University of Alexandria

138 Pages·2015·2.94 MB·English

Al Azhar University – Gaza
Deanship of Postgraduate Studies
College of Pharmacy

Magnitude and Manifestations of Malnutrition among
Cystic Fibrosis Patients in the Gaza Strip

By
Mohammed El-Kahwaji

Supervisors:
Dr. Mazen A. El-Sakka Dr. Mohammed K. Shbair
Assist. Prof. Pharmacognosy Assist. Prof. Toxicology
College of Pharmacy College of Pharmacy
Al-Azhar University Al-Azhar University

A Thesis Submitted in Partial Fulfillment of the Requirements for the Degree of Master in

Clinical Nutrition

2015
.
Al Azhar University – Gaza
Deanship of Postgraduate Studies
College of Pharmacy

Magnitude and Manifestations of Malnutrition among
Cystic Fibrosis Patients in the Gaza Strip
A proposal Submitted in Partial Fulfillment of the Requirements for the Degree of Master in
Clinical Nutrition
By
Mohammed El-Kahwaji
Bsc.Pharmacy 1997
This thesis was defended successfully on 10/ 03/ 2015

Approved by

Committee Members Signature
Dr. Mazen A. El-Sakka ---------------------
Dr. Mohammed K. Shbair ---------------------
Dr. Reyad K. Qedra ---------------------
Dr. Waleed A. Dawoud ---------------------

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114 ةيلاا – هط ةروس

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Dedication

To soul of my father
To my mother for her endless love
To my beloved wife for her support,
encouragement and patience,
To my sons Belal and Ahmed, my daughters
Nihad, Marah and Sara who are
the light of my life
To my brothers, sisters, family, friends and
Work colleagues,

I dedicate this modest effort
MoHammed A, El-Kahwaji
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Declaration

I hereby declare that this submission is my work and that, to the best of my
knowledge and belief, it contains neither material previously published or written by
another person nor material which to a substantial extent has been accepted for the
award of any degree at a university or other institute except where due
acknowledgement has been made in the text.
Signature: Mohammed
Name: Mohammed A. El-Kahwaji

Date: December 2014

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Acknowledgment

All praise and glory are due to ALLAH the all mighty for all the bounty and support
granted to me, peace and blessings are up on the prophet Mohammed.
I would like to record my gratitude to Dr. Mazen A. El-Sakka for his supervision,
advice and guidance from the early stages of the research until the end.
I acknowledge gratefully Dr. Mohammed K. Shbair for his advice and supervision
Special thanks to Mr. Ashraf El-Shanti the manager of Cystic Fibrosis Friend Center
in Gaza for his unlimited cooperation and support.
I deeply thank Dr. Amjad EL-Shanti Assist. Professor of epidemiology for his advices
and support.
I thank Dr. Samar El Nakhal for her support and advice.
I thank the team of clinical nurses and their manager in Al Naser hospital, especially
Mr. Hamdy El Khodari for the kind help given during blood sample collection .
I would like to thank Mr. Mohammed Abu Afash, the Director of the Palestinian
Medical Relief Society laboratory in Gaza city, and laboratory personnel for the great
help, high quality work and promptness.
Finally, thanks all the patients and their families who cooperated by answering the long
questionnaire, and gave blood samples; without their contributions, this work would
have never been finished.

Mohammed El-Kahwaji

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Abstract:
Introduction: Cystic fibrosis (CF) is the most common life-limiting autosomal recessive
disease; It is a multiorgans disease affecting mainly the lungs, pancreas, sweat glands, and
in males the Wolffian ducts; CF is characterized by a gradual decline in pulmonary
function, intestinal malabsorption and both are strong predictors of morbidity and mortality
in patients with CF. Goal: To determine the magnitude and the manifestations of
malnutrition among CF patients in Gaza-Strip in order to reduce the long-term
complications of malnutrition. Objectives: To study the magnitude (prevalence) of
different malnutrition aspects (stunting, wasting, underweight, anemia, vitamin D, ferritin,
deficiency, and zinc deficiency) among CF patients, to determine the relationship between
the different aspects of malnutrition and the socio-demographic factors of CF patients, to
determine the relationship between the different aspects of malnutrition from one side and
the knowledge, attitude and practice (KAP) of CF patient's parents about proper nutrition
for CF patients and to explore the manifestations associated with the different malnutrition
aspects. Methodology: A cross-sectional study with a measurement of dietary, lifestyle and
anthropometric exposures and KAP study includes 50 patients of CF less than 18 years were
as they filled questionnaire and gave blood samples for four tests (vit.D, zinc, firritn, Hb).
Anthropometric measurements were taken by trained staff Results: Most of families of CF
patients were poor families, consanguineous parents, most diagnosed by sweat test in mean
16 months, only 60% of them are able to get antibiotic, digestive enzymes and vitamins,
40.15% of CF parents have good knowledge about amount of creon must be used with each
type of food, 79.13% have good knowledge about CF as disease. Anemia found in 38% of
CF patients, ferritin deficiency in 8%, and zinc deficiency in 26% with statistically
significant with inability to provide digestive enzymes. Vitamin D deficiency and
insufficiency was 52% with significant relation with gender, about 70% of female patients
have degree of deficiency while only 40% of male patients have that. Anthropometric
measurement show that about 82% of CF patients suffer from stunting height for age
(Ht/Age) , mild or moderate or Severee with proportions 32%, 38%,12% respectively, about
28% of patients were underweight moderate to Severee 20%, 8% respectively with
statistically significant with low monthly income, respiratory manifestation and delay in
development. Conclusion: factors affect malnutrition among CF were monthly income,
knowledge of parents, female gender and health services, deficiency in digestive enzymes
or low knowledge about dose will cause aspects of malnutrition like underweight or zinc
deficiency, Anemia found in CF patients was not iron deficiency anemia but it is anemia of
chronic disease and does not needs iron supplement, most of parents have good knowledge
about nature and manifestations disease. Recommendations: Establish CF center at
Ministry of Health (MoH) with full equipments, supply with all new medications needed for
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CF patients, increase awareness of doctors and patients about disease and dose of digestive
enzymes also encourage patients to eat high calorie food with suitable dose of digestive
enzymes.

