PREVALENCE OF MALNUTRITION AMONG ADULT HOSPITALIZED PATIENTS AT KAUH. Done By: Smaher Al-Amoudi Mai Khatib Samah Bahamdan Renad Azhar

Transcription

1 Kingdom of Saudi Arabia Ministry of High Education King Abdul-Aziz University Faculty of Applied Medical Sciences Clinical Nutrition Department PREVALENCE OF MALNUTRITION AMONG ADULT HOSPITALIZED PATIENTS AT KAUH Done By: Smaher Al-Amoudi Mai Khatib Samah Bahamdan Renad Azhar BSc Students, College of Applied Medical Sciences, 4 th Year KAU, Jeddah Supervised by: Dr. Arwa Badr Al-Din Lecturer, Clinical Nutrition Department 1432 H 2011 G

2 Contents: Abstract. 2 CHAPTER I: NUTRITION & HEALTH. 3 CHAPTER II: NUTRTION CARE PROCESS. 7 Subjective global assessment (SGA). 13 Referral System. 17 CHAPTER III: RESEARCH. 21 Observation. 22 Subject, Material, Methods. 23 Results. 25 Discussion. 32 Conclusion & Recommendation. 36 Limitations. 37 Acknowledgment. 38 References. 39 List of Figures: Figure 1: explains the relationship between nutrition and disease. 5 Figure 2: NCPM explanatory diagram. 8 Figure 3: guidelines for adult nutrition screening and assessment. 16 Figure 4: Nutritional ranks of all patients by SGA Separately. 25 Figure 5: BMI categories of all patients (Considering the age). 26 Figure 6: Nutritional rank of all patients based on nutritional index. 27 Figure 7: Percentage of body weight changes within 1 week for all reassessed patients. 28 Figure 8: Nutritional status estimated by nutritional index for reassessed patients. 31 Figure 9: Percentages of malnutrition among patients as diagnosed by different methods

3 ABSTRACT: Nutritional status of twenty eight patients were screened and assessed at the beginning of the study, sixteen patients have been reassessed after one week. The techniques of nutritional assessment include subjective global assessment (SGA), anthropometric measures (weight (wt), height (ht), mid arm circumference (MAC), Skin fold thickness (SFT), and bioelectric impedance fat measurement) Biochemical assessment included serum albumin and hematocrit (HCT). Nutritional index were calculated from Serum albumin level and body weight changes. Mean and standard deviation of each measurement were computed and t-test were applied to examine the significance of differences between base line and reassessment data for the sixteen patients, significant p-value was set at < Malnutrition was noticed among patients by all assessment techniques with a variable degrees, highest percentage of positive malnutrition marker was observed by nutritional index calculated method (89.3%), followed by hematocrit level (78.6%), then serum albumin (75%)while SGA and BMI have detected 32% of malnutrition cases each. All reassessed nutrition markers have shown variable degree of decrease with the only significant p-value of SFT (0.02) in male patients. In conclusion malnutrition is an existing problem among hospitalized patients in KAUH and implementation of an integrated comprehensive nutrition care process is recommended as part of health care system. Key words: Nutrition, assessment, hospitalized, malnutrition

4 CHAPTER I NUTRITION & HEALTH - 3 -

5 Ironically, in our relatively rich society characterized by excessive food and drink consumption, it is common to find malnourished hospitalized patients for whom other clinical problems dominate the view of Doctors and nurses who fail to recognize it due to lack of training in this matter. Despite significant advances in prevention, detection and treatment, protein-calorie malnutrition remains an important problem in hospitalized patients. Its prevalence has been estimated at 26 % to 80% of patients admitted to hospital, depending on the type of the study (Kelly et. al., 2000). However, nutritional assessment techniques that were used in the few published studies; do not reliably differentiate changes in nutritional variables caused by a patient's nutritional state from those caused by the underlying disease itself. Additionally, reference standards that were developed from studies of healthy young adults may not be appropriate for the diseased population studied. A more realistic estimate of protein-calorie malnutrition in adult inpatients is probably closer to 20% of all admissions. Causes of malnutrition in patients can be divided into three major categories: 1. Decreased oral intake 2. Increased nutrient losses 3. Increased nutrient requirements. Most commonly, malnutrition is caused by a combination of decreased oral intake due to anorexia and increased nutrient requirements due to the underlying disease. Observable aspects of malnutrition are weight, subcutaneous fat loss, muscle wasting, edema, lethargy and death. Other consequences of malnutrition include: 1. Impaired immune response (Neumann et. al., 1975). 2. Decreased respiratory and cardiac function (Gottdiener et. al., 1978). 3. Delayed wound healing (Haydock & Hill, 1985)

6 The effects of nutrition and disease on the nutritional status of an individual can vary according to the nature of the disease, age, and types of food consumed (Naber et. al., 1997). There are two possible major environmental stressors that could influence individual s health status; these possible stressors are: 1. Poor nutritional status leads to impaired immune-competence and reduced resistance to infection. 2. Exposure to infectious disease can lead to appetite loss and anorexia, malabsorption, and elevated metabolic rate. (figure 1) Disease Nutritional Status Complications Figure 1: explains the relationship between nutrition and disease. Once started, the interactions between disease and weakened immune system become complex. The effect of these stressors on severity of nutrition-related disease symptoms such as anorexia, fever, and mal-absorption has an impact on nutritional status. On the other hand; specific nutritional deficiencies can influence immune status. Malnutrition in hospitalized patients leads to increase the severity of the diseases and illness, clinical complications, delayed recovery and accordingly longer hospital stays, this in turn increase the economic cost of health care process (Kelly et. al., 1999) As an example: People with HIV disease can quickly become malnourished and start to lose weight because the disease has the following effect: 1. It makes people lose their appetites so they don't eat as much as they did before they were infected

