Yearbook on Journal of the Japan Society of Nursing Research 2013

Post-discharge Self-management of Food Intake in Distal Gastrectomy Patients
Masumi Yamaguchi 1), Yayoi Kamakura 2), Junko Fukada 2), Masahiko Yoneda 2),
Yoshitaka Yamamura 3), Hisae Kanada 3)
Key Words :distal gastrectomy
self-control
food intake volume
activity
nutritional evaluation after
discharge

ABSTRACTThis study aimed to evaluate the post-discharge dietary self-management practices and nutritional recovery
of distal gastrectomy patients who had learned how to self-evaluate and maintain appropriate food intake
during hospitalization.
A total of 29 patients were followed-up from admission to postoperative month 3 for: food intake, which wasestimated from weight gain between before and after having a meal, and postprandial epigastric sensations
and discomfort using a self-administered record form; post-discharge daily physical activity and step counts,
from immediately after waking until just before going to bed, using an automated daily activity recorder;
and body weight and the arm muscle circumference as measures of nutritional status.
Serial changes in food intake and meal frequency suggest their successful self-management practices
regarding food intake, with food intake gradually recovering from 43% at discharge to 93.8% at postoperative
week 13. Although their physical activity and step counts gradually increased after discharge, relative bodyweight and arm muscle circumference at postoperative week 13 (93.6% and 94.6%, respectively) weremaintained from the time of discharge.
These findings demonstrate that, despite increased physical activity after discharge, patients maintained
their nutritional status, possibly as a result of the successful self-management of food intake.

I. Introduction

discharged during a transition phase when the metabolism ofmuscle protein and body fat switches from a catabolic to ananabolic state. During the anabolic state, in which the body
repairs damaged tissues and stores fat over subsequentmonths, it is necessary for patients to increase their energy
intake to maintain and improve nutritional status.
Regarding the recovery of nutritional status after
discharge, previous studies showed that postoperative bodymass index (BMI) was lower in patients who had followed
detailed dietary advice given by healthcare professionals
than in those who had not12), and that the eating behaviors
of patients changed after returning to the workplace despite
prior nutrition education from healthcare professionals13),which raises concerns about the actual dietary practicesof these patients and the effectiveness of current nutrition
education interventions for gastrectomy patients. It is
important to make full use of the physiological function of
the remnant stomach at each time point of recovery, as well
as reduce discomfort to ensure an adequate nutritional supply
for nutritional recovery after discharge. In clinical settings,
gastrectomy patients have conventionally been instructed at
the initiation of postoperative oral intake to “eat 6 small meals
a day”, “chew food very well”, and “spend 30 min eating eachmeal”; at discharge, they have been advised to “reduce meal
frequency to 3 times a day after 3-6 months” and “make highcalorie, high-protein food choices”. This approach merely
provides patients with choices as to whether they follow theadvice of health professionals, and they are less likely to use
the advice as a rational basis to self-evaluate the recovery of
the stomach to make appropriate decisions about food intake.
We developed a dietary education program to help
postoperative gastric cancer patients learn how to selfevaluate and maintain appropriate food intake in relation torecovery of the remnant stomach. The characteristic featureof this program is that patients keep a record of their bodyweight before and after a meal to quantify their food intake
objectively, along with postprandial epigastric sensations anddiscomfort, so that they can make an appropriate decision
regarding subsequent food intake as well as increase theirself-management skills over time. Our previous study

The incidence of gastric cancer is higher in Japan1); however,
the overall five-year survival rate has improved recently due
to advances in diagnostic technology and the introductionof mass screening that allows for earlier detection. With
most gastric cancer patients returning to work after surgery,improving quality of life (QOL) has become an important issue
in nursing interventions.
Surgery is the first-line treatment for gastric cancer, themost common of which is distal gastrectomy. A previous surveyof distal gastrectomy patients with Billroth I reconstruction
demonstrated, based on patients’ subjective assessment,that their food intake recovered to 80% of preoperative
levels 6 months after surgery2), and an endoscopic study
quantitatively evaluating the gastric remnant of discharged
patients revealed that the remnant stomach allowed avolume of 410 ml at 3 months postsurgery3). Previous studies
reported that gastrectomy patients had a postoperative
weight of approximately 90% that of the preoperative
weight4) 5), and their body weight did not recover more than
1 year after surgery6) 7) 8). A questionnaire survey conductedby a gastrectomy patient support group revealed that 95%
of respondents had postoperative weight loss9), 30% had
long-term weight loss persisting for more than 2 years after
surgery, and more than 60% encountered difficulties with
diet after surgery10). Postoperative weight loss in gastrectomy
patients has been attributed to a decrease in food intake,postprandial discomfort that often deters patients fromincreasing their food intake, increased physical activity after
discharge despite insufficient energy intake, and increased
frequency of diarrhea11). Furthermore, when considering
the metabolic responses of the body to surgical stress, ashorter postoperative hospital stay implies that patients are1) Graduate School of Nursing Aichi Prefectural College of Nursing & Health2) Aichi Prefectural College of Nursing & Health3) Aichi Cancer Center

Corresponding author. Tel.: +81 52 762 6111.
E-mail address: masumi-y@mbg.ocn.ne.jp (M. Yamaguchi)

65This paper was published at “the Japan Society of Nursing Research” Vol.29 No.2 in 2006.

