A quantitative analysis of the nutritional status of paediatric oncology patients is very important, particularly in children from developing countries where malnutrition is still a huge barrier to the optimum health of children in general. The current study evaluated the prevalence of undernutrition in children with cancer receiving treatment at a major referral hospital in Tanzania. The findings that 38.46% were found to be severely undernourished is very high compared to other studies done in Kenya, where the level of undernutrition was 18% among similar study populations. The differences could be due to different geographical areas where the availability of food is dependent on weather patterns that occur in different areas of Africa. Similarly, there is a difference in cultures among the people living in different areas regarding the type and amount of food consumed. Furthermore, the current study involved the majority of study participants who were admitted to the wards, meaning they had severe forms of disease, which may also be impairing their food intake(10).
When severely undernourished and moderately undernourished were combined, it shows that the level of undernutrition in children with cancer is 60%, which is higher than the reported prevalence from other studies done in other developing countries(11), (12). The impact of undernutrition is huge, as it is reported that malnourished paediatric patients cannot tolerate chemotherapy, which will result in frequent and severely suffering from chemotherapy-induced toxicities (CITs), including death. The main factors associated with undernutrition among children with cancer are symptoms such as nausea, mouth sores, and loss of appetite as a result of the chemotherapy treatment. The presentation of these symptoms is commonly associated with leading to difficulties in eating and, hence, is attributed to causing undernutrition amongst this population. A decreased appetite, for example, can impair nutritional status and, in turn, be associated with lower tolerance to treatments and a higher prevalence of infections. In another study that was done at another referal hospital in Tanzania, it was reported that CITs accounted for over 40% of deaths in children with cancer who were on treatment(13). If it could have been evaluated, the study could have reported the real culprit of the death as undernutrition.
Nevertheless, the current study shows that there is a 50% increase in the level of malnutrition when a child is suffering from cancer as compared to the general population, as reported by AG Khamis et al. in the burden and correlates of childhood undernutrition in Tanzania according to the composite index of anthropometric failure (CIAF), which reported that 1 in every three (or 3 in 10) underfive-year-old children are suffering from one or multiple forms of anthropometric failure. Although the current study was not limited to underfives, it shows a staggering number of 6 in 10 children having malnutrition after showing one or more anthropometric failures(14).
Furthermore, the value of 60% prevalence reported was greater than regional, national, and district-level values of undernutrition among paediatric patients. At the same study site, the prevalence of undernutrition among children admitted in the general paediatric ward was 55.8% (15); likewise, according to the recent Tanzania Demographic Health Survey (TDHS), on a national level, one-third (34%) of children under the age of 5 were reported to be stunted, 5% wasted, and 14% underweight(16). On a regional level, data from a study conducted in Arusha, Tanzania, indicated that 50%, 28%, and 16.5% of children were stunted, underweight, and wasted, respectively, corroborating our results(17). When comparing these different values, the high prevalence of undernutrition reported in the current study suggests that poor nutrition is a concern in children with cancer, but more importantly, many LMICs are already facing high rates of undernutrition in their paediatric population that is only being further exacerbated by cancer(18). In addition, the current study showed a high number of diagnosis of solid tumours, for which weight-for-height (WFH) and BMI would not be accurate measures of nutritional status as the weight of the tumour is also being considered. Hence, MUAC was a more reliable measure for this population and, in this setting, to provide an accurate portrayal of nutritional status. It is imperative that measures be taken to both understand what is contributing to the high prevalence of undernutrition and to set up interventions to combat the high proportion of undernourished children with cancer(19).