7 2. It speeds up the body's metabolism which means that additional food is needed to stop the person from losing weight. 3. It reduces the amount of nutrients the body can absorb from food because the gut becomes damaged by the virus and other types of infections 4. It increases the occurrence of thrush infections in the mouth and throat. The resulting sores can make it very painful for people to eat and swallow To make sure someone with HIV disease maintains a good nutritional status it is therefore important to do the following: 1. Increase overall food intake to provide more energy and prevent wasting by eating more high-protein foods and high-energy foods, fats and oils are high in energy and can be eaten in moderation 2. Increase the consumption of foods rich in vitamins and minerals to protect against infections. Many studies have reported that about 30% of patients in surgical wards were malnourished at admission, but the information about the nutritional status of nonsurgical hospital patients is limited (Naber et.al, 1997). If insufficient food intake is a factor in the development of nutritional depletion and also of the associated complications, then treatment should be focused on the disease as well as nutritional intervention. Therefore assessment of the nutritional status of patients at admission to an internal medicine ward and the association of nutritional status with the subsequent development of complications is an important measure

8 CHAPTER II NUTRTION CARE PROCESS - 7 -

9 Although the medical care process has been significantly advanced, the prevalence of malnutrition in hospitalized patients remains as high as 30% to 50%, with a larger number at risk for becoming malnourished during their hospital admission course. There have been a general agreements that a percentage of patients in all health care settings may have more complications due to their poor nutritional status (Charney & Marian, 2008). As previously mentioned these complications may lead to increased morbidity, mortality, length of stay, and cost of care. Therefore, appropriate nutrition intervention may result in improved outcomes in many health care settings. Nutrition care Process and Model (NCPM) Figure 2: NCPM explanatory diagram This graphic representing of the NCPM. The outer ring of the Model influences how patients/clients receive nutrition information. The practice setting reflects rules and regulations governing practice, the age and health conditions of particular patients/clients, and how a food and nutrition professional s time is allocated. The health care system mandates the amount of time available to food and nutrition professionals, - 8 -

10 the type of services provided, and who provides the services. The social system reflects patients /clients health related knowledge, values, and the time devoted to improving nutritional health. The economic aspect incorporates resources allocated to nutrition care, including the value of a food and nutrition professional s time in the form of salary and reimbursement. The middle ring of the Model distinguishes the unique professional attributes of food and nutrition professionals from those in other professions. The inner ring illustrates the four steps of the NCPM, which are described in Figure 2. The central core of the model depicts the essential and collaborative partnership with a patient/client. The model is intended to reflect the dynamic nature of relationships throughout the NCPM. (Lacey & Pritchett, 2003) SCREENING Nutrition screening, the entry to the Nutrition Care Process (NCP), ensures that patients or clients in a variety of health care settings receive appropriate and timely medical nutrition therapy and is a critical component of quality nutrition care Screening has been defined as a test or standardized examination procedure used to identify patients requiring special intervention. RDs are capable of screening patients and are accountable for developing a screening process that is cost-effective and accurately identifies patients/clients who might have a nutrition problem. Regardless of age or setting (acute care, sub-acute care, long-term care, outpatient, or home), all populations should be screened to determine the need for nutrition assessment. Screening is considered a supportive system to the Nutrition Care Process and Model (NCPM) because the screening can be conducted by any of the health care team members. The importance of nutrition screening in the health care arena has been recognized for patients in both acute and long-term care as they both are at the highest risk of developing nutrient deficiencies and nutrition-related complications (Chaney & Marian, 2008)

11 Because nutrient deficiencies or excesses often exist before admission and may not be readily apparent, screening for nutritional risk in outpatient setting including the emergency room, ambulatory clinics, and home care is important. Each facility or setting is responsible for determining the most appropriate mechanism for screening patients or clients. There are very few screens that have been validated. It is important to evaluate parameters used for screening to determine whether the screen is indeed identifying at-risk patients (Box 1). Height Weight Unintentional change in Food allergies Diet Laboratory data: albumin, hematocrit (only if laboratory turnaround time is rapid) Change in appetite Nausea/vomiting Bowel habits Chewing/swallowing ability Diagnosis Box 1: Criteria Often Used for Nutrition Screening An effective screening process, which can be completed by any qualified health care professional, is: Simple Efficient Quick Reliable Inexpensive Low risk to the individual being screened, and Has acceptable levels of sensitivity, specificity, and positive and negative predictive values Box 2: showing the features of an effective screening tool

