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Malnutrition risk of patients with oral cavity cancer and other related factors at national cancer hospital 2018-2019



Malnutrition risk of patients with oral cavity cancer and other related factors at national cancer hospital 2018-2019

Bach Viet Hoang*1   ,Thuy Thi Tran2, Dang Van Nguyen3, Duy Quoc Ngo4, Yen Thi Duong1, Lien Thi Nguyen1, Hang Thi Thu Dang1, Tien Thi Hong Nguyen1, Quang Van Le3,4 , Huong Thi Le1,2
�Clinical Nutrition Center, Viet Nam National Cancer Hospital, Viet Nam
� Department of Nutrition and Food Safety, Hanoi Medical University, Viet Nam 
�Department of Cancer, Hanoi Medical University, Viet Nam 
4Head and Neck Surgery Department, National Cancer Hospital, Viet Nam



Authors� email addresses and contributions:
JD: hoangvietbach90@gmail.com
Contribution: conceived the study question, and contributed to the study design, supervision of data collection, data analysis and interpretation, and writing the manuscript.

MJ: thuytttks@gmail.com
Contribution: undertook data collection and data analysis, and contributed to data interpretation, and writing the manuscript.

 HYPERLINK "mailto:Drdangnguyen@gmail.com" Drdangnguyen@gmail.com
Contribution: contributed to the study design
 
 HYPERLINK "mailto:duyyhn@gmail.com" duyyhn@gmail.com
Contribution: contributed to the study design

 HYPERLINK "mailto:yenduong.hmu@gmail.com" yenduong.hmu@gmail.com
Contribution: undertook data collection and data analysis

 HYPERLINK "mailto:nguyenliendc138@gmail.com" nguyenliendc138@gmail.com
Contribution: undertook data collection and data analysis

 HYPERLINK "mailto:danghang271295@gmail.com" danghang271295@gmail.com
Contribution: undertook data collection and data analysis

 HYPERLINK "mailto:hongtien95.dd@gmail.com" hongtien95.dd@gmail.com
Contribution: undertook data collection and data analysis

 HYPERLINK "mailto:lequang@gmail.com" lequang@gmail.com
Contribution: conceived the study question, and contributed to the study design.
 
 HYPERLINK "mailto:lethihuong@hmu.edu.vn" lethihuong@hmu.edu.vn
Contribution: conceived the study question, and contributed to the study design.






Corresponding Author: Bach Viet Hoang (Clinical Nutrition Center, National Cancer Hospital Department, Ha Noi, Viet Nam or National Cancer Center 323 Ilsan-ro, Ilsandong-gu, Goyang-si Gyeonggi-do, 410-769, Republic of Korea Goyang) Email:  HYPERLINK "mailto:hoangvietbach90@gmail.com" hoangvietbach90@gmail.com

ABSTRACT 
Background and Objectives: Malnutrition refers to deficiencies, excesses or imbalances in a person s intake of energy and/or nutrients. In the cancer, malnutrition is the common status in patients because of combination of undernourishment and in�ammation. In oral cavity cancer patients, malnutrition is becoming more and more common because of the localization of the tumor. The aim of this study is to evaluate the malnutrition risks and other related factors in patients with oral cavity cancer. Methods and Study Design: The cross-sectional research was carried out with the participation of 220 patients aged 18 years and older from May 2018 to October 2019 in attempt to evaluate the malnutrition risk and pathological factors of oral cavity cancer cases. Results: In accordance with the PG-SGA toolkit, while the percentage of patients facing mild and moderate malnutrition risk was 63.2%, that of severe malnutrition risk was 18.2%. Besides, 23.2% was malnourished as regard to BMI classification. Patients in stage IV had a higher possibility of malnutrition (4.71 times) than those in stage I (OR (95% CI): 4.71 (1.08 �20.57)). The method of preparing food for patients by ordering ready-to-eat foods raised the malnutrition situation by 6.67 times in comparison with incorporating the hospital diet (OR (95% CI); 6.67 (1.68 - 26.44)). Additionally, losing more than 10% of weight within 6 months also made the proportion of malnourished patients grow higher than those who experienced whether weight gain or unchanged within 6 months, the results were statistically significant. Furthermore, people with gastrointestinal symptoms were many times more likely to suffer from malnutrition than those without, the findings were of statistical significance. Conclusions: Oral cavity cancer patients posed a significant chance of malnutrition. Patients in late stage of disease, weight loss, gastrointestinal symptoms and non-compliance with pathological nutrition care were at greater risk of malnutrition than most cases.

Key Words: Oral cavity cancer, weight loss, malnutrition, PG SGA, National cancer Hospital

