functions,
including detoxification of various metabolites, protein synthesis, and the
production of biochemical, necessary for digestion. The liver is
a gland and plays a major role in metabolism with numerous functions in
the human body. Estimates regarding the organ's total number of functions
vary, but textbooks generally cite it being around 500 (Abdel-Misih and
Bloomston, 2010).
Diseases that interfere with liver function will lead to derangement
of these processes. However, the liver has a great capacity
to regenerate and has a large reserve capacity. In most cases, the liver
only produces symptoms after extensive damage.
Hepatomegaly refers to an enlarged liver and can be due to many
causes. It can be palpated in a liver span measurement. Liver
diseases may be diagnosed by liver function tests–blood tests that can
identify various markers. For example, acute-phase reactants are
produced by the liver in response to injury or inflammation
(Hirschfield and Gershwin, 2013).
Primary biliary cirrhosis is an autoimmune disease of the liver. It is
marked by slow progressive destruction of the small bile ducts of the
liver, with the intralobular ducts (Canals of Hering) affected early in
the disease. When these ducts are damaged, bile and other toxins
build up in the liver (cholestasis) and over time damages the liver
tissue in combination with ongoing immune related damage.
4
This can lead to scarring (fibrosis) and cirrhosis. (Rajani, et al.
2009).
2.2 Liver cirrhosis
Cirrhosis is a chronic disease of the liver in which diffuse destruction and
regeneration of hepatic parenchymal cells has occurred, in which diffuse
increase in connective tissue has resulted in disorganization of the lobular
architecture. The triad of parenchymal necrosis, regeneration and scarring
is always present regardless of individual clinical manifestations. In the
evolution of many chronic liver diseases cirrhosis is a stage that is
considered to be irreversible. Cirrhosis can be stabilized by controlling the
primary disease but its presence implies consequences such as portal
hypertension, intrahepatic shunting of blood, impaired parenchymal
function affecting protein synthesis, hormone metabolism and excretion of
bile. The most common complications are: gastrointestinal hemorrhage,
ascites, encephalopathy, bacterial infections, renal failure, hepatocellular
carcinoma and hepatic failure. Certain reversible components of cirrhosis
have been indicated where significant histological improvement have
occurred with regression of cirrhosis but complete resolution with a return
to normal architecture seems unlikely. The underlying immunological
response has usually been acting for months or years where inflammation
and tissue repairing are in progress simultaneously which leads in the end
to fibrosis and cirrhosis (Iredale and Guha, 2007). 2.2.1 Causes of liver cirrhosis
It has many possible causes; sometimes more than one cause is present in
the same person. Globally, 57% of cirrhosis is attributable to either hepatitis
B (30%) or hepatitis C (27%). Alcohol consumption is another important
cause, accounting for about 20% of the cases (Perz, et al. 2006).
5
Alcoholic liver disease (ALD). Alcoholic cirrhosis develops for 10–
20% of individuals who drink heavily for a decade or more. Alcohol
seems to injure the liverby blocking the normal metabolism of protein,
fats, and carbohydrates. This injury happens through the formation of
acetaldehyde from alcohol which itself is reactive, but also leads to the
accumulation of products in the liver. Patients may also have concurrent
alcoholic hepatitis with fever, hepatomegaly, jaundice, and anorexia.
AST and ALT are both elevated but less than 300 IU/ liter with an AST:
ALT ratio > 2.0, a value rarely seen in other liver diseases. In the United
States, 2/5 of cirrhosis related deaths are due to alcohol (Dan, 2012).
Non-alcoholic steatohepatitis (NASH). In NASH, fat builds up in the
liver and eventually causes scar tissue. This type of hepatitis appears to
be associated with obesity (40% of NASH patients) diabetes, protein
malnutrition, coronary artery disease, and treatment with corticosteroid
medications. This disorder is similar to that of alcoholic liver disease but
patient does not have an alcohol history. Biopsy is needed for diagnosis
(Friedman, 2014).
Chronic hepatitis C. Infection with the hepatitis C virus causes
inflammation of the liver and a variable grade of damage to the organ.
Over several decades this inflammation and grade change can lead to
cirrhosis. Among patients with chronic hepatitis C 20-30% will develop
cirrhosis. Cirrhosis caused by hepatitis C and alcoholic liver disease are
the most common reasons for liver transplant. (Friedman, 2014).
Chronic hepatitis B. The hepatitis B virus causes liver inflammation and
injury that over several decades can lead to cirrhosis. Hepatitis D is
dependent on the presence of hepatitis B and accelerates cirrhosis in co-
infection. Chronic hepatitis B can be diagnosed with detection of
HBsAG > 6 months after initial infection. HBeAG and HBV DNA are
determined to assess whether patient needs antiviral therapy (Dan,
6
2012).
Primary biliary cirrhosis. Damage of the bile ducts leading to secondary
liver damage. May be asymptomatic or complain of fatigue, pruritus,
and non-jaundice skin hyperpigmentation with hepatomegaly. There is
prominent alkaline phosphatase elevation as well as elevations in
cholesterol and bilirubin. Gold standard diagnosis is antimitochondrial
antibodies (positive in 90% of PBC patients). Liver biopsy if done
shows bile duct lesions. It is more common in women (Dan, 2012).
Autoimmune hepatitis. This disease is caused by the immunologic
damage to the liver causing inflammation and eventually scarring and
cirrhosis. Findings include elevations in serum globulins, especially
gamma globulins. Therapy with prednisone and/or azathioprine is
beneficial. Cirrhosis due to autoimmune hepatitis still has 10-year
survival of 80+ % (Dan, 2012). Hereditary hemochromatosis. Usually presents with family history of
cirrhosis, skin hyperpigmentation, diabetes mellitus, pseudogout, and/or
cardiomyopathy, all due to signs of iron overload. Labs show
fasting transferrin saturation of > 60% and ferritin >
300 ng/ml. Treatment is with phlebotomy to lower total body iron
levels (Dan, 2012).
Infection by a parasite common in developing countries
(schistosomiasis). Over a period of three years 410in-patients
harbouring Schistosoma mansoni were under the authors’ care in a
hospital in the Sudan. All had been infected for some times. The ratio of
males to females was 10:1; this was largely owing to the reluctance of
the women to enter hospital. Many of the patients were found only by
chance to be infected. In those with clinical manifestations of the disease
a dysenteric diarrhea with abdominal discomfort, anorexia and lack of
7
energy were the usual complains. Liver enlargement, in the Aljazeera
Hospital, is usually due to Schistosomiasis mansion infection and but
rarely to other causes. The cirrhotic changes in the liver may be due
either to the Schistosomiasis or to malnutrition, but the standard of
nutrition in the area is good.
2.2.2 Clinical features of liver cirrhosis
Fatigue and malaise are common in all forms of cirrhosis, but these
nonspecific symptoms are found in almost all acute and chronic liver
diseases. Characteristic but nondiagnostic physical findings of cirrhosis
include palmar erythema and spider nevi. Other typical findings include
gynecomastia, testicular atrophy, and evidence of portal hypertension
(splenomegaly, ascites, and prominence of the veins of the abdominal wall).