12 Of the parameters listed in Box 1, only unintentional weight change and decreased appetite/intake have been validated as indicators of nutritional status. The use of laboratory values as a measure of nutritional status should be carefully scrutinized, as levels of serum hepatic proteins are indicators of severity of illness and do not reflect nutritional status. Protocols should be established in all health care settings to create a time frame for rescreening of those patients who did not require nutrition assessment at admission but have an extended length of stay. An intervention strategy should also be in place to ensure consistent and accurate communication of the results of the nutritional risk screen to the RD. Different rapid screening forms have been designed and developed by some researchers and health professionals, the following are examples that could be easily performed by any of the health-care team personnel (tables 1,2, & 3). Parameter Score Have you lost weight recently without trying? No Yes If yes, how much weight (kilograms) have you lost? >15 Unsure Have you been eating poorly because of a decreased appetite? No Yes Total Table :1 is an example of a rapid screen that can Score of 2 or more = patient at risk of malnutrition

13 Another tool is the following short nutritional assessment questionnaire Question Score Did you lose weight unintentionally? >6kg in the past 6 mo 3 >3 kg in the past mo 2 Did you experience a decreased appetite over the past month? 1 Did you use supplemental drinks or tube feeding over the past month? 1 Table 2: screening tool for use in inpatient adult populations Score 0 or 1 = well-nourished and did not receive intervention. Score 2 = moderately malnourished and received nutritional intervention. Scored 3 = severely malnourished and received nutritional intervention. Another valid and reliable Screening tool that includes an assessment of the severity of illness and body mass index (BMI). (table 3). Score Step 1: BMI (kg/m 2 ) * 20 (>30 obese) < Step 2: % weight loss (unplanned in past 3-6 months) < >10 2 Step 3: If patient is acutely ill and has been or is likely to be without intake for > 5 days 2 Total score Risk 0 Low 1 Medium >2 High Table 3: An example of another simple nutrition *If unable to obtain height and weight, see MUST Explanatory Booklet for alternative measurements and use of subjective criteria

14 The Following algorithm in was developed by the American Society for Parenteral and Enteral Nutrition (ASPEN) to provide guidelines for adult nutrition screening and assessment. (Figure 3) Subjective global assessment (SGA) Subjective global assessment is a screening tool that uses the specific features of the history and physical examination. (Detsky et.al., 1985) A. History : 1. Weight loss in the previous 6 months, expressed as both kilograms and proportionate loss. i. < that 5% = small loss, ii. 5 to 10% = potentially significant loss, iii. > 10% as a definitely significant loss. 2. Dietary intake in relation to a patient s usual pattern. Patients are classified first as: i. Having normal or abnormal intake. ii. The duration and degree of abnormal intake are also noted (starvation, hypocaloric liquids, full liquid diet, suboptimal solid diet). 3. Presence of significant gastrointestinal symptoms (anorexia, nausea, vomiting, diarrhea). 4. Functional capacity or energy level (bedridden to full capacity). 5. Metabolic demands of the patient's underlying disease state. B. Physical examination which are noted as either normal (0), mild (1 +), moderate (2+), or severe (3+). 1. Loss of subcutaneous fat measured in the triceps region and the midaxillary line at the level of the lower ribs. 2. Muscle wasting in the quadriceps and deltoids as determined by loss of bulk and tone that is detectable by palpation

15 3. Edema in both the ankles 4. Edema in sacral region 5. The presence of ascites. C. Rating On the basis of the features of the history and physical examination, clinicians identify a SGA rank which indicates the patient's nutritional status. These categories are: (1) well nourished, (2) moderate or suspected malnutrition, and (3) severe malnutrition. In order to arrive at a SGA rank, we do not use an explicit numerical weighting scheme. Rather, a rank is assigned on the basis of subjective weighting. In this study, we place most of our screening judgment on the variables (weight loss, poor dietary intake, loss of subcutaneous tissue, and muscle wasting). the patients could be assigned: A rank if the patient has no positive finding or has any recent weight gain B rank if there was at least a 5% weight loss in the few weeks prior to admission without stabilization or weight gain, definite reduction in dietary intake, and mild subcutaneous tissue loss. C rank if the patient had to demonstrate obvious physical signs of malnutrition (severe loss of subcutaneous tissue, muscle wasting, and often some edema) in the presence of a clear and convincing pattern of ongoing weight loss

16 Subjective Global Assessment (SGA) Form Nutritional assessment can also be based on clinical criteria that is, the findings of a routine history and physical examination. (Select appropriate category with a checkmark, or enter numerical value where indicated by #. ) A. History 1. Weight change Overall loss in past 6 months: amount = # kg; % loss = # Change in past 2 weeks: increase, no change, decrease. 2. Dietary intake change (relative to normal) No change, Change: duration = # weeks Type: suboptimal liquid diet, full liquid diet hypocaloric liquids, starvation, other 3. Gastrointestinal symptoms (that persisted for >2 weeks) none, nausea, vomiting, diarrhea, anorexia. 4. Functional capacity No dysfunction (e.g., full capacity), Dysfunction: duration = # weeks. Type: working sub-optimally, ambulatory, bedridden. 5. Disease and its relation to nutritional requirements Primary diagnosis (specify) Metabolic demand (stress) : no stress, low stress, moderate stress, high stress. B. Physical (for each trait specify: 0 = normal, 1+ = mild, 2+ = moderate, 3+ = severe). # loss of subcutaneous fat (triceps, chest) # muscle wasting (quadriceps, deltoids) # ankle edema # sacral edema # ascites C. SGA rating (select one) A = Well nourished B = Moderately (or suspected of being) malnourished C = Severely malnourished