Yearbook on Journal of the Japan Society of Nursing Research 2013

demonstrated that this program helped distal gastrectomy(Billroth I reconstruction) patients to make appropriate
self-management decisions about food intake duringhospitalization 14); however, the findings obtained suggested
the need to assess the recovery of food intake and nutritional
status after discharge in a long-term follow-up study.
Therefore, this study aimed to evaluate post-discharge dietaryself-management practices among distal gastrectomy patients
who had participated in the dietary education program duringhospitalization by assessing serial changes in their foodintake, physical activity levels, and nutritional recovery.

by 50 g the next day,” and “if you have epigastric sensations or
discomfort, decrease or maintain the current meal size for the
next meal.” This information was described in the brochureand introduced in session 2. On the following day, during
daily weight measurements before lunch, patients planned
the size of the day’s meals by choosing one from the response
options listed in a self-administered record form as “increase,maintain, or decrease from the previous day”, and recorded
their choices. Nurses reviewed their choices once a day,provided patients with feedback regarding whether they had
made an appropriate decision, and corrected inappropriate
decisions.
In session 3, patients were given the following instructions
to be used as rational bases for changing their meal frequency
after discharge: “when you recover enough to consume nearly
2/3 of the preoperative size of a meal and have no weight
loss, omit one meal (between-meal snack).” In addition, atarget weight was set for each patient as follows: the weightat admission or that corresponding to a BMI of 22, whichever
was less.

II. Methods

1. Ethical proceduresThis study was approved by the Ethical Committees of
the Aichi Cancer Center (No. 12-29). All study participants
provided written informed consent after receiving a written
and verbal explanation of the purpose and procedures of thestudy, the non-consequential nature of participation refusal,
and privacy considerations.

4. Procedures

2. Patients

Based on the program, patients measured their body weight
before and after lunch every day for 3 days before surgery
and during the postoperative period (after the initiation of
postoperative food intake until discharge), and recorded
postprandial weight gain on the self-administered form asa measure of food intake. They also kept a record of theirfood intake, i.e., weight gain between before and after having
supper for three months after discharge, which was used asa measure of energy intake. Patients wore a daily activity
recorder every day while awake, from immediately after
waking until just before going to bed, to automatically record
their physical activity and step counts taken as measures ofenergy expenditure. The measures of nutritional status usedin this study were body weight and arm muscle circumference(AMC) estimated from arm circumference (AC) and triceps
skinfold (TSF) measurements taken once a month. Detailsof the measuring instruments are described in the section
below.

Of 67 gastric cancer patients who had undergone distal
gastrectomy (with Billroth I reconstruction) followed byinstruction sessions based on our dietary education program,
29 patients who gave consent for post-discharge follow-up
participated in this study. These patients included 21 men
and 8 women, with a mean age of 60.5 ± 11.2 years, mean BMIof 22.3 ± 3.2 at admission, and mean postoperative hospital
stay of 14 ± 5 days.
3. Summary of dietary education program

Our dietary education program aimed to provide patientswith rational bases to self-evaluate functional changes andrecovery of the stomach during their in-patient stay and makeappropriate self-management decisions about food intake andmeal frequency after discharge. In this program, patientswere given three sessions of instructions using a dietaryeducation brochure. The topics consisted of the following:
modifications to eating habits and food intake required
after surgery (session 1); postoperative changes in gastricfunction, and rational bases for making self-management
decisions about food intake (session 2); and food choices,
how to make decisions about changing the frequency of meals
after discharge, and target weight setting (session 3). Thesesessions were conducted in the above order before surgery,at the initiation of fluid intake, and at the time point at which
patients advanced to a soft-rice diet.
In this program, patients objectively quantified their foodintake, which is a characteristic feature of the program. Morespecifically, patients keep a record of their body weight before
and after meal ingestion using a 50-g resolution health scale
to determine postprandial weight gain and food intake.
Additionally, patient records of postprandial epigastricsensations and discomfort served as basic resources for themto increase self-management skills.
Patients were instructed to use the following as rationalbases to determine an appropriate meal size: “if you have noepigastric sensation or discomfort, increase your food intake

