Nutritional Status and Calorific Intake in Rheumatic Heart Diseases Patients, Operated in Sahid Gangalal National Heart Center (SGNHC) Abhishek Khadka 1, 2*, Surendra B. Katwal 1, Nikesh R. Shrestha 3 1 Central Campus of Technology (CCT), Dharan 2 Disable and Helpless Rehabilitation and Service Center (DHERSEC), Dharan 3 B. P. Koirala Institute of Health Sciences (BPKIHS), Dharan Rheumatic heart disease (RHD) remains a significant health problem in the developing world, affecting 15.6 million people worldwide, with a prevalence of 1.2/1000 in 5-15 year old school children in Nepal. RHD is largely a disease of poverty, of which overcrowding, poor nutrition, poor health-care access and limited health resources are major contributing factors. Considering the nutritional status of RHD, the survey was done in Dharan and nearby VDC s. Thirty post operative patients ranging from the age 9 to 37 were included in the survey. The daily calorific value was calculated on the basis of the questionnaire. On the survey it was found that there was a significant increase in calorific value but only six of them were meeting up the recommended calorific intake value. Besides it was found that there is a significant increase in carbohydrate, protein, vitamin A and riboflavin intake but not fat before and after the surgery in weight increasing patients. Loss of appetite was one major symptom of the diseases before the surgery and more over lack of knowledge about this disease had leaded the patients to the valve operation otherwise it can be cured in primary phase. Sixty percentages of total patients were categorized as normal after the surgery and the percentage of underweight was reduced from 36.67% to 30%. Poverty was major reasons for malnutrition in the patients in the pre-surgery conditions. Keywords: RHD, SGNHC, BMI, Calorie, Nutrition Introduction Group-A streptococcus (GAS) causes a broad spectrum of disease. GAS causes mild superficial infections of throat or skin to infections such as cellulitis and erysipelas, severe invasive infections including bacteraemia and necrotising fasciitis (often complicated by the streptococcal toxic shock syndrome) (WHO, 2005). GAS also causes post-streptococcal complications of acute rheumatic fever (ARF) and acute poststreptococcal glomerulonephritis (APSGN) and these may lead to further complications (e.g. ARF may cause rheumatic heart disease, which in turn may be further complicated by endocarditis or strokes) (WHO, 2005). Acute rheumatic fever is a non-supportive complication of group A beta hemolytic streptococcal sore throat. This commonly affects the school going children especially joints, skin subcuteaneous tisue, brain and heart. So, it s commonly called the diseases which licks the joint but bites the heart (English, 1993). It s concluded that approx 18.1 million people suffer from serious GAS whereas 1.78 million new cases occur each year. Over 50,000 deaths occur each year and GAS is responsible for this (WHO, 2005). RF is the inflammatory diseases which are caused by S. pyogenes such as scarlett fever or strep throat (Kumar et. al., 1989). In Nepal, the prevalence rate of RHD is 1.2 per 1000 in 5-15 year old school children in Nepal (Regmi and Pandey, 1997). RHD *Corresponding author, E-mail: k.abishake@enternepal.com 149
is largely a disease of poverty, of which overcrowding, poor nutrition, poor health-care access and limited health resources are major contributing factors (Meyer, 2009) As streptococcal sore throat, ARF occurs most commonly in young school child, median age between 9 to 11 years and very early infantry (Gene and Mam, 1989). Food has the significant role to pay in illness. Diet may have to be modified depending upon the heart diseases, the severity of the problem, and the nutritional status of the patient as well as metabolic change involved (Khanna et. al, 2005) Materials and Methods Thirty post operative RHD patients were taken in the survey from Dharan, Panchkanya, Bayarban, Chatara, Barahchhetra, Bhanjhyang, Nishane, Bharauli, Panmara. Rheumatic heart diseases patients were selected mainly from the information s based on information of organizations named DHERSEC. And every