17 Nutrition Screen for risk or presence of malnutrition - Acute care: within 24 hours - Long-term care: on admission or within 14 days of admission - Home care: on initial RN visit Nutritionally-at-Risk o Adults are considered at nutritional risk if any one of the following is present: o Actual or potential for developing malnutrition (involuntary loss or gain of >10% of usual body weight, within 6 months or > 5% of usual body weight in 1 month, or a weight of 20% over or under ideal body weight), presence of chronic disease, or increased metabolic requirements. o Altered diets or diet schedules (receiving total parenteral or enteral nutrition, recent surgery, illness, or trauma). o Inadequate nutrition intake including not receiving food or nutrition products (impaired ability to ingest or absorb food adequately) for > 7 days. Not-At-Risk Rescreen at: o regularly specified intervals or o when nutritional/ clinical status changes Stable Nutritionally- At-Risk At-Risk Nutrition Assessment including: o review of nutrition history o evaluation of anthropometric data, biochemical indices of nutrition status o review of clinical status o nutritionally focused physical exam Develop Nutrition Care Plan based on: o an interdisciplinary approach o objectives of care, including: immediate and longterm goals of nutrition therapy, educational needs, discharge planning, and/or home training o design of nutrition prescription o Enteral and Parenteral Nutrition Support Pathways Figure 3: guidelines for adult nutrition screening and assessment. Reassessment based on: o change in clinical status o Enteral and Parenteral Nutrition Support Pathways o organizational protocol

18 Referral System Referral is the act of sending a patient/client to another health professional for care beyond one s own expertise. In addition to correctly identifying clients who would benefit from nutrition care, a referral process ensures that patients/clients have identifiable methods of being linked to the RD who is ultimately responsible for the nutrition intervention. Referral mechanisms may be established based on specific medical diagnoses or other agreed upon criteria. On referral to the RD; the patient/client will undergo a comprehensive nutrition care process that ends up by nutritional diagnosis and nutrition care plan followed by regular follow up and revaluation. (Table 4a,b,c &d) Step 1: Nutrition Assessment Definition and purpose Data sources/tools for assessment Types of data collected Nutrition assessment Components Critical thinking Nutrition assessment is a systematic approach to collect, record, and interpret relevant data from patients, clients, family members, caregivers, and other individuals and groups. Nutrition assessment is an ongoing, dynamic process that involves initial data collection as well as continual reassessment and analysis of the patient s/client s status compared to specified criteria. Screening or referral form. Patient/client interview. Medical or health records. Consultation with other caregivers, including family members. Community-based surveys and focus groups. Statistical reports, administrative data, and epidemiologic studies Food- and nutrition-related history. Anthropometric measurements. Biochemical data, medical tests, and procedures. Nutrition-focused physical examination findings. Client history. Review data collected for factors that affect nutrition and health status. Cluster individual data elements to identify a nutrition diagnosis as described in diagnosis reference sheets. Identify standards by which data will be compared. Determining appropriate data to collect. Determine the need for additional information. Selecting assessment tools and procedures that match the situation. Applying assessment tools in valid and reliable ways. Distinguishing relevant from irrelevant data. Distinguishing important from unimportant data. Validating the data. Determination for continuation of care. If upon completion of an initial or reassessment it is determined that the problem cannot be modified by further nutrition care, discharge or discontinuation from this episode of nutrition care may be appropriate Table 4a: showing the first step of NCPM (Nutritional Assessment)

19 Step 2: Nutrition Diagnosis Definition and purpose Nutrition diagnosis is a food and nutrition professional s identification and labeling of an existing nutrition problem that the food and nutrition professional is responsible for treating independently. Data sources/tools for diagnosis Nutrition diagnosis components Nutrition diagnostic statement Critical thinking Determination for continuation of care Organized assessment data that is clustered for comparison with defining characteristics of suspected diagnoses as listed in diagnosis reference sheets. The nutrition diagnosis is expressed using nutrition diagnostic terms and the etiologies, signs, and symptoms that have been identified in the reference sheets describing each diagnosis. There are three distinct parts to a nutrition diagnostic statement: 1. The nutrition diagnosis describes alterations in a patient s/client s status. A diagnostic label may be accompanied by a descriptor such as altered, excessive, or inadequate. 2. Etiology is a factor gathered during the nutrition assessment that contributes to the existence or the maintenance of pathophysiological, psychosocial, situational, developmental, cultural, and/or environmental problems. _ The etiology is preceded by the words related to. _ Identifying the etiology will lead to the selection of a nutrition intervention aimed at resolving the underlying cause of the nutrition problem whenever possible. _ Major and minor etiologies may result from medical, genetic, or environmental factors. 3. Signs/symptoms (defining characteristics) The defining characteristics are a typical cluster of sings and symptoms that provide evidence that a nutrition diagnosis exists. The signs and symptoms are preceded by the words as evidenced by. Signs are the observations of a trained clinician. Symptoms are changes reported by the patient/client. A well-written nutrition diagnostic statement should be: Clear and concise; Specific to a patient/client; Limited to a single client problem; Accurately related to one etiology; and Based on signs and symptoms from the assessment data. Finding patterns and relationships among the data and possible causes. Making inferences. Stating the problem clearly and singularly. Suspending judgment. Making interdisciplinary connections. Ruling in/ruling out specific diagnoses. Because the nutrition diagnosis step involves naming and describing the problem, the determination for continuation of care follows the nutrition diagnosis step. If a food and nutrition professional does not find a nutrition diagnosis, a patient/client may be referred back to the primary provider. If the potential exists for a nutrition diagnosis to develop, a food and nutrition professional may establish an appropriate method and interval for follow-up. Table 4b: showing the second step of NCPM (Nutrition Diagnosis)