Key words: Cystic fibrosis; Malnutrition; Hemoglobin; zinc; vitamin D; ferritin; stunting;
wasting; underweight.

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يبرعلا صخلملا
ةزغ عاطق يف يسيكلا فيلتلا ىضرم ىدل ةيذغتلا ءوس راثأو رادقم ةساردل يبرع صخلم
ةدية عميمش ييتلاو ، ناسنلإا ةايحل ةددهملا ةيحنتملا ةيثارولا ضارملأا نم يسيكلا فيلتلا ضرم ربتعي :ةمدقملا
ي يرديش رو ديتد ضريملا ييمتيو ،روكذلا دنة ةقفادلا تاونقلاو ةيقرعلا ددغلاو سايركنبلاو نيتئرلا عثم ءاضةأ
ي رم دينة تاييفولا ةبيسنو ضريملا ةبسنل تارشؤم ام ناذللا صاصتملاا ءوسو ،يسفنتلا زاه لا ةفيظو يف
ة ي ايةق ييف ييسيكلا فييلتلا ي رم مديل ةييذغتلا ءوس راثأو رادقم ديدحش و :ةساردلا فده يسيكلا فيلتلا
نيتيريفلاو د نيمايتيف صيقنو اييمينلأاو ةيفاحنلاو نزويلا صقنو رصقلا عثم ةيذغتلا ءوس رادقم ةسارد :ضارغلأا
ةييةامتملاا عيماوعلاو ةييذغتلا ءويس نيم هيمولأا لأذي نييد تايقلاعلا ديدحشو ،يسيكلا فيلتلا رم مدل كن لاو
ةبيسانملا ةييذغتلا ويح يسيكلا فيلتلا رم ءادلآ قيبةتلاو هموتلاو ةفرعملاد اضيأ اهتقلاةو ، ةيفار وميدلاو
ةي رعتسم ةيسارد :ةةيجهنملا ةييذغتلا ءوسل ةفلتخملا همولأا لة ةبشرتملا راثلآاو ديدحتلو ، رملا مهلافطلأ
ءاييلوأ قييبةشو هموشو ةفرعم مدم ةساردو رملل ةيمس لا سيياقملاو ةايحلا طمنو ءاذغل ةنما تم تاسايق عم
تاينية اويةةأو نايبتيسلاا يلة اودايمأ ةنيس 18 نيم عقأ م رامةأ فيلتلاد ضيرم 50 ةساردلا تلمشو م رومأ
ةيميس لا تايسايقلا ميهل عيمةو نيدويلموميهلا ،نيتيرفلا ،كن لا ،د نيماتيف( ي تاصوحف عدرأ عمعل مهمد نم
ةيدارق ديموشو ،ةرييقف تلائاية ييسيكلا فييلتلا ي رم تلائاية ميظعم :جئاتنلا بردم قيرف ةةساود تذخأ يتلا
16 صيخيمتلل طيسوتملا ريمعلاو ، ريعلا صحف و ضرملا صيخمش ةليسوو ، تلااحلا مظعم يف نيودلأا نيد
و ، تاينيماتيفلاو ةمي اهلا تايمي نلإاو ةييويحلا تادايضملا ريفويش نوعيةتيسي ي رملا نيم طقف %60 ، رهش
ةييعيبط نيية ةييفرعملا اييمأ ،ةميي اهلا تاييمي نلإا تاييةر د ةديييم ةييفرعم مهيدييل يي رملا ءاييدأ نييم طييقف%40.16
Ferritin صيقنو ي رملا نيم %38 ييف ةدويموم ايمينلأا ، %79.13 نم رثكأ اهفرعيف ضرملا تافةاضمو
صييقن نيييد ةيئايصحي ةييقلاة عايين نايكو يي رملا نييم %26 ييف دوييموم كيين لا صيقنو طييقف %8 يييف دويموم
نيم %52 يلاويح يف دوموم د نيماتيف ةيافك مدة وأ صقن .ةم اهلا تامي نلإا ريفوش لة ةردقلا مدةو كن لا
رييمشو روكذيلا ي رملا نم ربكأ ثانلإا رملا يف صقنلا نأ ثيح سن لا عم ةيئاصحي ةقلاة عم رملا
تاييسايقلا . كييل مهيدييل روكذييلا نييم %40 اييمنيد صقنييلا اذيي مهيدييل ثايينلإا يي رملا نييم%70 ني ييلي إئاييتنلا
%32 ةةييسد مهنيم ةيشوافتم ةيمردد ريصقلا نيم نونايعي ييسيكلا فيلتلا رم نم%82 نأ لي ريمش ةيمس لا
ديديملا وأ طيسوتملا نزويلا ضيقن نيم نونايعي ي رملا نيم %28 يلاويحو . %12 ةديديشو %38 ةةسوتمو
عخديلا ةيلق نم عك نيدو رمعلاد نزولا ةقلاة نيد ةيئاصحي ةقلاة دومو عم ديدملل %8 و طسوتملل %20 ةبسند
ةييذغتلا ءويس ييف رثؤيش ييتلا عيماوعلا : اتنتةسلاا رملل روةتلاو ومنلا يف رخأتلاو يسفنتلا زاه لا عكاممو
ةيحييصلا تامديخلا فعي و عويثنلأا سني لاو ءاييدلآا ةيفرعم ةيلقو عرهيملا عخديلا ةييلق يي فييلتلا ي رم مديل
ةييذغتلا ءوس نم ةريثك هموأ ءارو بابسلأا م أ نم اهتةر د ةفرعملا ةلق وأ ةم اهلا تامي نلأا صقنو ةمدقملا
اييمينأ تيسيل يي و فييلتلا ي رم مديل ةدويموملا ايمينلأا . رملا ءلاؤ مدل نزولا ةلقو كن لا صقن اهنم
ايتحش لاو ةينم ملا ضاريملأا ايمينأ ي امنيو رملا مظعم دنة يعيبط هبش ديدحلا نو خم نلا ديدحلا صقن
عدايش يكرم ءايمني : ايةصوتلا . ضريملا نية ةدييم ةيفرعم مهيديل ي رملا ميظعم ديدحلاد ةمةدم تاملاة لي
اييم عيكد يي رملا دييو ش ، تارييبتخمو ة يهمأ نييم عيماك عكييمد يه م يييسيكلا فيلتلايد صاييخ ةحيصلا ةرازويل
ييةو ةداييز . عيصاوتم عكيمد تاينيماتيفو ةمي ا تايمي نيو ةييويح تادايضم نيم ةيثيدح ةييودأ نيم هنوماتحي
تاييمي نلإا تاييةرم نييةو ضرييملا نيية م روييمأ ءايييلوأو يي رملا ميييلعشو هشافةاييضمو ضرييملا نيية ءاييبطلأا
نيم ةبسانملا ةيمكلا عم ةيرارحلا تارعسلاد ين ءاذ وانش لة رملا عي مشو ةبسانملا ةيذغتلاو ةم اهلا
. ةم اهلا تامي نلإا