Other physical abnormalities, such as Dupuytren contracture, xanthelasma,
xanthomas, Kayser-Fleischer rings, a bronze discoloration of the skin, and
hyperpigmentation, are found in specific forms of cirrhosis. The cirrhotic
liver is usually large, and the left lobe is often palpable below the xiphoid
process. Only a patient in the advanced inactive stage of disease exhibits a
small and shrunken liver (Colledge, et al. 2010). 2.3 Complications of liver cirrhosis
2.3.1 Ascites
Ascites: ascites usually occurs when the liver stops working properly .fluid
fills the space between the lining of the abdomen and the organs. Ascites is
most often caused by liver scarring .this increases pressure inside the liver
blood vessels .the increased pressure can force fluid into the abdominal
cavity, causing ascites .liver damage is the single biggest risk factor for
ascites .some causes of liver damage include : cirrhosis, hepatitis B or C
and history of alcohol use .
Other conditions that may increase your risk of ascites include:
8
Ovarian,pancreatic,liver,or endometrial cancer
Heart or kidney failure
Pancreatitis
Tuberculosis
Hypothyroidism
Salt restriction is often necessary, as cirrhosis leads to accumulation of salt
(sodium retention). Traditionally, three fourths of spontaneous bacterial
peritonitis infections have been caused by aerobic gram-negative organisms
(50% of these being Escherichia coli). The remainder has been due to
aerobic gram-positive organisms (19% streptococcal species). Diuretics
may be necessary to suppress ascites. Diuretic options for inpatient
treatment include aldosterone antagonists (spironolactone) and loop
diuretics. Aldosterone antagonists are preferred for people who can take
oral medications and are not in need of an urgent volume reduction. Loop
diuretics can be added as additional therapy (Moore and Aithal, 2006). If a rapid reduction of volume is required, paracentesis is the preferred
option. This procedure requires the insertion of a plastic tube into the
peritoneal cavity. Human albumin solution is usually given to prevent
complications from the rapid reduction. In addition to being more rapid
than diuretics, 4–5 liters of paracentesis is more successful in comparison to
diuretic therapy (Moore and Aithal, 2006). 2.3.2 Esophageal variceal bleeding
Esophageal varices sometimes form when blood flow to your liver is
obstructed; most often by scar tissue in the liver caused by liver disease.
The blood flow to your liver begins to back up, increasing pressure within
the large vein (portal vein) that carries blood to your liver.
This pressure (portal hypertension) forces the blood to seek alternate
pathways through smaller veins, such as those in the lowest part of the
esophagus. These thin –walled veins balloon with the added blood.
Sometimes the veins can rupture and bleed.
9
Causes of esophageal varices include:
Severe liver scarring (cirrhosis)
Blood clot (thrombosis)
A parasitic infection
For portal hypertension, propranolol is a commonly used agent to lower
blood pressure over the portal system. In severe complications from portal
hypertension, transjugular intrahepatic portosystemic shunting (TIPS) is
occasionally indicated to relieve pressure on the portal vein. As this
shunting can worsen encephalopathy, it is reserved for those patients at low
risk of encephalopathy. TIPS is generally regarded only as a bridge to liver
transplantation or as a palliative measure (Moore and Aithal, 2006). 2.3.3 Hepatic encephalopathy
High-protein food increases the nitrogen balance, and would theoretically
increase encephalopathy; in the past, this was therefore eliminated as much
as possible from the diet. Recent studies show that this assumption was
incorrect, and high-protein foods are even encouraged to maintain adequate
nutrition (Sundaram and Shaikh, 2009). 2.3.4 Hepatorenal syndrome
The hepatorenal syndrome is defined as a urine sodium less than
10 mmol/L and a serum creatinine > 1.5 mg/dl (or 24 hour creatinine
clearance less than 40 ml/min) after a trial of volume expansion without
diuretics (Sundaram and Shaikh, 2009). 2.3.5 Spontaneous bacterial peritonitis
People with ascites due to cirrhosis are at risk of spontaneous bacterial
peritonitis (Sundaram and Shaikh, 2009).
2.3.6 Portal hypertensive gastropathy
Which refers to changes in the mucosa of the stomach in people with portal
hypertension, and is associated with cirrhosis severity (Kim, et al.
2010).
10
2.3.7 Infection
Cirrhosis can cause immune system dysfunction, leading to infection. Signs
and symptoms of infection may be aspecific and are more difficult to
recognize (for example, worsening encephalopathy but no fever) (Kim, et
al. 2010). 2.3.8 Hepatocellular carcinoma
Hepatocellular carcinoma is a primary liver cancer that is more common in
people with cirrhosis. People with known cirrhosis are often screened
intermittently for early signs of this tumor, and screening has been shown
to improve outcomes (Singal, et al. 2014). 2.4 Treatment of liver cirrhosis
The only established therapy for patients with alcoholic liver disease is to
stop drinking alcohol. Patients with alcoholic cirrhosis who continue to
drink seem to have a poorer prognosis than those who stop. The 5-year
survival rate for patients who drink is less than 40% but may reach 60% to
70% if abstinence is maintained. Although pessimism abounds, as many as
30% of patients with alcoholic liver disease may succeed in abstaining
completely. Thus, the emphasis in treatment should be to support patients’
efforts to stop drinking. Various rehabilitation units, peer support groups,
and psychotherapeutic techniques are available (Dan, 2012). 2.5 Nutritional support
The marked nutritional deficiencies noted in many patients with alcoholic
cirrhosis have led most physicians to recommend nutritional support during
the acute illness. A large cooperative study evaluated the role of
an enteral food supplement in decompensated alcoholic liver disease.
The investigators demonstrated a direct relation between caloric
intake and survival and found that vigorous nutritional support
enhanced survival, particularly in severely malnourished patients
11
(Colledge, et al. 2010).
2.6 Nutrition of liver cirrhosis patients
Together with the consequences described above deterioration in liver
function also have various nutritional consequences upon, for example on
protein, carbohydrate and lipid metabolism as they all are partly controlled
by the liver. Additionally, levels of neurotransmitters are affected by the
inflammatory state further affecting the risk of malnutrition. Frequent
finding in patients with liver cirrhosis is protein-calorie malnutrition
(PCM), leading to severe consequences to the general state and clinical
evaluation of the patient. It had been demonstrated that PCM is an
independent risk factor for death among patients with chronic hepatic
disease, contributing to the emergence of more severe complications in
cirrhotic patients, such as ascites, hepatic encephalopathy and infections.
Multiple factors which are common to the underlying disease directly
contribute to malnutrition, among them; anorexia, nausea, deficient food
intake and absorption and catabolic state (Singal, et al. 2014). In addition,
the many dietary restrictions used to control symptoms and specific
complications, such as ascites and hepatic encephalopathy, aggravate the
nutritional status, predisposing the patients to infections and worsening of
the functional hepatic status (Olde-Damink, et al. 2009). 2.6.1 Inadequate food intake
Ascites adds pressure in the abdomen reducing the space for the gastric
space to expand. Research investigating the effect of ascites has shown a
direct link to decreased gastric volume with increasing ascites, this will lead
to early loss of appetite (Aqel, et al, 2005)
2.6.2 Altered levels of Leptin and Ghrelin
High levels of TNF-α increase the levels of the satiety hormone Leptin.