1) Self-administered record form

Patients recorded their planned meal sizes, body weightmeasurements before and after meal ingestion, meal times,
and epigastric sensations and discomfort immediately and 1
hr after lunch on an A4-size form. The intensity of epigastricsensations was rated on a Likert scale from 0 (no sensation)
to 6 (very intense). Regarding discomfort, a total of 21
symptoms, including the 18 symptoms designated in the
diagnostic criteria for early dumping syndrome establishedby the Japan Society of Gastrointestinal Surgery, alongwith “eructation,” “heartburn,” and “general malaise,” ahypoglycemic symptom, were listed on the form as response
options, from which patients could choose those that matched
their conditions. Additional items, including daily meal
frequency, bowel movement frequency, and stool quality,
were also recorded after discharge.
2) Instruments measuring energy intake

A precision digital weighing scale and a 50-g resolution

66
This paper was published at “the Japan Society of Nursing Research” Vol.29 No.2 in 2006.

Yearbook on Journal of the Japan Society of Nursing Research 2013

III. Results

health scale (FG-150KA and UC-321, respectively, A&D
Company, Limited) were used before and after discharge,
respectively.

1. Patient characteristics

3) Device measuring energy expenditure

The tumor stages of the patients were IA (n=15), IB (4),II (3), IIIA (5), IIIB (1), and IV (1). The extent of lymph nodedissection was D1+α (n=1), D1+β (5), D2 (22), and D0 (1). Of
the 15 patients who had a job, 14 returned to work within
3 months after discharge. Oral intake was rescheduled in 2
patients with a postoperative anastomotic leakage, anddelayed in 6 due to fever. Three patients received adjuvant
chemotherapy.

Physical activity (kcal) and step counts were measured
using a daily activity recorder (Lifecorder EX, SUZUKEN CO.,LTD.), a device by which the intensity and cycle of acceleration
during physical activity are measured and converted into
energy expenditure (kcal). Its memory function allowed forthe continuous automatic recording of measurements for 200
days, which is another characteristic feature of the device.

2. Changes in food intake during 3 months after surgery

4) Instruments measuring nutritional status

Daily food intake and percentage food intake relative to preoperative levels were calculated for each patient and averaged
to weekly means up to postoperative week 13. The analysesof percentage food intake included 23 patients after excluding 6 who had participated in the study after surgery and had
no preoperative food intake data. Changes in the mean foodintake and mean percentage food intake by week after surgery are presented in Table 1, and the latter is graphicallyillustrated in Figure 1. The mean percentage food intake, i.e.,a measure of recovery relative to the mean preoperative foodintake of 617.6 ± 122.4 g (100%), was 25.3% at the initiationof food intake, increased to 43.0% at discharge, followed by
60.0%, 71.1%, and 81.6% at postoperative weeks 4, 6, and9, respectively, and recovered to 93.6% (564.8 ± 159.3 g) at
postoperative week 13, with 9 patients achieving a percentage
food intake of 100%.

Body weight was measured using the 50-g resolution healthscale (UC-321). The AMC was calculated by the formula: AC-3.14 × TSF, using AC and TSF measurements determined withan Eiken skinfold calipers.
5. Data analyses

Energy intake, which was analyzed as a percentage of the
postoperative to preoperative food intake (postoperative/
mean preoperative food intake × 100; percentage food intake),and energy expenditure, including daily physical activity andstep counts measured by the daily activity recorder, wereassessed for each patient, averaged to weekly means up to
postoperative week 13, and plotted graphically to examine
the time courses. In the analyses of nutritional status, postoperative daily body weight data up to postoperative week
13 were assessed as a percentage relative to the preoperative
weight (postoperative/preoperative weight × 100; percentage of preoperative weight) as well as a percentage to thetarget weight set at discharge (postoperative/target weight ×100; percentage of target weight), averaged to weekly means,and plotted graphically to examine serial changes. The AMC
estimated as above was expressed as a percentage of the ageand sex-specific national average AMC15) for comparison (estimated AMC/age- and sex-specific national average AMC × 100,
percentage AMC). Self-management practices after discharge
were evaluated for each patient regarding whether the two
decision-making bases presented in the dietary education
program, i.e., “consuming a meal size of greater than 2/3 ofthe preoperative size” and “having no weight loss”, were met
when they changed their meal frequency. The meal frequency
observed on most of the days of a week was used as the representative value for the week.