INTRODUCTION
Not only does positive nutrition play an essential role in cancer care and treatment but also makes a considerable contribution to enhancing the effectiveness of treatment, the quality of patients� lives as well as extending their life span  ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"lTOoK4Ti","properties":{"formattedCitation":"(1)","plainCitation":"(1)","noteIndex":0},"citationItems":[{"id":"mG2jJKxW/EqT2EUmM","uris":["http://zotero.org/users/local/oS44McCP/items/CUDYUCBI"],"uri":["http://zotero.org/users/local/oS44McCP/items/CUDYUCBI"],"itemData":{"id":409,"type":"webpage","abstract":"Involvement of a multidisciplinary team in cancer care may have added benefits over the existing system of patient management. A paradigm shift in the current patient management would allow more focus on nutritional support, in addition to clinical care. Malnutrition, a common problem in cancer pati �","container-title":"Asian Pacific journal of cancer prevention : APJCP","language":"en","note":"ISSN: 2476-762X\nissue: 6\nsource: pubmed.ncbi.nlm.nih.gov\npublisher: Asian Pac J Cancer Prev\nvolume: 15\nPMID: 24761928\nDOI: 10.7314/apjcp.2014.15.6.2933","title":"Optimizing Nutrition Support in Cancer Care","URL":"https://pubmed.ncbi.nlm.nih.gov/24761928/","author":[{"family":"Kc","given":"Menon"}],"accessed":{"date-parts":[["2020",5,31]]},"issued":{"date-parts":[["2014"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (1). Cancer patients regularly face the danger of unexpected weight loss. To be specific, 31-87% of them suffer from this condition, especially ones with oral cavity cancer - head and neck cancer  ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"LEFUohQX","properties":{"formattedCitation":"(2)","plainCitation":"(2)","noteIndex":0},"citationItems":[{"id":"mG2jJKxW/OdSUMgYQ","uris":["http://zotero.org/users/local/oS44McCP/items/LB6LFSCZ"],"uri":["http://zotero.org/users/local/oS44McCP/items/LB6LFSCZ"],"itemData":{"id":413,"type":"webpage","title":"Prognostic effect of weight loss prior tochemotherapy in cancer patients - The American Journal of Medicine","URL":"https://www.amjmed.com/article/S0149-2918(05)80001-3/pdf","accessed":{"date-parts":[["2020",5,31]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (2). This group of patients face high malnutrition risk (MR) due to local and systemic disorders attributable to pathological characteristics and treatments. With radiotherapy, 25% of patients suffer from complications such as loss of taste and/or dry mouth before and up to more than 80% after the end of treatment  ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"t57IuOLs","properties":{"formattedCitation":"(3)","plainCitation":"(3)","noteIndex":0},"citationItems":[{"id":"mG2jJKxW/Eg6lZhrm","uris":["http://zotero.org/users/local/oS44McCP/items/DBAXX3IE"],"uri":["http://zotero.org/users/local/oS44McCP/items/DBAXX3IE"],"itemData":{"id":414,"type":"article-journal","abstract":"The incidence of obesity in the United States and other developed countries is epidemic. Because the prevalence of comorbidities to obesity, such as type 2 diabetes, has also increased, it is clear there is a great need to monitor and treat obesity and its comorbidities. Body composition assessments vary in precision and in the target tissue of interest. The most common assessments are anthropometric and include weight, stature, abdominal circumference, and skinfold measurements. More complex methods include bioelectrical impedance, dual-energy X-ray absorptiometry, body density, and total body water estimates. There is no single universally recommended method for body composition assessment in the obese, but each modality has benefits and drawbacks. We present here the most common methods and provide guidelines by way of examples to assist the clinician/researcher in choosing methods appropriate to their situation.","container-title":"Journal of diabetes science and technology (Online)","ISSN":"1932-2968","issue":"6","journalAbbreviation":"J Diabetes Sci Technol","note":"PMID: 19885303\nPMCID: PMC2769821","page":"1139-1146","source":"PubMed Central","title":"Body Composition Methods: Comparisons and Interpretation","title-short":"Body Composition Methods","volume":"2","author":[{"family":"Duren","given":"Dana L."},{"family":"Sherwood","given":"Richard J."},{"family":"Czerwinski","given":"Stefan A."},{"family":"Lee","given":"Miryoung"},{"family":"Choh","given":"Audrey C."},{"family":"Siervogel","given":"Roger M."},{"family":"Cameron Chumlea","given":"Wm."}],"issued":{"date-parts":[["2008",11]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (3). Chemotherapy frequently leads to decreased nutrient intake in patients, primarily through direct as well as indirect mechanisms  ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"NvHkvqIx","properties":{"formattedCitation":"(4)","plainCitation":"(4)","noteIndex":0},"citationItems":[{"id":"mG2jJKxW/WcA7WArZ","uris":["http://zotero.org/users/local/oS44McCP/items/96LKLWLV"],"uri":["http://zotero.org/users/local/oS44McCP/items/96LKLWLV"],"itemData":{"id":417,"type":"webpage","abstract":"The scored PG-SGA is a nutrition assessment tool that identifies malnutrition in ambulatory oncology patients receiving radiotherapy and can be used to predict the magnitude of change in QoL.","container-title":"European journal of clinical nutrition","language":"en","note":"ISSN: 0954-3007\nissue: 2\nsource: pubmed.ncbi.nlm.nih.gov\npublisher: Eur J Clin Nutr\nvolume: 57\nPMID: 12571664\nDOI: 10.1038/sj.ejcn.1601552","title":"The Scored Patient-generated Subjective Global Assessment (PG-SGA) and Its Association With Quality of Life in Ambulatory Patients Receiving Radiotherapy","URL":"https://pubmed.ncbi.nlm.nih.gov/12571664/","author":[{"family":"E","given":"Isenring"},{"family":"J","given":"Bauer"},{"family":"S","given":"Capra"}],"accessed":{"date-parts":[["2020",5,31]]},"issued":{"date-parts":[["2003",2]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (4).
Malnutrition in cancer sufferers has a direct effect on the survival rate of this condition. Studies have estimated that for every 10% loss in muscle mass, the probability of morality is developed by 10%  ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"OwxSQK1n","properties":{"formattedCitation":"(5,6)","plainCitation":"(5,6)","noteIndex":0},"citationItems":[{"id":"mG2jJKxW/VOo3TgWQ","uris":["http://zotero.org/users/local/oS44McCP/items/EYP3CRDM"],"uri":["http://zotero.org/users/local/oS44McCP/items/EYP3CRDM"],"itemData":{"id":421,"type":"webpage","abstract":"We found that nutrition is a critical component in all the wound healing processes. The stress response to injury and any preexistent protein-energy malnutrition will alter this response, impeding healing and leading to potential severe morbidity. A decrease in lean body mass is of particular concer �","container-title":"Eplasty","language":"en","note":"ISSN: 1937-5719\nsource: pubmed.ncbi.nlm.nih.gov\npublisher: Eplasty\nvolume: 9\nPMID: 19274069","title":"Nutrition, Anabolism, and the Wound Healing Process: An Overview","title-short":"Nutrition, Anabolism, and the Wound Healing Process","URL":"https://pubmed.ncbi.nlm.nih.gov/19274069/","author":[{"family":"Rh","given":"Demling"}],"accessed":{"date-parts":[["2020",5,31]]},"issued":{"date-parts":[["2009"]]}}},{"id":"mG2jJKxW/iVtdWltL","uris":["http://zotero.org/users/local/oS44McCP/items/6LX9RJDW"],"uri":["http://zotero.org/users/local/oS44McCP/items/6LX9RJDW"],"itemData":{"id":425,"type":"webpage","abstract":"Sarcopenia is highly prevalent in the elderly population with traumatic injuries. Traditional measures of nutritional assessment, such as BMI and serum albumin, do not accurately predict outcome in the injured elderly. Sarcopenia, however, represents a potential new predictor for mortality, discharg �","container-title":"Critical care (London, England)","language":"en","note":"ISSN: 1466-609X\nissue: 5\nsource: pubmed.ncbi.nlm.nih.gov\npublisher: Crit Care\nvolume: 17\nPMID: 24050662\nDOI: 10.1186/cc12901","title":"Skeletal Muscle Predicts Ventilator-Free Days, ICU-free Days, and Mortality in Elderly ICU Patients","URL":"https://pubmed.ncbi.nlm.nih.gov/24050662/","author":[{"family":"Ll","given":"Moisey"},{"family":"M","given":"Mourtzakis"},{"family":"Ba","given":"Cotton"},{"family":"T","given":"Premji"},{"family":"Dk","given":"Heyland"},{"family":"Ce","given":"Wade"},{"family":"E","given":"Bulger"},{"family":"Ra","given":"Kozar"}],"accessed":{"date-parts":[["2020",5,31]]},"issued":{"date-parts":[["2013",9,19]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (5,6). For oral cavity cancer patients, cases with a BMI <22.8 have a greater chance of morality (relative risk [RR] = 1.292, p = .022). In addition, people with preoperative serum albumin levels <4.15 g/dl are frequently in assocation with inferior prognosis (RR = 1.313, p = .016)  ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"SoN5GR4D","properties":{"formattedCitation":"(7)","plainCitation":"(7)","noteIndex":0},"citationItems":[{"id":"mG2jJKxW/hyCfRPMH","uris":["http://zotero.org/users/local/oS44McCP/items/PTWESC8H"],"uri":["http://zotero.org/users/local/oS44McCP/items/PTWESC8H"],"itemData":{"id":472,"type":"article-journal","container-title":"Head & Neck","DOI":"10.1002/hed.20461","ISSN":"1043-3074, 1097-0347","issue":"11","journalAbbreviation":"Head Neck","language":"en","page":"998-1007","source":"DOI.org (Crossref)","title":"Nutritional factors and survival of patients with oral cancer","volume":"28","author":[{"family":"Liu","given":"Shih-An"},{"family":"Tsai","given":"Wen-Chen"},{"family":"Wong","given":"Yong-Kie"},{"family":"Lin","given":"Jin-Ching"},{"family":"Poon","given":"Chiu-Kwan"},{"family":"Chao","given":"Shou-Yee"},{"family":"Hsiao","given":"Ying-Lyung"},{"family":"Chan","given":"Man-Yee"},{"family":"Cheng","given":"Chi-Sheng"},{"family":"Wang","given":"Chen-Chi"},{"family":"Wang","given":"Ching-Ping"}],"issued":{"date-parts":[["2006",11]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (7). Amongst risk factors linked to prognosis of death, nutrition is related in about 35% of all human cancer deaths, ranges from 10% to 70%  ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"FfBO4p09","properties":{"formattedCitation":"(8)","plainCitation":"(8)","noteIndex":0},"citationItems":[{"id":"mG2jJKxW/HFyokBVA","uris":["http://zotero.org/users/local/oS44McCP/items/AZV2DFU5"],"uri":["http://zotero.org/users/local/oS44McCP/items/AZV2DFU5"],"itemData":{"id":456,"type":"article-journal","abstract":"Experimental and epidemiologic studies in recent years are pointing tq diet as an important contributor to the cancer death toll which in the US this year will reach nearly one half million. Obesity, high fat intake, low fiber content and a dearth of vitamin A-and C-containing fruits and vegetables have been identified as risk factors; but these are not independent variables. The complex network of metabolic mechanisms involved are still obscure and association is not necessarily causation. Experts may agree on the data, but differ on whether we know enough to recommend dietary changes to the public. The Society in its continued efforts toward cancer prevention, has taken the stand that the available evidence, although inferential, is sufficiently solid to share with the public, and its guidelines are compatible with currently acceptable good nutritional practice. This conference should be a landmark of progress in the Society's continuing surveillance of this active field of investigation.","container-title":"Cancer","DOI":"10.1002/1097-0142(19861015)58:8+<1791::AID-CNCR2820581402>3.0.CO;2-W","ISSN":"1097-0142","issue":"S8","language":"en","note":"_eprint: https://acsjournals.onlinelibrary.wiley.com/doi/pdf/10.1002/1097-0142%2819861015%2958%3A8%2B%3C1791%3A%3AAID-CNCR2820581402%3E3.0.CO%3B2-W","page":"1791-1794","source":"Wiley Online Library","title":"Keynote address: The role of diet and nutrition in cancer","title-short":"Keynote address","volume":"58","author":[{"family":"Weinhouse","given":"Sidney"}],"issued":{"date-parts":[["1986"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (8). High variations indicate the inadequate awareness in terms of nutrition as well as malnutrition possibility of cancer patients in general and in oral cavity patients in particular. The assessment of nutritional status of patients, therefore, should be centered more on. Nutrition managament is crucial for preventing or minimizing side effects of oncological treatment modalities  ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"5TAtmwQf","properties":{"formattedCitation":"(9)","plainCitation":"(9)","noteIndex":0},"citationItems":[{"id":"mG2jJKxW/KxOAY3QG","uris":["http://zotero.org/users/local/oS44McCP/items/2TU47KAR"],"uri":["http://zotero.org/users/local/oS44McCP/items/2TU47KAR"],"itemData":{"id":455,"type":"webpage","title":"Latest world cancer statistics � GLOBOCAN 2012: Estimated Cancer Incidence, Mortality and Prevalence Worldwide in 2012 � IARC","URL":"https://www.iarc.fr/news-events/latest-world-cancer-statistics-globocan-2012-estimated-cancer-incidence-mortality-and-prevalence-worldwide-in-2012/","accessed":{"date-parts":[["2020",5,31]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (9). This study was hence conducted in order to attain two key objectives:
To evaluate the nutritional status of patients with oral cavity cancer.
Analyze several factors related to nutritional status of patients with oral cavity cancer.

MATERIALS AND METHODS
Patients aged 18 years or older have been diagnosed with oral cavity cancer at National cancer Hospital. The patients have been receiving surgery, chemicals, radiotherapy at National cancer Hospital. The patients agree to be part of the analysis and have full records. 
Study design: Cross-sectional description 
Research period: 5/2018 - 10/2019. 
Choose a template and sample size: 
The sample size is calculated using the sample size formula for estimating a proportion in the population:
 EMBED Equation.3 