The high prevalence of under nutrition reported in the current study is attributed to the knowledge, attitude, and perception of the children’s primary caregivers. This is because for a cancer child to receive adequate and optimal nutrients, it depends on who is there to provide for her/him. The current study showed that most caregivers were of young age (26–35), signifying that they may be lacking experience of the child’s care(20). Also, in Tanzania, this is an age group of young mothers, which means they may be burdened with the care of another young child or children who take up most of their attention. This is also reflected in the age of the children with cancer they were caring, as most of them had children aged 6 to 10 years, which is the age when most of the children are left to care for themselves while the mother is busy with a very young, needy child. In addition, most caregivers (60.8%) did not complete primary-level education, meaning that, according to the Tanzanian education system, they don’t have adequate basic knowledge and skills on diet and nutrition. This shows that they are incapable of fulfilling the diet and nutritional needs of a child with cancer. Moreover, the majority of primary caregivers were peasants who engaged in small unsustainable farming activities, which are always prone to change in weather patterns, making it difficult for them to provide optimal food for the entire family. The food obtained through this means is not sufficient, and as it was reported that most of them lived in a house with more than seven family members, it complicates the matter even further. Nevertheless, transport costs to the hospital may have added to the cost of care and consumed the family’s budget to buy food, as most of the caregivers took up to 8 hours to reach the hospital with public transport, which is expensive. In addition, the majority of them (78.4%) reported being food insecure, which means that within the past 12 months, the food they bought for their families couldn’t last and they had no money to buy more. The level of food insecurity in Tanzania has been high, with 9% of the total population reported to be living in a severe food insecurity situation. This is attributed to poverty, a lack of agricultural knowledge, climate change, and the inappropriate distribution of cultivable land. However, this study was done in the lake zone area, where the land is cultivable; hence, poverty, climate change, and a low level of education stand as valid reasons for prevalent food insecurity(21), (22).
Similarly, studies have shown that a low level of education influences attitudes and perceptions, ultimately affecting the nutritional care given to a cancer child. This is also reflected in the food security status; the majority of caregivers in the current study had a low level of education and also reported being food insecure. On the other hand, when evaluating perceptions, there was a huge variation in perceptions among caregivers who reported being food secure or food insecure (P value < 0.001). The cancer children of food-insecure families were not getting a balanced diet, meaning they were lacking one or more nutritional contents that may have helped them overcome the effects of the disease and/or medications. These narratives are similarly pointed in a study done in Zambia where authors reported that, individual factors including insufficient knowledge and lack of finances were some of the challenges to healthcare providers of children with childhood cancers. Children with cancer need a constant supply of iron, folic acid, zinc, and copper since they are prone to suffering from anaemia. Consuming a balanced diet usually mitigates this effect. Similarly, a lack of protein in the diet makes lack of enough albumin in the child’s body, which helps in binding and transporting drug molecules and makes them less toxic outside the site of action(23). Studies have shown the importance of educating primary caregivers of cancer children on the effects of cancer on nutrition and the effects of nutrition on cancer, since this knowledge helps them put emphasis on the matter while caring for their sick children. Paraneoplastic syndromes, caused by cancer, usually present with an overt loss of appetite, deterring patients from consuming enough food. On the other hand, a lack of nutritional constituents causes the body fail to contain cancer cells. This is the basic knowledge that most food-insecure caregivers in the current study were lacking and therefore had a negative perception of the cancer’s effects on their overall nutrition. However, they maintained a positive perception when asked if their child needed nutritional support and agreed that their community would always benefit from learning about nutrition(24), (25).
Nonetheless, all primary caregivers had existing knowledge and understanding of nutrition, which may have been gained through experience and advice they received from the patient management team. This influenced their beliefs, and almost all of them agreed that their child needed a combination of a variety of foods. This shows that factors other than knowledge and understanding influenced the emergence of under nutrition in children. In addition to what has already been mentioned, food availability at the locality of primary caregivers and having money to buy food were mentioned. This is true since the lake zone area where the majority of participants reside is geographically divided and does have different weather patterns supporting the cultivation of different types of food. This is similar to what have been reported in Malaysia where it was also reported that seasonal variation in food security is associated with malnutrition (26), (27). Food is constantly transported from one area to another, increasing its cost. Since one-third of the population in Tanzania still lives in extreme poverty, with a poverty threshold of 1.9 U.S. dollars a day, according to the World Bank, it is difficult to afford the required food items, and the majority of participants affirmed that money impacts their ability to provide adequate nutrition for their children(28), (29).