3. Changes in physical activity during 3 months after surgery

Daily physical activity and step counts measured during 3
months after discharge were averaged to weekly means foreach patient. Changes in the mean daily physical activity andmean daily step counts by week after surgery are shown in
Table 1 and Figure 1, respectively. The mean (range) daily
physical activity was 75.9 (21-330) kcal at postoperative week
2 and gradually increased to 181.9 (33-431) kcal at postoperative week 13. The mean (range) daily step counts were 3,738(886-16,429) and 7,832 (1,928-16,583) steps at postoperative weeks 2 and 13, respectively, showing a gradual increaseover time.
4. Nutritional status during 3 months after surgery
1) Weight changes

6. Data reliability

Daily body weights were assessed for each patient as a percentage of the preoperative weight (% preoperative weight).
Data were averaged for all patients to weekly means (Table
1). Serial changes in the relative weight by week after surgery
are plotted graphically in Figure 1. The mean (range) percentage of preoperative weight was 97.7% (91.8%-105.7%)
at the initiation of food intake, 94.1% (88.4%-101.1%) at discharge, and 93.6% (85.3%-102.8%) at postoperative week
13, respectively, resulting in a mean weight loss of 3.95 ± 3.2
kg at postoperative week 13 relative to preoperative values.
Body weight was also assessed as a percentage of the target
weight determined for each patient upon discharge (i.e., theweight corresponding to a BMI of 22 for patients with a BMI of

We reviewed patient’s records every day during their hospitalization. In addition, we accompanied patients to their preand postprandial body weight measurements and food intake
assessment once before and twice after surgery to verify thecorrectness of their measuring procedures and measurement
records, which consequently proved to be correct for the 81
measurements observed. During the post-discharge followup period, we conducted these validity tests once a month
during their hospital visit (before and after lunch), in which
20 patients were found to follow the procedures as instructed,
and 9 were lost to the tests due to clinical reasons.
67

This paper was published at “the Japan Society of Nursing Research” Vol.29 No.2 in 2006.

Yearbook on Journal of the Japan Society of Nursing Research 2013

Table 1. Changes in the mean food intake, mean percentage food intake, mean daily physical activity,
mean percentage of preoparative weight, and mean percentage of taget weight

Time point

percentage Mean daily
Mean food intake Meanfood intake
physical activitygInitial food intake

156.9±128.0 (29)

Postoperative Week 2

317.0±107.1 (20)

Week 4364.5±97.0 (27)Discharge

Week 3

Week 5267.2±89.9 (29)341.1±94.3 (25)391.3±101.8 (28)Week 6

Week 7

Week 9Week 1047.8±17.1 (17)55.4±16.4 (21)517.4±155.2 (27)564.8±159.3 (26)%-97.7±3.0 (27)75.9±72.2 (21)108.5±80.3 (25)60.0±17.1 (23) 117.6±100.8 (28)64.6±15.8 (23) 130.5±103.3 (27)76.1±25.4 (23)521.5±155.2 (27)

Week 13-468.7±135.5 (27)508.7±134.8 (27)

Week 1243.0±19.2 (23)71.1±17.1 (22)504.9±129.9 (27)

Week 11kcal

431.8±114.2 (26)436.5±123.7 (27)

Week 8%25.3±23.0 (21)Mean percentage of Mean percentage of target weight %preoperative weight

70.8±22.7 (23)81.6±25.0 (23)85.0±26.2 (23)84.5±27.1 (23)85.9±26.4 (23)139.3±99.9 (26)144.5±90.3 (26)152.5±83.2 (26)147.5±72.4 (26)174.7±92.6 (26)173.0±96.1 (26)161.0±82.9 (26)93.8±24.4 (23) 181.9±104.8 (24)94.1±2.8 (29)95.1±2.3 (20)94.7±2.9 (24)94.2±3.2 (27)93.9±3.0 (28)93.6±3.3 (26)94.0±3.4 (27)94.0±3.8 (27)94.0±4.0 (27)94.1±4.0 (27)94.1±4.1 (27)93.9±4.3 (27)93.6±4.5 (26)BMI≧22

BMI<22106.8±7.3 (15)98.6±3.1 (12)103.3±7.7 (17)95.9±2.6 (12)105.6±8.2 (10)96.0±2.5 (10)104.7±7.9 (14)96.5±2.9 (10)103.6±8.4 (16)96.6±2.8 (12)103.0±8.0 (15)96.4±2.5 (12)103.1±7.9 (15)96.2±2.5 (11)103.4±7.8 (15)96.4±2.4 (12)102.9±7.5 (15)97.0±2.7 (12)102.9±7.7 (15)96.9±2.9 (12)103.1±8.0 (15)97.0±2.9 (12)103.2±8.1 (15)96.9±2.9 (12)102.8±8.5 (15)96.9±3.1 (12)102.7±8.5 (15)96.7±3.5 (12)Note: Food intake indicated weight gain between before and after having a meal. The mean preoperative food intake was 617.6±122.4g. The
target weight was defined as the weight corresponding to a BMI of 22 for patients with a BMI≧22, and the preoparative weight for thosewith a BMI of <22.

