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The effect of chemotherapy on nutritional status of breast cancer patients Submitted in partial fulfillment of the requirements for master’s degree in the Department of Community Health Sciences at the College of Applied Medical Sciences King Saud University By Aysha. M. Alharbi 25/1/1429 I TABLE OF CONTENT 1:Introduction 1 1-2:Rational 1-3:Objective 2:Literature review 2-1:Side effects of chemotherapy 5 5 6 6 2-2:Nutritional status 2-3:Malnutrition 2-4:Weight & chemotherapy 2-5:Hematology & chemotherapy 3:Study design & Methodology 3-1:Study design 3-2:Study area 3-3:Patients 3-4:Methods 3-4-1:Dietary intake assessment 7 11 12 14 20 20 20 20 20 22 3-4-2:Anthropometrics measurements 3-4-3:Sample collection and laboratory measurements 3-5:Statistical analysis 4:Results 4-1:The patients Demographic-socioeconomic characteristics 22 22 23 24 24 4-2:The patient’s medical history 24 4-3:The patients dietary history 4-4:24 hour food recall 4-5:Weight and general characteristics 4-6:Body mass indexes 24 28 30 34 4-7:Biochemical measures 35 5:Discussion & conclusion 37 6:Recommendations 42 7:Reference 43 II TABLE OF CONTENT 8:Appendix 8-1:Demographic data 8-2:Socioeconomic background 8-3:Dietary history 8-4:Dietary assessment 8-4-1:24-hour recall 8-4-2:Food frequency questionnaire 8-5:Anthropometric measurements 8-6:Biochemical measurements 8-7:The five steps of a breast self-examination 9:Arabic summary 55 56 57 58 59 59 60 62 63 64 66 III List of Table Table1: The patients' demographic-socioeconomic characteristics 25 Table2: The patients' medical history 26 Table3: The patients' dietary history 27 Table4 a: Food frequency questionnaire 29 Table4 b: Food frequency questionnaire 29 Table5a: Weight and general characteristics 32 Table5b: Weight and general characteristics 33 Table6: Classification of overweight and obesity by BMI 34 Table7: Grading system for anemia 35 Table8: patients characteristics 36 Table9: t-test for variable between baseline and 3 weeks after chemotherapy 36 IV Abbreviations AC Doxorubicin, cyclophosphamide Alb Albumin BCG Bromocresol green BMI Body mass index CDU Chemotherapy day unit CMF Cyclophosphamide, methotrexate, 5-fluorouracil FAC 5-fluorouracil, doxorubicin, cyclophosphamide FFQ Food frequency questionnaire Hb Hemoglobin MCV Mean corpuscular volume NCI National cancer institute RDA Recommended daily allowances REE Resting energy expenditure SD Standard deviations SPSS Statistical package for social sciences WNL Within normal limits V Summary Breast cancer is the most common cancer in women. Most studies address the effects of chemotherapy on increasing the survival. Few studies have focused on the effects of chemotherapy on nutritional status. Knowledge of changes in nutritional status due to cancer or due to its therapy will not only help in better management of nutritional problems, but will also enable better clinical outcome. The nutritional status of breast cancer patient receiving chemotherapy in the Kingdom of Saudi Arabia is not known. The present investigation was designed to study the nutritional status of breast cancer patients receiving chemotherapy, and to evaluate the effect of chemotherapy on weight, energy, albumin, and hemoglobin. A prospective study was carried out at the Riyadh Khorj Armed Forces Hospital. A total of 30 females diagnosed with breast cancer, aged 30 - 55 years who received chemotherapy for the first time were included in the study. Patients who had received chemotherapy before and patients with diabetes were excluded. Each patient was interviewed using questionnaire. The questionnaire includes information on medical history, socioeconomic history, and dietary history. Anthropometric measurements height, weight, and body mass index (BMI) was recorded before and after the start of chemotherapy. VI A blood sample was drawn before the start of chemotherapy and 3 weeks after the start of chemotherapy. It was used to estimate hemoglobin (Hb), mean corpuscular volume (MCV), and albumin (Alb). A 24-hour recall was obtained before the start of chemotherapy and 3 weeks after the start of chemotherapy. Each patient was asked to complete food frequency questionnaire. The present study has shown from (24 hour food recall) that energy intake before chemotherapy was 1445.96 kcal, and 3weeks after chemotherapy became 1445.73 kcal. Protein intake before chemotherapy was 45.86 g compared with 45.83g 3weeks after chemotherapy. All patients energy intake, protein intake were lower from RDA before and after chemotherapy The prevalence of weight loss was high among patients after the first cycle of chemotherapy. This study found that 50% of patients suffered from weight loss, which shows the impact of treatment on weight. Also 43.3% patients gained weight between the start of treatment and 3 weeks follow up. These changes in weight were not statistically significant on application of ttest. BMI decrease after the first cycle of chemotherapy but was not statistically significant on application of t-test. The percentage of anemia (Hb 12 g/dl) in women before chemotherapy was 43.33%. After 3 weeks 60% of these VII women became anemic. Patients had normal MCV level 79.17 g/l before chemotherapy while 3 weeks after chemotherapy MCV level was 79.80 g/l. A non significant (P<0.23) decrease in MCV was observed in patients after chemotherapy but still it was within the normal range. Patients showed a decrease in albumin level but within the normal level. These changes in biochemical indices were found to be statistically significant on application of t-test. This investigation has indicated that patients experienced weight change, and decrease in biochemical measurements, therefore, these patients are at risk of malnutrition and they need nutritional assessment to prevent or minimize the effect of chemotherapy on their nutritional status. 1 Introduction Cancer represents a major global public health problem. Annually it accounts for 7.1 million deaths Worldwide (WHO. 2003). It has been predicted that, by 2020, 15 million new cancer cases will be added every year (WHO. 2003). In Europe each year there are 2.9 million new cancer cases and 1.7 million deaths (Boyle and Ferlay. 2005). In the United States a total of 1,444,920 new cancer cases and 559,650 deaths from cancer were predicted to occur in 2007 (Jemal et al. 2007). In the Kingdom of Saudi Arabia, cancer accounts for about 5.5% of total mortality (Department of statistics KSA. 2006). Breast cancer is the most common female cancer. It is the leading cause of death among females (Shibuya et al. 2002). Breast cancer is the most frequent tumor among Saudi women, accounting 19.8% of female cancers (Ravichandran et al. 2005). Screening for breast cancer is carried out by mammography. It is the early detection method with proven efficacy (Day and Warren. 2000). The Self examination of a breast involved five steps (Appendix VI). Treatment of breast cancer includes surgery, chemotherapy, hormone therapy, and radiotherapy (National institutes 2001, Lake and Hudis. 2004). The establish risk factors of breast cancer include age, the number and timing of reproductive events, lactation, exposure to radiation, alcohol 2 consumption and family history of breast cancer (Mctiernan. 