VIEWS: 8 PAGES: 5 POSTED ON: 2/27/2011
16 SAMT DEEL 70 5 JULlE 1986 Incidence of malnutrition in adult patients at Groote Schuur Hospital, 1984 S. J. D. O'KEEFE, J. DICKER, I. DELPORT or surgical (305) wards berween rhe momhs of January and November 1984 was assessed by rhe following anrhropometric Summary measuremems: (i) height by a standard vertical measure; (i/) weighr by one set of barhroom scales (variability of measurement In order to determine nutritional status and the inci- less rhan 1%) in all pariems; (ii/) mid-arm circumference, defmed dence of malnutrition 700 consecutive adult medical as the poim mid-way berween the olecranon process and the acro- (395) and surgical (305) patients admitted to Groote mion, by graduared rape (arm muscle circumference was then Schuur Hospital between January and November calculared by the formula: mid-arm circumference (mm) - triceps skinfold rhickness (mm) x n-);6 (iv) rriceps skinfold thickness by 1984 were studied. Significant depletion in body Harpenden callipers (mean of 3 measurements) (measurements iii weight was observed in 20% of all patients, fat deple- and iv were made by the same individual in all patiems); and (v) tion in 300/0 and muscle depletion in 15%; 40% were frame size by rhe formula hypo-albuminaemic. Intergroup analysis demon- r = . height (cm) compared with standard tables.' strated that malnutrition was more common in medi- wnst circumference (cm) cal than surgical patients, and in non-white patients 38% of coloureds and 42% of blacks were fat depleted. Since malnutrition is associated with enhanced mortality and morbidity rates from any Standards disease state, the results indicate that, particularly in Internationally accepted srandards were chosen for evaluation of non-white patients, nutritional support should be the results. Ideal weights were estimated from the Merropolitan given greater emphasis in overall patient care. Life Insurance Tables (1983) according to the individual's height and frame size. To simplify analysis final data was computerized S Air Med J 1986: 70: 16-20. (ICL Model 36). The dara contained on rhe life tables was emered into the computer and curves obtained for the different sexes and frame sizes. A curve-fining rechnique was then used to obrain standard curves, all of which demonstrated correlation coefficients > 0;998. Triceps skinfold and mid-arm circumference standards The association between disease and malnutrition is well recog- were raken from the tables provided by Jelliffe. 6 nized. Recent studies have shown alarmingly high rates of malnutrition even in developed countries. For example, in the surveys of Bistrian el al. 1,2 in Boston, USA, rates of between Definition of abnormality 40% and 45% were demonstrated in general medical and In keeping wirh studies published by other centres1-5 the fol- surgical patients. Studies in the UK have shown equally high lowing cut-off points were used: (I) body weighr - reducrion frequencies. 3,. below 20% of ideal weighr; (iz) fat stores - significam depletion if At King Edward VIII Hospital, Durban, with a predomi- less rhan 60% of standard; 6 and (iiz) arm muscle circumference and nantly black population, even higher rates - with over 70% of area - significant loss if less than 80% of ideal. 6 male patients having significant reductions in protein and energy stores - were demonstrated.' It was assumed that this high rate reflected a generally poor nutritional state of the Exclusions community. However, linle is known of the incidence rate in All debilirared patients (95) who were unable to stand wirhout white and coloured patients in the RSA. Groote Schuur is a assistance were excluded since it was not possible to obtain general hospital containing over 1000 beds, roughly divided accurare measurements. between black, white and coloured patients. A study was undertaken to assess the relative frequencies of malnutrition in the different sections of the hospital in the hope that the Blood tests information obtained would help in the development of an Routine blood rests were documented wherever available and effective nutritional support system for the sick. included