%

110
100
90
80
70
60
50
40
30
20
10
0

%food intake% preoparative weight%AMC

Mean step counts

Steps
12000
10000
8000
6000
4000
2000

Initial Discharge
foodintake

2w

3w

4w

5w

6w

7w

8w

9w

10w 11w 12w 13w

0

Postoparative week

Figure 1. Serial changes in the mean percentage food intake, mean percentage of preoperative weight,
mean percentage AMC, and mean step counts.

The mean percentage food intake, mean percentage of preoperative weight, and mean percentage AMC are
indicated on the left ordinate, while the mean percentage AMC is shown on the right ordinate.

≥22 at admission, and the preoperative weight for the others).
Data were summarized for each of the two BMI subgroups(Table 1 and Figure 2). The mean percentage of target weight(% target weight) in patients with an admission BMI of ≥22
was 103.3% at discharge and 102.7% at postoperative week
13, while the relative weight was 95.9% and 96.7% at therespective time points in those with an admission BMI of <22,showing no decrease. Of the 27 patients who were followedup to postoperative week 13, 20 achieved a mean percentage

of target weight of 95% or greater, 6 a mean of 90% to lessthan 95%, and 1 attained 88.1%.
2) Changes in the AMC

68

As shown in Figure 1, the mean (range) percentage AMC
changed from 97.7 ± 9.5% (82.3%-119.1%, n=25) at discharge to 94.9 ± 7.5% (79.8%-112.1%, n=25), 94.3 ± 7.6%
(77.1%-106.3%, n=26), and 94.6 ± 7.9% (79.0%-109.8%,

This paper was published at “the Japan Society of Nursing Research” Vol.29 No.2 in 2006.

Yearbook on Journal of the Japan Society of Nursing Research 2013108

BMI<22

BMI≧22

%

106
104
102
100
98
96
94
92
90

2w

Initial Discharge
foodintake

3w

4w

5w

6w

7w

8w

9w

10w

11w

12w

13w

Postoparative week

Figure 2. Serial changes in the mean percentage of target weighComparisons between the subgroups of patients with a BMI of ≧22(n=17) and <22 (n=12). The target weightwas defined as a weight corresponding to a BMI of 22 for the former group and the preoperative weight for
the latter.
5 times

6 times

3 times

4 timesNonresponder

(n)
1
25

3

1
1

1
4

7

1
6

4

3

4

6

7

20

12
7

8

13

9
8

11

15

8

10
25

10

5

20

4

4
5

5

6

3w

4w

6
5

10

2w

8
4

7

15

0

8

4

5w

9

6w

9

9

7w

8w

9

9w

7

10w

5
11w

5

4

12w

13w

Postoperative week

Figure 3. Serial changes in meal frequency
The meal frequency observed on most days of the week was used as the representative value for the week.
The nonresponder indicates patients with missing date due to study discontinuation or readmission.

n=26) at postoperative months 1, 2, and 3, respectively.
5. Self-management of food intake
1) Changes in meal frequency after discharge

Serial changes in meal frequency (ranging between 6-3
times/day) by week after surgery are shown as a bar graphin Figure 3.
The percentage of patients having a meal frequency of
6 times/day was 86% (n=25) at postoperative week 2 andgradually decreased to 54% (n=15), 36% (n=10), 26% (n=7),
and 19% (n=5) at postoperative weeks 4, 5, 10, and 11,

69

respectively, although meal frequency remained unchanged
at 6 times/day in 15% (n=4) of patients even at postoperative week 13.
The percentage of patients having a meal frequency of 5
times/day was 10% (n=3) at postoperative week 2 and gradually increased thereafter to a peak of 39% (n=11) at postoperative week 5, with a subsequent gradual decrease.
The percentage of patients having a meal frequency of 4
times/day was 3% (n=1) at postoperative week 2, and gradually increased thereafter to a peak of 33% (n=9) at postoperative week 8, with a subsequent gradual decrease to 15% (n=4)
at postoperative week 12.

This paper was published at “the Japan Society of Nursing Research” Vol.29 No.2 in 2006.

Yearbook on Journal of the Japan Society of Nursing Research 2013

postoperative weeks 2 and 3, and dropped to 3.6% at
postoperative week 13.

The percentage of patients having a meal frequency of 3
times/day was 3% (n=1) and 12% (n=3) at postoperative
weeks 3 and 6, respectively, and gradually increased thereafter to 50% (n=13) at postoperative week 13.