2003, Santen et al. 2007). Diet has a significant effect on cancer incidence (Rodler and Zajkas. 2002). The incidence of breast cancer is much higher among women in industrialized countries than among women in countries with more traditional lifestyles (Jasienska et al. 2001). In fact, food consumption patterns could provide major insights into cancer risk and prevention despite the fact that their significance is not fully appreciated (Grandics. 2003). Moreover, It has been hypothesized that dietary factors may reduce risk for secondary cancer events and increase survival in breast cancer patients. Many women attempt to modify their diets and improve nutritional status following diagnosis (Rock. 2003), therefore, Maunsell et al. (2002) assessed dietary changes in the year after diagnosis among 250 women with newly diagnosed breast cancer. They found that there is 77% decrease in meat intake and 72% increase in fruit and vegetable intake. There are many factors that may affect a cancer patient's nutritional status. These factors include dietary intake, treatment related side effects (anorexia, nausea, vomiting), and the presence of cytokine mediated metabolic changes (Van Cutsem and Arends. 2005). Cachexia occurs in about half of all cancer patients and is associated with decrease survival time. Cancer cachexia involves the loss of weight, mainly in skeletal 3 muscle and adipose tissue that is not caused simply by anorexia. The syndrome of cachexia includes anemia and immunosuppression along with a number of biochemical changes indicating systemic effects of the cancer. It is a major factor of morbidity and mortality in cancer (Rubin. 2003). Several side effects (nausea, vomiting, hair loss, loss or gain of body weight) are associated with chemotherapy of breast cancer which may adversely affect their nutritional status (Bergh et al. 2001). Chemotherapy can change nutritional needs and alter the survivor’s food intake, digestion, and absorption. The need for food intake may be increased during cancer treatment (Brown et al. 2003). Women with breast cancer now have more treatment options and a better chance of long-term survival than ever before because of continuing research into new treatment methods. Chemotherapy has been shown to improve substantially the long-term disease-free and overall survival in both premenopausal and postmenopausal women up to the age of 70 years. Chemotherapy has a range of acute and late side effects (such as weight gain, weight loss, nausea and vomiting) that has the potential to substantially affect patients’ quality of life (National Institutes.2001). Nutritional need changes for most persons during the phases of cancer treatment. Cancer survivors are often highly motivated to seek information about food choices, physical activity, dietary supplement use, and 4 complementary nutritional therapies to improve their treatment outcomes, quality of life, and survival. For these long-term cancer survivors, an appropriate weight, a healthful diet, and a physically active lifestyle aimed at preventing cancers and other chronic diseases become a priority (Brown et al. 2003). Therefore, this study is designed to assess the nutritional status of breast cancer patients receiving chemotherapy, and to evaluate the effect of chemotherapy on weight, energy intake, albumin, and hemoglobin. 5 Rational: Knowledge of changes in nutritional status due to cancer or due to its therapy will not only help in better management of nutritional problems, but will also enable better clinical outcome. The nutritional status of breast cancer patient receiving chemotherapy in the Kingdom of Saudi Arabia is un-known. Therefore, the present investigation was designed to study the nutritional status of breast cancer patients receiving chemotherapy, and to evaluate the effect of chemotherapy on weight, energy intake, albumin, and hemoglobin. Objective: The objectives of this study were: - To evaluate the nutritional status of breast cancer patients receiving chemotherapy. - To evaluate the effect of chemotherapy on weight, energy intake, albumin, and hemoglobin. 6 Literature review 2-1: Side effects of chemotherapy The use of adjuvant chemotherapy for early breast cancer patients can significantly improves the overall survival. However, this type of therapy is associated with several side-effects. The critical issue is whether the survival benefits counterbalances the side-effects (Bergh et al. 2001). Chemotherapy of breast cancer patient can have many adverse affects, most of which resolve after treatment is completed. The most serious, even life threatening, are secondary leukemia and cardiac dysfunction (Harold and Eric. 2000, Ng and Green. 2007). Women receiving adjuvant chemotherapy for breast cancer have substantial problems that lead to fatigue, menopausal symptoms and cognitive changes (Downie et al. 2006). Some of the acute side effects of chemotherapy are nausea, vomiting, mucositis, taste and smell changes, and hair loss occurs in varying degrees with the different chemotherapy regimens (Young and Mathias. 2004, Bergkvist and Wengström. 2006, Stringer et al. 2007, Yun and Kim. 2007). Also women with breast cancer may be at increased risk of osteoporosis because of loss of bone mineral density owing to premature ovarian failure from chemotherapy (Swenson et al. 2005), other changes due to chemotherapy such as loss of body weight, loss of muscle mass, weight 7 gain, eating and digestive difficulties are usually temporary but can sometimes persist (Brown et al. 2003). On the other hand the gastrointestinal tract often suffers greatly from cancer treatments, causing taste change and other symptoms (including dry mouth, decreased appetite, nausea, and vomiting) (Williams et al. 2006). These symptoms often result in poor nutritional intake. Gastrointestinal tract cells are often affected because cytotoxic chemotherapy works by killing rapidly proliferating cells. In addition to the previous chemotherapy side effect breast cancer patients may suffer from tumor lysis syndrome. Chemotherapy may result in the massive release of potassium, phosphate, uric acid, and other breakdown products of dying tumor cells into the blood. Tumor lysis syndrome develops within hours to a few days after the beginning of the treatment (Casciato. 2004). 2-2: Nutritional status Nutritional status is vital to patients' overall clinical management. Food intake and appetite alterations have been identified as some of the main causes of malnutrition. The acceptance of foods is influenced by emotional and psychological factors in addition to those associated with the treatment and the disease itself (Garofolo and Lopez. 2002). Metabolic disturbance is another problem among cancer patients, and this is often represented by catabolic status. It has been shown that the weight loss that occur in 8 cachexia lead to reductions in lean body tissue (Fanelli et al. 1996, Laviano et al. 1996). Cancer treatment itself, and particularly chemotherapy and radiotherapy seem to be an important nutritional risk factor. The treatment is associated with several side effects (nausea, vomiting, oral mucositis, constipation, and food aversion) which play an important role in decreased food intake, nutrient loss, energy expenditure alterations and weight loss, particularly lean body mass (Andrassy and Chwals. 