a full blood coum; erythrocyte sedimentation rate (ESR), glucose, urea and electrolyte levels; albumin and total protein values; liver funcrion tests and prothrombin index. Control values Patients and methods were obtained from the hospital laboratory. Survey design A sample of 700 adult patients admined to medical (395 parients) Results Fig. I illusrrares the overall rares of malnutrition based on the various anthropometrical and plasma indices measured. Significant Department of Medicine, University of Cape Town and deficirs were derected in benveen 20% and 40% of the 605 patiems. utrition Unit and Gastro-intestinal Clinic, Groote Schuur In general, medical pariems were more malnourished (Table I). Hospital, Cape Town Most parienrs were below expected weight for heighr, 22% of S. J. D. O'KEEFE, M.D., M.sC, M.R.C.P. medical and 16% of surgical patienrs being under 80% of ideal J. DICKER, B.SC HO:-.lS (DIETETICS) body weighr. However, between 10% and 12% were significantly 1. DELPORT, B.SC (DIETETICS) overweighr, i.e. over 120% of standard. Triceps skinfold thicknesses were below 60% of comrol values in 31 % of medical and 28% of SAMJ VOLUME 70 5 JULY 1986 17 PERCENTAGE surgical patients, whereas mid-arm circumference measurements 100 were below 80% of the standard in 22% and 15% of patients respectively. Hypo-albuminaemia (i.e. < 35 g/l) was observed in 40% of all patients surveyed. 90 Table II and Fig. 2 illustrate the differences between white, coloured and black patients. In general, black patients fared worst. 80 However, low body mass was most common in coloured patients: 25% being below 80% of ideal. Depletion in fat stores was seen in 42% of black patients. Blacks were also lowest in mid-arm circum- 713 ference and albumin concentration measurements, with 57% having albumin concentrations < 35 g/l. Conversely, total plasma protein concentrations were highest in blacks, indicating relatively high 60 plasma globulin concentrations. Interestingly, the sub-group of coloured male patients were most deficient in mass, triceps skinfold 50 ALE and mid-arm circumference measurements, the respective defi- ciency rates being 31 %, 57% and 29%. Associations between malnutrition and disease state Fig. 3. illustrates depletion rates in patients divided in broad disease-related categories. While there was considerable overlap, gastro-intestinal disease was most commonly associated with mal- nutrition, i.e. 36% of all malnourished patients had a gastro- intestinal disorder. HYPo-albuminaemia was most commonly seen in patients with liver disease, while 50% of patients with cancer were severely muscle depleted (i.e. cachectic). 1 234 ANTHROPOMETRIC PARAMETERS Correlations between the various indices of nutritional status Fig. 1. Overall incidence of protein energy malnutrition at Groote Strong positive correlations were obtained between percentage Schuur Hospital, 1984. ideal body mass and mid-arm circumference measurements (r = TABLE I. RESULTS OF ANTHROPOMETRIC MEASUREMENTS AND BLOOD TESTS IN THE MEDICAL AND SURGICAL SUBGROUPS Medical (%) Surgical (%) (N=341) (N= 264) Weight (% of standard) > 120 10,9 12,1 < 100 58,0 61,0 <80 21,7 15,5 <60 1,5 1,5 Triceps (% of standard) <60 31,2 27,8 > 120 24,4 28,0 MUAC (% of standard) <80 22,0 15,2 MU MC (% of standard) <80 16,0 10,9 Albumin (g/I) <35 40,2 40,0 <25 7,8 8,0 Total protein (gll) <60 30,9 23,7 Normal range Hb (12 -18 g/I) 12,6±2,6 12,7±2,3 WCC (4-11 x 10 9 11) 9,7±8,5 9,2±4,3 ESR « 7 mm/1st h) 48,7±44,8 52,9 ±45,6 MCV (81 - 95 f1) 87,5±48,2 88,8 ±65,5 AST (0 - 40 UII) 30,0±37,2 26,4±32,6 AP (30 -115 UII) 146,6_ 195,7 140,5 ± 136,4 Glucose (3,9 - 5,6 mmolll) 6,8±3,8 7,97±8,9 PI (80 -100) 77,3± 18,4 77,6 ± 13, i Triceps = triceps skinfold thickness; MUAC = mid-arm circumference: MUMC = calculated mid-arm muscle circumference; Hb := haemoglobin; wee = white cell count; MCV = mean corpuscular volume: AST = aspartate aminotransferase; AP = alkaline phos- phatase; PI := prothrombin index. o 18 SAMT DEEL 70 5 JULlE 1986 PERCalTAGE 0,84; P < 0,001) and also between percentage ideal body mass and calculated mid-upper arm muscle circumference (r = 0,82; P < 100 0,001). The relationship between percentage ideal body mass and triceps skinfold, however, was not as strong (r = 0,64; P < 0,01). _BLACK No significant correlation was found between albumin concentra- c::J COLOUF:ED tions and anthropometric measurements. c:=J~~HITE 80 70 Other blood tests ALB Tables I and II also show the group mean values for the various 60 routine blood tests. Of note were the particularly low prothrombin index values, particularly in black patients, which could either reflect low vitamin-K stams or the presence of liver disease. 