Therein:
n: the sample size of the study
p: proportion of cancer patients facing malnutrition risk according to PG-SGA, taken from previous study p = 0.711  ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"HmeHkyym","properties":{"formattedCitation":"(10)","plainCitation":"(10)","noteIndex":0},"citationItems":[{"id":"mG2jJKxW/taiZny0n","uris":["http://zotero.org/users/local/oS44McCP/items/8AKEGV28"],"uri":["http://zotero.org/users/local/oS44McCP/items/8AKEGV28"],"itemData":{"id":459,"type":"article-journal","abstract":"Background\n              . Radiotherapy (RT) has been associated with increased risk of malnutrition in cancer patients, particularly in those with head and neck cancer (HNC). The aim of this prospective study was to evaluate the effects of compliance of patients with individual dietary counselling on body composition parameters in HNC patients under RT.\n              Material and Methods\n              . Sixty-nine consecutive patients (mean age:\n              \n                61.0\n                �\n                13.8\n              \n              ) were prospectively followed. Bioelectrical impedance analysis (BIA) was performed to determine body composition parameters before, in the middle of, and at the end of RT. All patients received nutritional counselling and majority of them (94.6%) received oral nutritional supplement (ONS) during RT or chemoradiotherapy. If a patient consumed e"75% of the recommended energy and protein intake via ONS and regular food, he/she was considered to be �compliant� (\n              \n                n\n                =\n                18\n              \n              ), while those who failed to meet this criteria were considered to be �noncompliant� (\n              \n                n\n                =\n                30\n              \n              ).\n              Results\n              . Body mass index, weight, fat percentage, fat mass, fat free mass, and muscle mass did not decrease significantly over time in compliant patients, but in noncompliant patients, all of these indices decreased significantly from baseline compared to the end of treatment (\n              \n                p\n                <\n                0.001\n              \n              ). Hand grip strength did not differ significantly between the two groups at baseline and over time in each group. When retrospectively evaluated, heavy mucositis was less commonly observed in compliant than noncompliant patients (11.1% versus 88.9%, resp.) (\n              \n                p\n                <\n                0.009\n              \n              ).\n              Conclusion\n              . We conclude that body composition parameters were better in head and neck cancer patients considered as compliant with nutritional counselling than noncompliant ones during RT period.","container-title":"Journal of Nutrition and Metabolism","DOI":"10.1155/2017/8631945","ISSN":"2090-0724, 2090-0732","journalAbbreviation":"Journal of Nutrition and Metabolism","language":"en","page":"1-7","source":"DOI.org (Crossref)","title":"The Effects of Compliance with Nutritional Counselling on Body Composition Parameters in Head and Neck Cancer Patients under Radiotherapy","volume":"2017","author":[{"family":"Hopanci Bicakli","given":"D."},{"family":"Ozkaya Akagunduz","given":"O."},{"family":"Meseri Dalak","given":"R."},{"family":"Esassolak","given":"M."},{"family":"Uslu","given":"R."},{"family":"Uyar","given":"M."}],"issued":{"date-parts":[["2017"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (10).
(: relative value = 0.1
(: statistical significance level, take � = 0.05. Then, Z (1-� / 2) = 1.96.
Getting into the formula, the sample size of the research was calculated: n = 156. Eventually, the sample size was rounded up to at least 160 patients.
Sampling: By convenient sampling, 220 patients with oral cavity cancer undergoing surgery, chemicals, radiotherapy were selected during the study period.
Research indicators and variables:
Subject information were collected from hospitalized patients according to the toolkit:
� 	Variables: general information about the patient (age, gender, occupation), anthropometric index, some hematological and biochemical test results.
� 	Index: nutritional status (PG-SGA, BMI)
Research procedure
Eligible hospitalized patients were chosen to take part in the research:
- Interviewing to collect information of research subjects and combine with observation to classify nutrition risk checklist according to PG-SGA (Patient-generated subjective global assessment: Subjective overall assessment).
- Measuring anthropometric indicators
- Making statistics of blood and biochemical formula findings from patient records to assess nutritional status on the basis of biochemical and hematological criteria.
Statistical analysis
All items were analyzed using descriptive statistics.
 Data are encrypted, processed and analyzed by STATA 12.0 software:
 Test ( is used to measure the discrepancy between two ratios2, statistically significant with p <0.05. In the case of samples less than 5, make use of (2 with Fisher correction.
 T-Student for the comparison of average (p <0.05)
Ethical considerations
The study was approved by the Ethics Committee in Biomedical Research of National Cancer Hospital. The study subjects were clearly explained about the purpose and significance of the research and voluntarily participated in the research. The information gathered is solely for research purposes.
RESULTS
General information and treatment characteristics are show in Table 1. Table 1 shows that 220 patients were selected for the study, the largest slice of 59.5% belonged to the 40-59 aged group. The rate of male patients was 75.9% which roughly tripled that of female. The most common cancer was palate cancer (48.2%), followed by other cancers including tongue (32.7%), floor of mouth (12.7%). The vast majority of patients were detected in stages III and IV (28.6% and 45.9%). The method of treatment at the time of study was mainly radiotherapy (66.8%), followed by surgery (33.2%). Patients with weight loss had a high proportion, specifically 5-10% weight loss was 15.6%, over 10% weight loss was 8.4% in 1 month. These rates increased in 6 months, 5-10% weight loss and over 10% weight loss were 33.5% and 16.8% respectively. The majority of researched subjects had oral feeding (91.4%). While more than a half had self-cooked food (63.2%), only 7.7% purchased food outside. According to the classification of PG-SGA, there was a high possibility that the patients would face malnutrition risk. To be specific, 63.2% were at risk of mild and moderate malnutrition (PG SGA B) and the figure for severe malnutrition was 18.2% (PG SGA C). Conforming to BMI classification, 23.2% of subjects were underweight.
       The risk of malnutrition are show table 2,3,4,5. The table 2 indicates that the later the stage of cancer, the greater the risk of malnutrition. Whilst the proportion of patients encountering malnutrition danger in stage IV was 88.1%, that in stage I decelerated by 29% to 59.1%, the difference was statistically significant with p <0 ,05. As a further matter, nutrition routes were also closely related to patients� risk of malnutrition. The results in Table 2 illustrates that 100% of patients in the feeding tube group posed the risk of malnutrition, higher than those who could still have oral feeding (79.6%), the difference was of statistical significance with p <0.005.
According to the table 3, the most common gastrointestinal symptoms were no appetite (47.3%), dry mouth (45.9%), fatigue (43.6%), pain (42.3%), mouth sores (35.5%). The study demonstrates that the proportion of patients with mouth sores registered a higher rate of being underweight (32.1%) than those without (18.3%), the difference was statistically significant with p <0.05. Patients with smells bother me (42.9%) made up a higher percentage of underweight than patients without (19.5%), the difference was statistically significant with p <0.05.
Table 4 presents some pathological factors which include stage of cancer, weight loss, and digestive symptoms; food preparation methods both heightened the possibility of malnutrition in patients. The later the stage of disease, the higher the risk of malnutrition. Patients in stage IV posed a higher chance of malnutrition (4.71 times) than those in stage I (OR (95% CI): 4.71 (1.08 �20.57)). As regard to the symptoms of weight loss, the more weight they lost, the greater the risk of malnutrition. PG SGA indicated that 5-10% weight loss within 6 months would raise the risk of malnutrition in cancer suffers by 14.43 times (OR (95% CI): 13.43 (2.35 � 76.62)), especially if patients had critical weight loss (>10%), the risk would be risen by 20 times (OR (95% CI): 19.86 (1.73 � 28.16)) in comparison with those who did not lose weight. Patients with gastrointestinal symptoms were approximately 50 times more likely to face nutritional deficiency than those without (OR (95% CI): 49.18 (10.4 � 232.58)).
         In table 5, in conformity with BMI, unintended weight loss was also of significance to the acceleration of malnutrition risk in patients. Specifically, if the group of patients underwent more than 10% weight loss within 6 months, the possibility of underweight would surge by 16.56 times as against the other group (OR (95% CI): 16.56 (4.53 � 60.48)). Moreover, ones who arbitrarily ordered food outside were at risk of being 6.67 times more likely to be malnourished than those following the hospital diet (OR (95% CI): 6.67 (1.68 - 26.44)).
DISCUSSION
The research conducted on 220 patients with oral cavity cancer. According to research findings, 63.2% of patients were at risk of mild and moderate malnutrition, 18.2% were at risk of severe malnutrition which were higher than what had been stated in the study of the authors Phan Thi Bich Hanh (2017) (51.7%)  ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"dIcgSCwb","properties":{"formattedCitation":"(11)","plainCitation":"(11)","noteIndex":0},"citationItems":[{"id":51,"uris":["http://zotero.org/users/local/K9afcoqq/items/JVI8JE9M"],"uri":["http://zotero.org/users/local/K9afcoqq/items/JVI8JE9M"],"itemData":{"id":51,"type":"post-weblog","abstract":"Lu�n vn th�c s) T�nh tr�ng dinh d��ng v� kh�u ph�n th�c t� c�a b�nh nh�n ung th� ��ng ti�u h�a c� i�u tr� h�a ch�t t�i b�nh vi�n �i h�c Y H� N�i nm 2016   2017.Ung th� (UT) ��ng ti�u h�a l� m�t trong nh�ng ung th� ph� bi�n tr�n th� gi�i v� & ","container-title":"MedLib","language":"en-US","note":"source: thuvieny.com\nsection: Nghi�n c�u chuy�n s�u","title":"T�nh tr�ng dinh d��ng v� kh�u ph�n th�c t� c�a b�nh nh�n ung th� ��ng ti�u h�a c� i�u tr� h�a ch�t t�i b�nh vi�n �i h�c Y H� N�i nm 2016   2017","URL":"https://thuvieny.com/tinh-trang-dinh-duong-va-khau-phan-thuc-te-cua-benh-nhan-ung-thu-duong-tieu-hoa-co-dieu-tri-hoa-chat-tai-benh-vien-dai-hoc-y-ha-noi-nam-2016-2017/","accessed":{"date-parts":[["2020",6,15]]},"issued":{"date-parts":[["2019",3,1]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (11). The main reason for the discrepancy is: Our studied subjects are of oral cavities group- the first part of the alimentary canal, which are dissimilar to that of two mentioned researches (all cancers). Particularly, with oral cavity cancer, its pathological symptoms such as mouth sores, no appetite, problems swallowing , etc. do cause a remarkable impact on oral feeding ability of patients, from which the food intake can be limited then leads to higher possibility of malnutrition risk in contrast to other cancer group (11,12) . In comparison with other international studies, the ones in the U.K, Australia, China represent that the proportions of patients with high malnutrition risk were 71%, 76%, 48.2%, respectively  ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"DqfhVh9t","properties":{"formattedCitation":"(12\\uc0\\u8211{}14)","plainCitation":"(12�14)","noteIndex":0},"citationItems":[{"id":"mG2jJKxW/OY1w6aZj","uris":["http://zotero.org/users/local/oS44McCP/items/AR3L56GH"],"uri":["http://zotero.org/users/local/oS44McCP/items/AR3L56GH"],"itemData":{"id":504,"type":"article-journal","abstract":"Learning Objectives After completing this course, the reader will be able to: Explain how malnutrition (deficit or excess) is used as a decisive factor in treatment of cancer patients. Describe the interactions and influences of overweight/obesity on tumor metabolism and of individualized tumor metabolism on tumor burden and undernutrition. Use the association of sarcopenic obesity to predict and manage poorer performance status and decreased survival in cancer patients. This article is available for continuing medical education credit at CME.TheOncologist.com Objective. Nutritional status in cancer has been mostly biased toward undernutrition, an issue now in dispute. We aimed to characterize nutrition status, to analyze associations between nutritional and clinical/cancer-related variables, and to quantify the relative weights of nutritional and cancer-related features. Methods. The cross-sectional study included 450 nonselected cancer patients (ages 18�95 years) at referral for radiotherapy. Nutritional status assessment included recent weight changes, body mass index (BMI) categorized by World Health Organization's age/sex criteria, and Patient-Generated Subjective Global Assessment (PG-SGA; validated/specific for oncology). Results. BMI identified 63% as e"25 kg/m2 (43% overweight, 20% obese) and 4% as undernourished. PG-SGA identified 29% as undernourished and 71% as well nourished. Crossing both methods, among the 319 (71%) well-nourished patients according to PG-SGA, 75% were overweight/obese and only 25% were well nourished according to BMI. Concordance between BMI and PG-SGA was evaluated and consistency was confirmed. More aggressive/advanced stage cancers were more prevalent in deficient and excessive nutritional status: in 83% (n = 235/282) of overweight/obese patients by BMI and in 85% (n = 111/131) of undernourished patients by PG-SGA. Results required adjustment for diagnoses: greater histological aggressiveness was found in overweight/obese prostate and breast cancer; undernutrition was associated with aggressive lung, colorectal, head-neck, stomach, and esophageal cancers (p < .005). Estimates of effect size revealed that overweight/obesity was associated with advanced stage (24%), aggressive breast (10%), and prostate (9%) cancers, whereas undernutrition was associated with more aggressive lung (6%), colorectal (6%), and head-neck (6%) cancers; in both instances, age and longer disease