1998). These conditions predispose patients towards malnutrition, especially when there are frequent periods of chemotherapy treatment (Angus and Burakoff. 2003, Garofolo et al. 2005). Nutritional screening and assessment play an important role in the early recognition of cancer-associated malnutrition (Holmes and Molassiotis. 2005). Nutritional screening is the process of discovering characteristics or risk factors known to be associated with dietary problems. Its main purpose is to identify individuals who are at risk. As opposed to the more timeconsuming and detailed process of nutritional assessment, screening should be a simple procedure aimed at identifying the nutritional status in an expedient manner. Nutritional assessment is a comprehensive process of identifying individuals and populations at risk and planning, implementing, 9 and evaluating a course of action .The evaluation of nutritional status is a complex matter and for it to be of clinical importance the ideal method should be able to predict whether an individual would have increased morbidity and mortality rates in the absence of nutritional support. Moreover, disease and nutrition interact in such a way that the disease may cause secondary malnutrition or that malnutrition may adversely influence the underlying disease. In fact, patient outcomes are multifactor (Slaviero et al. 2003). An assessment of patients’ nutritional status is usually based on the evaluation of laboratory test results, anthropometric measurements, clinical history, and physical examination. In general, laboratory parameters reflect the net result of the synthesis, distribution, and loss or excretion (Davies. 2005). Therefore, to assess the nutritional status of breast cancer patients, anthropometric measurements were used. One nutrition-related variable is BMI. Normal BMI at the time of breast cancer diagnosis has been associated with optimal survival, and extremes of BMI have been associated with less favorable survival. Goodwin et al. (2003) believed that a similar association may also be present for diet and breast cancer outcomes. There may be optimal ranges of dietary intake that are associated with the best outcomes, and extremes may be associated with worse outcomes. It has been suggested that diets that minimize extremes in 10 nutrient intake and a lifestyle that results in a normal BMI may be associated with the best breast cancer outcomes (Goodwin et al. 2003). Dietary counseling has been shown to be effective in the management of nutritional problems in the early stages of nutritional decline (Ravasco et al. 2005). In fact nutrition therapy can help cancer patients get the nutrients to maintain body weight and performance status, prevent body tissue from breaking down and rebuild tissues (Tian et al. 2007). Therefore, assessment and planning for survivors should begin while treatment is being planned and should focus on current nutritional status and anticipated nutritional problems related to treatment (Brown et al. 2003). It has been suggested that maintaining energy balance or preventing weight loss during cancer treatment, is the most important nutritional goal for survivors especially those who are already undernourished (Brown et al. 2003). On the other hand patients who are unable to meet their nutritional needs, oral nutritional supplements can improve dietary intake. Oral supplementation is the simplest, most natural and least invasive method of increasing nutrient intake (Ravasco et al. 2003), on the other hand enteral tube feeding is indicated in patients who are unable to meet their nutritional needs orally. In patients with cancer enteral tube feeding has been shown to be preferable to parenteral feeding for several reasons, 11 including a lower incidence of overall and infectious complications, and to reduce length of hospital stay (Bozzetti et al. 2001). 2-3: Malnutrition Malnutrition is a state produced by insufficient or excessive intake of protein-energy, vitamin and mineral deficiency, excessive intake of inappropriate substances such as alcohol. Malnutrition increases the duration of hospitalization as well as hospital expenses. In contrast to wellnourished and normal weight patients, the malnourished ones are more likely to stay longer in hospital due to further complications (Juretiae et al. 2004). Cancer-associated malnutrition can result from local effects of a tumor, the host response to the tumor and anticancer therapies. Although cancer patients often have reduced food intake (due to systemic effects of the disease, local tumor effects, psychological effects or adverse effects of treatment), alterations in nutrient metabolism and resting energy expenditure (REE) may also contribute to nutritional status (Van Cutsem and Arends. 2005). The consequences of malnutrition include impairment of immune functions, performance status, muscle function, quality of life, and responses to chemotherapy are decreased (Van Cutsem and Arends. 2005). 12 Cancer-related malnutrition is associated with significant healthcarerelated costs. Nutritional support is required to improve prognosis, and reduces the consequences of cancer-associated nutritional decline (Van Cutsem and Arends. 2005). Estimated prevalence rates of malnutrition vary according to tumor site, disease stage and the type of treatment used (Meyenfeldt. 2005). 2-4: Weight & chemotherapy Weight gain has been associated with adjuvant chemotherapy but not with tamoxifen therapy. In a systematic review of the relation between obesity at diagnosis and breast cancer outcomes, twenty six out of thirty four studies showed a statistically significant association between obesity and breast cancer recurrence, whereas eight studies found no such associations (Grunfeld et al. 2005). Women with breast cancer who are overweight or gain weight after diagnosis are found to be at greater risk for breast cancer recurrence and death compared with lighter women (Chlebowski et al. 2002). A number of reasons for the weight gain associated with adjuvant chemotherapy for breast cancer have been proposed, including the type of chemotherapy/length of treatment, fatigue, decreased level of physical activity, increase in energy intake, decrease in REE, and development of amenorrhea/menopause. However, there is conflicting evidence on the 13 impact of these factors. Overall, the mechanisms for this weight gain are not well understood, making effective intervention difficult (Campbell et al. 2007). A significant increase in weight occur in 50–96% of all early stage breast cancer patients during treatment with chemotherapy, with the median gain in weight ranging from 2.5– 6.2 kg over treatment and followup periods up to 1 year. Chemotherapy has been found to be a strong clinical predictor of weight gain in women with early stage breast cancer that is independent of age at diagnosis, nodal status, BMI at diagnosis, and reported caloric intake (Wahnefried et al. 2001). The degree of weight gain in response to chemotherapy appears to be dependent on the chemotherapeutic agents used. Women treated with cyclophosphamide, methotrexate, 5-fluorouracil (CMF) are reported to have significant gain in both body weight and fat mass during treatment (Lankester et al. 2002), other studies (Kutynec et al. 1999, Wahnefried et al. 2001) using doxorubicin and cyclophosphamide (AC)- AC includes doxorubicin one of a group of drugs called anthracyclines- find no weight gain during chemotherapy. Women with breast cancer receiving adjuvant chemotherapy show no significant changes in weight during the first year of their treatment. They do, however, appear to undergo unfavorable changes in body composition 14 (Freedman et al. 2004). In a small pilot study of 10 premenopausal breast cancer patients receiving chemotherapy, a six months program focused on strength training included aerobic exercise and guidance toward a low-fat, high-vegetable and high-fruit diet resulted in significant changes in total body weight and percent body fat compared with controls who experienced weight gains (Rock and Wahnefried. 