50 Evidence for a fairly high incidence of liver disease in black WEIGHT <60~'~ patients was obtained from the high alkaline phosphatase and low 40 albumin levels compared with high globulin concentrations. ESRs <80% MUSCLE were high in all groups, in keeping with the overall gravity of illnesses encountered. 30 20 Discussion let The distinction between malnutrition and physiological 'slim- ness' is often difficult and arbitrary cur-off points at which the degree of nutrient depletion is considered to become significant 1 2 .', 4 are necessary. In the present report, levels used in other ANTHROPOMETRIC PARAMETERS investigations in the same field have been employed so that cross-hospital comparisons can be made. I-5 The levels are Fig. 2. Incidence of malnutrition among the different racial based on a combination of clinical experience and knowledge groups. of the association between protein-calorie malnutrition and TABLE 11. RESULTS OF ANTHROPOMETRIC MEASUREMENTS AND BLOOD TESTS IN THE RACIAL SUBGROUPS White (%) Coloured (%) Black (%) (N= 292) (N= 237) (N=76) Weight (% of standard) > 120 11,6 11,8 9,2 < 100 50,0 66,6 71,0 <80 13,7 25,3 19,7 <60 1,7 1,3 1,3 Triceps (% of standard) <60 19,0 38,4 42,4 > 120 28,5 25,4 18,8 MUAC (% of standard) <80 12,2 24,2 28,7 MUMC (% of standard) <80 12,0 15,0 18,0 Albumin (gll) <35 38,8 37,0 56,7 <25 5,5 8,6 14,9 Total protein (gll) <60 36,5 21,1 17,9 Normal range Hb (12 -18 gll) 12,8±2,3 12,7±2,6 11,9±2,7 WCC (4-11 x 10 9 11) 9,4±8,75 9,74±5,1 9,3±5,1 ESR « 7 mm/1st h) 41,6±36,9 50,5±44,7 78,9±50,2 MCV (81 - 95 f1) 89,9±53,3 86,3±52,2 86,3±75,3 AST (0 - 40 UII) 26,6 ± 29,7 27,9±35,6 39,5±52 AP(30-115UII) 133,3 ± 112,9 143,2± 186 192,7 ± 296,6 Glucose (3,9 - 5,6 mmol/I) 7,8±8,6 7,14±3,7 6,25±3,04 PI (80 -1 00) 77,7±16,7 78,7±14,3 72±158,7 Triceps = triceps skinfold thickness; MUAC = mid-arm circumference; MUMC = calculated mid-arm muscle circumference; Hb = haemoglobin; wee;::: white cell count MCV = mean corpuscular volume; AST = aspartate aminotransferase; AP = alkaline phos- phatase: PI = prothrombin index. SAMJ VOLUME 70 5 JULY 1986 19 PERCENTAGE PERCENTAGE 100 1(1(1 9(1 _GIT _LI\.JEF~ 90 c:::JHAEMATOLOGY c::::=J CARD IO\.JA:;CULAR c=J t~EOPLASTIC c=JREt~AL 8.3 !::::::":,,IRESPI RATORY 80 ALB 1:::::::::::1 ENDOCF: IHE ALB <35 g.···L 70 713 ~lUSCLE 6G <80i~ 60 - TFUCEP~; 50 TRICEP:3 (·jEII3HT 40 413 . ::: 30 ... 30 : ~H .m WEII3HT MU:::CLE :m 20 213 . . ::: ::: 10 : ~~ ~ 10 . ::: :m 1 2 3 4 1 2 3 4 ANTHROPOMETRIC PARAMETERS ANTHROPOMETRIC PARAMETERS Fig. 3. Association between malnutrition and different disease-related categories. decreased host defence:· 8•9 Depletion below the cut-off level disease but also between malnutrition and unemployment was used is generalll associated with increased morbidity and shown. Overall, when patients were subdivided into males and mortality rates. 4 • ,10-13 It should also be noted that measure- females, the subgroup most depleted in anthropometric mea- ments were limited to the assessment of protein and fat stores surements were coloured men - 31% were weight-, 57% were and deficiencies of vitamins and trace elements could have fat- and 29% were muscle-depleted. However, abnormally low been missed. Unfortunately, the equipment required for these albumin concentrations were observed in 60% of black men measurements was not available. Some disease states, such as compared with only 40% of white and coloured patients. alcoholic liver disease and beriberi, are associated with normal The nutritional status of white patients was within the ran/?e caloric but deficient micronutrient intake. It