High prevalence and risk factors of undernutrition in adult cancer patients at Hawassa University Hospital: a call for targeted interventions

Introduction

Cancer is a severe illness marked by the uncontrolled proliferation of abnormal cells within particular tissues or organs, posing a serious threat to normal bodily functions (Saini et al., 2020). These malignant cells can invade surrounding tissues and spread to other areas of the body, causing a range of symptoms and health complications depending on the location and stage of the disease (American Cancer Society, 2019a; American Cancer Society, 2019b). Globally, cancer holds a prominent place in public health concerns, currently ranking as the second leading cause of death after cardiovascular diseases. Studies from various regions, including Europe and North America, have indicated that approximately one in every two hundred people will develop cancer during their lifetime (American Cancer Society, 2019b; Public Health Canada, 2018; Cancer trends report, 2023). It is estimated that cancer accounts for one in every six deaths worldwide (Mathur, Nain & Sharma, 2015). An individual’s risk of developing cancer is influenced by several factors, such as age, dietary and lifestyle habits, genetic predisposition, and environmental exposures (Blackadar, 2016).

Malnutrition remains a widespread issue among cancer patients in Ethiopia, with reported prevalence rates ranging from 48.1% to 58.4%, influenced by factors such as disease stage, loss of appetite, and gastrointestinal complications like diarrhea (Muhamed et al., 2022; Gebremedhin, Cherie & Tolera, 2021). In sub-Saharan Africa, the cancer burden is also considerable, with approximately 800,000 new cancer cases and 500,000 cancer-related deaths recorded in 2020. Breast cancer (129,400 cases among women) and cervical cancer (110,300 cases) together accounted for nearly 30% of all cancer diagnoses in both sexes (Bray & Parkin, 2022).

Projections by the World Health Organization (WHO) estimate that by 2035, there will be 24 million new cancer cases and 14.5 million related deaths globally each year (WHO, 2020). In sub-Saharan Africa specifically, cancer incidence is expected to rise by 85%, reaching about 1.28 million new cases and 970,000 deaths annually by 2030 (Hamdi et al., 2021).

Within Ethiopia, cancer accounts for roughly 5.8% of all national mortality according to the National Cancer Registry (FMoH, 2015). Data from Addis Ababa suggest approximately 64,000 new cancer cases are diagnosed annually, a number expected to increase as behaviors associated with economic transition—including smoking, substance use, poor dietary habits, and physical inactivity—become more widespread (Misganaw et al., 2015). A review of national cancer trends between 2010 and 2019 estimated 53,560 new cancer cases and 39,480 cancer-related deaths (Awedew, Asefa & Belay, 2022). Among these, breast cancer leads as the most common cause of cancer mortality, responsible for 22.6% of deaths, followed by cervical cancer (9.3%), leukemia (6.1%), non-Hodgkin’s lymphoma (4.8%), and colon cancer (4.5%) (Afework et al., 2022). Collectively, these figures reflect cancer’s growing impact as a serious and escalating public health concern in Ethiopia.

The relationship between nutrition and cancer has been acknowledged since the early 20th century. Both the disease itself and its treatments can negatively affect taste, smell, appetite, and the body’s ability to consume or absorb necessary nutrients, often leading to malnutrition—a condition caused by insufficient intake of essential nutrients. Malnutrition in cancer patients contributes to fatigue, weakness, impaired immunity, and reduced capacity to tolerate treatment (Muthike, Imungi & Muchemi, 2017).

Various studies has highlighted the adverse consequences of malnutrition in individuals with cancer, including worsened health outcomes, reduced survival rates, and increased healthcare costs (Arends et al., 2017a; Arends et al., 2017b; Van Cutsem & Arends, 2015; Van Tap et al., 2023). It has been linked to impaired immune function, greater susceptibility to infections, increased psychological stress, and significant loss of body weight and muscle mass (Martin, Senesse & Gioulbasanis, 2015; Nishikawa et al., 2021).

For example, a study from Japan involving gastric cancer patients reported a markedly higher incidence of surgical site infections among malnourished patients compared to those with adequate nutritional status (36% vs. 14%, P < 0.0001) (Arends et al., 2017a; Arends et al., 2017b). Weight loss remains a primary sign of cancer cachexia—a complex, inflammation-driven wasting syndrome common in advanced cancer stages. Even modest weight loss (over 2.4%) at the time of diagnosis is associated with increased risks of complications and mortality (Madeddu et al., 2018). Severe pre-treatment weight loss in cancer patients can range from 7% to 57%, further contributing to poor clinical outcomes and higher complication rates (Zhu, Wang & Gao, 2018).