نزولا ةلق ،ةفاحنلا ،رصقلا ، د نيماتيف ،كنز ،نيدولموميهلا ،ةيذغتلا ءوس ،يسيكلا فيلتلا : ةيحاتفملا املكلا
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List of Abbreviations

BMI Body Mass Index
BMIZ BMI Z-score
CBC Complete Blood Count
CF Cystic Fibrosis
CFF Cystic Fibrosis Foundation
CFFC Cystic Fibrosis Friends Center
CFNBS Cystic Fibrosis New Born Screening
CFQ Cystic Fibrosis Questionnaire
CFRD Cystic Fibrosis Related Diabetes
CFTR Cystic Fibrosis Transmembrane Conductance regulator
CHD Coronary Heart Disease
Cl Chloride
CVD Cardiovascular disease
DM Diabetes Mellitus
EAR Estimated Average requirement
EFA Essential Fatty Acid
ELISA Enzyme linked Immunosorbent Assays
EPI Exocrine Pancreatic insufficiency
Hb Hemoglobin
HCL Hydrocholeric acid
Hct Hematocrit
HFA Height for Age
HRQOL Health Related Quality of Life
Hrs hours
Ht/Age Height for Age
HTN Hypertension
HTZ Height Z-score
ICFMA International Cystic Fibrosis Mucoviscidosis Association
KAP Knowledge, Attitude and Practice
Kg Kilogram
KSA Kingdom of Saudi Arabia
MCH Mean Corpuscular hemoglobin
MCHC Mean Corpuscular Hemoglobin Concentration
MCV Mean Corpuscular Volume
Mg Milligram
µg Microgram
MoH Ministry of Health
Na Sodium
NGO'S Non-Governmental Organizations
NICU Neonate Intensive Care Unit
NIS New Israelian Shikel
PA Pseudomonas Aeuginosa
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