duration were of significance. Conclusion. Undernutrition and overweight/obesity have distinct implications and bear a negative prognosis in cancer. This study provides novel data on the prevalence of overweight/obesity and undernutrition in cancer patients and their potential role in cancer histological behavior.","container-title":"The Oncologist","DOI":"10.1634/theoncologist.2009-0283","ISSN":"1549-490X","issue":"5","language":"en","note":"_eprint: https://theoncologist.onlinelibrary.wiley.com/doi/pdf/10.1634/theoncologist.2009-0283","page":"523-530","source":"Wiley Online Library","title":"The Diversity of Nutritional Status in Cancer: New Insights","title-short":"The Diversity of Nutritional Status in Cancer","volume":"15","author":[{"family":"Chaves","given":"Mariana Ramos"},{"family":"Bol�o Tom�","given":"Carolina"},{"family":"Monteiro Grillo","given":"Isabel"},{"family":"Camilo","given":"Maria"},{"family":"Ravasco","given":"Paula"}],"issued":{"date-parts":[["2010"]]}}},{"id":"mG2jJKxW/c5v8N9aU","uris":["http://zotero.org/users/local/oS44McCP/items/FXCM96RT"],"uri":["http://zotero.org/users/local/oS44McCP/items/FXCM96RT"],"itemData":{"id":509,"type":"article-journal","abstract":"Malnourished patients with gastrointestinal tumours are at risk for postoperative complications and death. The aim of this study was to determine which nutritional assessment method better predicts outcome. Seventy-four patients, 45 men and 29 women; mean (SD) age of 63 (102) yr (range = 34 to 83), undergoing surgical resections for esophageal (n = 19) gastric (n = 43) and pancreatic (n = 12) tumors were preoperatively assessed by Patient Generated Subjective Global Assessment, anthropometry, and by laboratory sampling. Forty-three (58%) of them were unnourished; 25 Subjective Global Assessment (SGA)-A, 34 SGA-B, and 15 SGA-C cases. Mean (SD) of dominant hand adductor pollicis muscle thickness (DAPM) was 13 (3.5) mm and mean (SD) serum albumin was 3.8 (0.5) g/dL. Mean (SD) hospital staying for patients who complicated and died was 34 (29) days and 23 (13) days for survivors (not significant); SGA-B cases were significantly associated with higher mortality (n = 12, P<0.001). Patients with a mean (SD) DAPM below 10.8 (3.7) mm died more frequently than those with a mean (SD) greater than 14 (3) mm (P < 0.001). None of the methods was significantly related to hospital stay, but receiver operating characteristic curves (95% confidence interval) for PG-SGA and DAPM thickness (0.75 and 0.74) reliably predicted mortality (P<0.001) and these methods may be used as preoperative parameter.","container-title":"Nutrition and Cancer","DOI":"10.1080/01635581.2012.721157","ISSN":"1532-7914","issue":"8","journalAbbreviation":"Nutr Cancer","language":"eng","note":"PMID: 23163846","page":"1174-1181","source":"PubMed","title":"Preoperative nutritional assessment and prognosis in patients with foregut tumors","volume":"64","author":[{"family":"Poziomyck","given":"Aline Kirjner"},{"family":"Weston","given":"Antonio Carlos"},{"family":"Lameu","given":"Edson Braga"},{"family":"Cassol","given":"Ornella Sari"},{"family":"Coelho","given":"Luisa Jussara"},{"family":"Moreira","given":"Luis Fernando"}],"issued":{"date-parts":[["2012"]]}}},{"id":"mG2jJKxW/Gr0nfut7","uris":["http://zotero.org/users/local/oS44McCP/items/Q87RIRCU"],"uri":["http://zotero.org/users/local/oS44McCP/items/Q87RIRCU"],"itemData":{"id":507,"type":"webpage","title":"Clinical Application of Subjective Global Assessment in Chinese Patients With Gastrointestinal Cancer - PubMed","URL":"https://pubmed.ncbi.nlm.nih.gov/19630112/","accessed":{"date-parts":[["2020",6,1]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (12�14). This once again emphasizes that gastrointestinal cancer suffers are prone to nutritional deficiency.
Unintended weight loss of patients is worth noting: the percentage of patients losing 1-5%, 5-10% and more than 10% within 1 month were 42.5%, 15.6% and 8.4%, accordingly. The findings of this study were similar to those of Pirus Ghadjar (65.2%) and higher than the 2013 study of radiotherapy head and neck patients  ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"mkSNfJ0B","properties":{"formattedCitation":"(15,16)","plainCitation":"(15,16)","noteIndex":0},"citationItems":[{"id":"mG2jJKxW/qk7JhJ5w","uris":["http://zotero.org/users/local/oS44McCP/items/FRV5C7TY"],"uri":["http://zotero.org/users/local/oS44McCP/items/FRV5C7TY"],"itemData":{"id":435,"type":"article-journal","abstract":"Early oral feeding is the preferred mode of nutrition for surgical patients. Avoidance of any nutritional therapy bears the risk of underfeeding during the postoperative course after major surgery. Considering that malnutrition and underfeeding are risk factors for postoperative complications, early enteral feeding is especially relevant for any surgical patient at nutritional risk, especially for those undergoing upper gastrointestinal surgery. The focus of this guideline is to cover nutritional aspects of the Enhanced Recovery After Surgery (ERAS) concept and the special nutritional needs of patients undergoing major surgery, e.g. for cancer, and of those developing severe complications despite best perioperative care. From a metabolic and nutritional point of view, the key aspects of perioperative care include: \u0015 integration of nutrition into the overall management of the patient \u0015 avoidance of long periods of preoperative fasting \u0015 re-establishment of oral feeding as early as possible after surgery \u0015 start of nutritional therapy early, as soon as a nutritional risk becomes apparent \u0015 metabolic control e.g. of blood glucose \u0015 reduction of factors which exacerbate stress-related catabolism or impair gastrointestinal function \u0015 minimized time on paralytic agents for ventilator management in the postoperative period \u0015 early mobilisation to facilitate protein synthesis and muscle function The guideline presents 37 recommendations for clinical practice. � 2017 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd. All rights reserved.","container-title":"Clinical Nutrition","DOI":"10.1016/j.clnu.2017.02.013","ISSN":"02615614","issue":"3","journalAbbreviation":"Clinical Nutrition","language":"en","page":"623-650","source":"DOI.org (Crossref)","title":"ESPEN guideline: Clinical nutrition in surgery","title-short":"ESPEN guideline","volume":"36","author":[{"family":"Weimann","given":"Arved"},{"family":"Braga","given":"Marco"},{"family":"Carli","given":"Franco"},{"family":"Higashiguchi","given":"Takashi"},{"family":"H�bner","given":"Martin"},{"family":"Klek","given":"Stanislaw"},{"family":"Laviano","given":"Alessandro"},{"family":"Ljungqvist","given":"Olle"},{"family":"Lobo","given":"Dileep N."},{"family":"Martindale","given":"Robert"},{"family":"Waitzberg","given":"Dan L."},{"family":"Bischoff","given":"Stephan C."},{"family":"Singer","given":"Pierre"}],"issued":{"date-parts":[["2017",6]]}}},{"id":"mG2jJKxW/Rb6CU0Cw","uris":["http://zotero.org/users/local/oS44McCP/items/FCZMGDMM"],"uri":["http://zotero.org/users/local/oS44McCP/items/FCZMGDMM"],"itemData":{"id":489,"type":"webpage","abstract":"Weight loss before and during chemoradiation was commonly observed. Weight loss before but not during treatment was associated with worse survival.","container-title":"Radiation oncology (London, England)","language":"en","note":"ISSN: 1748-717X\nsource: pubmed.ncbi.nlm.nih.gov\npublisher: Radiat Oncol\nvolume: 10\nPMID: 25679310\nDOI: 10.1186/s13014-014-0319-y","title":"Impact of Weight Loss on Survival After Chemoradiation for Locally Advanced Head and Neck Cancer: Secondary Results of a Randomized Phase III Trial (SAKK 10/94)","title-short":"Impact of Weight Loss on Survival After Chemoradiation for Locally Advanced Head and Neck Cancer","URL":"https://pubmed.ncbi.nlm.nih.gov/25679310/","author":[{"family":"P","given":"Ghadjar"},{"family":"S","given":"Hayoz"},{"family":"F","given":"Zimmermann"},{"family":"S","given":"Bodis"},{"family":"D","given":"Kaul"},{"family":"H","given":"Badakhshi"},{"family":"J","given":"Bernier"},{"family":"G","given":"Studer"},{"family":"L","given":"Plasswilm"},{"family":"V","given":"Budach"},{"family":"Dm","given":"Aebersold"}],"accessed":{"date-parts":[["2020",6,1]]},"issued":{"date-parts":[["2015",1,17]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (15,16). Especially, by contrasting weight changes between 01 month and 06 months, there was a shift from the marginal weight loss group to the considerable one (within 6 months, 32.9% of patients lost 1-5 %, 33.5% lost 5-10%, 16.8% lost more than 10%). This could be explained by the fact that unintended weight loss associated with cancer is distinct from weight loss due to lack of food/fasting  ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"LyDlr9YH","properties":{"formattedCitation":"(17\\uc0\\u8211{}19)","plainCitation":"(17�19)","noteIndex":0},"citationItems":[{"id":"mG2jJKxW/8IgHMWxg","uris":["http://zotero.org/users/local/oS44McCP/items/PEXDBUFS"],"uri":["http://zotero.org/users/local/oS44McCP/items/PEXDBUFS"],"itemData":{"id":441,"type":"webpage","title":"Critical weight loss is a major prognostic indicator for disease-specific survival in patients with head and neck cancer receiving radiotherapy | British Journal of Cancer","URL":"https://www.nature.com/articles/bjc2013458","accessed":{"date-parts":[["2020",5,31]]}}},{"id":"mG2jJKxW/9hoaxzKi","uris":["http://zotero.org/users/local/oS44McCP/items/RSW5GZ4D"],"uri":["http://zotero.org/users/local/oS44McCP/items/RSW5GZ4D"],"itemData":{"id":493,"type":"article-journal","container-title":"CA: A Cancer Journal for Clinicians","DOI":"10.3322/canjclin.27.4.205","ISSN":"1542-4863","issue":"4","language":"en","note":"_eprint: https://acsjournals.onlinelibrary.wiley.com/doi/pdf/10.3322/canjclin.27.4.205","page":"205-208","source":"Wiley Online Library","title":"Weight loss in cancer patients","volume":"27","author":[{"family":"Theologides","given":"Athanasios"}],"issued":{"date-parts":[["1977"]]}}},{"id":"mG2jJKxW/iU6bGBzi","uris":["http://zotero.org/users/local/oS44McCP/items/VIQPFDWM"],"uri":["http://zotero.org/users/local/oS44McCP/items/VIQPFDWM"],"itemData":{"id":496,"type":"webpage","title":"Cancer cachexia Dhanapal R, Saraswathi T R, Rajkumar N G - J Oral Maxillofac Pathol","URL":"http://www.jomfp.in/article.asp?issn=0973-029X;year=2011;volume=15;issue=3;spage=257;epage=260;aulast=Dhanapal","accessed":{"date-parts":[["2020",6,1]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (17�19). 
There are a variety of variables affecting the weight loss of cancer patients. Such causes may include: reduced food intake, malabsorption, increased basal metabolic energy, side effects of treatment or the tumor itself producing subtances that elevate the protein lysis  ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"7ohl778t","properties":{"formattedCitation":"(19)","plainCitation":"(19)","noteIndex":0},"citationItems":[{"id":"mG2jJKxW/iU6bGBzi","uris":["http://zotero.org/users/local/oS44McCP/items/VIQPFDWM"],"uri":["http://zotero.org/users/local/oS44McCP/items/VIQPFDWM"],"itemData":{"id":496,"type":"webpage","title":"Cancer cachexia Dhanapal R, Saraswathi T R, Rajkumar N G - J Oral Maxillofac Pathol","URL":"http://www.jomfp.in/article.asp?issn=0973-029X;year=2011;volume=15;issue=3;spage=257;epage=260;aulast=Dhanapal","accessed":{"date-parts":[["2020",6,1]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (19). The malnutrition situation of patients is likely to escalate over time, even when receiving treatment, such that the quality of treatment is directly affected  ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"REkOOUHF","properties":{"formattedCitation":"(15,20)","plainCitation":"(15,20)","noteIndex":0},"citationItems":[{"id":"mG2jJKxW/qk7JhJ5w","uris":["http://zotero.org/users/local/oS44McCP/items/FRV5C7TY"],"uri":["http://zotero.org/users/local/oS44McCP/items/FRV5C7TY"],"itemData":{"id":435,"type":"article-journal","abstract":"Early oral feeding is the preferred mode of nutrition for surgical patients. Avoidance of any nutritional therapy bears the risk of underfeeding during the postoperative course after major surgery. Considering that malnutrition and underfeeding are risk factors for postoperative complications, early enteral feeding is especially relevant for any surgical patient at nutritional risk, especially for those undergoing upper gastrointestinal surgery. The focus of this guideline is to cover nutritional aspects of the Enhanced Recovery After Surgery (ERAS) concept and the special nutritional needs of patients undergoing major surgery, e.g. for cancer, and of those developing severe complications despite best perioperative care. From a metabolic and nutritional point of view, the key aspects of perioperative care include: \u0015 integration of nutrition into the overall management of the patient \u0015 avoidance of long periods of preoperative fasting \u0015 re-establishment of oral feeding as early as possible after surgery \u0015 start of nutritional therapy early, as soon as a nutritional risk becomes apparent \u0015 metabolic control e.g. of blood glucose \u0015 reduction of factors which exacerbate stress-related catabolism or impair gastrointestinal function \u0015 minimized time on paralytic agents for ventilator management in the postoperative period \u0015 early mobilisation to facilitate protein synthesis and muscle function The guideline presents 37 recommendations for clinical practice. � 2017 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd. All rights reserved.","container-title":"Clinical Nutrition","DOI":"10.1016/j.clnu.2017.02.013","ISSN":"02615614","issue":"3","journalAbbreviation":"Clinical Nutrition","language":"en","page":"623-650","source":"DOI.org (Crossref)","title":"ESPEN guideline: Clinical nutrition in surgery","title-short":"ESPEN guideline","volume":"36","author":[{"family":"Weimann","given":"Arved"},{"family":"Braga","given":"Marco"},{"family":"Carli","given":"Franco"},{"family":"Higashiguchi","given":"Takashi"},{"family":"H�bner","given":"Martin"},{"family":"Klek","given":"Stanislaw"},{"family":"Laviano","given":"Alessandro"},{"family":"Ljungqvist","given":"Olle"},{"family":"Lobo","given":"Dileep N."},{"family":"Martindale","given":"Robert"},{"family":"Waitzberg","given":"Dan L."},{"family":"Bischoff","given":"Stephan C."