Malnutrition is the second most frequently diagnosed condition among cancer patients. This nutritional risk results from a complex and multifaceted process that goes beyond simple starvation, involving factors such as psychological distress, poor dietary intake, gastrointestinal disturbances, elevated energy demands, decreased physical activity, and metabolic alterations affecting different organs and tissues (Martin, Senesse & Gioulbasanis, 2015; Muscaritoli, Lucia & Farcomeni, 2017). These challenges are largely driven by disease-related metabolic changes, severe side effects from cancer treatments, and socioeconomic barriers (Ferigollo & Bazzan, 2018). Treatment-associated complications—including fatigue, dry mouth, nausea, constipation, and diarrhea—further interfere with a patient’s ability to consume adequate food and fluids (Milliron, Packel & Dychtwald, 2022).

While certain groups of cancer patients are at higher risk for malnutrition, evidence suggests that many of these patients remain untreated for this condition (Trujillo, Claghorn & Dixon, 2019). A prospective observational study across 22 oncology centers in Italy reported that 15–20% of cancer patients were malnourished at the time of diagnosis, with rates climbing to 80–90% among those with advanced-stage disease (Muscaritoli, Lucia & Farcomeni, 2017). Moreover, it is estimated that 10–20% of cancer-related deaths are due to the effects of malnutrition rather than the cancer itself (Arends et al., 2017a; Arends et al., 2017b). These findings confirm that malnutrition is not only common but also a significant contributor to increased morbidity and mortality in this population (Gu et al., 2019).

Research indicates that malnourished cancer patients often endure longer hospital stays (Li et al., 2018; Abrha et al., 2019). In contrast, those who maintain a varied and balanced diet are better able to meet their nutritional needs (Arimond et al., 2011; Labadarios, Steyn & Nel, 2011). A diverse diet has been associated with lower risks of disease recurrence and functional decline in cancer patients. Nutritional guidelines emphasize the importance of dietary variety to ensure adequate intake of micronutrients and energy, particularly for individuals at risk of deficiencies. Maintaining proper nutritional status can improve treatment outcomes, enhance immune function, and support recovery throughout cancer care (Muthike, Imungi & Muchemi, 2017; Schwedhelm et al., 2016; Ravasco, 2019; Arends et al., 2017a; Arends et al., 2017b; Doyle et al., 2006).

Given this evidence, early nutritional assessment is crucial for implementing timely and effective nutritional interventions, reducing complications, and improving patient survival rates (Parsons et al., 2023). Recognizing the central role of nutrition in cancer management, this study aims to provide updated and comprehensive insights into the nutritional challenges faced by cancer patients. Using structured questionnaires and the Patient-Generated Subjective Global Assessment short form (PG-SGA-SF) (Naphat, Nuttapong & Somthawin, 2021), this study also explores the key factors influencing the nutritional status of patients receiving care at the Hawassa University Comprehensive Specialized Hospital Cancer Treatment Center.

Material and Methods

Data collection methods and variables

Results

Lifestyle characteristics of patients with cancer

Our results showed varying levels of substance use among the study participants. Specifically, 27.2% reported consuming alcohol, while 6.4% and 14% indicated smoking and chewing khat habits, respectively (Fig. 1). Chewing chat and alcohol consumption can significantly affect dietary intake by influencing appetite, nutrient absorption, and food choices. Chat chewing can suppress appetite, leading to reduced food intake, while alcohol consumption may result in poor dietary choices and nutrient loss from the body. Both behaviors can adversely affect overall nutrition.

Dietary diversity of the respondents

Among the 393 participants, a significant proportion, 63.4%, had low dietary diversity scores, while 31.3% achieved medium dietary diversity, and only 5.3% attained high dietary diversity. This finding highlights a considerable dietary inadequacy among cancer patients in the study setting, indicating that most patients are at risk of micronutrient deficiencies due to limited variety in their daily food intake (Fig. 2).

Discussion

This study aimed to assess the nutritional status and related factors among adult cancer patients at the Hawassa University Comprehensive Specialized Hospital Cancer Treatment Center. The findings showed that more than half of the patients were undernourished, with prevalence rates similar to those reported in other Ethiopian studies and some international settings. For example, studies conducted in Addis Ababa hospitals found undernutrition rates of 58.4% and 57% (Parsons et al., 2023; Adam et al., 2023), and a Saudi Arabian study reported a prevalence of 51.1% (Alsaleh et al., 2021). However, the rate observed in this study was lower compared to reports from countries like South Korea (61%) (Wie et al., 2010), Iran (60.7%) (Shahvazi, Onvani & Heydari, 2017), China (77%) (Ge, Lin & Yang, 2019), Brazil (71.1%) (Ferigollo et al., 2018), and the Philippines (83%) (Caballero, Lapitan & Buckley, 2013). Conversely, our results were higher than those from West China Hospital (39.5%) (Zhu, Wang & Gao, 2018) and Egypt (33%) (Abd Allah, Gad & Abdel-Aziz, 2020). Such differences may arise from variations in population characteristics, sample sizes, sampling techniques, socioeconomic status, healthcare quality, or nutritional assessment tools.