patient was asked to fill the consent before doing the survey (to pass the ethical issues). If patients agree then the nutritional analysis was done. The patient name was coded in patient id as ethical issues are one of the important factors for doing the research. In the survey the height and weight before the surgery was noted from the discharge summary from SGNHC and the present height and weight was measured through measuring tape and weighing machine. Based on these data the BMI was computed before as well as after the surgery and it was categorized as per the standard of WHO as shown in Table 1. Table 1. Category of BMI Classification BMI Category Risk of Developing Health Problem Underweight Less than 18.5 Increased Normal Weight 18.5-24.9 Least Overweight 24.9-29.9 Increased Obese Class I 30-34.9 High Obese Class II 35-39.9 Very High Obese Class III 40 Extremely High In addition to this the quantitative amount of dietary food items was also noted before as well as after the surgery. Based on the response of the questionnaire by the patients the nutrients like fats, carbohydrate, protein, vitamin A and riboflavin was computed from the food composition table provided from Department of Food Technology and Quality Control (DFTQC) on the food items that are eaten daily. The daily calorific value was calculated from the nutrients computed from fats, proteins and carbohydrates. The adequacy of calorific intake was determined from the daily calorific intake. Since the post operative patients of RHD has reduced physical activity the daily calorific value for men was 2350 Kcal and for females it was 1800 Kcal as per mentioned in the book of Subangi A. 150
Joshi. The adequacy was determined by the following: i. ii. 2350 calorific intake 2350 1800 calorific intake 1800 100% for males 100% for females A paired sample of t-test was done through 95% level of confidence as the statistical analysis via SPSS 16.0. Results and Discussion General results- In the results it was found that the number of female candidates was more than males. The females to males ratio was 1.3:1 i.e., 17 females and 13 males were taken in the survey. It was also seen that the nine of the respondents were from Dharan, four each from Panmara and Barban and five from Chatara. Similarly regarding the age it was seen that the maximum respondent s age was 22 whereas the mean age of the patients was 21.67 with a standard deviation of 7.102. The age of the patients was ranging from the nine to 37 years. In the same way New York Heart Association (NYHA) index from SGNHC was noted from the discharge summary. In the NYHA classification it was seen that NYHA III category patients was more as compared to other. The NYHA classification of the patients is given in Table 2. Table 2. Distribution of Sample according to NYHA NYHA 151 Frequency I 3 II 10 III 13 IV 4 Total 30 The main caste of the research area was Tamangs, Rai and Limbu, Dalits, Chhetri, Newar, Tamang, other terai caste (Madhesis) and Tharus. It was found that in the survey the Dalits were more as compared to other caste. Anthropometric results- In the weight it was seen that there was the maximum weight gain of 8 kg in the patients and 4 kg maximum weight decrease in the patients. It was seen that there was weight increase in 28 patients and two patients had the weight decrease. It was found that there was a significant increase in weight among weight increasing patients (p<0.05) whereas in the case of weight decreasing patients it was found that there was no significant decrease in weight in (p>0.05). Similarly in the height it was seen that 17 patients had already completed the stage of growth and only 13 patients were found to be height increase. The increase in height in height increasing patients was found to be significant increase (p<0.05). Regarding BMI was computed from the height and weight from the data recorded and measured. In the case of the BMI, it was seen increase as well as decrease in BMI in patients. Average BMI increase among 28 patients was found to be 2.377 kgm -2 whereas the average decrease in BMI in two patients was 1.18kg m- 2 Representing the BMI in according to category given in Table 3.