},{"family":"Singer","given":"Pierre"}],"issued":{"date-parts":[["2017",6]]}}},{"id":"mG2jJKxW/qopgJJev","uris":["http://zotero.org/users/local/oS44McCP/items/CXHLWEI9"],"uri":["http://zotero.org/users/local/oS44McCP/items/CXHLWEI9"],"itemData":{"id":482,"type":"article-journal","container-title":"Oncology Nursing Forum","DOI":"10.1188/10.ONF.303-310","ISSN":"0190-535X, 1538-0688","issue":"3","journalAbbreviation":"Oncology Nursing Forum","page":"303-310","source":"DOI.org (Crossref)","title":"Understanding Weight Loss in Patients With Colorectal Cancer: A Human Response to Illness","title-short":"Understanding Weight Loss in Patients With Colorectal Cancer","volume":"37","author":[{"family":"Bapuji","given":"Sunita Bayyavarapu"},{"family":"Sawatzky","given":"Jo-Ann V."}],"issued":{"date-parts":[["2010",5,1]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (15,20). However, if taken care of, the malnutrition situation will be significantly improved. A study on patients with head and neck cancer with radiation therapy monitored for 9 years indicated that the group of patients who received enough energy (e"35 kcal and e"1.5g protein / kg / day) encountered less weight loss and muscle mass than the group that did not  ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"o7VW48Il","properties":{"formattedCitation":"(16)","plainCitation":"(16)","noteIndex":0},"citationItems":[{"id":"mG2jJKxW/Rb6CU0Cw","uris":["http://zotero.org/users/local/oS44McCP/items/FCZMGDMM"],"uri":["http://zotero.org/users/local/oS44McCP/items/FCZMGDMM"],"itemData":{"id":489,"type":"webpage","abstract":"Weight loss before and during chemoradiation was commonly observed. Weight loss before but not during treatment was associated with worse survival.","container-title":"Radiation oncology (London, England)","language":"en","note":"ISSN: 1748-717X\nsource: pubmed.ncbi.nlm.nih.gov\npublisher: Radiat Oncol\nvolume: 10\nPMID: 25679310\nDOI: 10.1186/s13014-014-0319-y","title":"Impact of Weight Loss on Survival After Chemoradiation for Locally Advanced Head and Neck Cancer: Secondary Results of a Randomized Phase III Trial (SAKK 10/94)","title-short":"Impact of Weight Loss on Survival After Chemoradiation for Locally Advanced Head and Neck Cancer","URL":"https://pubmed.ncbi.nlm.nih.gov/25679310/","author":[{"family":"P","given":"Ghadjar"},{"family":"S","given":"Hayoz"},{"family":"F","given":"Zimmermann"},{"family":"S","given":"Bodis"},{"family":"D","given":"Kaul"},{"family":"H","given":"Badakhshi"},{"family":"J","given":"Bernier"},{"family":"G","given":"Studer"},{"family":"L","given":"Plasswilm"},{"family":"V","given":"Budach"},{"family":"Dm","given":"Aebersold"}],"accessed":{"date-parts":[["2020",6,1]]},"issued":{"date-parts":[["2015",1,17]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (16). Pathological characteristics, nutrition routes, food preparation methods are fundamental factors uplifting the danger of malnutrition in patients. In particular, pathological features comprise such factors: stage of cancer, treatment method, unintended weight loss and gastrointestinal symptoms. In terms of the stage of disease, according to the research results, when the subjects are in stage IV, the risk of malnutrition goes up by approximately 5 times compared to those in stage I (OR (95% CI): 4.71 (1.08 �20.57)). This could be explained by the fact that: in the late stages of disease, ulcerative lesions of the cancer cause a direct impact on the patients� consumption ability since the oral cavity is the gateway of the digestive tract; thus, any lesions triggering pain, compression, reduction or loss of taste are reasons reduced food intake, and thereby leads to malnutrition  ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"RqrQoj4Q","properties":{"formattedCitation":"(21)","plainCitation":"(21)","noteIndex":0},"citationItems":[{"id":"mG2jJKxW/5MqXry98","uris":["http://zotero.org/users/local/oS44McCP/items/5XS38TMC"],"uri":["http://zotero.org/users/local/oS44McCP/items/5XS38TMC"],"itemData":{"id":444,"type":"webpage","abstract":"Patients with weight loss more than 10% during the six months before surgery are at a great risk for the occurrence of major postoperative complications.","container-title":"Head & neck","language":"en","note":"DOI: 10.1002/(sici)1097-0347(199708)19:5<419::aid-hed9>3.0.co;2-2\nISSN: 1043-3074\nissue: 5\nsource: pubmed.ncbi.nlm.nih.gov\npublisher: Head Neck\nvolume: 19\nPMID: 9243270\nDOI: 10.1002/(sici)1097-0347(199708)19:5<419::aid-hed9>3.0.co;2-2","title":"Assessment of Malnutrition Parameters in Head and Neck Cancer and Their Relation to Postoperative Complications","URL":"https://pubmed.ncbi.nlm.nih.gov/9243270/","author":[{"family":"Ma","given":"van Bokhorst-de van der Schueren"},{"family":"Pa","given":"van Leeuwen"},{"family":"Hp","given":"Sauerwein"},{"family":"Dj","given":"Kuik"},{"family":"Gb","given":"Snow"},{"family":"Jj","given":"Quak"}],"accessed":{"date-parts":[["2020",5,31]]},"issued":{"date-parts":[["1997",8]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (21) . Once malnutrition becomes more severe, the mortality rate will inevitably rise  ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"usjg3yMD","properties":{"formattedCitation":"(22)","plainCitation":"(22)","noteIndex":0},"citationItems":[{"id":"mG2jJKxW/Gd4QrZJY","uris":["http://zotero.org/users/local/oS44McCP/items/MLXFATTJ"],"uri":["http://zotero.org/users/local/oS44McCP/items/MLXFATTJ"],"itemData":{"id":467,"type":"article-journal","abstract":"Objectives\nPatients with head and neck cancer (HNC) frequently encounter weight loss with multiple negative outcomes as a consequence. Adequate treatment is best achieved by early identification of patients at risk for critical weight loss. The objective of this study was to detect predictive factors for critical weight loss in patients with HNC receiving (chemo)radiotherapy ((C)RT).\nMaterials and methods\nIn this cohort study, 910 patients with HNC were included receiving RT (�surgery/concurrent chemotherapy) with curative intent. Body weight was measured at the start and end of (C)RT. Logistic regression and classification and regression tree (CART) analyses were used to analyse predictive factors for critical weight loss (defined as >5%) during (C)RT. Possible predictors included gender, age, WHO performance status, tumour location, TNM classification, treatment modality, RT technique (three-dimensional conformal RT (3D-RT) vs intensity-modulated RT (IMRT)), total dose on the primary tumour and RT on the elective or macroscopic lymph nodes.\nResults\nAt the end of (C)RT, mean weight loss was 5.1�4.9%. Fifty percent of patients had critical weight loss during (C)RT. The main predictors for critical weight loss during (C)RT by both logistic and CART analyses were RT on the lymph nodes, higher RT dose on the primary tumour, receiving 3D-RT instead of IMRT, and younger age.\nConclusion\nCritical weight loss during (C)RT was prevalent in half of HNC patients. To predict critical weight loss, a practical prediction tree for adequate nutritional advice was developed, including the risk factors RT to the neck, higher RT dose, 3D-RT, and younger age.","container-title":"Oral Oncology","DOI":"10.1016/j.oraloncology.2015.10.021","ISSN":"1368-8375","journalAbbreviation":"Oral Oncology","language":"en","page":"91-96","source":"ScienceDirect","title":"Prediction model to predict critical weight loss in patients with head and neck cancer during (chemo)radiotherapy","volume":"52","author":[{"family":"Langius","given":"Jacqueline A. E."},{"family":"Twisk","given":"Jos"},{"family":"Kampman","given":"Martine"},{"family":"Doornaert","given":"Patricia"},{"family":"Kramer","given":"Mark H. H."},{"family":"Weijs","given":"Peter J. M."},{"family":"Leemans","given":"C. Ren�"}],"issued":{"date-parts":[["2016",1,1]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (22). Regarding treatment methods, the research results illustrate that both chemotherapy and surgical chemotherapy patients were at high risk of malnutrition, particularly the radiotherapy group with 84.3% being the cases. The study in 2015 on patients with head and neck cancer treated with radiotherapy demonstrates that the impact of radiotherapy was undoubtedly the increase in the proportion of patients suffering >5% weight loss during the treatment (22). The research also shows similar results with a half of the patients shedding a moderate number of kilograms after radiation therapy, 5.1 � 4.9% of their weight on average  ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"FOJeQsc1","properties":{"formattedCitation":"(23)","plainCitation":"(23)","noteIndex":0},"citationItems":[{"id":"mG2jJKxW/ECBXr761","uris":["http://zotero.org/users/local/oS44McCP/items/FY848NSH"],"uri":["http://zotero.org/users/local/oS44McCP/items/FY848NSH"],"itemData":{"id":449,"type":"webpage","title":"More Than 10% Weight Loss in Head and Neck Cancer Patients During Radiotherapy Is Independently Associated with Deterioration in Quality of Life: Nutrition and Cancer: Vol 65, No 1","URL":"https://www.tandfonline.com/doi/abs/10.1080/01635581.2013.741749","accessed":{"date-parts":[["2020",5,31]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (23). Thus, treatments, especially radiotherapy, have a great influence on weight loss and malnutrition, thereby worsen the quality of life and prognosis of patients with oral cavity cancer  ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"cX2tADE9","properties":{"formattedCitation":"(24\\uc0\\u8211{}26)","plainCitation":"(24�26)","noteIndex":0},"citationItems":[{"id":"mG2jJKxW/qKpJUIQp","uris":["http://zotero.org/users/local/oS44McCP/items/3QUPWU4W"],"uri":["http://zotero.org/users/local/oS44McCP/items/3QUPWU4W"],"itemData":{"id":520,"type":"article-journal","abstract":"Purpose\nTo evaluate the effectiveness of nutrition intervention during radiation for patients with locoregionally advanced (III-IVa) nasopharyngeal carcinoma (NPC).\n\nMaterials and Methods\nWe retrospectively reviewed 117 patients with locoregionally advanced (III-IVa) NPC treated between December 2015 and March 2016 in Zhejiang Cancer Hospital. All the patients underwent radical chemo-radiotherapy. First, all the patients were divided into the nutrition intervention group and the control group, depending on whether they accepted nutrition intervention. Repeated measures were used to analyze the change of nutritional indicators before, during, and after radiation therapy and to simultaneously compare the difference in nutritional status between the two groups at the same time point. Subsequently, the 117 patients were divided into the malnourished group (weight loss > 5%) and the non-malnourished group (weight loss d" 5%) according to whether their weight loss was over 5% of their body weight during radiotherapy. Chi-square tests and logistic regression analysis were used to explore the influence factors for the weight loss.\n\nResults\nThe repeated measures showed that all indicators including weight, body mass index (BMI), albumin, pre-albumin(PA), and prognostic nutritional index (PNI) dramatically declined in both groups compared with their levels before radiation therapy (All p < 0.001). However, there was no significant difference between the intervention and non-intervention groups regarding the mean values of nutritional indicators at the same time point, that before, during, and after radiation therapy, except BMI (All p > 0.05). Logistic regression analysis revealed grade e" 3 radiation-induced oral mucositis as the prognostic factor for a poor nutrition status (odds ratio, OR = 3.232, p = 0.021, confidence interval, CI [1.198, 8.820]). Besides this, patients with a decrease of >15% in pre-albumin level were more likely to be malnourished (OR = 2.442, p = 0.041, CI [1.036, 5.757]). Similar to that observed in our former analysis, we did not find that existing nutrition intervention can significantly improve nutritional status (OR = 1.217, p = 0.704, CI [0.042, 3.348]).\n\nConclusions\nOur study shows that the nutritional status of the patients gradually declined during treatment. We concluded that grade e" 3 radiation-induced oral mucositis would aggravate the extent of malnutrition during radiation therapy in patients with locoregionally advanced NPC. Pre-albumin level was a predictive marker for weight loss in patients with NPC. However, current nutrition intervention during radiation therapy can't significantly reverse nutritional status.","container-title":"Oncotarget","DOI":"10.18632/oncotarget.19381","ISSN":"1949-2553","issue":"48","journalAbbreviation":"Oncotarget","note":"PMID: 29137377\nPMCID: PMC5663549","page":"83723-83733","source":"PubMed Central","title":"An evaluation of nutrition intervention during radiation therapy in patients with locoregionally advanced nasopharyngeal carcinoma","volume":"8","author":[{"family":"Jin","given":"Ting"},{"family":"Li","given":"Kai-Xin"},{"family":"Li","given":"Pei-Jing"},{"family":"Huang","given":"Shuang"},{"family":"Chen","given":"Xiao-Zhong"},{"family":"Chen","given":"Ming"},{"family":"Hu","given":"Qiao-Ying"},{"family":"Shi","given":"Lei"},{"family":"Chen","given":"Yuan-Yuan"}],"issued":{"date-parts":[["2017",7,19]]}}},{"id":"mG2jJKxW/I7hfgOMD","uris":["http://zotero.org/users/local/oS44McCP/items/95HUJKTE"],"uri":["http://zotero.org/users/local/oS44McCP/items/95HUJKTE"],"itemData":{"id":524,"type":"article-journal","abstract":"OBJECTIVES: The purpose of the present study was to evaluate the nutritional status of cancer patients receiving radiotherapy (RT) and to assess the possible contributions of nutritional support to patients with malnutrition.\nMETHODS: Prospectively, 207 patients referred to our outpatient radiotherapy department were included. The patients were classified according to tumor site (head/neck, breast, lung, stomach, or colorectal). Nutritional status at the onset, at the end of RT, and 3 and 6 months after irradiation was evaluated with the subjective global assessment (SGA). All of the patients were supported with additional portions of meal or standard enteral feeding formula during and after the irradiation period as long as they were in the moderately or severely malnourished groups, respectively.\nRESULTS: At the onset, malnutrition was present in 31% of all patients, and it increased to 43% at the end of RT. This difference predominated in head/neck cancer patients. Malnutrition ratios in head/neck cancer patients at the onset and after RT were 24% and 88%, respectively. By a 6-month follow-up, the ratio of patients with malnutrition decreased to 8%. Nutritional status of all groups was found to improve during the 6-month follow-up period, except for the breast cancer group, which included no patients with severe malnutrition at any time.