الفهرس 
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Abstract
The liver plays a central role in regulation of nutrition by trafficking the metabolism of nutrients, and many factors disrupt this metabolic balance in end-stage liver failure. Consequently, when the liver fails, numerous nutritional problems occur. Also, nutrition and liver are so closely intertwined that a slight change in either can positively or negatively affect the other. Because of this close relationship, it has long been recognized that malnutrition is highly prevalent in liver cirrhosis patients.
There are several factors that contribute to malnutrition in liver failure such as, inadequate dietary intake of nutrients, reduction in their synthesis or absorption and increased protein loss, hypermetabolic state as well as increased energy-protein expenditure and requirements.
The most important tools to assess nutritional status are appetite/intake, anthropometrics combined with visual assessment of body muscle mass/body wasting, and biochemical indicators. In addition, a comprehensive nutritional assessment should be performed by a clinician such as a dietitian or a physician knowledgeable in nutritional needs for early stages liver cirrhosis patients.
The aim of this study:
Was to assess dietary patterns and nutritional status of patients with early stages liver cirrhosis.
Setting:
The study was conducted at the Medical Outpatients Clinic at Saidy Salim General Hospital. The hospital is affiliated to The Ministry of Health and Population at Kafr-El sheikh Governorate. This clinic provides public non paid services during all week days except Friday, at morning shift only from (8 am to 2pm) and is composed of one room that contains one bed for patients’ examination. Administrative offices comprise, a medical office, a nursing station, a supporting biochemistry lab and general toilets.
Subjects
A convenient sample of 254 adult patients having early stages liver cirrhosis constituted the sample of the study and showing up at the above mentioned setting.
Tool of the study:
To fulfill the objectives of the study, a tool was developed by the researcher based on a thorough review of literature. It was entitled as:
”Early stages liver cirrhosis patients dietary patterns and nutritional status structured interview schedule”.
The developed tool comprised the following parts:
The first part comprised the following:
A- Sociodemographic data: these data included age, sex, area of residence, marital status, level of education, occupation, income, room number, number of family members (living at home), level of physical activity and having meals outside home.
B- Clinical data: these data included: etiology or underlying cause (long-term alcohol abuse, hepatitis B and C infection, and fatty liver disease),patient’s diagnosis, duration of the disease, current medication, on the counter drugs, such as (laxatives or analgesics, vitamins, minerals, and herbals), subjective complains as (abdominal pain, nausea) and objective signs as edema, diagnostic procedures as ( endoscopy, CT scan, x-ray and ultrasound) and therapies, or treatments that may increase nutrient needs or induce malabsorption, were also included.
The second part was adapted to assess dietary patterns throughout a72-hour recall that included a list of food and drinks intake during the previous three days before admission, and a list of food consumption by the patients and how often they were consumed. The listed items were weighed in a 6- point Likert scale where 1= more than one time daily, 2= one time daily, 3=2-3 times per week, 4= once weekly, 5= rarely,6= unpleasant (not eaten)).
The third part: was developed to assess nutritional status throughout clinical examination that included subjective and objective physical signs of malnutrition.
Scoring system: each positive response was scored from (4-1). A score of 4 was assigned to the response choice” always”, 3 for” sometimes”, 2 for ”rarely” and 1 for ”no”.
In addition it comprised anthropometric (height, weight, BMI, MAC, TSF and Body composition) and Biochemical (haemoglobin, white blood cells, platelet count, lymphocyte count, prothrombin time, prothrombin activity) measurements.
The tool was revised by 5-experts in the field of the study for content validity and necessary modifications were done. A pilot study was conducted to ensure the clarity and applicability of the developed tool and to identify obstacles that might be encountered during data collection.
Data was collected from the identified subjects through interviewing about 30-45 minutes for each patient. Data were collected throughout the period of 4 months starting from half of September 2016, till the end of January 2017.
