Lakshmi, a 60-year-old lady from rural Tamil Nadu, came to the surgical OPD with complaints of abdominal pain for the past month. After some tests were done, we found that she had cancer in her large intestine - a condition that would require surgery to remove it.
The bigger worry, however, was whether it would be possible to do surgery on her at all, considering how poorly nourished she looked.
Lakshmi was just skin and bones with a BMI of 15 (Normal: 22.5-27.5). She looked extremely pale, and her blood tests showed a haemoglobin of 5.7, less than half the normal. As expected, her blood tests also revealed that she was severely deficient in protein and other nutrients.
The outcome of any surgery depends a lot on the individual's nutritional status.
Malnourished patients are at a higher risk of developing complications like infection, poor wound healing, prolonged weakness, and even death in severe cases. Disease and poor nutrition form a vicious cycle where one impacts the other and causes the patient's condition to worsen.
If the disease affects any part of the digestive system, food intake or absorption will be affected—and the result will be even worse.
Lakshmi belonged to a poor household that was surviving on agriculture. Being a dependent member of a large family, she experienced neglect. Her diet on most days consisted of only two meals of kanji (rice with water). Since she developed abdominal pain, her food intake was further reduced, worsening her already malnourished body.
Any patient with cancer of the large intestine requires a fairly major operation. In patients who are malnourished but do not require urgent surgery, it is best to postpone it and build them up nutritionally. Unfortunately, Lakshmi’s tumor was blocking her intestine. If not operated immediately, the blocked intestine could burst and cause a life-threatening infection.
Hence, she underwent emergency surgery, but the procedure had to be modified because she was malnourished. Her tumor was removed, but the ends of the intestines on either side of the tumor were not sewn together as the chances of them fusing were extremely low. This is because her body did not have enough reserve nutrition to undertake such a healing task.
Therefore, a stoma (intestine brought out through the abdomen for the stools to pass) was created.
Sadly, her condition did not improve after the surgery. She developed an infection of the surgical wound due to low immunity (another result of poor nutrition). She could not begin eating in time as her intestines hadn't regained their function soon after the surgery. When she required chemotherapy after the operation, adequate doses of the same couldn’t be administered as her body wouldn’t tolerate the side effects.
Eventually, Lakshmi abandoned her treatment and did not return to the hospital. Before she did so, she often complained about her poor quality of life. “I always feel tired and sick. I am unable to do things I was able to do before my illness. I feel like I am a huge burden on my family as they have to look after all my needs,” she said.
All doctors understand the importance of good nutrition in the treatment of diseases. However, most patients seeking healthcare have poor nutritional status even before they contract these diseases. This is due to various cultural and socioeconomic factors. Systemic biases such as caste and gender, among others, also feed into this cycle. While doctors do not have control over these factors, they continue to hold responsibility for helping the patient in whatever capacity they can.
“You have lost 5 kgs since the last chemotherapy dose two weeks ago. You need to gain weight before we can plan your surgery,” said the oncologist treating Mr Ramesh (name changed), an auto rickshaw puller suffering from oral cancer. He referred the patient to the dietician, who suggested a 'high calorie and high protein diet.'
However, a short discussion with the patient revealed a different cause for the weight loss. “I do feel hungry, but I am unable to eat. My jaw hurts a lot, and my mouth is full of ulcers. It is excruciating to swallow anything,” said Ramesh, who has not received good medications for pain relief.
How would a diet prescription help Ramesh if his pain - the root cause of his weight loss - was not addressed?
“Will my cancer grow now that my surgery is postponed?” he wondered as he left the ward. This anecdote shows that a healthcare professional can make a difference by showing a little more interest in finding out the why of poor nutrition before focusing on diet change.
The diet advised must also be realistic for the patient to follow.
Poor nutrition also poses an enormous financial burden on the family. “Her treatment has been delayed multiple times now. Her haemoglobin is still low. We have run out of money and cannot afford another blood transfusion. We are finding it difficult even to pay the rent,” said Prashant (name changed).
Prashant's wife was getting treatment for breast cancer in a tertiary care center in South India. Prashant and his wife left for their hometown in West Bengal the next day, hoping they could arrange some money and return to continue treatment.
The importance of nutrition for a healthy body is emphasized from a very early age in school. Yet, most people fail to understand its significance. As of 2021, up to 30% of the World’s population was malnourished, India being the largest contributor with 194.4 million people not receiving enough nutrition. According to the United Nations' progress reports, 1 in 3 people lack regular access to adequate food and, 1 in 10 suffer from hunger-related problems in India.
The stories of Lakshmi and the others shed light on the fact that poor nutrition is a silent roadblock to adequate healthcare. Nutrition is the often-overlooked cornerstone of recovery - from diseases and surgery. It is a linchpin for both surgical outcomes and overall health.
It is also a stark reminder that the barriers to good healthcare often lie beyond the scope of the hospital's four walls. We can only open the doors to improved surgical outcomes and a healthier future by addressing this silent roadblock.
Edited by Christianez Ratna Kiruba and Parth Sharma.
Image by Janvi Bokoliya.