20 Step 3: Nutrition Intervention Definition and A nutrition intervention is a purposefully planned action(s) designed with the intent of changing a nutritionrelated behavior, risk factor, environmental condition, or aspect of health status. It consists of two interrelated purpose components: planning and intervention. The intervention is typically directed toward resolving the nutrition diagnosis or the nutrition etiology. Less often, it is directed at relieving signs and symptoms. Data sources/tools for interventions Critical thinking Determination for continuation of care The ADA Evidence-Based Nutrition Practice Guides or other guidelines from professional organizations. The ADA Evidence Analysis Library and other secondary evidence such as the Cochrane Library. Current research literature. Results of outcome management studies or quality improvement projects. Nutrition intervention components Planning Prioritize diagnoses based on urgency, impact, and available resources. Write a nutrition prescription based on a patient s/client s individualized recommended dietary intake of energy and/or selected foods or nutrients based on current reference standards and dietary guidelines and a patient s/client s health condition and nutrition diagnosis. Collaborate with the patient/client to identify goals of the intervention for each diagnosis. Select specific intervention strategies that are focused on the etiology known to be effective based on current evidence. Define time and frequency of care, including intensity, duration, and follow-up. Implementation Collaborate with a patient/client and other caregivers to carry out the plan of care. Communicate the plan of nutrition care. Modify the plan of care as needed. Follow-up and verify that the plan is being implemented. Revise strategies based on changes in condition or response to intervention. Setting goals and prioritizing. Defining the nutrition prescription or basic plan. Making interdisciplinary connections. Matching intervention strategies with patient/client needs, nutrition diagnoses, and values. Choosing from among alternatives to determine a course of action. Specifying the time and frequency of care. If a patient/client has met intervention goals or is not at this time able/ready to make needed changes, the food and nutrition professional may discharge the client from this episode of care as part of the planned intervention. Table 4c: showing the third step of NCPM (Nutrition Intervention)

21 Step 4: Nutrition Monitoring & Evaluation Definition and purpose Data Nutrition monitoring and evaluation identifies the amount of progress made and whether goals/expected outcomes are being met. It identifies outcomes relevant to the nutrition diagnosis and intervention plans and goals. Sources/tools for monitoring and evaluation Self-monitoring data or data from other records including forms, spreadsheets, and computer programs. Anthropometric measurements, biochemical data, medical tests, and procedures. Patient/client surveys, pretests, posttests, and/or questionnaires. Mail or telephone follow-up. Types of outcomes measured Nutrition monitoring and evaluation components Critical thinking Nutrition-related history. Anthropometric measurements. Biochemical data, medical tests, and procedures. Nutrition-focused physical findings. This step includes three distinct and interrelated processes: 1. Monitor progress: _ check patient/client understanding and compliance with plan; _ determine whether the intervention is being implemented as prescribed; _ provide evidence that the plan/intervention strategy is or is not changing patient/client behavior or status; _ identify other positive or negative outcomes; _ gather information indicating reasons for lack of progress; and _ support conclusions with evidence. 2. Measure outcomes: _ Select outcome indicators that are relevant to the nutrition diagnosis or signs or symptoms, nutrition goals, medical diagnosis, and outcomes and quality management goals. 3. Evaluate outcomes _ Compare current findings with previous status, intervention goals, and/or reference standards. Selecting appropriate indicators/measures. Using appropriate reference standard for comparison. Defining where patient/client is in terms of expected outcomes. Explaining variance from expected outcomes. Determining factors that help or hinder progress. Determination for continuation of care Based on the findings, we may actively continue care or if nutrition care is complete or no further change is expected, discharge the patient/client. If to be continued, reassessment may result in refinements to the diagnosis and intervention. If care does not continue, a patient/client may still be monitored for nutritional status changes Table 4d: showing the fourth step of NCPM (Nutrition monitoring & evaluation)

22 CHAPTER III RESEARCH

23 Observation: 1. As 4 th year students we are involved in the hospital training for a period of two full working days each week, and during our training practice in the educational hospital we have observed the gap between what we are taught in the theoretical sessions and what we have to follow in our training practice. 2. Despite the international recommendations that based on clinical evidences and call for implementation of nutrition care process and models that have been mentioned here chapter 2, we have observed the shortage of this implementation. 3. We have also observed that only few physicians are convinced with the important role of nutrition in the health care process 4. Few journals have discussed the issue of malnutrition among hospitalized patient and as we mentioned in the literature there are evidences that support the implications of nutritional status on the disease course. 5. We also have observed that a considerable number of admitted patients are already seemed to be malnourished. Our question: - Is malnutrition considered an existing problem among our hospitalized patients? To answer this question: We assess the nutritional status of a number of admitted patients and reassess it after a period of one week. Location of the study: The present study was conducted in King Abdul-Aziz University Hospital, Jeddah, KSA