2002(a)). Between 50% and 90% of cancer patients lose weight, and about 40% lose more than 10% of their total body weight. Weight loss greater than 10% is associated with an increased risk of morbidity and mortality, and in cancer patients weight loss is a negative prognostic factor (Thorese et al. 2002). 2-5: Hematology & chemotherapy Cancer patient may suffer from protein breakdown which can reduced body protein stores. This catabolic state may occur as a consequence of the malignant disease itself, chemotherapy or complications of the therapy, e.g. infections and organ failure (Garofolo et al. 2005). Altered nutritional and inflammatory status correlates with increased risk of severe hematological toxicity following chemotherapy (Alexandre et al. 2003). Protein loss may be an important cause of the hypoalbuminemia. More than 80% of cancer patients have a reduction serum albumin concentration (Dreizen et al. 1990). 15 Many patients with breast cancer suffer from anemia, as a consequence of the disease itself or its treatment. Anemia has a negative impact on treatment outcome and on overall survival, is a common complication in patients with cancer (Caro et al. 2001). A retrospective data from 249 women treated for breast cancer, showed that anemia during adjuvant chemotherapy is a negative prognostic indicator for survival of patients with breast cancer (Boehm et al. 2007). Anemia in patients with cancer is an independent prognostic factor for survival, and associated with shorter survival (Leyland-Jones et al. 2005). Anemia is a potential contributor to the functional impairment that often occurs during and after chemotherapy. Many patients experience mild to moderate degrees of anemia that are not considered serious enough to warrant transfusion therapy, but anemia may adversely affect functional capacity (Gabrilove et al. 2001). A variety of factors are known to be involved in anemia development, some of these factors relate to the tumor itself (blood loss, bone marrow infiltration or nutritional deficiencies) or to chemotherapy treatment. The most commonly used chemotherapy regimens in the adjuvant setting, 5-fluorouracil, doxorubicin, cyclophosphamide (FAC) - Doxorubicin is an anthracycline- and CMF, and they have induced similar rates of anemia 16 about 43–47% of patients. Moreover, severe anemia has been observed in 11% of patients treated with FAC (Leonard et al. 2005). Approximately 50% of cancer patient develop anemia. It is generally defined as hemoglobin level <12 g/dl .The severity of anemia depends on many factors including the nutritional status of the patient, the type of cancer , the stage and extent of tumor burden (especially bone marrow involvement), and bleeding. Cancer-related anemia can be associated with debilitating symptoms and can have a profound effect on health (Kirshner et al. 2004). There are four prediction tools for identification of patients with breast cancer who are most likely to develop severe anemia during chemotherapy: precycle Hb concentration, cycle of chemotherapy, age (≥65 years), platelet count, and type of chemotherapy (Spivak. 2005). Kailajarvi et al. (2000(a)) investigated the effect of chemotherapy drugs on serum hormones, proteins, lipids and common biochemical test in postmenopausal women with breast cancer, and found that serum albumin decreased slightly after chemotherapy. Dranitsaris et al. (2005), examined 331 patients receiving adjuvant chemotherapy for breast cancer, and they found that 3% patients were anemic at the start of the study, compared with 25% at the final cycle of chemotherapy, and the result of Tchekmedyian study (2002), revealed that 37% patient were anemic (Hb < 12 g/ dl) prior to chemotherapy, and an 17 additional 41% became anemic during chemotherapy. In a retrospective study performed on 104 patients treated for breast cancer, Hurria et al. (2005) found that hemoglobin level decrease from cycle 1 to cycle 2. Alexandre et al. (2003) investigated the influence of malnutrition and inflammation on acute haematological toxicity. They found that patients had lower hemoglobin, and serum-albumin levels. Also hematological tests of seven women with breast cancer during chemotherapy, showed a slight, non-significant and transient decrease in hemoglobin and in albumin (Kallajavi et al.2001). In retrospective survey Engl et al. (2005) studied hemoglobin level of 129 patients during chemotherapy. They found hemoglobin prior to primary surgery was 13.8 g/dl, pre-chemotherapy hemoglobin 12.8 g/dl, and hemoglobin during chemotherapy was 11.0 g/dl. The hemoglobin level decrease during chemotherapy. Gianni et al. (2008) found that among the 2,215 breast cancer patients treated with adjuvant chemotherapy in two randomized trials, anemia was recorded in 11% during adjuvant chemotherapy. Grade 2 and 3 anemia occurred in 1% of patients, respectively. Moderate or severe anemia is rare among patients treated with AC followed by CMF. Low baseline hemoglobin and white blood cells are associated with a higher risk of anemia. 18 Tas at el. (2002) investigated the incidence and severity of chemotherapy-induced anemia caused by chemotherapy regimens used in the treatment of malignancies in 552 adults. They found that before chemotherapy, 44% of patients with breast cancer had anemia. After chemotherapy 60 % were anemic. Severe anemia was observed in less than 1% of patients. No difference was found in the incidence of anemia between the FAC and CMF regimens used in the adjuvant setting. Denison et al. (2003) studied the incidence of anemia in 247 breast cancer patients receiving chemotherapy and found that 28.7% of patients were anemic. 42% of patients with a hemoglobin level of > or = 12 g/dl at baseline developed anemia during adjuvant chemotherapy. The total incidence of anemia in patients with primary breast cancer who underwent surgery followed by adjuvant multi-agent chemotherapy was 58.7%. They also reported that 20.2%, 19.2% and 19.2% patients showed a decrease in hemoglobin levels by 1 g/dl, 1-2 g/dl and > 2 g/dl, respectively. Only 18.6% of the patients who were found to be anemic received anemia treatment. Ushering et al. (2004) monitored the nutritional status of cancer patients receiving different treatment, by follow-up assessments of the effect of type and duration of treatment on patient’s nutritional status. They found that the different treatments used for treating cancer tend to affect 19 adversely the nutritional status of the patients. A progressive decrease in weight of patients was observed as chemotherapy progressed, which was reflected in the body mass index. Hemoglobin concentrations declined substantially with radiotherapy and chemotherapy. Moderately low values of serum albumin were observed in both males (67%) and females (50%). 