should also be reported from the USA. While the surveys from Boston .2 noted that there is a further underestimation in the incidence reported higher rates of fat depletion and hypo-albuminaemia, of malnutrition since body weight, and to a lesser extent the larger study from Nashville 14 detected slightly lower inci- skinfold thickness, are commonly falsely elevated because of dence rates. fluid retention and oedema in acute and chronic illness. The normal standards used were taken from recognized Breakdown of the survey into disease categories indicates international sources, which make no distinction between that although malnutrition can be seen in any sick patient, colour, race or ethnicity. While the definition of 'normality' those with gastro-intestinal disease are most susceptible. Low remains controversial, it is now generally accepted that a albumin concentrations were especially common in patients common set of ideal standards are appropriate for all members with liver disease, presumably due to diminished hepatic of the species Homo sapiens. The only difference between the protein synthesis rates. This may also partially account for the standards used in the present study and those referred to for lower mean albumin concentrations seen in the subgroup of the purpose of comparison 1,2,5,14 was that the latest Ideal black patients since group mean aspartate transaminase and standards for weight measurements produced by the Merro- alkaline phosphatase concentrations were also higher. politan Life Insurance Company were used. Over the weight The lack of association between albumin concentration and ra~ge of the patients, it is calculated that the ideal weight now body weight confirms the clinical impression that albumin proposed exceeds the previous (1959) ideal value by, on average, should not be used on its own as the measurement of nutritional 4%. Thus the incidence of underweight will be slightly overesti- status. Routine monitoring of patients receiving nutritional mated when used for direct comparison. support commonly demonstrates disparate results between Malnutrition was significantly more common in black and nitrogen balance and albumin concentrations, so that the coloured than in white patients. Grossly depleted fat stores patient can be demonstrated to be in positive nitrogen balance were found in 42% of black and 38% of coloured compared and yet his albumin concentration may remain low or even with only 14% of white patients. This could be explained by drop - presumably the additional protein is incorporated into the gravity of sickness - non-white patients are generally skeletal rather than visceral proteins - of which albumin is an referred to hospital in later stages of their illness - and also example. In such situations, albumin is a sensitive index of the by the higher 'background' malnutrition in the local non-white presence of sepsis and a thorough search for the site should be communities. The complex association between malnutrition, undertaken. However, patients who are obviously marasmic, sickness and poverty was demonstrated in the earlier Durban with severe muscle wasting, quite commonly have relatively 11 study5 in which association not only between malnutrition and well-maintained albumin concentrations. 20 SAMT DEEL 70 5 JULlE 1986 The explanation for the high incidence of malnutrition in the midst of plenty for want of attention to the ways which hospital patients is complex. Acute illness causes anorexia and alone make it possible for them to take food . . . remember a decrease in food intake and the acute stress results in how much he has had and how much he ought to have today.' increased metabolic expenditure and protein catabolism - both of which deplete body stores. Conversely, malnourished people have reduced host defence mechanisms and are therefore We are grateful to the Departments of Medicine and Surgery, more susceptible to disease. Thus a vicious circle of malnutri- University of Cape Town, for allowing us to assess their patients. tion and disease can occur which eventually culminates in We also thank the South African Medical Research Council for