24 Subjects: 28 adult patients, 12 male, and 16 female, their age ranged from 18 to 65 Since this hospital is well-established teaching hospital therefore, the patients are attracted from all of over the province. The patients belonged to various wards irrespective of the disease with exception of critically ill, cancer, HIV, renal, liver and psychotic patients were excluded. Materials: Methods: Weight Scale (Detecto ) Measuring tape Skin fold caliper (Dynatron ) Bioelectric impedance body composition analyzer (OMRON Fat loss monitor Model HPF-306C) Patient s records Assessment and reassessment documentation form Subjective Global Assessment form Subjective global assessment form was used as a screening tool and completed by patient s interview and examination. All anthropometric measurements were applied to all 28 patients at the beginning of the study, on performing the reassessment after an interval period of one week many of these patients were discharged from the hospital and only 16 patients (9females and 7 males) only were available for the reassessment. In order to lessen the individuals variability in applying assessment methods; each assessment methods was done by the same member of the research team at both base line and reassessment instance

25 Anthropometric measurements: 1- The body weight: weight was measured at mid-day, as determined by using a common hospital ward scale. 2- Height: was estimated using Demi-Span(by using ordinary simple measuring tape to measure the distance from the sternal notch and the notch in between ring and middle finger) Height in cm is calculated using the formulas, for male: Height in cm= (1.40 X demi-span in cm) and for female: Height in cm= (1.35 X demi-span in cm) ) Estimation of height using demispan was used for all fit and unfit patient in order to unify the method to decrease the statistical errors 3- Mid-Upper arm circumference (rough indicator of body fat): were determined by using ordinary simple measuring tape to measure the circumference of the left upper arm, at the mid-point between the tip of the shoulder and the tip of the elbow (olecranon process and the acromium). 4- Body Mass Index BMI ( rough indicator for human body fat based on an individual's weight and height): was calculated using the standard formula: Weight/(Height)2. 5- The skin fold thickness (estimate body fat content as a percentage of body weight): was determined by using skin fold caliper. The measurement is taken with the person standing upright, with arms hanging down loosely. The skin fold is pulled away from the muscle and measured with the caliper, taking a reading 4 seconds after the calipers have been released. The measuring point is half way between the olecranon process of the ulna and the acromion process of the scapula. 6- Bioelectrical impedance method (estimate body fat mass as a part of total body weight): by using Fat Loss Monitor Device to take measurements then body fat percent is calculated in the device by a formula that includes 5 factors: electric resistance, height, weight, age and gender

26 Biochemical measurements: Blood tests that are commonly used in similar studies to indicate malnutrition from the hospital records and compared with reference standards. 1- Serum Albumin (Krause, 2008) 2- Hematocrit (Bistrian, et.al., 1976) 3- Nutritional Risk Index were calculated and used as an additional nutrition indicator. Nutritional Risk Index = (1.489 X serum albumin, g/l) x (present weight/usual weight) (Buzby GP, et al. 1988) Statistical Analysis: Data were coded and fed to computer for the calculation of mean and standard deviation and significance of changes for the various variables by using a statistical package Microsoft Office Excel 2007 program, Results Nutritional ranking as diagnosed by subjective global assessment for all patients was 43%, 32% and 25% for well nourished, suspected of being malnourished and severely malnourished respectively (Figure 4). Well nourished Suspected of being malnourished Severely malnourished % 25% % 37.50% % 37.50% No. Males No. Females % Males % Females Figure 4: Nutritional ranks of all patients by SGA Separately

27 Anthropometric and biochemical measurements averages were as shown in table 5. Age-specific BMI was as follows 32.2%, 46.4%, 10.7% and 10.7% for underweight, normal weight, overweight and obese respectively for (Figure 5) % 50.00% 40.00% 30.00% 20.00% 10.00% All Females Males 0.00% Under wt Normal Over wt Obese Males n=12 Figure 5: BMI categories of all patients (Considering the age) Separately Age Year Weight (kg) Height (m) BMI (kg/m 2 ) MAC (cm) Skin fold Table 5: mean, minimums, and maximums of anthropometrics and biochemical data. (mm) Fat% (SF) Fat% Mean Minimum Maximum Females n=16 Mean Minimum Maximum (BI) HTC % Albumin (g/l) The averaged circumference of the Mid-arm was found to be 29.7 in males (between 10 th & 15 th percentile) and 27.7 in females (between 10 th & 15 th percentile)

28 Averaged albumin level was found to be 32.3 g/dl in males and 26.6 in females, and the individual interpretation of its serum level revealed an equal distribution of all patients among the four categories of albumin-based nutritional diagnosis namely normal, and mild, moderate and sever decrease. 78.6% of patients were malnourished as diagnosed by hematocrit level that is less than 43.7% in males and 37.4% in females. The averaged triceps skin fold was found to be 22.8 mm and 23.1 mm in males and females respectively, While on calculating body fat using the triceps skin fold the averaged body fat was 10.5% in males and 16.8% in females. Nutritional index was calculated for all patients assuming that usual body weight = current body weight and revealed the percentage shown in figure 6. No. % 42.90% 42.90% 3.60% 10.70% Figure 6: Nutritional rank of all patients based on nutritional index