20 Study design & Methodology Study design: This is a prospective study. Study area: The study was conducted at the chemotherapy day unit (CDU) Riyadh Armed Forces Hospital. The CDU start at seven’ clock in the morning and breast cancer patients received chemotherapy three days in the week Monday, Tuesday, and Wednesday. The researcher review patients files every day and choose patients who met the inclusion criteria to interview them. Patients: A total of 30 female patients between 30 and 55 years of age newly diagnosed with breast cancer, scheduled for chemotherapy in Riyadh Armed Forces Hospital were included in the study. Patients who had received chemotherapy before the study, and patients with diabetes were excluded. Methods: Each patient was interviewed before chemotherapy, and follow-up assessments were performed on the third week after initiation of treatment before the second chemotherapy cycle. 21 All patients in this study received one cycle of chemotherapy, and the chemotherapy reagent patients received was 5-fluorouracil, doxorubicin, cyclophosphamide (FAC). The time between cycles was three weeks. Patients were interviewed in the day of the first cycle before treatment start and all anthropometrics measurement, dietary intake assessment, and blood sample were collected in the day of the first cycle. The researcher collected all information and parameters except the blood sample were collected by one of CDU nurses. The patients were interviewed using questionnaire that was developed after a comprehensive review of literature in this field. It was written in Arabic and consists of the following part: - Demographic-socioeconomic data contained information about age, number of children, number of full term pregnancies, breast feeding, education, family income (Appendix I). - Medical history includes data such as type of chemotherapy, vitamins and other supplementation, complaints, and diseases (Appendix I). - Dietary history data includes information about number of meals per day, main meal, fast food, snacks (Appendix I). The nutritional status of patients were assessed before and after chemotherapy through anthropometric (Height, weight, and BMI), dietary (24-hour recall, Food frequency questionnaire (FFQ)), and biochemical (Hb, MCV, and Alb) methods. 22 Dietary intake assessment: -A 24 hour food recall method was used to collect information on nutrients intake. The patients were asked to recall the types and approximate amount of food consumed over the previous 24 hour (Appendix II). - FFQ includes the most commonly eaten foods. The FFQ was used to investigate the most frequent consumed food items (weekly and daily) (Appendix III). Anthropometrics measurement: Three variables (body weight, height, BMI) were collected for the anthropometrics measurement of the patients. -Body weight was obtained by using beam balance scale (Seca mode708 scale). Weight was taken to the nearest 0.l kg. -Height was obtained by using stadiometer. Reading was reported to the nearest 0.5 cm, in duplicate and measure was taken bare footed. The patients were without head cover and their feet were to gather against the measuring board and head were kept right. - Body mass index was calculated by using equation. BMI = [weight (kg)/ height (m²)] (Appendix IV). Sample collection and laboratory measurements: Blood samples (10 ml) were collected from the patients before and 23 three weeks after the start of treatment. All laboratory measurements were carried out in the hospital. - Hb and MCV were estimated in the blood samples using coulter automated method (Packman coulter company- USA). - Alb was estimated by using bromocresol green dye (BCG) (Roche hitachi system -USA) (Appendix V). For the purpose of this study we defined anemia in breast cancer patient receiving chemotherapy according to NCI (Groopman et al. 1999) a patient with Hb <12g/l will be consider to be anemic. Statistical analysis: Statistical analysis was performed using the Statistical Package for Social Sciences (SPSS version 15). For descriptive purposes means and standard deviations (± SD) were reported. Changes in the outcome variable between baseline and the end of 3 weeks of chemotherapy were determined using t-test. 24 Results Patients’ demographic-socioeconomic characteristics The information from the questionnaire showed that a total of 30 breast cancer women receiving chemotherapy met the study criteria. Table 1 shows that 76.7 % of the patients have medium physical activity, 93.3% of them were married, 36.7% of the study subjects were university graduates, and 63.3% of them were housewife. The highest percentage (40%) of women had less than 5000 SR monthly income. Patients’ medical history Patients’ medical history showed that 26.7% of patients used supplementation. Most of the patients (56.7%) were disease free, and didn’t have any complaints. Table 2 shows that 6.7% of patients were anemic before the treatment. 20% complain the lack of appetite, and 13.3% had nausea and vomiting. Patients’ dietary history The results from the dietary survey showed that 53.3% of women had mentioned that they have three meals per day, and their main meal was lunch. 50% of them eat fast food, and 73.3% of women eat between meals (Table 3). 25 Table 1: The patients Demographic-socioeconomic characteristics. Physical activity Low Medium High Breast feeding Yes No children Marital status Married Divorce Widow Education level Illiterate Can read and write Primary Secondary High University Employment status Employed Unemployed Income Less than 5000 SR 5000 SR-7000 SR 8000SR -10'000 SR More than 10'000 SR n % 6 23 1 20.00 76.67 3.33 19 4 63.33 13.33 28 1 1 93.33 3.33 3.33 5 2 6 3 3 11 16.67 6.67 20.00 10.00 10.00 36.67 11 19 36.67 63.33 12 5 8 5 40.00 16.67 26.67 16.67 26 Table 2: The patients medical history. Type of chemotherapy Multi agent Vitamins & supplements Yes Disease High blood pressure Heart disease GI disorders Anemia Ulcers Complaints Lack of appetite Nausea &Vomiting Indigestion Constipation n % 30 100 8 26.67 5 4 1 2 1 16.67 13.33 3.33 6.67 3.33 6 4 1 2 20.00 13.33 3.33 6.67 27 Table 3: The patients dietary history . Shopping for food Weekly Monthly Preparing food The patient Patient daughter Maid Meals per day One meal Two meals Three meals More than 3 Main meal Breakfast Lunch Dinner Skip main meal Yes Fast food Yes Eat between meals Yes Snacks One Two Three n % 15 15 50.00 50.00 24 3 3 80.00 10.00 10.00 1 11 16 2 3.33 36.67 53.33 6.67 2 27 1 6.67 90.00 3.33 2 6.67 15 50.00 22 73.33 10 10 2 33.33 33.33 6.67 28 24 hour food recall The results from the 24 hour food recall showed that the mean energy intake before chemotherapy was 1445.9 kcal, and 3weeks after chemotherapy became 1445.7 kcal. This is non-significant (p=0.636) change in energy intake before and 3 weeks after chemotherapy. The REE before chemotherapy was 1602kal/kg/d, and 3weeks after chemotherapy became 1599 kal/kg/d. The t-test shows no significant (p=0.812) change in REE. The protein intake before chemotherapy was 45.86g compared with 45.83g 3 weeks after chemotherapy. The t-test shows no significant (p=0.573) change in protein intake before and 3 weeks after chemotherapy. Carbohydrate intake before chemotherapy was 150.6g, and 3 weeks after chemotherapy became 150.5g, and fat intake before chemotherapy was 36.3g compared to 36.4g after chemotherapy. No significant change in carbohydrate intake and fat intake before and 3 weeks after chemotherapy. 