In this study, low dietary diversity significantly influenced nutritional status. Cancer patients with lower dietary diversity scores were more prone to malnutrition, a pattern consistent with findings from Ethiopia and Iraq (Fattahi et al., 2020; Girma & Nana, 2023). Since dietary diversity reflects diet quality, patients consuming fewer food groups likely have inadequate nutrient intake, increasing their risk of undernutrition.

The study also identified semi-solid and liquid diets as major contributors to undernutrition, with 40.3% of patients unable to eat solid foods. Adequate nutrition is critical to managing treatment side effects and supporting immune function, yet many patients experience difficulties such as dysphagia and nausea. Similar studies report that problems with chewing and swallowing solid foods are common among cancer patients undergoing therapy (Chen et al., 2018). These issues can be aggravated by conditions like dry mouth, frequently observed in cancer patients (Dysphagia Section Oral Care Study Group et al., 2012), which reduces nutrient density intake and worsens malnutrition.

Additionally, 41.5% of patients reported nausea, which showed a strong association with undernutrition. Nausea and vomiting are well-known side effects of chemotherapy that significantly impair nutritional status (Rao & Faso, 2012; Farrell et al., 2013). This link aligns with other research showing that patients experiencing nausea and poor appetite are at elevated risk of malnutrition (Conigliaro et al., 2020; Muhamed et al., 2022), highlighting the importance of symptom management in nutritional care.

Constipation was also found to be a significant factor related to undernutrition in this patient population. Affecting nearly 60% of cancer patients (Wickham, 2017), constipation often results from cancer treatments, opioid use, surgeries, immobility, low-fiber diets, and dehydration. Consistent with prior studies (FAO & FHI, 2016; Viana et al., 2020), constipation was commonly reported and negatively impacted nutrition by reducing appetite due to discomfort and by impairing digestion and nutrient absorption. These results underline the necessity of effective constipation management to improve nutritional outcomes.

Overall, the findings emphasize the critical role of healthcare professionals in cancer treatment centers to identify and manage factors contributing to undernutrition. Personalized and comprehensive nutritional care is essential to optimize treatment success (Gabor, Stein & Tommy, 2021). Despite increasing recognition of the importance of nutrition in cancer care, research from Ethiopia and elsewhere shows that healthcare providers often lack adequate nutritional knowledge and practices (Biruk et al., 2020; Alkhaldy, 2019; Munuo et al., 2016; Caldow, Palermo & Wilson, 2022; Tafese & Shele, 2015). Therefore, the current quality of nutrition-related care in the study setting requires further evaluation through longitudinal and controlled studies.

The strength of this study lies in identifying malnutrition risk factors specific to cancer patients, highlighting the need for tailored regional and temporal interventions. However, its cross-sectional design limits the ability to establish cause-and-effect relationships.

Conclusions

This study uncovers a notably high prevalence of undernutrition among adult cancer patients at the Hawassa University Comprehensive Specialized Cancer Treatment Center. Key contributors to undernutrition include nausea, reliance on semi-solid and liquid diets, limited dietary diversity, and constipation, reflecting the multifaceted nutritional challenges faced during cancer treatment. Compared to a previous study at the same center reporting a 48% malnutrition rate (Muhamed et al., 2022), our findings indicate an increasing trend. Additionally, the high prevalence of anemia underscores the necessity for proactive management of hematological complications alongside nutritional care.

The results emphasize the critical role of healthcare providers in addressing these nutritional issues through targeted interventions. Routine nutritional assessments should guide personalized care strategies, with nutrition integrated as a fundamental aspect of cancer treatment. Interventions should prioritize enhancing dietary diversity and nutrient intake while effectively managing symptoms like constipation and nausea through evidence-based methods. Furthermore, fostering collaboration among dietitians, nurses, and physicians is essential to deliver comprehensive nutritional support.

Given that healthcare professionals are at the forefront of patient care, strengthening their nutritional knowledge and skills within cancer care frameworks is crucial. Such capacity building can significantly improve the nutritional status, overall well-being, and treatment outcomes of cancer patients, ultimately contributing to more effective and holistic cancer management.

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