Also reduced levels of Ghrelin further slows down appetite. Lack of
appetite and early satiety increases risk of malnutrition (Kalaitzakis, et al.,
12
2007) 2.6.3 Reduced production of bile
Bile is produced by the liver and a reduction in production is correlated
with disease of the liver. A reduction in bile production affects the
absorption of fat-soluble vitamins such as A, D, E and K. Malabsorption of
fat and fat-soluble vitamins (Juakiem, et al., 2014). 2.6.4 Altered metabolism
By-pass of nutrient rich blood due to portal vein hypertension without
appropriate metabolism. Reduced storage capacity of glycogen results in
early fasting metabolism converting body proteins to glucose via
glyconeogenese. All liver cirrhosis patients develop insulin resistance (IR)
and IR can be used as a marker for early diagnosis. IR will over time lead to
Hepatogenous Diabetes in the a majority of liver cirrhosis patients (Juakiem
et al., 2014) 2.7 Nutritional assessment of patients with liver cirrhosis
2.7.1 Food intake
Methods of evaluating food intake in this patient population does not differ
from other patients and are based on the preference of the professional who
performs the evaluation as well as the literacy level of the patient. Some of
these methods include 24- hour food recalls, food frequency questionnaires,
calorie counts, and food diaries (Johnson, et al. 2013). The 24-hour re- call is perhaps the most rapid, low cost method, al-though it
relies on the patient’s memory and may be difficult to obtain in patients
with encephalopathy or Alzheimer’s disease. (Johnson, et al. 2013).
Serum levels of albumin, one of the most abundant hepatic proteins, have
long been used as a marker of nutrition status and malnutrition. More
recently, prealbumin levels that have a shorter half- life and are able to
13
show changes more rapidly than albumin levels have been considered as the
nutrition marker of choice by many practitioners. How- ever albumin,
prealbumin, and many of the other hepatic proteins such as transferrin are
affected by numerous factors other than nutrition status. They are negative
acute-phase proteins, which means their levels decrease in response to
infection/inflammation, injury, or trauma (Johnson, et al. 2013).
Patients at risk for malnutrition should receive aggressive nutrition therapy.
Another use for these hepatic proteins is to evaluate the effectiveness of
nutrition therapy as one study by Casati et al. (1998) has reported that
prealbumin and retinol-binding protein levels correlate positively with
nitrogen balance of patients who receive parenteral nutrition. 2.7.2 Dietary management of liver cirrhosis
In general, patients with cirrhosis are advised to consume 4-6 small
frequent meals through- out the day to be able to meet their higher needs.
Researchers have recommended that the simple addition of a carbohydrate
and protein-rich evening snack may also help nitrogen balance, improve
muscle cramps and prevent muscle breakdown by supplying the body with
overnight carbohydrate energy, and preventing gluconeogenesis. (Zillikens,
et al. 2003).
2.8 Dietary modification in patients with liver cirrhosis
Energy: The primary goal for a patient suffering from liver cirrhosis should
be to avoid by all means possible intentional or unintentional weight loss
and sustain a diet rich in nutrients. It has been suggested that patients with
liver cirrhosis should receive 35–40 kcal/kg per day (Plauth, et al. 2006). Protein: The consensus of opinion nowadays is that protein restriction be
avoided in all but a small number of patients with severe protein intolerance
and that protein be maintained between 1.2 and 1.5gm of proteins per kg of
14
body weight per day. In severely protein intolerant patients, particularly in
patients in grades III-IV HE, protein may be reduced for short periods of
time (Merli and Riggio, 2009). Carbohydrate: An intake of 4-6 gm/kg carbohydrate ensures adequate
glycogen reserves needed for the maintenance of liver function for
protection against further injury to the liver and for its protein sparing
action (Plauth, et al. 2006). Fats: Mortality from cirrhosis in many countries is greater than what per
capita alcohol consumption would predict. Several investigations have
concluded that excess dietary fat may encourage cirrhosis progression. High
intakes of total fat, saturated fat, and polyunsaturated fat have been
implicated (Plauth, et al. 2006). Antioxidants and B-vitamins: Due to a reduction in food intake and
documented deficiencies of several nutrients in cirrhosis, patients should
take at least a multiple vitamin with minerals that meets 100% of the dietary
allowance for all vitamins and minerals (Leevy and Moroianu, 2005). Sodium: A sodium-restricted diet is standard treatment. A 2000 mg
sodium-restricted diet is effective, when combined with diuretic therapy, for
controlling fluid overload in 90% of patients with cirrhosis and ascites.
Evidence also indicates that sodium-restricted diets improve survival
(Leevy and Moroianu, 2005).
Branched-chain amino acids: In a multicenter randomized trial of 646
patients with decompensated cirrhosis, the ingestion of 12 g/day of
branched-chain amino acids over 2 years was associated with decreased
mortality of roughly 35%, compared with nutrition support from diet alone.
(Muto, et al. 2005).
Omega-3: Use of omega-3 polyunsaturated fatty acids (n-3 PUFAs) as a
potential treatment of NAFLD have been described. n-3 PUFAs, besides
having a beneficial impact on most of the cardio-metabolic risk factors
15
(hypertension, hyperlipidemia, endothelial dysfunction and atherosclerosis)
by regulating gene transcription factors, carbohydrate responsive element-
binding protein], impacts both lipid metabolism and on insulin sensitivity.
In addition to an enhancement of hepatic beta oxidation and a decrease of
the endogenous lipid production, n-3 PUFAs are able to determine a
significant reduction of the expression of pro-inflammatory molecules
(tumor necrosis factor-α and interleukin-6) and of oxygen reactive species
(Di Minno et al. 2012). 2.9 Medical management
2.9.1 Medications
A healthy diet is encouraged, as cirrhosis may be an energy-consuming
process. Close follow-up is often necessary. Antibiotics are prescribed for
infections, and various medications can help with itching. Laxatives, such
as lactulose, decrease risk of constipation; their role in preventing
encephalopathy is limited (Iredale and Guha, 2007). 2.10 Meal satisfaction
As liver disease is often chronic and progressive, frequent monitoring of
medication and progression of the disease is necessary. Therefore, besides
the quality of the medical therapy, good quality of care is important to these
patients as they frequently interact with their physicians. Besides good
medical therapy, good quality of care determines patient satisfaction.