29 Food frequency questionnaire Table 4 a: Food frequency questionnaire Food groub Starch Meat Fat Milk Fruit Vegetable 1-3 times a week n % 11 36.37 9 30.00 22 73.33 7 23.33 10 33.33 7 23.33 4-6 times a week n % 10 33.33 15 50.00 6 20.00 14 46.67 4 13.33 6 20.00 >6 times a week n % 9 30.00 6 20.00 2 6.67 3 10.00 11 36.37 13 43.33 4-6 times a day n % 7 23.33 3 10.00 4 13.33 5 16.67 4 13.33 4 13.33 >6 times a day n % 3 10.00 0 00.00 0 00.00 1 3.33 0 00.00 0 00.00 Table 4 b: Food frequency questionnaire Food groub Starch Meat Fat Milk Fruit Vegetable 1-3 times a day n % 17 56.67 12 40 26 86.67 16 53.33 18 60.00 17 56.67 30 Weight and general characteristics Table 5a, and 5b show that the percentage of women who had gain weight was 43.3%, and women who had lost weight were 50%. It has been observed that 20% of women, who had weight loss suffered from high blood pressure, and 13.3% complained of lack of appetite, while 15.4% of those with weight gain suffered from high blood pressure, 15.3% suffered from heart disease, and 30.8% complained of lack of appetite (Table 5a). Higher weight loss prevalence (46.7%) was found among women who had 2-5 times full term pregnancies, and the prevalence of weight gain (30.8%) was observed in those who had 2-9 times full term pregnancies. The highest percentage (26.7%) of women who had weight loss had 6 children or more, while those with weight gain had 4-6 children. Table 5a shows that (33.3%) of women who had weight lost were illiterate and 33.3% were university graduates. Approximately 46.2% of women who had weight gain were university graduates, 73.3% of women who had weight loss were unemployed, and 53.9% of women who had weight gain were employed. Higher weight loss prevalence (46.7%) and weight gain (38.5%) was found among women who had a family income less than 5000 SR. The results of the dietary survey showed that 66.7% of women who had weight loss mentioned that they had three meals per day, and their 31 main meal was lunch, while 40% of them eat fast food. The highest percentage of weight loss (46.7%) was found among women who were taking two snacks per day. About 46.1% of those who gained weight had three meals per day, and their main meal was lunch, while 61.5 % of them eat fast food. The highest percentage of weight gain (38.5%) was found among women who were taking one snack per day (Table 5b). In the present study prevalence of weight gain was 43.3% (69.3 vs 70.46kg) patients weight gain was between (0.1-7.4 kg), and 69.2% of the total women who gain weight aged between 40-50 years. On the other hand women who had weight loss were 50% (72.8 vs 71.6 kg), patients loss between (0.1-7 kg), and 46.7% of the total women who had weight loss aged between 40-50 years. The t-test shows no significant change in weight before and 3 weeks after chemotherapy. 32 Table 5a : Weight and general characteristics Loss weight Variable n % Gain weight % n Age 30 - < 40 40 - < 50 ≥ 50 Vitamins and supplements intake Yes Presence of disease High blood pressure Heart disease GI disorders Anemia Ulcers Presence of complaints Lack of appetite Nausea &Vomiting Indigestion Constipation No.of pregnancies 2-5 6-9 10 - 13 > 13 No.of children Non 1-3 4-6 >6 Education level Illiterate Can read and write Primary Secondary High University Employment status Employed Unemployed 3 7 5 20.00 46.67 33.33 2 9 2 15.38 69.23 15.38 4 26.67 4 30.77 3 1 0 1 1 20.00 6.67 0 6.67 6.67 2 2 1 0 0 15.38 15.38 7.69 0 0 2 1 0 1 13.33 6.67 0 6.67 4 2 1 1 30.77 15.38 7.69 7.69 7 6 0 1 46.67 40.00 0 6.67 4 4 2 1 30.77 30.77 15.38 7.69 1 5 5 4 6.67 33.33 33.33 26.67 2 3 5 3 15.38 23.08 38.46 23.08 5 1 1 2 1 5 33.33 6.67 6.67 13.33 6.67 33.33 0 1 4 1 1 6 0 7.69 30.77 7.69 7.69 46.15 4 11 26.67 73.33 7 6 53.85 46.15 33 Table 5b : Weight and general characteristics Loss weight Variable n % Income 7 46.67 Less than 5000 SR 3 20.00 5000 SR - 7000SR 5 33.33 8000SR - 10'000 SR 0 0 More than 10'000 SR Shopping for food 66.67 Weekly 10 33.33 Monthly 5 Preparing food 66.67 She (the patient) 10 20 Patient daughter 3 13.33 Maid 2 Meals per day 6.67 One meal 1 26.67 Two meals 4 66.67 Three meals 10 0 More than 3 0 Main meal 0 Breakfast 0 93.33 Lunch 14 Dinner 1 6.67 Skipping main meal 0 Yes 0 Fast food 40.00 Yes 6 Snacks per day Non 20.00 3 33.33 One 5 46.67 Two 7 0 Three 0 Gain weight % n 5 1 3 4 38.46 7.69 23.08 30.77 5 8 38.46 61.53 12 0 1 92.31 0 7.69 0 5 6 2 0 38.46 46.15 15.38 2 11 0 15.38 84.61 0 2 15.38 8 61.53 3 5 3 2 23.08 38.46 23.08 15.38 34 Body mass indexes (BMI) Table 6 shows that before chemotherapy (30%) women consider to be normal, 16.7% overweight, 43.3% obese, and (10%) extreme obesity. After treatment 23.3% women consider normal, 26.7% women overweight, 40% women obese, and 10% have extreme obesity. Table 6:Classification of overweight and obesity by BMI Body mass index Severity Underweight Normal Overweight Obesity Extreme obesity Source: Chlebowski et al. 2002 before BMI (kg/m2) <18.5 18.5-24.9 25.0-29.9 30.0-39.9 ≥40 n 0 9 5 13 3 30 % 0 30.00 16.67 43.33 10.00 100 after n 0 7 8 12 3 30 % 0 23.33 26.67 40.00 10.00 100 35 Biochemical parameters Patients had normal albumin level 41.96 g/l before chemotherapy while 3 weeks after chemotherapy albumin level was 40.7 g/l. A significant (P<0.01) decrease in albumin was observed in patients after chemotherapy but still it is within the normal range (Alb reference 36-51g/l). Patients had normal MCV level 79.17 fl before chemotherapy while 3 weeks after chemotherapy MCV level was 79.80 fl. A non significant (P<0.23) change in MCV was observed in patients after chemotherapy but within the normal level. According to National Cancer Institute (NCI) grading system (Groopman et al. 1999) for anemia (Table 7), before chemotherapy 3.3% patient had grade 4 anemia, 3.3% patient had grade 2, 36.7% patients had grade 1, and 56.7% patient had normal hemoglobin level. Three weeks after chemotherapy 53.3% patients became grade 1, 6.7% patients had grade 2, and only 40 % patient with normal hemoglobin level. The t-test shows significant change in hemoglobin before chemotherapy and 3 weeks after chemotherapy (p 0.035). Table 7:Grading system for anemia Severity Grade 0 (WNL) Grade 1 (mild) Grade 2 (moderate) Grade 3 (severe) Grade 4 (life threatening) before Hb ≥11.0 g/dL 9.5–10.9 g/dL 8.0–9.4 g/dL 6.5–7.9 g/dl <6.5 g/dL N 17 11 1 0 1 30 % 56.67 36.67 3.33 0 3.33 100 after N 12 16 2 0 0 30 Hb: hemoglobin, WNL: within normal limits.WNL hemoglobin values are 12.0–16.0 g/dl for women. Source: Groopmanet al. 1999 % 40.00 53.33 6.67 0 0 100 36 Table 8: Patients characteristics n Mean Std.Deviation Age 30 43.43 6.88 Number of children 26 5.08 2.63 Number of full term pregnancies 26 6.54 3.64 Family size 30 7.47 4.74 Table 9: t-test for variable between baseline and 3 weeks after chemotherapy Mean SD t P Weight 0.0933 2.07 0.247 0.807 BMI 0.0226 0.83 0.149 0.883 Hb 0.4667 1.16 2.2 0.035 - 0.633 2.85 - 1.22 0.233 MCV Alb 1.233 2.46 2.747 0.018 Energy intake 0.233 2.67 0.478 0.636 Protein intake 0.033 0.31 0.571 0.573 Fat intake -0.033 0.18 -1.00 0.325 0.067 0.45 0.812 0.423 Carbohydrate intake BMI:body mass index, Hb:hemoglobin,MCV:Mean corpuscular volume Alb:Albumin.