29 Among the reassessed 16 patient, there was an average body weight change of -1.4 and kg in males and females respectively (table 6). Weight 1 (kg) Male: 65 Weight 2 (kg) Male: 64 Weight changes (kg) -1.4 Mean Female: 52.5 Female: Male: 18 Male: 19 ± 2.5 STDEV Female: 13 Female: 13 ± 3.3 P value Male: 0.18 Female: 0.49 Table 6: Mean, standard deviation and P values of body weight and weight changes for reassessed patients Calculating nutritional risks based on percentage of weight changes revealed that, 68.75% of patients were categorized as having no risk, 31.25% at mild risk and 0% have moderate and severe risk (table 7) 10.00% % of BWC 5.00% 0.00% -5.00% % % Figure7: Percentage of body weight changes within 1 week for all reassessed patients

30 Interpreting % of weight changes from usual body weight Nutritional risk No. % No risk Mild Moderate 0 0 Severe 0 0 Table 7: Nutritional risk among reassessed patients by % of weight changes The average body fat loss among reassessed male patients was 2%, while female patients have lost an average of 0.9% of their body fat as measured by bioelectric impedance (table 8) the p-values were 0.98 and 0.31 for males and females respectively. BODY fat % 1 Body fat % 2 Mean Male: 21.3 Female: 18.5 Male: 19.3 Female: 17.6 STDEV Male: ± 5.96 Female:±14.14 Male: ± 8.66 Female: ± P value Male:0.98 Female:0.31 Table 8: mean, standard deviation and P values of Body fat % changes On the second assessment both genders were found to decrease their triceps skin fold thickness by an average of 1.6 mm in males and 0.1 in females with a p-value of 0.02 and 0.65 for males and females groups respectively. The body fat percentage calculated from the second measurement (By TSF) was 0.3% less in both genders with a p-values of 0.28 and 0.48 for males and females respectively (table 9)

31 Mean Male: Female: Skin Fold Skin fold Skin fold changes Body fat % Body fat % Fat % changes Male: ±12.7 ±12.7 ±1.4 ±8.7 ±8.3 ±0.7 STDEV Female : ±8.7 ±9.7 ±2.4 ±9.3 ±8.7 ±1.1 P value Male Female Table 9: mean, standard deviation and P values of Body fat % changes as estimated from triceps skin fold (mm) On reassessing the mid-arm circumference, it decreased by 0.7 in males (below 10 th percentile) and 0.6 in females between 10 th & 15 th percentile). With a p-value 0.18 for both (table 10). MAC 1 (mm) Mean Male: 29.6 Female: 27.7 STDEV Male:±6.6 Female:±7.5 P value Male:0.18 Female:0.18 MAC 2 (mm) Male: 28.9 Female:27.1 Male:±7.4 Female:±6.7 Table 10: mean, standard deviation and P values of Mid arm circumference Reassessment of serum albumin revealed an averaged decrease of 0.6 g/l and 2.7 g/l in males and females respectively. The p-values were 0.71 & 0.78 respectively (table 11). The hematocrit was found to be low in both genders (23.3% in males and 29.9% in females) and increased at the end of the week by an average of 2.9 % in males and 1% in females (table 11)

32 Mean Male Female HCT% 1 HCT% HTC changes Albumin 1 (g/l) Albumin 2 (g/l) Albumin changes STDEV Male Female ±17.34 ±5.79 ±13,90 ±6.92 ±3.4 ±2.8 ±7.56 ±10.39 ±6.6 ±8.21 ±3.9 ±3.7 P value Male Female Table 11: mean, standard deviation and P values of biochemical data Nutritional indices of the reassessed patients were as follows 14% males and 66.7% females were severely malnourished, 71% males and 11% females were moderately malnourished and the rest show normal nutritional indices (figure 8). Severe malnourishment Mild malnourishment Moderate malnourishment No malnourishment % 0 0% % 0 0% % % % % Male No. Male % Female No. Female % Figure 8: Nutritional status estimated by nutritional index for reassessed patients

33 Discussion Based on BMI, Kelly et.al, 2000, have found 13% of 337 British patients to be underweight. This was less than our finding where we observed underweight in 32% of our sample. A result that reported a far higher prevalence than our findings is that of Khattak et. al. which was conducted in 2002 on 355 Pakistani patients and used weight, MAC, TSF, Hb and BG, they found 100% of females are malnourished. An old study that have been conducted in USA in 1974 by Bistrian et. al., they have reported malnutrition in patients based on BMI, 45%; TSF, 75%; MAC, 55%; Serum albumin, 44%; & HCT, 48%. Similar measurements in our study show BMI, 32%; serum albumin, 75%; HCT, 78.6%. Nabers et. al. in 1997 have reported 45% of 155 patients were malnourished by SGA which is more than the 25% of our sample, and as diagnosed by nutritional index malnutrition ranged between 71% to 90% according to disease a result that is close to our finding 89.3 %. A study of 500 hospital admissions in Scotland reported that based on BMI and a triceps skin-fold thickness or mid-arm muscle circumference <15th percentile 40% of patients admitted were undernourished. Of these 500 patients, 67% lost weight during their hospital stay. (McWhirter JP, Pennington, 1994) this goes in accordance with our finding of an average MAC percentile between 10 th and 15 th and close to the 32% diagnosed as malnourished on admission and 50% who lost weight after one week