Patient satisfaction, in turn, has proven to be important in compliance with
treatment, seeking medical advice and maintenance of a continuous
relationship with a physician. Also, patient satisfaction and quality of care
are increasingly of interest to health insurance companies or health
maintenance organizations that wish to negotiate prices when purchasing
health care (Weaver, et al. 2003). Murray (2001) has developed a methodology protocol to develop a
standardized series of questionnaires measuring Quality of Care Through
16
the Patient's Eyes (QUOTE), based on market research theory, which
asserts that client satisfaction should be measured by looking at the
discrepancy between what clients need/expect and what they actually
receive. QUOTE instruments consist of two parts: the weight (importance)
patients assign to different aspects of health care, second, patients'
experiences with health care (performance). From the combined effect of
importance and performance, the quality index can be obtained. One study found that aspects of care such as accessibility, cooperation with
other health care workers, and accommodation are of lesser importance to
patients with chronic liver disease. In another study the researcher found
dissatisfaction on items pertaining to accessibility (by telephone), doctors'
and nurses' psychosocial approach, information, cooperation with other
health care workers, privacy, and patient authority, rather than medical
competence, contact, and communication, with the exception of
'information' (Hekkink, et al. 2003). A study was done by Sahin, et al. (2006) to determine the factors affecting
general satisfaction level of patients with the food services in a military
hospital in Turkey. Results showed that patient-specific demographic
characteristics were insignificant in explaining satisfaction level with food
services, but the variables of taste and appearance of the food were
statistically significant and important determinants of patient satisfaction
with the foods served at the hospital. 2.11 Previous studies
According to Greenberger et al., (2007) in a case studies of three patients
with HE treated with vegetable and animal protein diets revealed that
vegetable protein diets resulted in lower HE index scores as well as
decreased serum ammonia levels. The patients who received animal
proteins in this study had higher fetor hepaticus, which was also parallel to
their mental status deterioration. In another study, Uribe et al. (2009) also
17
compared the effects of 40g and 80 g vegetable protein diets, along with a
40g animal protein diet. They found improved patient performance on both
vegetable diets. However, patients on the 80g vegetable diet complained of
the volume of food they need to consume for 80g of protein, since many
vegetable protein sources are also rich sources of fiber and lead to increased
fullness. Although a bit harder and bulkier to eat, the high fiber content of
vegetable protein sources seems to have its own benefits on patients with
cirrhosis, by decreasing ammonia levels.
Chapter Three
Subjects and Methods
18
Chapter Three
3. Subjects and Methods
3.1 Type of research:
Descriptive, cross – sectional Hospital based study.
3.2 Study area:
Ibn –Sina Specialized Hospital was built in early 80th in previous century
and it located in Khartoum Sudan, south Khartoum Mohamed Nagib
street and between 17th and 21th street.
Ibn – Sina have three major departments:
- Gastroenterology (GIT).
- Nephrology.
- ENT.
3.3 Study population:
All patients admitted to hospital with liver cirrhosis and who agreed to
participate in the study during the study period from September to
November 2015. Exclusion end stage and severe complication.
3.4 Study sample and method of selection:
30 patients were case –findings as sampling technique from medical
wards in IBN-SINA hospital.
3.5 Data collection:
3.5.1 Primary data:
By questionnaire including Socio economic, demographic, medical
and diet histories.
Weights and heights were measured to calculate the BMI.
The food intake data were collected by 24 hour record method.
HB, albumin, ALP, ALT and AST were taken from patients files.
19
3.5.2 Secondary data:
Website, books, journals, previous studies.
3.6 Data analysis:
Data were analyzed using statistical packages for social sciences (SPSS)
version 20, significant considered at P. value less than (0.05).
20
Chapter Four
Results
20
Chapter Four
4. Results
Table (1) General information of patients
Parameters N %
Gender Male 20 66.7
Female 10 33.3
Total 30 100.0
20-40 years 8 26.7
Age group 41 - 60 years 9 30.0
61-80 years 10 33.3
> 80 years 3 10.0
Total 30 100.0
Illiterate 9 30.0
Level of education Primary 5 16.7
Secondary 7 23.3
University 9 30.0
Total 30 100.0
Marital status Single 7 23.3
Married 23 76.7
Total 30 100.0
Omdurman 3 20.0
Bahri 3 10.0
Khartoum 1 3.3
Algaziera 8 26.7
Residence Northern State 4 13.3
Kassala 2 6.7
Port Sudan 3 3.3
White Nile 3 6.7
Halfa 3 10.0
Total 30 100.0
Unemployed 15 50.0
Worker 4 13.3
Occupation Employee 5 16.7
Farmer 2 6.7
Free business 4 13.3
Total 30 100.0
Table (1) shows the general information of the patients. Males were
20(66.7%), females 10(33.3%). The highest percentage 10(33.3%) in the
age group 61-80 years and the lowest percentage 3(10%) in the age group
above 80 years. Nine (30%) were illiterate and the same percentage have
university level of education. Married patients were 23(76.7%) and single
21
patients were 7(23.3%). Most of the patients 8(26.7%) were resident in
Algaziara area, only 1(3.3%) in Port Sudan. Half of the patients (50%)
were unemployed and 2(6.7%) were farmers.
Table (2) Distribution of patients according to other chronic diseases
N %
Other diseases Yes 17 56.7
No 13 43.3
Total 30 100.0
DM 3 17.6
HTN 4 23.5
Diseases Renal Disease 1 5.9
DM+HTN 7 41.2
DM+HTN + Renal Disease 2 11.8
Total 17 100.0
Other chronic diseases among patients in this study are shown in Table
(2). The majority 17(56.7%) were suffering from other chronic disease,
which include diabetes mellitus and hypertension 7(41.2%), hypertension
4(23.5%), diabetes mellitus 3(17.6%), diabetes mellitus, hypertension and
renal disease 2(11.8%) and renal disease 1(5.9%).
Tables (3) Distribution of the patients according to presenting
symptoms of liver cirrhosis (N=30)*
Symptoms N %
Fatigue 7 23.3
Bleeding easily 4 13.3
Bruising easily 0 0.0
Itchy skin 9 30.0
Jaundice 19 63.3
Ascites 15 50.0
Loss of appetite 22 73.3
Nausea 15 50.0
Swelling of legs 17 56.7
Weight loss 27 90.0
Hepatic encephalopathy 7 23.3
22
Table (3) shows the common symptoms of liver cirrhosis among the
patients which were weight loss 27(90%), loss of appetite 22(73.3%)
jaundice 19(63.3%), swelling of legs 17(56.7%), nausea 15(50%) and
ascites 15(50%). On the other the less common symptoms were itchy skin
9(30%), fatigue 7(23.3%), hepatic encephalopathy 7(23.3%), and
bleeding easily 4(13.3%).
Table (4) Distribution of the patients according to number of meal
consumed per day
N %
One 0 0.0
Number of meals per day Two 3 10.0
Three 27 90.0
Total 30 100.0
Table (4) shows that the majority of patients 17(90%) eat three meals per
day, and 3(10%) eat two meals per day.
Table (5) Distribution of the patients according to type food cooking
at home
N %
Frying 0 0.0
Boiling 0 0.0
Type of food cooking Grilled 0 0.0
Salty 2 6.7
Stew 28 93.3
Total 30 100.0
Table (5) shows that the majority of the patients 28(93.3%) their food
cooking was stew and 2(6.7%) salty cooking method.