(P 0.05) 37 Discussion & Conclusion In the present study the 24 hour food recall shows that energy intake before chemotherapy was 1445.96 kcal, and 3weeks after chemotherapy became 1445.73 kcal. All patients energy intake was lower than recommended daily allowances (RDA) which is (1900-2200kcal). The REE before chemotherapy was 1602kal/kg/d, and 3weeks after chemotherapy became 1599 kal/kg/d. Our finding was different from Harvie et al. (2005). Harvie study shows that there was significant increase in energy intake among breast cancer patients over a course of chemotherapy. The difference in energy intake may be due to difference in the socioeconomic (low income) status. Also protein intake before chemotherapy was 45.86 g compared with 45.83g 3weeks after chemotherapy, and the recommended protein intake daily allowances for females in the same age of the study patients is 50g. So all patients protein intake was lower than RDA before, and after chemotherapy. However, energy and protein intake was not statistically significant in this study. Weight changes are valuable indicators of nutritional risk. Assessment of changes in body weight over time can be a more informative indicator of nutritional decline (Davies. 2005). Up to 60% of women diagnosed with breast cancer experience an increase in body weight associated with 38 chemotherapy (Holmes and Kroenke. 2004), and there is evidence that heavier women and women who gain weight after diagnosis have an increased risk of disease recurrence and death compared to normal weight women (Chlebowski et al. 2002). Women with a high BMI have double the risk of 5-year recurrence and a 60% increased risk of death over 10 years in comparison to normal weight women (Saxton et al. 2006). In the present study prevalence of weight gain was 43.3% (69.3kg vs 70.46 kg). Patients gained weight was between 0.1-7.4 kg. Although this trend was not statistically significant. In this study it has been found that 69.2% of the total women who gain weight aged between 40-50 years. Lankester et al. (2002) also reported that 64% women treated with chemotherapy gained weight. However, Campbell et al. (2007) studied 10 women undergoing adjuvant chemotherapy for breast cancer, and found that seven women gained weight. Weight change ranged from -2.9 to + 6.8 kg there was no significant weight change across treatment, and three women lost weight over the course of treatment. In Ingram and Brown (2004) study, women did not experience marked weight gain during therapy. Although in this study it has been found that 50% of the women lost weight and 46.7% of them were between 40-50 years of age, but most studies found that an overall trends toward weight gain. 39 The prevalence of weight loss was high among patients after the first cycle of chemotherapy. In this study it has been found that 50% of patients suffered from weight lost. The prevalence of weight gain between the start of treatment and 3 weeks follow up was 43.3%. These changes in weight were not statistically significant. Body mass index is positively associated with patients suffering from colon, kidney, esophagus, and breast cancer (Reeves et al. 2007). In the present study BMI before chemotherapy and 3 weeks after chemotherapy was (29.94 vs 29.92 ;P = 0.9) this changes in BMI was not statistically significant on application of t-test. This result is in contrast to the finding of Campbell et al. (2007), who found increase in BMI after chemotherapy. Biochemical and hematological parameters are subject to homeostatic mechanisms and may be altered by underlying disease and/or treatment. The most common biochemical measurements used to assess nutritional status are blood parameters such as serum albumin and hemoglobin (Davies. 2005). In this study patients had albumin level within normal range before and 3 weeks after chemotherapy (41.9g/l vs 40.7 g/l) respectively. This finding is in agreement with the finding of Usharani et al. (2004). A significant 40 decrease in albumin before chemotherapy and 3 weeks after chemotherapy ( p=0.018) was observed. Anemia is the most common hematological abnormality in cancer patients; unfortunately, it is often un-recognized and un-treated. The pathogenesis of anemia in cancer is complex and most of the time multifactorial involving factors related to the tumor itself or its therapy (Abdel-Razeq. 2004). The hemoglobin level before chemotherapy was 12g/dl and after chemotherapy was decrease to 11.5 g/dl. 43.3% of women were anemic (Hb 12 g/dl) before chemotherapy. After 3 weeks 60% of these women became anemic. This is similar to the finding of Usharani et al (2004) and Engl et al. (2005). Only two patients mentioned that they were anemic and were taking supplementation that means anemia wasn’t recognized in other patient that can affect their nutritional status. The t-test shows a significant change in hemoglobin before chemotherapy and 3 weeks after chemotherapy (p 0.035). Kallajavi et al. (2000(b)), investigated the effect of chemotherapy on various laboratory tests, and found that hemoglobin decreased transiently at 5-8 weeks but remained within the reference limits, and albumin did not change. Nutritional screening should be applied to all patients suffering from cancer. Screening should be undertaken immediately following admission to ensure that any nutritional decline due to therapy or disease progression 41 is identified as early as possible and can be dealt with. There is increasing evidence that malnutrition has an adverse impact on morbidity and mortality. This investigation has found that breast cancer patients receiving chemotherapy experiences weight change, and decrees in biochemical parameters. Therefore, these patients are at risk of malnutrition if they didn't have any help to prevent or to minimize the effect of chemotherapy on their nutritional status, moreover, there is much remains to be studied bout the nutritional status of breast cancer patient receiving chemotherapy in the Kingdom of Saudi Arabia. 42 Recommendations Based on the findings of this study, the following recommendations should be considered: All breast cancer patients receiving chemotherapy should have nutritional assessment with the start of the treatment, and should focus on current nutritional status and anticipated nutritional problems related to treatment During active cancer treatment patient should maintain adequate energy intake to prevent weight loss. Clinicians can advise their overweight or obese patients to increase physical activity, and follow a healthy diet. 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Dermatology.2007;215: 36-40. 55 Appendix I اﻟﺮﻗﻢ اﻟﺘﺴﻠﺴﻠﻲ رﻗﻢ اﻟﻤﻠﻒ ﺗﺎرﻳﺦ ﺑﺪاﻳﺔ اﻟﻌﻼج 56 )Appendix I( continue اﻟﺮﻗﻢ اﻟﺘﺴﻠﺴﻠﻲ (1اﻟﺒﻴﺎﻧﺎت اﻟﺼﺤﻴﺔ اﻟﻌﻤﺮ ﻧﻮع اﻟﻌﻼج اﻟﻜﻴﻤﻴﺎﺋﻲ اآﺜﺮ ﻣﻦ ﻋﻘﺎر ﻋﻘﺎر ﻣﻔﺮد ﻧﻌﻢ هﻞ ﺗﺘﻨﺎوﻟﻴﻦ ادوﻳﺔ ﻣﻘﻮﻳﻪ ) اﻟﻔﻴﺘﺎﻣﻴﻨﺎت او أي ادوﻳﺔ ﻣﻘﻮﻳﺔ (؟ ﻻ هﻞ اﻧﺖ ﻣﺼﺎﺑﻪ ﺑﺎي ﻣﻦ اﻻﻣﺮاض اﻟﺘﺎﻟﻴﺔ : اﻣﺮاض اﻟﻘﻠﺐ اﻣﺮاض اﻟﺠﻬﺎز اﻟﻬﻀﻤﻲ اﻣﺮاض اﻟﺮﺋﺘﻴﻦ ﺿﻐﻂ اﻟﺪم اﻣﺮاض اﻟﻜﺒﺪ اﻣﺮاض اﻟﻜﻠﻰ ﻗﺮﺣﺔ اﻟﻤﻌﺪﻩ ﻏﻴﺮ ذﻟﻚ ----------------------------------------- هﻞ ﺗﻌﺎﻧﻴﻦ ﻣﻦ أي ﻣﻦ اﻻﻋﺮاض اﻟﺘﺎﻟﻴﺔ : ﻓﻘﺪان اﻟﺸﻬﻴﺔ ﺻﻌﻮﺑﺎت ﻓﻲ اﻟﻤﻀﻎ او اﻟﺒﻠﻊ اﺿﻄﺮاﺑﺎت اﻟﻬﻀﻢ اﺳﻬﺎل ﻏﺜﻴﺎن ،ﻗﻲء اﻣﺴﺎك ﻏﻴﺮ ذﻟﻚ-------------------------- اﻟﻨﺸﺎط اﻟﺠﺴﻤﻠﻨﻲ ﻣﻨﺨﻔﺾ ﻣﺘﻮﺳﻂ ﻋﺎﻟﻲ 57 )Appendix I(continue اﻟﺮﻗﻢ اﻟﺘﺴﻠﺴﻠﻲ اذا آﺎن ﻟﺪﻳﻚ اﻃﻔﺎل اﺟﻴﺒﻲ ﻋﻦ اﻻﺗﻲ : ﻋﺪد اﻻﻃﻔﺎل ﻋﺪد ﻣﺮات اﻟﺤﻤﻞ هﻞ ﺗﺮﺿﻌﻴﻦ اﻃﻔﺎﻟﻚ رﺿﺎﻋﺔ ﻃﺒﻴﻌﻴﺔ ؟ ﻻ ﻧﻌﻢ (2اﻟﺒﻴﻠﻨﺎت اﻻﺟﺘﻤﺎﻋﻴﺔ واﻻﻗﺘﺼﺎدﻳﺔ : ﻋﺪد اﻓﺮاد اﻻﺳﺮة اﻟﺤﺎﻟﺔ اﻻﺟﺘﻤﺎﻋﻴﺔ ﻋﺰﺑﺎء ﻣﺘﺰوﺟﺔ ﻣﻄﻠﻘﺔ ارﻣﻠﺔ اﻟﻤﺴﺘﻮى اﻟﺘﻌﻠﻴﻤﻲ اﻣﻴﺔ ﺗﻘﺮا وﺗﻜﺘﺐ اﺑﺘﺪاﺋﻲ ﻣﺘﻮﺳﻂ ﺛﺎﻧﻮي ﺟﺎﻣﻌﻲ ﻓﺎآﺜﺮ ﻣﻮﻇﻔﻪ اﻟﺤﺎﻟﺔ اﻟﻮﻇﻴﻔﻴﺔ رﺑﺔ ﻣﻨﺰل دﺧﻞ اﻻﺳﺮة اﻟﺸﻬﺮي اﻗﻞ ﻣﻦ ٥٠٠٠رﻳﺎل 10000-8000رﻳﺎل 7000-5000رﻳﺎل اآﺜﺮ ﻣﻦ ١٠٠٠٠رﻳﺎل 58 )Appendix I( continue اﻟﺮﻗﻢ اﻟﺘﺴﻠﺴﻠﻲ ﻣﻊ ﻣﻦ ﺗﻌﻴﺸﻴﻦ ؟ -------------------------------------- آﻢ ﻣﺮة ﺗﺸﺘﺮﻳﻦ اﺣﺘﻴﺎﺟﺎت اﻟﻤﻨﺰل اﻟﻐﺬاﺋﻴﺔ ؟ ------------------------------------------- ﻣﻦ ﻳﻘﻮم ﺑﺎﻋﺪاد اﻟﻄﻌﺎم ﻟﻚ ؟-------------------------------------------------- (3اﻟﺒﻴﺎﻧﺎت اﻟﻐﺬاﺋﻴﺔ آﻢ ﻋﺪد اﻟﻮﺟﺒﺎت اﻟﻐﺬاﺋﻴﺔ اﻟﺘﻲ ﺗﺘﻨﺎوﻟﻴﻨﻬﺎ ﺧﻼل اﻟﻴﻮم ؟ وﺟﺒﺔ وﺟﺒﻴﻦ ﺛﻼث وﺟﺒﺎت اآﺜﺮ ﻣﻦ ﺛﻼث وﺟﺒﺎت ﻣﺎهﻲ اﻟﻮﺟﺒﺔ اﻟﺮﺋﻴﺴﻴﺔ ﺧﻼل اﻟﻴﻮم ؟ ﻓﻄﻮر ﻏﺪاء هﻞ اﻧﺖ ﻣﻌﺘﺎدة ﻋﻠﻰ ﻋﺪم ﺗﺘﻨﺎول اﻟﻮﺟﺒﺔ اﻟﺮﺋﻴﺴﻴﺔ؟ هﻞ ﺗﺘﻨﺎوﻟﻴﻦ اﻟﻮﺟﺒﺎت اﻟﺴﺮﻳﻌﺔ؟ ﻧﻌﻢ ﻋﺸﺎء ﻻ ﻧﻌﻢ ﻻ اذا آﺎﻧﺖ اﻻﺟﺎﺑﺔ ﺑﻨﻌﻢ ﻓﻤﺎ هﻲ اﻟﻮﺟﺒﺔ اﻟﺘﻲ ﺗﻔﻀﻠﻴﻨﻬﺎ؟----------------------------------- هﻞ اﻧﺖ ﻣﻌﺘﺎدة ﻋﻠﻰ ﺗﺘﻨﺎوﻟﻴﻦ أي ﻧﻮع ﻣﻦ اﻟﻄﻌﺎم ﺑﻴﻦ اﻟﻮﺟﺒﺎت؟ آﻢ ﻋﺪد اﻟﻤﺮات اﻟﺘﻲ ﺗﺘﻨﺎوﻟﻴﻦ ﻓﻴﻬﺎ اﻟﻄﻌﺎم ﺑﻴﻦ اﻟﻮﺟﺒﺎت ؟ ﻣﺮة ﻣﺮﺗﻴﻦ ﺛﻼث ﻣﺮات اآﺜﺮ ﻣﻦ ﺛﻼث ﻣﺮات ﻧﻌﻢ ﻻ 59 Appendix II اﻟﺮﻗﻢ اﻟﺘﺴﻠﺴﻠﻲ اﻟﻮﺟﺒﺎت اﻟﻐﺬاﺋﻴﺔ ﻟﻠﻴﻮم اﻟﺴﺎﺑﻖ اﻟﻄﺎﻗﺔ اﻟﺪهﻦ اﻟﻮﺟﺒﺔ اﻟﻔﻄﻮر وﺟﺒﺔ ﺧﻔﻴﻔﺔ اﻟﻐﺪاء وﺟﺒﺔ ﺧﻔﻴﻔﺔ اﻟﻌﺸﺎء وﺟﺒﺔ ﺧﻔﻴﻔﺔ ﺑﺮوﺗﻴﻦ ﻧﻮع اﻟﻄﻌﺎم ﻧﺸﺎء اﻟﻜﻤﻴﺔ 60 Appendix III اﻟﺮﻗﻢ اﻟﺘﺴﻠﺴﻠﻲ ﻧﻮع اﻟﻄﻌﺎم ﺧﺒﺰ ﺑﺴﻜﻮت رز آﻮرن ﻓﻠﻴﻜﺲ ﻣﻜﺮوﻧﺔ ﻟﺤﻢ ﺟﻤﻞ ﻟﺤﻢ ﻏﻨﻢ ﻟﺤﻢ ﺑﻘﺮ آﺒﺪ دﺟﺎج ﺳﻤﻚ ﺟﻤﺒﺮي ﺑﻴﺾ ﺳﺠﻖ زﻳﺖ ﻧﺒﺎﺗﻲ زﻳﺖ زﻳﺘﻮن ﺳﻤﻦ ﻣﺎﻳﻮﻧﻴﺰ ﻣﺎرﺟﻴﻦ زﺑﺪة ﺣﻠﻴﺐ آﺎﻣﻞ اﻟﺪﺳﻢ ﺣﻠﻴﺐ ﻗﻠﻴﻞ اﻟﺪﺳﻢ ﺣﻠﻴﺐ ﻣﻨﺰوع ﻟﺒﻦ آﺎﻣﻞ اﻟﺪﺳﻢ ﻟﺒﻦ ﻗﻠﻴﻞ اﻟﺪﺳﻢ ﻟﺒﻦ ﻣﻨﺰوع زﺑﺎدي ﺟﺒﻨﺔ ﻟﺒﻨﺔ ﺗﻔﺎح ﻣﻮز ﺷﻤﺎم ﻓﻲ اﻻﺳﺒﻮع اﺑﺪا ﻣﺮﻩ ٣-٢ ﻓﻲ اﻟﻴﻮم ٦-٤ ﻣﺮة ٢ ٣ <٣ 61 )Appendix III (continue اﻟﺮﻗﻢ اﻟﺘﺴﻠﺴﻠﻲ ﻧﻮع اﻟﻄﻌﺎم ﺑﺮﺗﻘﺎل ﺑﻄﻴﺦ ﺗﻤﺮ ﺟﺰر ﺑﻄﺎﻃﺲ ﻃﻤﺎﻃﻢ ﺧﻴﺎر ﻣﻠﻔﻮف ﺑﺎﻣﻴﺔ ﺑﺎذﻧﺠﺎن ﺳﻠﻄﺔ ﻣﺮﺑﻰ ﻋﺴﻞ ﻣﻜﺴﺮات ﺑﺮﺟﺮ ﻟﺤﻢ ﺑﺮﺟﺮ دﺟﺎج ﺑﻴﺘﺰا ﺑﻄﺎﻃﺲ ﻣﻘﻠﻲ ﻣﺮﻗﻮق ﻣﻄﺎزﻳﺰ ﺟﺮﻳﺶ آﺒﺴﺔ ﻣﻨﺪي ﺣﻨﻴﻨﻲ ﻗﺮﺻﺎن ﺷﺎي ﻗﻬﻮﻩ ﻣﺸﺮوﺑﺎت ﻏﺎزﻳﺔ ﻋﺼﻴﺮ ﻓﻮاآﺔ ﻏﻴﺮ ذﻟﻚ ﻓﻲ اﻻﺳﺒﻮع اﺑﺪا ﻣﺮﻩ ٣-٢ ﻓﻲ اﻟﻴﻮم ٦-٤ ﻣﺮة ٢ ٣ <٣ 62 Appendix IV Anthropometric measurements: 0 before the start of chemotherapy Height Weight BMI 3weeks after the start of chemotherapy 63 Appendix V Biochemical measurements: Laboratory test Hb before chemotherapy Hb after chemotherapy MCV before chemotherapy MCV after chemotherapy Alb before chemotherapy Alb after chemotherapy Level Reference Units 11.5 ـ16.5 g/dl 75 ـ95 fl 36 ـ51 g/L 64 Appendix VI The five steps of a breast self-examination Step 1: Begin by looking at your breasts in the mirror with your shoulders straight and your arms on your hips and you should look for: - Breasts that are their usual size, shape, and color - Breasts that are evenly shaped without visible distortion or swelling If you see any of the following changes, bring them to your doctor's attention: - Dimpling, puckering, or bulging of the skin. - A nipple that has changed position or an inverted nipple (pushed inward instead of sticking out) redness, soreness, rash, or swelling. Step 2: Now, raise your arms and look for the same changes. Step 3: While you're at the mirror, gently squeeze each nipple between your finger and thumb and check for nipple discharge (this could be a milky or yellow fluid or blood). Step 4: Next, feel your breasts while lying down, using your right hand to feel your left breast and then your left hand to feel your right breast. Use a firm, smooth touch with the first few fingers of your hand, keeping the fingers flat and together. Cover the entire breast from top to bottom, side to side—from your collarbone to the top of your abdomen, and from your armpit to your cleavage. 65 Follow a pattern to be sure that you cover the whole breast. You can begin at the nipple, moving in larger and larger circles until you reach the outer edge of the breast. You can also move your fingers up and down vertically, in rows, as if you were moving a lawn. Be sure to feel all the breast tissue: just beneath your skin with a soft touch and down deeper with a firmer touch. Begin examining each area with a very soft touch, and then increase pressure so that you can feel the deeper tissue, down to your ribcage. Step 5: Finally, feel your breasts while you are standing or sitting. Many women find that the easiest way to feel their breasts is when their skin is wet and slippery, so they like to do this step in the shower. Cover your entire breast, using the same hand movements described in Step 4. (Breastcancer.2007). 66 اﻟﻤﻠﺨﺺ اﻟﻌﺮﺑﻲ ﺳﺮﻃﺎن اﻟﺜﺪي هﻮ اﻟﺴﺮﻃﺎن اﻷآﺜﺮ ﺷﻴﻮﻋﺎ ﻟﺪى اﻟﻨﺴﺎء .ﻣﻌﻈﻢ اﻟﺪراﺳﺎت ﺗﻬﺪف إﻟﻰ ﻣﻌﺮﻓﺔ ﺗﺄﺛﻴﺮ اﻟﻌﻼج اﻟﻜﻴﻤﻴﺎﺋﻲ ﻋﻠﻰ اﻟﻤﺮض واﻟﺸﻔﺎء ﻣﻨﻪ .وﻟﻜﻦ اﻟﺪراﺳﺎت اﻟﺘﻲ ﺑﺤﺜﺖ ﻓﻲ ﺗﺄﺛﻴﺮ اﻟﻌﻼج اﻟﻜﻴﻤﻴﺎﺋﻲ ﻋﻠﻰ اﻟﻮﺿﻊ اﻟﻐﺬاﺋﻲ ﻗﻠﻴﻠﺔ ﺟﺪا. اﻟﻮﺿﻊ اﻟﻐﺬاﺋﻲ ﻟﻤﺮﺿﻰ اﻟﺴﺮﻃﺎن ﻳﻤﻜﻦ أن ﻳﺘﺄﺛﺮ ﺑﺎﻟﻤﺮض واﻟﻌﻼج اﻟﻤﺴﺘﺨﺪم ﻟﻤﺮﺿﻰ اﻟﺴﺮﻃﺎن. اﻟﺘﻐﺬﻳﺔ أﺛﻨﺎء اﻟﻌﻼج اﻟﻜﻴﻤﻴﺎﺋﻲ ﻣﻬﻤﺔ ﻟﺼﺤﺔ اﻟﻤﺮﻳﺾ .اﻟﻬﺪف اﻟﺮﺋﻴﺴﻲ ﻗﺒﻞ وأﺛﻨﺎء وﺑﻌﺪ اﻟﻌﻼج اﻟﻜﻴﻤﻴﺎﺋﻲ هﻮ إﻋﻄﺎء اﻟﻤﺮﻳﺾ اﻟﺴﻌﺮات اﻟﺤﺮارﻳﺔ اﻟﻜﺎﻓﻴﺔ ﻟﻠﻤﺤﺎﻓﻈﺔ ﻋﻠﻰ اﻟﻮزن وﻟﻠﻤﺤﺎﻓﻈﺔ ﻋﻠﻰ اﻟﺒﺮوﺗﻴﻦ أﻻزم ﻻﺳﺘﻤﺮار ﺟﻬﺎز اﻟﻤﻨﺎﻋﺔ .ﻟﺬاﻟﻚ ﻓﺈن هﺬﻩ اﻟﺪراﺳﺔ ﺗﻬﺪف إﻟﻰ ﺗﻘﻴﻴﻢ اﻟﻮﺿﻊ اﻟﻐﺬاﺋﻲ ﻟﻤﺮﺿﻰ ﺳﺮﻃﺎن اﻟﺜﺪي اﻟﺬﻳﻦ ﻳﺘﻠﻘﻮن اﻟﻌﻼج اﻟﻜﻴﻤﻴﺎﺋﻲ ،وﺗﻘﻴﻴﻢ ﺗﺄﺛﻴﺮ اﻟﻌﻼج اﻟﻜﻴﻤﻴﺎﺋﻲ ﻋﻠﻰ اﻟﻮزن ، واﻟﺴﻌﺮات اﻟﺤﺮارﻳﺔ ،و اﻻﺑﻴﻮﻣﻴﻦ ،و اﻟﻬﻴﻤﻮﻏﻠﻮﺑﻴﻦ. اﻟﺪراﺳﺔ أﺟﺮﻳﺖ ﻓﻲ ﻣﺴﺘﺸﻔﻰ اﻟﻘﻮات اﻟﻤﺴﻠﺤﺔ ﺑﺎﻟﺮﻳﺎض ﺷﻤﻠﺖ اﻟﺪراﺳﺔ ﻣﺎ ﻣﺠﻤﻮﻋﻪ ٣٠اﻣﺮأة ﻣﺼﺎﺑﺔ ﺑﺴﺮﻃﺎن اﻟﺜﺪي ﻋﻤﺮهﺎ ﻣﺎ ﺑﻴﻦ ٢٥إﻟﻰ ٥٥ﺳﻨﺔ ،واﻟﻼﺗﻲ ﻳﺘﻠﻘﻴﻦ اﻟﻌﻼج اﻟﻜﻴﻤﻴﺎﺋﻲ ﻟﻠﻤﺮة اﻷوﻟﻰ .ﺗﻢ اﺳﺘﺒﻌﺎد اﻟﻤﺮﻳﻀﺎت اﻟﻼﺗﻲ ﺗﻠﻘﻴﻦ اﻟﻌﻼج اﻟﻜﻴﻤﻴﺎﺋﻲ ﻣﻦ ﻗﺒﻞ واﻟﻤﺼﺎﺑﺎت ﺑﻤﺮﺿﻰ اﻟﺴﻜﺮي. أﺟﺮﻳﺖ ﻣﻘﺎﺑﻠﺔ ﻟﻜﻞ ﻣﺮﻳﻀﺔ ﻗﺒﻞ ﺑﺪء اﻟﻌﻼج اﻟﻜﻴﻤﻴﺎﺋﻲ ،وﺑﻌﺪ ﺛﻼﺛﺔ أﺳﺎﺑﻴﻊ ﻣﻦ ﺑﺪاﻳﺘﻪ .وﻗﺪ اﺳﺘﺨﺪام اﺳﺘﺒﻴﺎﻧﻪ ﻓﻲ إﺟﺮاء اﻟﻤﻘﺎﺑﻠﺔ ،اﻻﺳﺘﺒﻴﺎن ﺗﻀﻤﻦ ﻣﻌﻠﻮﻣﺎت ﻋﻦ اﻟﺘﺎرﻳﺦ اﻟﻄﺒﻲ ،واﻻﺟﺘﻤﺎﻋﻲ، واﻻﻗﺘﺼﺎدي ،واﻟﺘﺎرﻳﺦ اﻟﻐﺬاﺋﻲ. ﺗﻢ ﺟﻤﻊ اﻟﺒﻴﺎﻧﺎت اﻟﺘﺎﻟﻴﺔ ﻣﻦ ﻗﺒﻞ اﻟﺒﺎﺣﺜﺔ ﻋﻦ اﻟﻤﺮﻳﻀﺎت اﻟﻼﺗﻲ ﺷﻤﻠﺘﻬﻦ اﻟﺪراﺳﺔ: اﻟﻘﻴﺎﺳﺎت اﻟﻤﺘﺮﻳﺔ :اﻟﻄﻮل واﻟﻮزن وﻣﺆﺷﺮ آﺘﻠﺔ اﻟﺠﺴﻢ )اﻟﻜﺘﻠﺔ( ﺳﺠﻠﺖ ﻗﺒﻞ اﻟﻌﻼج اﻟﻜﻴﻤﻴﺎﺋﻲ ،وﺑﻌﺪ ﺛﻼﺛﺔ أﺳﺎﺑﻴﻊ ﻣﻦ ﺑﺪء اﻟﻌﻼج اﻟﻜﻴﻤﻴﺎﺋﻲ. ُأﺧﺬت ﻋﻴﻨﻪ ﻣﻦ اﻟﺪم ﻗﺒﻞ اﻟﺒﺪء ﺑﺎﻟﻌﻼج اﻟﻜﻴﻤﻴﺎﺋﻲ ،وﺑﻌﺪ ﺛﻼﺛﺔ أﺳﺎﺑﻴﻊ ﻣﻦ ﺑﺪء اﻟﻌﻼج اﻟﻜﻴﻤﻴﺎﺋﻲ .وﻗﺪ 67 اﺳﺘﺨﺪﻣﺖ ﻟﺘﻘﺪﻳﺮ اﻟﻬﻴﻤﻮﻏﻠﻮﺑﻴﻦ ،واﻻﻟﺒﻴﻮﻣﻴﻦ .أﺟﺮﻳﺖ اﻟﺘﺤﺎﻟﻴﻞ ﻓﻲ ﻣﺨﺘﺒﺮات اﻟﻤﺴﺘﺸﻔﻰ. اﻟﻨﺘﺎﺋﺞ: أﻇﻬﺮت اﻟﺪراﺳﺔ أن ﻣﻌﺪل ﺧﺴﺎرة اﻟﻮزن آﺎن ﻋﺎﻟﻴﺎ ﺑﻴﻦ اﻟﻤﺮﺿﻰ ﺑﻌﺪ ﺗﻠﻘﻴﻬﻢ اﻟﻌﻼج اﻟﻜﻴﻤﻴﺎﺋﻲ وﺟﺪﻧﺎ أن ٪٥٠ﻣﻦ اﻟﻤﺮﺿﻰ ﻋﺎﻧﻮا ﻣﻦ ﻧﻘﺺ اﻟﻮزن وذﻟﻚ ﺑﻌﺪ أول ﺟﻠﺴﺔ ﻣﻦ اﻟﻌﻼج اﻟﻜﻴﻤﻴﺎﺋﻲ ﻣﻤﺎ ﻳﻮﺿﺢ ﻣﺪى ﺗﺄﺛﻴﺮ اﻟﻌﻼج ﻋﻠﻰ اﻟﻮزن. ﻣﻌﺪل زﻳﺎدة اﻟﻮزن ﻣﺎ ﺑﻴﻦ ﺑﺪاﻳﺔ اﻟﻌﻼج واﻟﺜﻼث أﺳﺎﺑﻴﻊ اﻟﺘﺎﻟﻴﺔ ﺑﻠﻐﺖ ٪٤٣٫٣٣وهﺬﻩ ﻧﺴﺒﺔ ﻣﻘﺎرﺑﺔ ﻟﻤﻌﺪل ﺧﺴﺎرة اﻟﻮزن ﻟﻨﻔﺲ اﻟﻤﺠﻤﻮﻋﺔ وهﺬا ﻳﺠﻌﻠﻨﺎ ﻧﺴﺘﻨﺘﺞ أن اﻟﻌﻼج اﻟﻜﻴﻤﻴﺎﺋﻲ ﻟﻪ ﺗﺄﺛﻴﺮﻳﻦ ﻣﺘﻀﺎدﻳﻦ ﻋﻠﻰ اﻟﻮزن ﻓﻬﻮ ﻗﺪ ﻳﻮدي إﻟﻰ زﻳﺎدة أو ﻧﻘﺼﺎن ﻓﻲ اﻟﻮزن. ٪٤٣٫٣٣ﻣﻦ اﻟﻤﺮﺿﻰ آﺎﻧﻮا ﻣﺼﺎﺑﻴﻦ ﺑﻔﻘﺮ اﻟﺪم ) هﻴﻤﻮﺟﻠﻮﺑﻴﻦ اﻗﻞ ﻣﻦ ١٢ﺟﺮام( ﻗﺒﻞ اﻟﻌﻼج وﺑﻌﺪ ٣اﺳﺎﺑﻴﻊ ﻣﻦ ﺑﺪاﻳﺔ اﻟﻌﻼج ارﺗﻔﻌﺖ اﻟﻨﺴﺒﺔ ﻟﺘﺼﺒﺢ .٪٦٠ﻣﻦ هﺬﻩ اﻟﻨﺴﺒﺔ ﻣﺮﻳﻀﺘﻴﻦ ﻓﻘﻂ آﺎن ﻟﺪﻳﻬﻤﺎ ﺗﺸﺨﺺ ﻣﺴﺒﻖ ﺑﻔﻘﺮ اﻟﺪم ﻗﺒﻞ اﻟﻌﻼج. اﻟﺘﻮﺻﻴﺎت: اﺳﺘﻨﺎدا إﻟﻰ ﻧﺘﺎﺋﺞ اﻟﺪراﺳﺔ ﻧﻮﺻﻲ ﺑﻤﺎ ﻳﻠﻲ: ﻳﻨﺒﻐﻲ ﺗﻘﻴﻴﻢ اﻟﺤﺎﻟﺔ اﻟﻐﺬاﺋﻴﺔ ﻟﻜﻞ ﻣﺮﺿﻰ ﺳﺮﻃﺎن اﻟﺜﺪي اﻟﺬﻳﻦ ﻳﺘﻠﻘﻮن اﻟﻌﻼج اﻟﻜﻴﻤﻴﺎﺋﻲ ﻣﻊ ﺑﺪاﻳﺔ اﻟﻌﻼج ،وﻳﻨﺒﻐﻲ اﻟﺘﺮآﻴﺰ ﻋﻠﻰ اﻟﻮﺿﻊ اﻟﻐﺬاﺋﻲ اﻟﺤﺎﻟﻲ و ﻣﺸﺎآﻞ اﻟﺘﻐﺬﻳﺔ اﻟﻤﺘﻮﻗﻌﺔ اﻟﻤﺘﻌﻠﻘﺔ ﺑﺎﻟﻌﻼج. أﺛﻨﺎء اﻟﻌﻼج اﻟﻜﻴﻤﻴﺎﺋﻲ ﻳﺠﺐ اﻟﻤﺤﺎﻓﻈﺔ ﻋﻠﻰ آﻤﻴﺔ ﻣﺘﻮازﻧﺔ ﻣﻦ اﻟﻄﺎﻗﺔ ﻟﻤﻨﻊ ﻓﻘﺪان اﻟﻮزن. ﻳﻤﻜﻦ ﻟﻸﻃﺒﺎء ﻧﺼﺢ ﻣﺮﺿﺎهﻢ ذوي اﻟﻮزن اﻟﺰاﺋﺪ واﻟﻤﺼﺎﺑﻴﻦ ﺑﺎﻟﺴﻤﻨﺔ إﻟﻰ زﻳﺎدة اﻟﻨﺸﺎط اﻟﺒﺪﻧﻲ ،وإﺗﺒﺎع ﻧﻈﺎم ﻏﺬاﺋﻲ ﺻﺤﻲ. ﻧﺤﺘﺎج إﻟﻰ زﻳﺎدة اﻷﺑﺤﺎث ﻟﺘﺤﺪﻳﺪ اﻟﻮﺿﻊ اﻟﻐﺬاﺋﻲ ﻟﻤﺮﺿﻰ ﺳﺮﻃﺎن اﻟﺜﺪي اﻟﺬﻳﻦ ﻳﺘﻠﻘﻮن اﻟﻌﻼج اﻟﻜﻴﻤﻴﺎﺋﻲ ﻟﻤﻨﻊ ﻧﻘﺺ اﻟﻌﻨﺎﺻﺮ اﻟﻐﺬاﺋﻴﺔ وﺗﺤﺴﻴﻦ ﻧﻮﻋﻴﺔ اﻟﺤﻴﺎة.