34 Bistrian et.al. USA, 1974 McWhirter JP et.al. Scotland, 1994 Nabers et.al. Netherland 1997 Kelly et.al. UK, 2000 Khattak et.al. Pakistan, 2002 Our Study. Jeddah, 2011 Subjects Under.wt - 67% - 13% 100% 32% BMI 45% 40% % TSF 75% % 25% MAC 55% <15th %tile % 10 th 15 th %tile Albumen 44% % HCT 48% % SGA % % Nutrition Index % - 90% %. Table 12: Shows the Comparison between published similar studies The prevalence of malnutrition in hospital patients has been worrying for over 30 years. (Bistrian et. al., 1976; Hill et.al., 1977; Baron, 1986; Baber et. al., 1997; Kelly et.al, 1999; Khattak et.al., 2002;) Until the present time, evidence suggests that malnutrition remains a significant problem in hospitalized patients, and it may be going undiagnosed. Our study was conducted in the King Abdulaziz university hospital, in order to know whether or not mal-nourishment exist in the hospitalized patients, we have concluded that 57% of our subjects were either malnourished or suspected to be as diagnosed by subjective global assessment method, and according to the percentage of weight loss 31.25% were at risk of being malnourished. Using the serum albumin level and calculating the nutritional index indicate that most of the patient (about 89% ) are malnourished even if they show anthropometric measurements that fall within range. Hematocrit was used as an indicator of hydration status in order to support our referring to albumin level for nutritional status, but we were still considering the negative feedback of acute conditions on album in levels plus excluding liver patients (Figure 9)

35 Surveys elsewhere consistently find that about 20% of patients in general hospitals are malnourished (the World Health Organization 1995). Despite the frequency of malnutrition, it is undiagnosed in up to 70% of patients. This is partly because of the lack of simple laboratory tests and because biochemical tests for nutritional status are difficult to interpret. Around 70-80% of malnourished patients currently enters and leave hospital without action being taken to treat their malnutrition and without the diagnosis appearing on their discharge summary. 100% 80% 60% 40% 20% 0% % of Malnourished Figure 9: Percentages of malnutrition among patients as diagnosed by different methods Although malnutrition is a common cause and consequence of illness particularly in hospitalized adult people, limited number of studies was found. The patients either found to be malnourished on admission or got malnourished in the hospital, the acquirement of malnutrition in hospital was indicated in our study by decreased some nutritional markers on reassessing the patients after one week and although the t-test show no significant results; we refer this to the short gap between assessment and reassessment and significant results could be noticed on longer hospital stay

36 It has been observed that complications are significantly greater for patients who decline nutritionally, regardless of nutritional status at admission compared with the reference group. This is associated with higher hospital charges and a higher likelihood of complications (Braunschweig et al., 2000). In 2006, the National Institute for Health and Clinical Excellence (NICE) recommended that all admitted patient should be screened and monitored regularly for malnutrition, but these standards are weakly policed and are probably insufficient to stop many older people becoming malnourished if the quality of food service system is poor. It has been suggested that the nutritional assessment upon admission reflects the patient's nutritional and living conditions, current treatment and is predictive of patient's outcome (death or survival) (Gazzotti et al., 2000). In hospital, the catering service systems can have a major impact on the nutritional intake of hospitalized patients (Wilson et al., 2000). It appears that it is crucial to improve the quality of hospital catering, especially to prevent malnutrition (Rigaud et al., 1999). Contributing to the problem of inadequate nutrient intake, patients are frequently ordered to have nothing by mouth and are not fed by any other route (Sullivan, 1999). This is associated with further aggravation of the problem. It has been proposed that evaluation of nutritional status in hospitalized patients is ignored and a simple screening sheet can be used to identify patients in need of further nutritional assessment and treatment (Thorsdottir et al., 1999). In the hospitals, patients show high nutritional instability, with high prevalence of both underweight and overweight. Food habits, demonstrate a lack of variety and a high frequency of food taboos, which might limit the consumption of various nutrients (Cabral et al., 1998). In patients with less severe degrees of illness, the existence of malnutrition leads to a worse outcome than in sicker patients. Malnutrition continues to be a persistent problem in hospitalized patients, which can be readily identified using simple and easily available indices and, furthermore, readily treated (Giner et al., 1996)

37 This study is very limited but it indicates the possible magnitude of the problem of mal-nourishment and the urgent need for the nutritional assessment /intervention in the hospitalized patients. Conclusion & Recommendations 1. Patients do have a real nutritional problem that surely can influence their disease course and length of hospital stay 2. Although t-test has not shown significant p-value except for TSF in males, prolonged hospital stay can result in higher significant changes. 3. Nutrition care process is not fully implemented in our health care system due to: a. Shortage of skilled staff b. Inadequate nutrition education of health staff that render nutrition one of the pillars of health care process 4. Current nutritional assessment techniques provide reliable prognostic information but are poor diagnostic techniques. 5. According to the our results that show decline in nutritional status of a considerable numbers of reassessed patients, Nutritional support should be considered in normally nourished patients who are not eating enough for more than five to seven days, who are not eating enough and selected hypermetabolic patients. 6. The final solution to malnutrition in hospitals probably lies in recognizing human nutrition as a discrete discipline, in which all medical graduates should reach a minimum level of competence, and some will specialize. 7. As data about nutritional status of hospitalized patients in our country is very limited if any, this study should be repeated on larger scale for longer period of time