The following were the most important results of the present study:
Regarding socio-demographic data: the mean age of the studied patients was (53.59 ±6.33) years. The ages of the majority of the studied patients (73.6%) were ≥50 years. More than half of the studied patients (59.1%) were females.
Regarding the residence it was found that more than two- thirds of the patients (63.4%) were living in rural area, the remaining (36.6%) were urbans. The majority of patients (84.3%) were married, while only (2.4%) were single and none of them were divorced.
According to the educational level more than one third of studied patients (40.6%) were illiterate, while only (5.1%) of them have had bachelor degree. Concerning occupation, more than two thirds of patients (64.2%) were farmers and only (15.4%) were employed.
As regards income, high percent of studied patients (74.0%) had low income. And none of them didn’t practice any type of sports. Also, only (5.1%) were having meals outside home.
In relation to their clinical data: about half of studied patients (49. 2%) had hepatitis C and fatty liver as a cause of the disease. In addition, only (12.2%) of them had other causes as bilhariziasis and none of them were having alcohol as a cause of the disease.
More than half of the studied patients (55.9%) used legalone as a current medication, while only (2.8%) of them were using sofosbovir and mpiviropack. The majority of them (90.2%) were using analgesics as an on the counter drugs, but none of them used vitamins.
Concerning duration of the disease; the mean duration of the disease was (1.89±1.10) years. Also, the majority of studied patients (94.9%) were complaining of abdominal pain, and about (89.9%) complained of nausea. Furthermore, none of them complained of diarrhea and distention and all of them (100%) had undergone an ultrasound as a diagnostic test, while none of them had undergone an x-ray.
According to assessed food patterns within 72 hr recall: the findings indicated that the studied patients were having bread in their breakfast and dinner throughout three days with a mean and standard deviation of (295.4 ± 49.3, 297.3 ± 29.6 and162.8 ± 60.2), respectively and (187.7 ± 58.9, 168.9 ± 45.5 and 206.0 ± 70.8), respectively for dinner. Concerning snacks between breakfast and lunch more than half of patients were having tea with a mean and standard deviation of (100.0 ± 0.0, 100.0 ± 0.0 and100.0 ± 0.0), respectively.
Few patients were having juices with a mean and standard deviation of (200.0 ± 0.0 and 200.0 ± 0.0), respectively. The majority were having rice, in lunch throughout the three days, with a mean and standard deviation of (332.4 ± 65.1, 344.4 ± 62.0 and 330.3 ± 51.1), respectively. Few patients were having lentils and eggplant, with a mean and standard deviation of (200.0 ± 0.0), respectively.
Assessment of their nutritional status: seventy six point four percent of the subjects were always complaining of ”easy hair fall”. Also, (77.2%) were having dental caries. Few patients (2.4%) of the studied sample were having changes in skin color and tremors.
The findings revealed that, there were no severe symptoms experienced among the study participants. No significant correlations were elicited between overall dietary patterns and patients’ nutritional status. In addition, there were significant relationships between each of (weight, BMI and skin fold thickness) and the overall dietary patterns since p (<0.001for each). There were no significant relationships between overall dietary patterns and the other anthropometric and biochemical measurements.
According to the findings of the present study, it can be concluded that:
Considering the high prevalence of malnutrition in early stage cirrhotic patients together with the lack of simple and accurate methods of assessment of malnutrition in this patient population, it is reasonable to assume that malnutrition occurs in all patients.
Based on these results the following recommendations are suggested:
1. Regular and complete nutritional assessment of liver cirrhosis patients should be carried out for early detection and treatment of malnutrition.
2. Nutritional health education program must be organized for early stages liver cirrhosis patients in order to limit occurrence of further malnutrition and its complication.
3. Nutritional support, advice and guidelines by dietitian should be undertaken for all cirrhotic patients to prevent occurrence of complications of malnutrition and improve clinical outcomes.
Future researches are needed regarding:
1- Factors affecting nutritional status of liver cirrhosis patients and their effects on the patients outcomes.
2- The impact of nutritional programs on liver cirrhosis patients’ outcomes.