Incidence of malnutrition in adult patients at Groote Schuur

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					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
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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.
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                                                                     7. Grant JP. Handbook of Towl Pareneeral Nucricion. Philadelphia: WB
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reduction in nutritional status during disease. Today there is       8. Bistrian BR, Blackburn GL, Scrimshaw, Flan JP. Cellular immunity in
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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
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                                                                        surgical patient. Arch Surg 1979; 114: 121-125.
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and encephalopathy. 16                                                  gastrointestinal surgery. AmJ Surg 1980; 139: 160-167.
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                                                                        patients with chronic peptic ulcer. JAMA 1936; 106: 458.
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                                                                    15. O'Keefe SJD, Moldawer LL, Young VR, Blackburn GL. The influence of
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                                                                    16. O'Keefe SJ. Nutrition in liver disease. In: Grant AM, Todd E, eds.
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