23
Table (6) Distribution of the patients according to reception of
dietary advices
N %
Yes 7 23.3 Received dietary advises
No 23 76.7
Total 30 100.0
Doctor 0 0.0
Source of advises Nurse 0 0.0
Dietitian 7 100.0
Total 7 100.0
Table (6) shows that 7(23.3%) of the patients received dietary advises in
the hospital and all of them received these advises from dietitian.
Table (7) Distribution of the patients according to consumption of
alcohol
N %
Yes 8 26.7 Drinking alcohol
No 22 73.3
Total 30 100.0
< 5 years 2 25.0
Duration 5-10 years 3 37.5
> 10 years 3 37.5
Total 8 100.0
24
Table (7) shows that drinking alcohol was found in 8(26.7%) of the
patients, of them 3(37.5%) for more than 10 years, 3(37.5%) for 5-10
years and 2(25%) less than 5 years.
Table (8) Distribution of the patients according to smoking
N %
Yes 6 20.0 Smoking
No 24 80.0
Total 30 100.0
< 5 years 1 16.7
Duration 5-10 years 1 16.7
> 10 years 4 66.6
Total 6 100.0
Table (8) shows that smoking cigarette was found in 6(20%) of the
patients, of them 4(66.6%) for more than 10 years, 1(16.7%) for 5-10
years and 1(16.7%) less than 5 years.
Table (9) Distribution of the patients according to eating served
meals
N %
Yes 25 83.3 Eating served meal
No 5 16.7
Total 30 100.0
Quantity of meal 2 40.0
Causes behind no eating served meals Can't eat, need fluid 2 40.0
Nausea, eat, but not all 1 20.0
Total 5 100.0
25
Table (9) shows that the majority of patients 25(83.3%) eating several
meals, and 5(16.7%) did not. Two (40%) of those who did not eat
several meals said that it was due to the quality of meal, 2(40%)
because they can't eat and need fluids, and 1(20%) due to nausea did
not eat all types of meals.
Table (10) Distribution of the patients according to satisfaction
towards meal services provided in the hospital
Very Good Satisfactory
Needs
good Improvement
N % N % N % N %
Taste/flavor 1
3.3 9 30.0 18 60.0 2 6.7
of food
The variety of 0
0.0 18 60.0 9 30.0 3 10.0
received food
The temperature 12
40.0 15 50.0 0 0.0 3 10.0
of hot food
Cold food 12 40.0 15 50.0 2 6.7 1 3.3
Friendless and
services from 3 10.0 25 83.3 1 3.3 1 3.3
the staff
The size of portion 7 23.3 14 46.7 7 23.3 2 6.7
Time of food 12
40.0 17 56.7 0 0.0 1 3.3
Distribution
Cleanness of forks, 15
50.0 13 43.3 0 0.0 2 6.7
spoons and dishes served
Quality of food services 5
16.7 20 66.7 2 6.7 3 10.0
in the hospital
Table (10) shows that most of the patients in this study regarded the
food services provided to them in the hospital as good in terms of taste
and flavor, variety, temperature, size and portion, cleanliness and
quality of food services.
26
Table (11) Distribution of the patients according to consumption
of hospital diet
N %
consumption of hospital diet Yes 19 63.3
No 11 36.7
Total 30 100.0
Table (11) shows that the majority of the patients 19(63.3%) consumed
hospital diet and 11(36.7%) consumed liquid diet.
Table (12) Distribution of the patients according to meeting his/her
cultural food preferences by the hospital
N %
The hospital meeting patients' cultural food preferences Yes 9 30.0
No 21 70.0
Total 30 100.0
Table (12) shows that the majority of the patients 21(70%) claimed that
the hospital did not meet their cultural food preferences and 9(30%)
said it met their preferences.
Table (13) Distribution of the patients according to frequency of
visits by dietitian in the hospital
N %
Frequency of dietitian visits Do not visit 13 43.3
One time 17 56.7
Total 30 100.0
Table (13) shows that 17(56.7%) of the patients visited one time by
dietitian in the hospital and 13(43.3%) were not visited at all.
27
Table (14) Distribution of the patients according to their opinions
towards the quality of food services compared to other states
hospitals
Total N %
Yes 21 70.0 The hospital food quality is better than other states hospitals
No 9 30.0
Total 30 100.0
As shown in Table (14) the majority of patients 21(70%) agreed that the
hospital food quality is better than that of the other hospitals and
9(30%) did not agree on that.
Table (15) Distribution of the patients according to improvement in
health due to change in diet
N %
Improved 19 63.3 Improvement in health due to change in diet
No change 11 36.7
Total 30 100.0
Table (15) showed that 19(63.3%) of the patients health status was
improved due to change in diet, and 11(36.7%) did not.
28
Table (16) Distribution of the patients according to BMI and
nutritional status
N %
Underweight (< 18.5) 18 60.0 BMI range
Normal (18.5-24.9) 12 40.0
Total 30 100.0
Weight Loss 6 20.0
Edema 4 13.3
Anemia 3 10.0
Nutritional status Loss of weight + anemia 6 20.0
No change in nutrition status 7 23.3
Loss weight, edema, anemia 2 6.7
Loss weight + edema 2 6.7
Total 30 100.0
Table (16) shows that underweight BMI (< 18.5) was reported in
18(60%) of the patients and normal BMI (18.5 – 24.9) was reported in
12(40%) of the patients. On the other hand no change in nutritional
status was found in 7(23.3%), loss of weight 6(20%), loss of weight in
combination with anemia 6(20%), edema 4(13.3%), anemia 3(10%),
loss of weight, edema, anemia 2(6.7%), loss of weight and edema
2(6.7%).
29
Table (17) Differences between males and females in BMI and nutritional status
Male Female Chi P
N % N % squire value
BMI range Underweight (< 18.5) 11 36.7 7 23.3
Normal (18.5-24.9) 9 30.0 3 10.0 0.62 0.35*
Total 20 66.7 10 33.3
Loss weight 5 16.7 1 3.3
Edema 3 10.0 1 3.3
Anemia 1 3.3 2 6.7
Nutritional status Loss of weight + anemia 1 3.3 5 16.7 12.3 0.04**
Normal 6 20.0 1 3.3
Loss weight, edema, anemia 2 6.7 0 0.0
Loss weight + edema 2 6.7 0 0.0
Total 20 66.7 10 33.3
* No significant differences (P > 0.05)
** Significant differences (P < 0.05)
Figure (1) Differences between males and females in BMI
Gender
FemaleMale
Co
un
t
12
10
8
6
4
2
BMI range
Underw eight (< 18.5)
Normal (18.5-24.9)
Figure (2) Differences between males and females in nutritional status
30
Gender
FemaleMale
Co
un
t
7
6
5
4
3
2
1
0
Nutritional status
Loss w eight
Edema
Anemia
Loss of w eight + ane
mia
Normal
Loss w eight, edema,
anemia
Loss w eight + edema
As shown in Table (17) and Figures (1 and 2), no significant differences
in BMI were found between males and fame patients (P > 0.05), where the
prevalence of underweight among males was 11(36.7%) and females
7(23.3%). On the other hand significant differences were found between
males and females in nutritional status (P < 0.05), where loss of weight in
combination was found in only 1(3.3%) of the male patients compared to
5(16.7%) of female patients and males of normal nutritional status were
6(20%) compared to only 1(3.3%) female has the same nutritional status.