\nCONCLUSION: The results of the present study may be helpful in planning an appropriate nutritional support for cancer patients undergoing radiotherapy according to the irradiation site.","container-title":"American Journal of Clinical Oncology","DOI":"10.1097/01.coc.0000198745.94757.ee","ISSN":"1537-453X","issue":"2","journalAbbreviation":"Am. J. Clin. Oncol.","language":"eng","note":"PMID: 16601440","page":"183-188","source":"PubMed","title":"Evaluation of nutritional status in cancer patients receiving radiotherapy: a prospective study","title-short":"Evaluation of nutritional status in cancer patients receiving radiotherapy","volume":"29","author":[{"family":"Unsal","given":"Diclehan"},{"family":"Mentes","given":"Bulent"},{"family":"Akmansu","given":"Muge"},{"family":"Uner","given":"Aytug"},{"family":"Oguz","given":"Mehmet"},{"family":"Pak","given":"Yucel"}],"issued":{"date-parts":[["2006",4]]}}},{"id":"mG2jJKxW/Pj1uRuaN","uris":["http://zotero.org/users/local/oS44McCP/items/ZU3Z9746"],"uri":["http://zotero.org/users/local/oS44McCP/items/ZU3Z9746"],"itemData":{"id":522,"type":"article-journal","abstract":"BACKGROUND AND AIMS: We performed a systematic review to examine the effect of nutritional interventions on nutritional status, quality of life (QoL) and mortality in patients with head and neck squamous cell cancer (HNSCC) receiving radiotherapy or chemoradiotherapy.\nMETHODS: We searched Pubmed, EMBASE, CENTRAL and Cinahl from inception through January 3rd, 2012 to identify randomized controlled trials (RCTs) from a broad range of nutritional interventions in patients with HNSCC during (chemo)radiotherapy. Two reviewers independently assessed study eligibility and risk of bias, and extracted data.\nRESULTS: Of 1141 titles identified, 12 study reports were finally included, describing 10 different studies with 11 interventions. Four out of 10 studies examined the effects of individualized dietary counseling, and showed significant benefits on nutritional status and QOL compared to no counseling or general nutritional advice by a nurse (p�<�0.05). Three studies on oral nutritional supplements (ONS) were inconsistent about the effect on nutritional status compared with no supplementation. One study showed that nasogastric tube feeding had beneficial effects on nutritional status compared to ONS, but not in all patient groups (p�<�0.04). One study showed benefits of percutaneous endoscopic gastronomy (PEG) feeding on nutritional status shortly after RT compared with nasogastric feeding (p�=�0.001). Two studies showed that prophylactic PEG feeding was not superior over tube feeding if required.\nCONCLUSIONS: This review shows beneficial effects of individualized dietary counseling on nutritional status and QoL, compared to no counseling or standard nutritional advice. Effects of ONS and tube feeding were inconsistent.","container-title":"Clinical Nutrition (Edinburgh, Scotland)","DOI":"10.1016/j.clnu.2013.06.012","ISSN":"1532-1983","issue":"5","journalAbbreviation":"Clin Nutr","language":"eng","note":"PMID: 23845384","page":"671-678","source":"PubMed","title":"Effect of nutritional interventions on nutritional status, quality of life and mortality in patients with head and neck cancer receiving (chemo)radiotherapy: a systematic review","title-short":"Effect of nutritional interventions on nutritional status, quality of life and mortality in patients with head and neck cancer receiving (chemo)radiotherapy","volume":"32","author":[{"family":"Langius","given":"Jacqueline A. E."},{"family":"Zandbergen","given":"Myrna C."},{"family":"Eerenstein","given":"Simone E. J."},{"family":"Tulder","given":"Maurits W.","non-dropping-particle":"van"},{"family":"Leemans","given":"C. Ren�"},{"family":"Kramer","given":"Mark H. H."},{"family":"Weijs","given":"Peter J. M."}],"issued":{"date-parts":[["2013",10]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (24�26). More importantly, the unintended weight loss in 6 months plays a vital role in increasing the malnutrition rate. Research results indicate that for 5-10% weight loss group, the risk of malnutrition increases 13 times higher than no weight loss/weight gain (OR (95% CI): 13.43 (2.35 � 76.62)); for over 10% weight loss, the risk increases roughly by 20 times (OR (95% CI): 19.86 (1.73 - 228.16). Over 5% weight loss in 1 month and over 10% in 6 months are the common symptoms in cancer patients with the proportion ranging from 30 to 55% in head and neck cancer patients  ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"WHNlknWL","properties":{"formattedCitation":"(27\\uc0\\u8211{}29)","plainCitation":"(27�29)","noteIndex":0},"citationItems":[{"id":61,"uris":["http://zotero.org/users/local/K9afcoqq/items/F4J45QL5"],"uri":["http://zotero.org/users/local/K9afcoqq/items/F4J45QL5"],"itemData":{"id":61,"type":"article-journal","abstract":"BACKGROUND: Malnutrition is reported frequently in head and neck cancer patients. The impact of malnutrition on surgical outcome is not clearly understood. The purpose of this study was to define the usefulness of six different parameters in scoring malnutrition and to determine the nutritional parameter primarily related to postoperative complications.\nMETHODS: Sixty-four patients undergoing major surgery for advanced head and neck cancer were studied prospectively, and six different parameters were used to define malnutrition. Logistic regression was used to relate nutritional parameters to postoperative complications.\nRESULTS: The parameters applied all identified different aspects of the nutritional status, as malnutrition varied between 20% and 67%. Logistic regression analysis identified a weight loss of more than 10% to be the most prominent predictive parameter for the occurrence of major postoperative complications.\nCONCLUSIONS: Patients with weight loss more than 10% during the six months before surgery are at a great risk for the occurrence of major postoperative complications.","container-title":"Head & Neck","DOI":"10.1002/(sici)1097-0347(199708)19:5<419::aid-hed9>3.0.co;2-2","ISSN":"1043-3074","issue":"5","journalAbbreviation":"Head Neck","language":"eng","note":"PMID: 9243270","page":"419-425","source":"PubMed","title":"Assessment of malnutrition parameters in head and neck cancer and their relation to postoperative complications","volume":"19","author":[{"family":"Bokhorst-de van der Schueren","given":"M. A.","non-dropping-particle":"van"},{"family":"Leeuwen","given":"P. A.","non-dropping-particle":"van"},{"family":"Sauerwein","given":"H. P."},{"family":"Kuik","given":"D. J."},{"family":"Snow","given":"G. B."},{"family":"Quak","given":"J. J."}],"issued":{"date-parts":[["1997",8]]}}},{"id":70,"uris":["http://zotero.org/users/local/K9afcoqq/items/4CE49W4C"],"uri":["http://zotero.org/users/local/K9afcoqq/items/4CE49W4C"],"itemData":{"id":70,"type":"article-journal","abstract":"The aim of this prospective study was to investigate the incidence of weight loss in head and neck cancer patients on commencing radiotherapy treatment at a regional oncology centre. Of the 100 patients included in the study, 33% presented with carcinoma of the larynx. Fifty-seven per cent of patients had lost weight on commencing treatment. A mean weight loss of 6.5 kg, equating to approximately 10% of body weight, was reported. A significant number of patients experienced a dry and/or sore mouth, had difficulty masticating and swallowing food, had altered taste perception, were missing meals or had symptoms of uncontrollable nausea and constipation. Since radiotherapy treatment may further limit oral intake, it is essential that dietetic intervention is addressed for all head and neck cancer patients and incorporated into the treatment plan on diagnosis before definitive management commences.","container-title":"European Journal of Cancer Care","DOI":"10.1046/j.1365-2354.1999.00156.x","ISSN":"0961-5423","issue":"3","journalAbbreviation":"Eur J Cancer Care (Engl)","language":"eng","note":"PMID: 10763643","page":"133-136","source":"PubMed","title":"Incidence of weight loss in head and neck cancer patients on commencing radiotherapy treatment at a regional oncology centre","volume":"8","author":[{"family":"Lees","given":"J."}],"issued":{"date-parts":[["1999",9]]}}},{"id":58,"uris":["http://zotero.org/users/local/K9afcoqq/items/PWQHXZWW"],"uri":["http://zotero.org/users/local/K9afcoqq/items/PWQHXZWW"],"itemData":{"id":58,"type":"webpage","title":"Nutritional Status in Head and Neck Cancer Patients - PubMed","URL":"https://pubmed.ncbi.nlm.nih.gov/7602677/","accessed":{"date-parts":[["2020",6,15]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (27�29). This condition not only heightens the rate of complications but also inhibits the effectiveness of surgery, radiotherapy and chemotherapy  ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"TkVtjHAq","properties":{"formattedCitation":"(30)","plainCitation":"(30)","noteIndex":0},"citationItems":[{"id":72,"uris":["http://zotero.org/users/local/K9afcoqq/items/D4E35WI8"],"uri":["http://zotero.org/users/local/K9afcoqq/items/D4E35WI8"],"itemData":{"id":72,"type":"webpage","title":"Bioelectric Impedance and Individual Characteristics as Prognostic Factors for Post-Operative Complications - PubMed","URL":"https://pubmed.ncbi.nlm.nih.gov/15975694/","accessed":{"date-parts":[["2020",6,15]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (30). While there have not been adequate studies to compare the level of increased risk, the findings of the study suggest that special attention should be paid to the weight changes of oral cancer patients in terms of prognosis and treatment, even when the malnutrition has not been diagnosed. Concerning gastrointestinal symptoms, patients who develop these symptoms are roughly 50 times more likely to suffer from malnutrition than those without (OR (95% CI): 49.18 (10.40 - 232.58)). The explanation for this could be: the gastrointestinal-related symptoms such as anorexia, fatigue, taste disorder, pain, etc. are closely associated with weight loss in cancer patients which is considered to be an immediate cause of malnutrition. For that reason, the�emergence�of�gastrointestinal-related signs also greatly raised the likelihood of malnutrition.
Also according to the research findings, patients ordering food outside are 7 times more likely to be underweight than those who incorporate the hospital diet (OR (95% CI): 6.67 (1.68- 26.44)). This situation could be explained by the fact that the vast majority of Vietnamese foods do not satisfy the requirements on energy, micronutrients and food safety  ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"vCjRRxLm","properties":{"formattedCitation":"(31)","plainCitation":"(31)","noteIndex":0},"citationItems":[{"id":133,"uris":["http://zotero.org/users/local/K9afcoqq/items/EWMRDM87"],"uri":["http://zotero.org/users/local/K9afcoqq/items/EWMRDM87"],"itemData":{"id":133,"type":"webpage","title":"TH�C N ��NG PH� TH�C TR�NG V� BI�N PH�P KH�C PH�C - Chi C�c An To�n Th�c Ph�m Kon Tum","URL":"http://atvstpkontum.gov.vn/news/AN-TOAN-THUC-PHAM/THUC-AN-DUONG-PHO-THUC-TRANG-VA-BIEN-PHAP-KHAC-PHUC-24/","accessed":{"date-parts":[["2020",6,16]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (31). Meanwhile, a balanced diet with a sufficient amount of vegetables and fruits controlled by nutritionists will help lower the risk of contracting diseases and malnutrition in patients with oral cavity cancer. Several reports have found that each serving of fruits and vegetables on a daily basis reduces the risk of oral cancer by 49%. On the contrary, using processed food increases the risk of oral cavity cancer (RR (95% CI): 1.91 (1.19-3.06))  ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"Or7pKbn8","properties":{"formattedCitation":"(32)","plainCitation":"(32)","noteIndex":0},"citationItems":[{"id":81,"uris":["http://zotero.org/users/local/K9afcoqq/items/BJ3Q2FE4"],"uri":["http://zotero.org/users/local/K9afcoqq/items/BJ3Q2FE4"],"itemData":{"id":81,"type":"webpage","title":"Meat Consumption and Risk of Oral Cavity and Oropharynx Cancer: A Meta-Analysis of Observational Studies","URL":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3988178/","accessed":{"date-parts":[["2020",6,15]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (32). Meanwhile, the diets of most Vietnamese citizens are seriously lacking the quantity of vegetables and fruits, whereas the consumption of processed meat is on the increase  ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"6abtGjWY","properties":{"formattedCitation":"(33,34)","plainCitation":"(33,34)","noteIndex":0},"citationItems":[{"id":63,"uris":["http://zotero.org/users/local/K9afcoqq/items/Y4RNRT9S"],"uri":["http://zotero.org/users/local/K9afcoqq/items/Y4RNRT9S"],"itemData":{"id":63,"type":"webpage","abstract":"A prospective study into the nutritional status of 114 patients with untreated primary squamous cell carcinoma of the head and neck was undertaken to assess its possible prognostic value for survival. Nutritional status was evaluated by anthropometry, creatinine height index estimation, serum albumi �","container-title":"Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery","language":"en","note":"ISSN: 0194-5998\nissue: 1\nsource: pubmed.ncbi.nlm.nih.gov\npublisher: Otolaryngol Head Neck Surg\nvolume: 93\nPMID: 3920627\nDOI: 10.1177/019459988509300114","title":"Nutritional Status--A Prognostic Indicator in Head and Neck Cancer","URL":"https://pubmed.ncbi.nlm.nih.gov/3920627/","author":[{"family":"Gb","given":"Brookes"}],"accessed":{"date-parts":[["2020",6,15]]},"issued":{"date-parts":[["1985",2]]}}},{"id":84,"uris":["http://zotero.org/users/local/K9afcoqq/items/BLYNXDCW"],"uri":["http://zotero.org/users/local/K9afcoqq/items/BLYNXDCW"],"itemData":{"id":84,"type":"webpage","title":"Impact of Severe Malnutrition on Short-Term Mortality and Overall Survival in Head and Neck Cancer - PubMed","URL":"https://pubmed.ncbi.nlm.nih.gov/21802345/","accessed":{"date-parts":[["2020",6,15]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (33,34). Therefore, a specialized and comprehensive nutrition care should be designed and given to patients, especially hospitalized cancer patients. Moreover, it is essential to spread foundational messages for the general public to get the correct perception about the necessary nutrition diet for cancer prevention as well as treatment.
Conclusion 
Oral cavity cancer patients posed a significant chance of malnutrition. Patients in late stage of disease, weight loss, gastrointestinal symptoms and non-compliance with pathological nutrition care were at greater risk of malnutrition than most cases. Therefore, Nutrition management in patients with oral cavity cancer is very important.