Discussion

Despite the major influence of post-discharge dietary selfmanagement practices on the QOL of gastrectomy patients,
most medical facilities provide these patients with dietaryeducation that merely introduces general information, butdoes not focus on increasing their self-management skills
to evaluate functional recovery of the remnant stomach
and make appropriate decisions regarding their food intake
and meal frequency to reduce discomfort. These skills are
essential in their daily lives after discharge; therefore, it isdesirable for them to learn such skills during hospitalization
through a systematic education program. In this study, weevaluated the post-discharge dietary self-management
practices and nutritional status of distal gastrectomy patients
who had received our in-patient dietary education program,which we had previously developed as a learning system forthese patients.
In terms of energy intake, patients who had received the
dietary education program had a mean percentage foodintake (relative to the mean preoperative food intake of
617.6 ± 122.4 g) of 25.3% at the initiation of food intake
and 43.0% at discharge, followed by 60.0%, 71.1%, and81.6% at postoperative weeks 4, 6, and 9, respectively, andtheir percentage food intake recovered to 93.8% (564.8 ±159.3 g) at postoperative week 13. Given previous studies
on gastrectomy patients by Liedman et al.3) estimating
endoscopically that the remnant stomach allowed avolume of 410 ml at postoperative month 3, by Hotta et al.2)
demonstrating that patients’ food intake recovered to 80%of their preoperative levels at postoperative month 6, and by
Wu et al.16) indicating, based on a questionnaire survey, thatpatients’ food intake did not recover more than 1 year after
surgery, it is reasonable to assume that the present results
demonstrated favorable outcomes.
In this dietary education program, patients measured theirbody weight before and after meal ingestion to estimate theirfood intake from postprandial weight gain, a learning system

2) Changes in percentage food intake and percentage of target
weight after reducing the meal frequency

Using data from the 19 patients who gradually reduced
their meal frequency from the initial level of 6 times/day
before postoperative week 13, we analyzed the mean foodintake and mean percentage food intake during the week of
the change in meal frequency (Figure 4).
During the week when these patients reduced their meal
frequency to 5, 4, and 3 times/day, they had a mean foodintake of 417, 471, and 544 g, respectively, a percentage
food intake of 68.0%, 75.5%, and 90.3%, respectively, and apercentage of target weight of 101.5%, 101.9%, and 102.4%,
respectively, which demonstrated that the two requirements
for reducing the meal frequency of “consuming a meal sizeof greater than 2/3 of the preoperative size” and “having noweight loss” were met.
3) Postprandial discomfort and diarrhea

Table 2 shows the occurrence of each of the postprandial
discomfort symptoms associated with food intake over the
total number of days surveyed using the self-administered
record form. The most common symptoms that occurred
during hospitalization included eructation (29.3%), bloating(13.6%), borborygmus (9.5%), and general heat sensation(8.0%), among which eructation and bloating persisted after
discharge to postoperative week 5, and the occurrence of
these symptoms decreased thereafter. Although heartburn
was less common, its occurrence temporarily increased at
postoperative weeks 2 and 3 (3.4% and 3.7%, respectively)
and decreased thereafter.
The most common discomfort symptoms reported at
postoperative week 13 were bloating (9.5%), eructation(8.0%), abdominal discomfort, and pain (4.4% for both).
The daily frequency of diarrhea exceeded 10% at

g

（n）

600

（11）

500
400
300

（18）

（14）

200
100
0

5 times

4 times

3 times

100
90
80
70
60
50
40
30
20
10
0

%

Food intake% Food intake

Figure 4. The mean food intake and mean percentage food intake during the week of a change in the meal frequency
The diagram shows the mean food intake and mean percentage food intake of 19 patients who made self-management decisions about
meal frequency during the week of a change in the meal frequesncy. The mean food intake (g) is indicated on the left ordinate, themean percentage food intake is shown on the right ordinate, and meal frequency is given on the abscissa.

70This paper was published at “the Japan Society of Nursing Research” Vol.29 No.2 in 2006.

30.6

17.5

This paper was published at “the Japan Society of Nursing Research” Vol.29 No.2 in 2006.