31
Table (18) Differences in nutritional status and BMI according to age
(N=30)
20-40 years 41 - 60 years 61-80 years > 80 years Chi
Squire P value N % N % N % N %
BMI range Underweight (< 18.5) 3 10.0 5 16.7 7 23.3 3 10.0
4.17 0.24 Normal (18.5-24.9) 5 16.7 4 13.3 3 10.0 0 0.0
Total 8 26.7 9 30.0 10 33.3 3 10.0
Nutritional status
Loss weight 1 3.3 1 3.3 3 10.0 1 3.3
14.05 0.02
Edema 2 6.7 1 3.3 1 3.3 0 0.0
Anemia 0 0.0 2 6.7 1 3.3 0 0.0 Loss of weight + anemia 1 3.3 1 3.3 2 6.7 2 6.7
Normal 3 10.0 3 10.0 1 3.3 0 0.0 Loss weight, edema, anemia 1 3.3 0 0.0 1 3.3 0 0.0 Loss weight + edema 0 0.0 1 3.3 1 3.3 0 0.0
Total 8 26.7 9 30.0 10 33.3 3 10.0
Figure (3) Differences in BMI of the patients according to age group
Age group
> 80 years
61-80 years
41 - 60 years
20-40 years
Co
un
t
8
7
6
5
4
3
2
BMI range
Underw eight (< 18.5)
Normal (18.5-24.9)
Figure (4) Differences in nutritional status of the patients according
to age group
32
Age group
> 80 years
61-80 years
41 - 60 years
20-40 years
Co
un
t
3.5
3.0
2.5
2.0
1.5
1.0
.5
Nutritional status
Loss w eight
Edema
Anemia
Loss of w eight + ane
mia
Normal
Loss w eight, edema,
anemia
Loss w eight + edema
Table (18) shows that no significant differences in BMI of the patients
according to age group (P > 0.05), where 3(10%), 5(16.7%), 7(23.3%) and
3(10%) of the patients in age groups (20-40 years), 41-60 years, 61-80
years and > 80 years respectively fall in the range of underweight BMI.
Concerning nutritional status significant differences were found between
the four age groups (P < 0.05), where loss of weight with anemia found in
1(3.3%), 1(3.3%), 2(6.7%) and 2(6.7%) of the patients in the age groups
(20-40 years), 41-60 years, 61-80 years and > 80 years respectively.
33
Table (19) Differences of mean values in BMI, HB, albumin and liver
enzyme according to gender of the patients
Gender Mean±SD P value
Male 18.9±3.18
BMI 0.02* Female 16.6±3.06
Male 11.2±2.27
Hb (g/dl) 0.07** Female 8.8±1.86
Male 2.7±0.87
Albumin (g/dl) 0.18** Female 2.2±0.69
Male 139.6±144.55
ALP (U/L) 0.03* Female 73.7±31.29
Male 41.8±28.46
ALT (U/L) 0.31** Female 31.4±18.22
Male 74.8±83.86
AST (U/L) 0.04* Female 35.6±16.44
* Significant differences (P < 0.05)
** No significant differences (P > 0.05)
Table (19) shows the mean differences in BMI, Hb (g/dl), albumin
(g/dl), ALP (U/L), ALT (U/L), and AST (U/L) between males and
females. The mean values of in BMI, Hb (g/dl), albumin (g/dl), ALP
(U/L), ALT (U/L), and AST (U/L) in males were (18.9±3.18),
(11.2±2.27), (2.7±0.87), (139.6±144.55), (41.8±28.46) and
(74.8±83.86) respectively, while in females were (16.6±3.06),
(8.8±1.86), (2.2±0.69), (73.7±31.29), (31.4±18.22), and (35.6±16.44)
respectively. Significant differences the values of BMI, ALP and AST
were found between males and females (P < 0.05) and no significant
differences between the two groups in Hb, albumin and ALT values (P
> 0.05).
34
Table (20) Differences of mean values of 24 hour intake according to
gender patients
Gender Mean±SD P value
Male 1092.6±428.49
Energy (kcal) 0.83* Female 1126.7±336.46
Male 159.8±62.09
CHO (g) 0.39* Female 181.8±73.25
Male 61.4±25.74
Protein (g) 0.97* Female 61.7±18.29
Male 28.2±15.37
Fat (g) 0.39* Female 23.4±9.39
* No significant differences (P > 0.05)
Table (20) shows that the mean values of total 24 intake of energy
(kcal), carbohydrate (g), protein (g) and fat (g) for males were
(1092.6±428.49), (159.8±62.09), (61.4±25.74) and (28.2±15.37) respectively, and
for females were (1126.7±336.46), (181.8±73.25), (61.7±18.29) and (23.4±9.39)
respectively. There were no significant differences between males and
females in 24 hour recall of total energy, carbohydrate, protein and fat
intake (P > 0.05) (both males and female intake fall with limits of intake
lower than recommended).
35
Table (21) Differences in mean values in BMI and HB according to
age of the patient
Age group N BMI P value
> 80 years 3 14.67
61-80 years 10 17.65
0.04 * 41 - 60 years 9 18.95
20-40 years 8 19.09
Age group N HB g/dl P value
61-80 years 10 9.9
20-40 years 8 10.3
0.87** > 80 years 3 10.3
41 - 60 years 9 11.0
* Significant differences (P < 0.05)
** No significant differences (P > 0.05)
Table (21) shows that the mean values of BMI were 14.67, 17.65, 18.95
and 19.09 for the age groups > 80 years, 61-80 years, 41-60 years and
20-40 years respectively. There are significant differences in BMI
between the four age groups in the study group (P < 0.05). The mean
values of Hb (g/dl) were 9.9, 10.3, 10.3 and 11.0 for the age groups 81-
80 years, 20-40 years, > 80 years and 41-60 years respectively. No
significant differences found in Hb (g/dl) level among the study group
due to age group (P > 0.05).
36
Table (22) Differences in mean values in albumin and liver enzyme
according to age of the patient
Age group N Albumin (g/dl) P value
41 - 60 years 9 2.09
> 80 years 3 2.27
0.18* 61-80 years 10 2.53
20-40 years 8 3.04
Age group N ALP (U/L P value
61-80 years 10 92.30
20-40 years 8 109.11
0.23* 41 - 60 years 9 115.56
> 80 years 3 231.37
Age group N ALT (U/L) P value
61-80 years 10 33.41
41 - 60 years 9 38.71
0.89* 20-40 years 8 41.74
> 80 years 3 44.33
Age group N AST (U/L) P value
61-80 years 10 41.16
41 - 60 years 9 47.19
0.18* 20-40 years 8 80.11
> 80 years 3 124.97
* No significant differences (P > 0.05)
Table (22) shows that the mean values of albumin, ALP, ALT and AST
among the study group were not significantly different according to age
(P > 0.05).