ACKNOWLEDGEMENTS (optional)
We would like to express our sincere gratitude towards National cancer Hospital for facilitating the study process. We would also like to thank the hospitalized patients at National cancer hospital for their persistance and dedication in assisting us to complete this study.
AUTHOR DISCLOSURE
The authors declare no conflict of interest.
       This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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Table 1. General information and treatment characteristics of research subjects

General informationFrequency (N=220)Ratio (%)Age18 � 39 years old   
40 � 59 years old
e" 60 years old
Average23
131
66
53.3� 12.110.5
59.5
30.0
GenderMale
Female167
5375.9
24.1Type of cancerTongue
Floor of mouth
Gingiva
Palate
Oral mucosa
Salivary glands
Lips
Others72
28
4
106
7
2
0
132.7
12.7
1.8
48.2
3.2
0.9
0
0.5Stage of cancerI
II
III
IV22
34
63
10110.0
15.5
28.6
45.9Treatment methodSurgery
Radiation therapy73
14733.2
66.8Nutrition routeOral feeding
Feeding tube201
1991.4
8.6Food prepartionHospital diet
Self-cooked
Order outside
Others48
139
17
1621.8
63.2
7.7
7.3BMI< 18.5
18.5 � 22.5
> 22.551
155
1423.2
70.4
6.4PG GSAPG SGA A
PG SGA B
PG SGA C41
139
4018.6
63.2
18.2Weight change in 01 monthNo change/ weight gain
Lose 1-5%
Lose 5-10 %
Lose >10%56
71
26
1433.5
42.5
15.6
8.4Weight change in 06 monthNo change/ weight gain
Lose 1-5%
Lose 5-10 %
Lose >10%28
55
56
2816.8
32.9
33.5
16.8


