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.
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
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).
ANTHROPOMETRIC PARAMETERS Correlations between the various indices of
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
<35 40,2 40,0
<25 7,8 8,0
Total protein (gll)
<60 30,9 23,7
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.
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 <
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.
Other blood tests
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
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
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
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
<35 38,8 37,0 56,7
<25 5,5 8,6 14,9
Total protein (gll)
<60 36,5 21,1 17,9
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
9(1 _GIT _LI\.JEF~
c:::JHAEMATOLOGY c::::=J CARD IO\.JA:;CULAR
c=J t~EOPLASTIC c=JREt~AL
!::::::":,,IRESPI RATORY 80 ALB
1:::::::::::1 ENDOCF: IHE
ALB <35 g.···L
6G <80i~ 60
30 ... 30 : ~H
.m WEII3HT MU:::CLE :m
10 : ~~ ~ 10 . :::
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
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