37
Table (23) Differences in mean values in of 24 hour intake of patients
according to age of the patient
Age group N Energy (Kcal) P value
> 80 years 3 803.17
61-80 years 10 899.99 0.08 41 - 60 years 9 1232.36
20-40 years 8 1327.25 Age group N CHO (g) P value
> 80 years 3 130.90
61-80 years 10 141.00 0.36 41 - 60 years 9 185.68
20-40 years 8 192.41 Age group N Protein (g) P value
> 80 years 3 26.77
61-80 years 10 53.97 0.03 41 - 60 years 9 71.28
20-40 years 8 72.85 Age group N Fat (g) P value
> 80 years 3 14.63
61-80 years 10 23.48 0.07 41 - 60 years 9 27.27
20-40 years 8 34.24
As shown in Table (23) no significant differences found in the values of
total energy, carbohydrate and fat intake by the study group according
to age (P > 0.05), but significant difference was found in their total
protein intake.
Chapter Five
Discussion
38
Chapter Five
5. Discussion
This study aimed to assess the dietary management of liver cirrhosis
patients and their satisfaction towards meal services in IBN-SINA hospital.
Thirty patients diagnosed with liver cirrhosis participated in this study, of
them males were (66.7%), females (33.3%). The highest percentage
(33.3%) in the age group 61-80 years and the lowest percentage (10%) in
the age group above 80 years.
In this study, Table (10) shows that most of the patients regarded the food
services provided to them in the hospital as good in terms of taste and
flavor, variety, temperature, size and portion, cleanliness and quality of
food services, moreover Table (14) shows that the majority of patients
(70%) agreed that the hospital food quality is better than that of the other
hospitals. This reflects relatively acceptable level satisfaction among the
study group regarding meal services, due to their demographic
characteristics, where Nine (30%) were of the patients in this study were
illiterates, most of the patients (26.7%) were resident in Algaziara area.
This agreed with study in Turkey by Sahin, et al. (2006) patient-specific
demographic characteristics were insignificant in explaining satisfaction
level with food services, but the variables of taste and appearance of the
food were statistically significant and important determinants of patient
satisfaction with the foods served at the hospital. On the other hand
Hekkink, et al. (2003) found that aspects of care such as accessibility,
cooperation with other health care workers, and accommodation are of
lesser importance to patients with chronic liver disease. In another study
the researcher found dissatisfaction on items pertaining to accessibility (by
telephone), doctors' and nurses' psychosocial approach, information,
cooperation with other health care workers, privacy, and patient authority,
39
rather than medical competence, contact, and communication, with the
exception of 'information'.
Concerning dietary management of the patients, Table (15) showed that
(63.3%) of the patients’ their health status improved due to change in diet,
and (36.7%) did not. Table (11) shows that the majority of the patients
(63.3%) consumed hospital diet. This indicates positive role of dietary
modification and special in management of liver cirrhosis. Zillikens, et al.
(2003) stated that patients with cirrhosis are advised to consume 4-6 small
frequent meals through- out the day to be able to meet their higher needs.
Researchers have recommended that the simple addition of a carbohydrate
and protein-rich evening snack may also help nitrogen balance, improve
muscle cramps and prevent muscle breakdown by supplying the body with
overnight carbohydrate energy, and preventing gluconeogenesis. As with
the amount, the source and quality of protein consumed by patients with
cirrhosis has also been the subject of numerous research studies.
As for nutrition status of patients in this study, the underweight on BMI (<
18.5) was reported in (60%) of the patients and normal on BMI (18.5 –
24.9) was reported in (40%) of the patients.
On the other hand no change in nutritional status was found in (23.3%),
loss of weight (20%), loss of weight in combination with anemia (20%),
edema (13.3%), anemia (10%), loss of weight, edema, anemia (6.7%), loss
of weight and edema (6.7%). This indicates liver cirrhosis significantly
affect the nutritional status of the patients. Moreover, significant
differences the values of BMI, ALP and AST were found between males
and females (P < 0.05) and no significant differences between the two
groups in Hb, albumin and ALT values (P > 0.05), in addition, no
significant differences were found in Hb (g/dl) level among the study
group due to age group (P > 0.05). Anthropometric measurements
40
correlated significantly with measurements of albumin concentration but
not with liver function tests. These data suggested that malnutrition is
common in patients with alcoholic and nonalcoholic liver disease
(Thuluvath and Triger, 2009).
Concerning 24 hour recall intake by the patients in this study, Table (20)
shows that the mean values of total 24 intake of energy (kcal), carbohydrate
(g), protein (g) and fat (g) for males were (1092.6±428.49), (159.8±62.09),
(61.4±25.74) and (28.2±15.37) respectively, and for females were
(1126.7±336.46), (181.8±73.25), (61.7±18.29) and (23.4±9.39)
respectively. There were no significant differences between males and
females in 24 hour recall of total energy, carbohydrate, protein and fat
intake (P > 0.05) (both males and female intake fall with limits of intake
lower than recommended). In addition, Table (23) no significant
differences were found in the values of total energy, carbohydrate and fat
intake by the study group according to age (P > 0.05), but significant
difference was found in their total protein intake. Uribe et al. (2009) also
compared the effects of 40g and 80 g plant protein diets, along with a 40g
animal protein diet. They found improved patient performance on NCTs
while on both vegetable diets. So, the quality of protein and all
macronutrients affects the malnourished patient situation as by as the
quantities Casati et al. (1998).
Chapter Six
Conclusion and
Recommendations
41
Chapter Six
6. Conclusion and Recommendations
6.1 Conclusion
- The majority of the patients with liver cirrhosis in this study were
males, most of them in older ages (61-80 years), the majority from
outside Khartoum State and half of them unemployed.
- Most of the patients in this study regarded the food services
provided to them in the hospital as good in terms of taste and
flavor, variety, temperature, size and portion, cleanliness and
quality of food services.
- The majority of the patients’ health status improved due to change
in diet. High proportion of the patients consumed modified diet,
which indicates positive role of dietary modification and special in
management of liver cirrhosis.
- Low BMI was found among high proportion of the patients in this
study, in addition to high prevalence of loss of weight and anemia.
Significant differences were found between males and females in
BMI, but no significant differences found due to age.
- All patients reported abnormal levels of albumin, ALT, and AST.
Significant differences in the values of BMI, ALP and AST were
found between males and females and no significant differences
between the two groups in Hb, albumin and ALT values, in
addition, no significant differences were found in Hb (g/dl) level
among the study group due to age group.
- All patients’ 24 hour recall intake was found to be lower than
recommended in energy, carbohydrates, protein and fat. There were
no significant differences between males and females as well as
between different age groups of patients in 24 hour recall of total
42
energy, carbohydrate, protein and fat intake.
6.2 Recommendations
- The healthcare providers should provide liver cirrhosis patients
with the best and most appropriate nutrition intervention beneficial
to patient according to their needs, clinical status, and disease stage.