BMI Category Table 3. Representing BMI according to its Category No. of Patients before the Surgery No. of the Patients after the Surgery Underweight 11 9 Normal Weight 17 18 Over Weight 1 2 Obese class II 1 1 Total 30 30 In the case of the BMI it was found that there was a significant increase in BMI in the case of the BMI increasing patients (p<0.05) whereas in the case of the BMI decreasing patients it was found that there was no significant decrease in BMI in the case of the BMI decreasing patients (p>0.05). Dietary intake results- All most all of the post operative patients are reduced physical activity. In the case of nutrients fats, carbohydrate, protein vitamin A and riboflavin was computed. From which fats, protein and carbohydrate was the major energy giving constituent. In the weight increasing patients it was found that there was a significant increase in riboflavin, protein, vitamin-a and carbohydrate after the surgery (p<0.05) but in the case of the fat it was found that there was no significant increase in fat (p>0.05). And in the case of the weight decreasing patients it was found that there was no significant increase in either of nutrients computed (p>0.5). The general fruits and vegetables taken by patients are given in Table 4. Table 4. General fruits, vegetables and meats products consumed by the patients Main Food Grains Fruits Food Available Rice, maize, wheat, millet, etc Papaya, banana, guava, mango, litchi, sugarcane, cucumber, apple Green Leaves Roots and Tubers Oil seeds Pulses Other Vegetables Fermented Products Meat Serve Liquid Foods Mustard leaves, radish leaves, ferns Potato and sweet potato Mustard Black gram, cowpea, soyabean, gram, Pumpkin, cauliflower, cabbage, brinjal, radish, carrot, etc. Kinema, gundruk, sinki Pork, chicken, mutton, fish, eggs, buff, Milk, coffee, black tea, milk tea As per mentioned in discharge summary of SGNHC, the patients had stopped eating leafy vegetables like cabbage, abandoned citrus fruits and vegetables. In addition to this the post operative patients had stopped eating liver of animal. It was also found that tab farin was one of the common medicines being used by the patients as an oral anti-coagulating agent. 152
Calorific values- The comparative calorific intake values of patients before and after the surgery was computed from the major energy giving constituent i.e., protein, carbohydrate and fat. In the adequacy of the calorific intake it was seen that only 5 post operative patients are getting the daily recommended calorie as per mentioned. Conclusion From this research it was concluded that there was a lack of knowledge of rheumatic heart diseases and balanced diet. Among the 30 patients it was found that only 60% i.e., 18 patients were categorized to normal category. It was also found that poverty was one of the main causes of the diseases other it could be treated in pre-surgery phase i.e, ARF. It was also found that the post operative patients were using warfarin an anti-coagulating agent. If they are lacking the then there may be the coagulation of blood in brain which may results in paralysis. Besides this the duration of surgery is also an important factor, the surgery duration was ranging from 18 to 24 months. The average carbohydrate intake was found to be 270.5gm before the surgery and 346.5 gm after the surgery, similarly fat was 5.75 gm before the surgery and 3.91 gm after the surgery. In the case of protein it was found that the intake of protein was 33.42 gm before the surgery and 51.28 gm after the surgery, vitamin A was 293.65 IU before and 718.6 IU and riboflavin was 0.46 mg before and after the surgery it was 0.954 mg per day. The average calorific value for male was found to be 1354.4 kcal before the surgery whereas after the surgery it was found to be 1708.24 kcal per day and in the case of females 1201 kcal and after the surgery it was found that 1563.76 kcal. It was also found that there was a positive correlation between the weight increase and calorific value increase i.e., 0.244 and was found to be significant. Acknowledgements This research would be incomplete without help of my mates Dr. Hannah Meyer (University of Melbourne, Australia), Pratikshaa Rai (BPKIHS, Dharan), Seema Limbu (Nepal Medical College, Birgunj), Bandhana Neupane (MCOMS, Pokhara), Binod Yadav (librarian of Central Library of BPKIHS) and Central Library of BPKIHS, for assisting me in this research. References English P. C. (1993). Rheumatic fever in America and Britain. A biological, epidemiological and medical history. New Jersey: Rutgers University Press: 17-52 cited from Meyer H. (2009), Rheumatic Heart Disease: Quality of life for their patients and families in Eastern Nepal, Nossal Institute of Global Health, University of Melbourne. Gene H., Mam S. (1989). Rheumatic Fever and other rheumatic diseases of heart, 2: 1721. Khanna K., Gupta S., Passi S. J., Serh R., Mahna R. and Puri S (2005). Textbook of nutrition and Dietetics, 5 th Edition, R. Gangadharan New Dehli: 226-240. Kumar V, Abbas A. K., Fausto N. Robbins and Cotran (2005). Pathologic Basis of Disease. 7 th ed. Gruliow R, editor: Elsevier Saunders. Meyer H. (2009). Rheumatic Heart Disease: Quality of life for their patients and families in Eastern Nepal, Nossal Institute of Global Health, University of Melbourne. Regmi P. R., Pandey M. R. (1997). Prevailance of rheumatic fever and rheumatic heart diseases in school children of Kathmandu City. Indian Heart J.; 49; 518-20. WHO, (2005). Department of child health and adolescent health and development. The current evidence of the group A streptococcal diseases; 1. 153