death. financial support. A further preventable reason for hospital malnutrition is that of iatrogenic starvation. Little regard is paid to patients' eating habits. The increasing number of sophisticated tests carried out on patients often indirectly result in them being REFERENCES constantly fasted or spending time away from the ward and 1. Bistrian BR, Blackburn GL, Hallowell E, Heddle R. Protein starus of consequently missing meals. Some postoperative patients are general surgical patients. JAMA 1974; 230: 858-860. still kept on 'dextrose water' drips for prolonged periods while 2. Bistrian BR, Blackburn G L, Vitale J er af. Prevalence of malnutrition in general medical patients. JAMA 1976; 235: 1567-1570. awaiting the return of normal bowel function. However, at our 3. Hill GL, Blackett RL, Pickford L ec al. Malnutrition in surgical patienrs: an hospital referral for nutritional support has improved to a unrecognized problem. Lancec 1977; i: 689. 4. O'Keefe SJ, EI-Zayadi AR, Carraher TE er af. Malnutrition and incompet- mean of 8 ± 7 days, the median being 5 days. ence in patienrs with liver disease. Lancec 1980; ii: 615-617. It was nevertheless distressing to note that patients' body 5. O'Keefe SJD, Thusi D, Epstein S. The fat and the thin - a survey of weight measurements are no longer routinely taken at the time nutritional starus and disease patterns among urbanized black South Africans. S Afr Med J 1983; 63: 679-683. of admission and during their hospital stay. This is tragic 6. Jelliffe DB. Assessmenc of che Nucricional Scacus of a Communicy (WHO since, with the advent of effective nutritional support tech- Monograph Series No. 53). Geneva: World Health Organization, 1966. 7. Grant JP. Handbook of Towl Pareneeral Nucricion. Philadelphia: WB niques, it is now possible to prevent the previously 'obligatory' Saunders, 1980: 8-26. reduction in nutritional status during disease. Today there is 8. Bistrian BR, Blackburn GL, Scrimshaw, Flan JP. Cellular immunity in semi-starved states in hospitalised adults. AmJ Clin Nucr 1975; 28: 1148. no disease state in which an appropriate form of nutrition 9. Law D, Dudrick SJ, Abdon TL Immunocompetency of patients with cannot be given. Thus even where 'bowel rest' is required protein calorie malnutrition. Ann Incern Med 1973; 79: 543-550. nutrition can be maitained by using intravenous or elemental 10. Klidjian AM, Foster KJ, Kammerling RM ec al. Relation of anthropometric and dynamometric variables to serious postoperative complications. Br Med feeding techniques. The increased requirements in catabolic J 1980; 281: 899-900. illness can also be met by specialized dietary formulas. 15 11. Mullen JL, Genner MH, Buzby GP ec al. Incidence of malnutrition in the surgical patient. Arch Surg 1979; 114: 121-125. Protein intake can be maintained in patients with liver failure 12. Buzby GP, Mullen JL, Matthews DC ec af. Prognostic nutritional index in and encephalopathy. 16 gastrointestinal surgery. AmJ Surg 1980; 139: 160-167. It is hoped that the results of this survey will provide an 13. Srudley AO. Percentage of weight loss as an indicator of surgical risk in patients with chronic peptic ulcer. JAMA 1936; 106: 458. incentive for hospitals to develop more interest in the nutri- 14. O'Leary P, Dunn G, Basil S ec af. Incidence of malnutrition among patients tional needs of their patients and to form an appropria te admined to a VA hospital. Souch Med J 1982; 75: 1095-1098. 15. O'Keefe SJD, Moldawer LL, Young VR, Blackburn GL. The influence of nutritional support service. In conclusion, it is appropriate to intravenous nutrition on protein dynamics following Sll.rgery. Metabolism quote the immortal words of Florence Nightingale written 1981; 30: 1150-1158. 16. O'Keefe SJ. Nutrition in liver disease. In: Grant AM, Todd E, eds. over 100 years ago: 'Every careful observer of the sick would Handbook of Eneeral and Pareneeral Nucricion. 1st ed. Oxford: Blackwell agree in this, that thousands of patients are annually starved in Scientific Publications, 1982.
Pages to are hidden for
"Incidence of malnutrition in adult patients at Groote Schuur "Please download to view full document