- Nutritional care by dietitian of the nutritional regimen should be
undertaken for all cirrhotic patients to reduce occurrence of
complications of malnutrition and improve clinical outcome.
- A high protein diet is important for people with chronic liver
disease as the protein is used to maintain muscles and body tissues
(including the liver) and to keep the body working normally.
- Sodium restriction and other modifications should be considered in
patient meal.
- Local or stable diet should be high- lighted in the patient’s meals.
- Patients should be advised to modify their intake of energy, protein,
carbohydrate and fat according to their nutritional status.
- Small, frequent meals 4-7 times a day, including an evening snack
are recommended.
- Meal services, as well as follow up by nutritionists and dietitians
with patients of liver cirrhosis should be improved.
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43
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Appendixes
A
Appendix 1
Questionnaire Form
Questionnaire about;
Dietary Management of Liver Cirrhosis in IBN –SINA hospital (in
patient )
1. NO……………………………………………………………… 2. Name…
3. Sex ; Male ( ) Female ( )
4. Age : less than 20 ( ) 20-29 ( ) 30-39 ( ) 40- 49 ( )
50-59 ( ) 60-69( ) 70and more ( )
5. Level of education?
Illiterates ( ) Primary ( ) Secondary ( ) University ( ) Postgraduate ( )
6. Marital Status:
Single ( ) Married ( ) Divorced ( ) Widow ( )
7. Residence……………….. 8. Occupation?............................................................. 9. Did you suffer from any other disease? Yes ( ) No ( ) ,
If yes what?
DM ( ) HTN ( ) Heart disease ( ) Renal disease ( ) 10. The type of food cooking at home:
Frying ( ) Boiling ( ) Grilled ( ) Salty ( ) Stow ( ) 11. Number of meals per
day in hospital?
One ( ) Two ( ) Three
( ) 12. Dietary advised? Yes ( ) No ( )
If yes by whom : Doctor ( ) Nurse ( ) Dietitian ( )
13. The symptom of liver cirrhosis:
a) Fatigue( )
b) Bleeding easily ( )
c) Bruising easily( )
d) Itchy skin ( )
e) Yellow discoloration in the skin and eyes (jaundice) ( )
B
f) Fluid accumulation in your abdomen (ascites) ( )
g) Loss of appetite ( )
h) Nausea ( )
i) Swelling in your legs ( )
j) Weight loss ( )
k) Confusion, drowsiness and slurred speech (hepatic encephalopathy)
( )
14. Are you drinking alcohol? Yes ( ) No ( )
If yes, for how long?
……………………………………………………………………………
…...
15. Are you smoking? Yes ( ) No ( )
If yes for how long....................................................................... 16. Do you eat served meal in hospital?
Yes ( ) No( )
17. If you don't eat served meal, what is the cause?
1- quantity of meal 2- quality of meal
3- time of meal 4- appearance of meal
18. The taste/flavor of your food was:
1- Very good 2- Good 3- Satisfactory 4- Needs improvement
19. The variety of foods you received was:
1- Very good 2- Good 3- Satisfactory 4- Needs improvement
20. The temperature of your hot food was
1- Very good 2- Good 3- Satisfactory 4- Needs improvement
21. cold food was
1- Very good 2- Good 3- Satisfactory 4- Needs improvement
C
22. Friendliness and service from staff was:
1- Very good 2- Good 3- Satisfactory 4- Needs improvement
23. The size of portions were:
1- Very good 2- Good 3- Satisfactory 4- Needs improvement
24. Time of food distribution of your food was:
1- Very good 2- Good 3- Satisfactory 4- Needs improvement
25. The cleanness of fork, spoons and dishes served was:
1- Very good 2- Good 3- Satisfactory 4- Needs improvement
26. Quality of foods services in this hospital was:
1- Very good 2- Good 3- Satisfactory 4- Needs improvement
27. Are you on a special diet? Yes ( ) No ()
28. Have we met your cultural food preferences? Yes( ) No ( )
29. Dietitian visit for you was:
1- daily 2- per 3 days 3- per5 days 4-weekly 5- do not visit
30. Can you say that this hospital serves more quality foods services compared to other
States
Hospital? 1- Yes 2- No
31. What improvement have you noticed concerning your health after the change in diet?
Improved ( ) No change ( ) 32. Weight ( ) 33. Height ( ) 34. BMI ( )
35. Nutritional status; loss weight ( ) edema ( ) anemia ( ) 36. 24 hr recall
Break fast ……………………………………………………………………………………
D
…………………………………………………………………………………… ……………………………………………………………………………………
Snacks………………………………………………………………………… …………………………………………………………………………………… ……………………………………………………………………………………
Lunch…………………………………………………………………………
……………………………………………………………………………………
……………………………………………………………………………………
……………………………………………………………………………………
……………………………………………………………………………………
Snacks……………………………………………………………………………
……………………………………………………………………………………
Dinner…………………………………………………………………………
…………………………………………………………………………………
……………………………………………………………………………………
……………………………………………………………………………………
Snacks…………………………………………………………………………
……………………………………………………………………………………
……………………………………………………………………………………
Total energy (kacl) ………… CHO (g) ………., Protein (g) …….. Fat (g)
………….
Hb (g/dl) ………… Albumin (g/dl) ………. ALP (U/L) ……….. ALT (U/L)
………
AST (U/L) ………………….. (All these measures from the record)
E
Appendix 2
General instructions given to the patients
. A diet most suitable for liver cirrhosis patients would be:
high in carbohydrate and proteins, low in fat and fortified with
B-complex vitamins and fat soluble vitamins.
1. Increased energy at 50-75% above usual
requirements if malabsorption is present.
2. Diet should provide 1-1.5 g of high quality protein /kg body
weight the protein found in lean meat, poultry (chicken no
skin), or fish , Egg whites , low fat yogurt and skimmed milk
cheese , salmon and tuna.
3. Methods of cooking are: either boiling, grilling or use oven.
4. If steatorrhea is present should restrict fat, if sever steatorrhea
add fat - soluble vitamin, omega 3 fatty acids should be
included such as fish and fish oil.
5. Supplement diet with complex vitamin ,vitamins C and K
,zinc ,and magnesium through foods or supplement .Food rich
in vitamin C sweet red papers and sweet green papers guavas ,
dark green leafy vegetable (Swiss chard),Kiwifruit, broccoli,
strawberry, orange , lemon , grapefruit, green peas, Tebaldi,
Vitamin K reach in fresh and dry parsley, beet, olive oil, pear.
Zinc reach in sea food, beef and lamb wheat germ beans.
6. Adequate Carbohydrates: to spare protein
Carbohydrates are found in breads, cereals, grains (rice, oats),
starchy vegetables (potatoes, corn, peas), and biscuit
7. Reduce salt and avoid salty food , such as canned food , table
salt , chips , pickles , olives and white chees as much to
protect
F
yourself from body fluid retention , low sodium intake 2-4 g is
recommended with ascites .
8. You can use lemon and spices to add taste to your food 9. Small frequent meals and snack 3 time per day.
10. If esophageal avarices, use soft, low fiber.
11. Stop alcohol.