71

8.0

10.7

9.0

9.5

10.7

8.3

9.0

7.1

5.2

7.6

8.8

11.8

20.0

15.5

10.2

1.2

0.6

1.2

0.6

1.9

1.7

9.5

0.6

8.0

4.4

3.3

5.1

3.6

2.9

3.5

2.3

2.9

2.9

4.7

3.7

4.5

0.7

0.7

0.6

1.2

1.2

0.6

2.9

1.2

1.2

3.7

4.4

4.0

4.5

3.0

1.2

5.2

2.9

2.4

2.9

2.9

5.0

1.7

3.3

2.2

2.4

1.2

0.6

2.3

0.7

0.6

1.2

0.6

0.6

1.2

1.8

1.8

0.6

2.0

0.7

0.7

1.3

0.6

0.6

0.6

1.2

0.6

0.6

3.7

3.4

1.4

0.7

1.3

3.0

1.2

1.8

2.9

2.4

1.2

1.9

1.7

1.0

General abdominal postprandial Abdominal
Chest
Palpitations Nausea Heartburn oppression
heat
pain
sensation discomfort diarrhea

0.7

1.3

0.6

0.6

1.2

2.5

0.9

Cold
sweat

0.6

0.6

1.2

0.6

1.9

0.9

Vomiting

0.6

1.2

0.6

1.8

1.2

0.5

Generalmalaise

1.2

0.6

Fatigue

0.6

0.6

1.2

Drpws
omess

0.6

0.6

Headache

0.6

Pallor

0.6

Vertogo

3.6

4.0

6.4

5.4

6.5

2.9

7.6

5.9

4.1

5.3

11.8

10.2

137

150

156

166

170

172

171

170

170

170

161

59

215

Days

Daily surveyed
diarrhea

The value given for each symptom at each time point indicated the occurrence(%) of the symptom over the number of days surveyed. Of the 22 symptom items surveyed, “flushed face” and“fainting” did not occur. “Postprandial diarrhea” indicates diarrhea associated with meal ingestion. “Postprandial diarrhea” was inclued in the calculation for the frequency of “daily diarrhea.”

13W

12W

11W

11.2

10W

9W

11.6

18.7

21.8

29.4

8W

7W

6W

5W

30.4

4W

3W

33.9

2W

13.6

Eructation Bloating Borborygmus

pre-discharge 29.3

Postoparativeweek

Symptom items (%)

Table 2. Changes in the occurrence of postprandial discomfort and diarrhea

Yearbook on Journal of the Japan Society of Nursing Research 2013

Yearbook on Journal of the Japan Society of Nursing Research 2013

designed to provide patients with objective feedback on adaily basis and help them learn how to manage their foodintake in relation to discomfort symptoms. By continuingthese self-management practices after discharge, patients
could increase their skills to self-evaluate the appropriatenessof their food intake decisions. Indeed, our patients reported
their food intake in terms of gram during post-discharge
follow-up visits, which was a positive behavioral change
resulting from the program. Although it has been proposedthat dietary monitoring of discharged patients requires an
independent observer17), we verified the data collected bypatient self-measurement and recording, suggesting thatthe procedures used in this program could be useful formonitoring food intake.
Regarding energy expenditure, the mean daily physicalactivity gradually increased from 75.9 kcal at postoperative
week 2 to 181.9 kcal at postoperative week 13, during
which time the mean daily step counts gradually increased
from 3,738 to 7,832 steps, a number that is similar to theaverage daily step counts of Japanese adults18), indicating
the recovery of these patients. Physical activity and step
counts were automatically recorded by the daily activity
recorder; therefore, these measurements did not serve asa source of feedback to the patients. Hence, the increase in
the mean percentage food intake may reflect these patients
appropriately managing their food intake and meal frequency
independently of their postoperative physical activity levels.
As for a measure of nutritional status, the mean percentage
of preoperative body weight, was maintained at 94.1% atdischarge and 93.6% at postoperative week 13. Although
the present study reported a greater weight-loss reduction
than that of previous studies5)7)19)20), weight was only slightly
maintained, which was similar to previous findings. In thisstudy, target weight was defined as the weight corresponding
to a BMI of 22 for patients with a BMI of ≥22, or the
preoperative weight for those with a BMI of <22; weight loss
may have occurred in the former subgroup of patients andweight gain may have been promoted in the latter. The mean
percentage of target weight in patients with a BMI of ≥22
was 103.3% at discharge and 102.7% at postoperative week
13, showing satisfactory weight maintenance. In patientswith a BMI of <22, body weight decreased to 95.9% of theirpreoperative levels at discharge and was maintained at 96.7%
at postoperative week 13. Relative to the age- and sex-specificnational average AMC, these patients had a mean percentage
AMC of 97.7 ± 9.5% at discharge, showing a subsequent
decrease at postoperative month 1 to 94.9 ± 7.5%, which wasmaintained thereafter. Since similar results were observed forbody weight and the AMC, it is assumed that the nutritional
status of these patients was maintained for 3 months after
surgery; however, the use of dietary supplements may need
to be considered as an option for patients with an admission
BMI of <22 to improve their nutritional status.
When evaluating self-management practices for foodintake and meal frequency, these patients gradually increased
their food intake with each postoperative week, with 50%(n=13) of patients reducing their meal frequency to 3 times/
day at postoperative week 13. After discharge, during theweek when they reduced their meal frequency to 5, 4, and3 times/day, these patients had a mean percentage foodintake of 68.0%, 75.5%, and 90.3%, respectively, and apercentage of target weight of 101.5%, 101.9%, and 102.4%,
respectively. Based on the results showing that the two