Table 2. The risk of malnutrition by stage of cancer, treatments, nutrition route and food preparation methods
PG SGA
N=220PG SGA A
N (%) PG SGA B/C
N (%)pStage of cancerI (n = 22)9 (40.9)13 (59.1)0.009II (n = 34)5 (14.7)29 (85.3)III (n = 63)15 (23.8)48 (76.2)IV (n = 101)12 (11.9)89 (88.1)Treatment methodSurgery   (n = 73)18 (22.7)55 (75.3)0.106Radiation therapy (n = 147)23 (15.7)124 (84.3)Nutrition routeOral feeding (n = 201)41 (20.4)160 (79.6)0.029Feeding tube (n = 19)0 (0.0)19 (100.0)Food preparationHospital diet (n = 48)10 (20.8)38 (79.2)0.461Self-cooked (n = 139)28 (20.1)111 (79.9)Order outside (n = 17)1 (5.9)16 (94.1)Others (n = 16)2 (12.5)14 (87.5)* PG SGA A: No risk of malnutrition; PG SGA B / C: There is a risk of malnutrition, including PG SGA B: a slight or moderate malnutrition risk; PG SGA C: severe malnutrition risk.







Table 3. Malnutrition according to acquired gastrointestinal symptoms

Gastrointestinal symptoms
N (%)BMI <18,5
n = 51BMI e" 18,5
n = 169PNo appetite
104 (47,3)	Yes23 (22.1)81 (77.9)0.723No28 (24.1)88 (75.9)Dry mouth
101 (45,9)Yes  25 (24.8)76 (75.2)0.611No 26 (21.9)93 (78.1)Fatigue
96 (43,6)Yes  26 (27.1)70 (72.9)0.228No 25 (20.2)99 (79.8)Pain 
93 (42,3)Yes 25 (26.9)68 (73.1)0.266No 26 (20.5)101 (79.5)Things taste funny or have no taste 89 (40,5)Yes22 (24.7)67 (75.3)0.656No29 (22.1)102 (77.9)Problems swallowing
85 (38,6)Yes  25 (29.4)60 (70.6)0.082No 26 (19.3)109 (80.7)Mouth sores
78 (35,5)Yes  25 (32.1)53 (67.9)0.021No26 (18.3)116 (81.7)Smells bother me 
35 (15,9)Yes 15 (42.9)20 (57.1)0.003No 36 (19.5)149 (80.5)Nausea 
31 (14,1)Yes 5 (16.1)26 (83.9)0.315No 46 (24.3)143 (75.7)Constipation 
31 (14,1)Yes 9 (29.0)22 (71.0)0.405No 42 (22.2)147 (77.8)Vomiting
13 (5,9)Yes 5 (38.5)8 (61.5)0.178No 46 (22.2)161 (77.8)Diarrhea
3 (1,4)      Yes 1 (33.3)2 (66.7)0.675No50 (23.0)167 (77.0)Feel full quickly27 (12,3)Yes7 (25.9)20 (74.1)0.718No44 (22.8)149 (77.2)* BMI <18.5: Underweight patients; BMI e"18.5: normal-weight or overweight patient
Table 4. Relationship between some pathological factors and the malnutrition risk of patients according to PG SGA
Pathological factorsPG SGA (B+C/A)MR/
No MROR* (95%CI)Treatment methodSurgery 55/181Radiation therapy124/231.30 (0.52 � 3.21)Stage of cancerI13/91II29/56.22 (1.10 �35.14)III48/151.68 (0.37 � 7.63)IV89/124.71 (1.08 �20.57)Nutrition routeOral feeding160/411Feeding tube19/0-Gastrointestinal symptomsNo4/161Yes175/2549.18 (10.40-232.58)Food preparationHospital diet38/101Self-cooked111/280.68 (0.18 � 2.49)Order outside16/16.31 (0.34 � 117.99)Others 14/21.01 (0.16 � 6.27)Weight change in 01 monthNo change/Weight gain42/141Lose 1-5%56/150.30 (0.08 � 1.06)Lose 5-10 %24/20.12 (0.02 � 0.99)Lose >10%13/10.40 (0.02 � 8.62)Weight change in 06 monthsNo change/Weight gain17/111Lose 1-5%40/151.53 (0.43 � 5.43)Lose 5-10 %52/413.43 (2.35 � 76.62)Lose >10%26/219.86 (1.73 � 28.16)(*) The model controls variables consisting of gastrointestinal symptoms, weight change in 01 month, cancer types, age groups, weight change in 06 months; PG-SGA group A: no malnutrition risk, PG-SGA groups B and C: moderate and severe malnutrition risk. �




Table 5. Relationship between pathological factors and the underweight risk in cancer patients according to BMI
Pathological factorsBMI (<18,5/ e" 18,5)MR/ 
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