requirements for reducing meal frequency, i.e., “consuming
a meal size of greater than 2/3 of the preoperative size” and“having no weight loss,” were fulfilled, it is assumed thatthese patients made appropriate decisions to modify theirmeal frequency. In this program, patients were instructed
to make dietary self-management decisions in relation toepigastric sensations and discomfort. The occurrence of
postprandial discomfort decreased after discharge and was
below 10% at postoperative week 13, with the frequency
of diarrhea decreasing to 3.6%. These results suggest that,
despite increased physical activity after discharge, patients
maintained their nutritional status through the successful
self-management of food intake.
In this study, we demonstrated serial changes in theobjective parameters of food intake, post-discharge daily
physical activity, and nutritional status (including daily
body weight and monthly AMC measurements) of distal
gastrectomy patients over a period from hospitalization to 13
weeks postsurgery. These longitudinal quantitative data canbe used as basic data, as an alternative to conventional data
based on the subjective perceptions of patients. In addition,
the present findings indicating that patients who taken partin the in-patient dietary education program appropriately
increased their food intake and decreased meal frequency,
while maintaining their nutritional status after surgery,suggest their successful self-management practices regarding
food intake, in other words, the effectiveness of the dietaryeducation program.
V. Conclusions

To evaluate the post-discharge dietary self-management
practices of distal gastrectomy patients who had received
an in-patient dietary education program to learn how to
self-manage their food intake in relation to recovery of theremnant stomach, we assessed their food intake (a weightgain between before and after having a meal), physicalactivity (kcal) and step counts using a daily activity recorder,and nutritional status (AMC estimated from skinfold
measurements) for three months after surgery. This study
included 29 patients and obtained the following results.
1) Measures of energy expenditure: The mean (range)
daily physical activity gradually increased from 75.9 (21330) kcal at postoperative week 2 to 181.9 (33-431) kcal
at postoperative week 13, and the mean (range) daily step
counts gradually increased from 3,738 (886-16,429) to 7,832(1,928-16,583) steps during that period.
2) Measure of energy intake: The mean percentage foodintake (relative to the mean preoperative food intake of 617.6± 122.4 g) was 25.3% at the initiation of food intake, andincreased to 43.0% at discharge, followed by 60.0%, 71.1%,
and 81.6% at postoperative weeks 4, 6, and 9, respectively,
and recovered to 93.8% (564.8 ± 159.3 g) at postoperative
week 13.
3) Measures of nutritional status: The mean (range)
percentage of preoperative weight was 94.1% (88.4%101.1%) at discharge and 93.6% (85.3%-102.8%) at
postoperative week 13. In patients with an admission BMIof ≥22, for whom the weight corresponding to a BMI of 22
was used as the target weight, the mean percentage of target
weight was 103.3% at discharge and 102.7% at postoperative
week 13, while in patients with an admission BMI of <22,
for whom the preoperative body weight was used as the72

This paper was published at “the Japan Society of Nursing Research” Vol.29 No.2 in 2006.

Yearbook on Journal of the Japan Society of Nursing Research 2013

target weight, the relative weight was 95.9% and 96.7%,
respectively, at the respective time points. The mean (range)
percentage AMC relative to the age- and sex-specific national
average was 97.7 ± 9.5% (82.3%-119.1%) at discharge and94.6 ± 7.9% (79.0%-109.8%) at postoperative month 3.
4) After discharge, during the week when they reduced
their meal frequency to 5, 4, and 3 times/day, patients hada mean percentage food intake of 68.0%, 75.5%, and 90.3%,
respectively, and a mean percentage of target weight of
101.5%, 101.9%, and 102.4%, respectively, indicating thatthese patients appropriately reduced their meal frequency.
5) Taken together, independently of increased physicalactivity after discharge, patients maintained their nutritional
status, suggesting their successful self-management practices
regarding food intake.

Assessment of the Anthropometric Indicators for Evaluation of
Recovery of Nutritional Status), Japan Journal of Nursing Science,
12, 33-39, 1992
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11) Watanabe, M.: Diarrhea, Aoki, T., and Hanyu, N. (ed.): Managementof postgastrectomy disorders, 146-151, Iyaku (Medicine andDrug) Journal Co., Ltd., Osaka, 2000 (in Japanese).
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This paper was published at “the Japan Society of Nursing Research” Vol.29 No.2 in 2006.