Q J Med 2000; 93: 93-98
© 2000 Association of Physicians
Still hungry in hospital: identifying malnutrition in acute hospital admissions
From the Department of Human Nutrition, University of Glasgow, Royal Infirmary, Glasgow, and 1 Department of Surgery, Royal Infirmary, Glasgow, UK
Received 4 August 1999 and in revised form 9 December 1999
Address correspondence to Professor M.E.J. Lean, Department of Human Nutrition, University of Glasgow, Royal Infirmary, Glasgow G31 2ER
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Summary |
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 Top Summary IntroductionMethodsResultsPrevalence of nutritional...Referral to dietetic departmentDiscussionReferences |
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We assessed the prevalence, methods for recognition and clinical management of malnutrition in acute admissions in a large academic inner-city hospital. Of a total of 337 patients, it was possible to measure both height and weight in 219 patients (65% of admissions). As an alternative for bed-bound patients, mid-upper arm circumference was not very reliable in predicting BMI (sensitivity 98%; specificity 65%), and waist circumference even less so. Of these, 13% were malnourished (body mass index BMI <18.5 kg/m2 or BMI 18.5–20 kg/m2 with reported weight loss >3 kg in the last 3 months). Six patients (31% of those with BMI <18.5 kg/m2) and one with BMI 18.5–20 kg/m2 were recognized as suffering from malnutrition and referred to the dietitian. Review of case records could not establish if the diagnosis was missed in the remainder, or if a conscious decision was taken not to manage malnutrition actively. Malnutrition in acute hospital admissions goes apparently unrecognized and unmanaged in 70% of cases. Since there are serious consequences, and effective simple treatment is readily available, increased awareness is required, with routine assessment of nutritional status in all patients.
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Introduction |
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TopSummaryIntroductionMethodsResultsPrevalence of nutritional...Referral to dietetic departmentDiscussionReferences |
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Ironically, in our affluent society characterized by excessive food and drink consumption, it is common to find malnourished hospital patients1,2 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’.3 The WHO has recently defined normal weight as BMI 18.5–25 kg/m2, thus reducing the lower limit of normal from BMI 20 kg/m2 in otherwise-healthy people.3,4 Malnutrition can be defined by abnormal BMI, with cut-offs 17–18.5, 16–17 and <16 kg/m2 representing grades 1 to 3 of ‘thinness’, respectively.4 Malnutrition has clearly observable aspects. Weight and subcutaneous fat losses, muscle wasting, oedema, lethargy, and ultimately death are among the most obvious. Other consequences of malnutrition include impaired immune responses,5 decreased respiratory and cardiac function6 and delayed wound healing.7 Malnutrition in hospital leads to prolonged ill health, clinical complications, delayed recovery and therefore longer hospital stays, which in turn increase the economic costs of health services.3 If it can be diagnosed, treatment with food or nutritional supplements can be effective.3,8,9
In line with the recommendations for research by the latest report of the Nuffield Trust,2 the purpose of this study was to assess the prevalence and recognition of malnutrition, and the action taken during admissions and in the discharge plans, among hospital elective and emergency inpatients in a large inner-city teaching hospital. The data were related to figures from the general population provided by the 1995 Scottish Health Survey.
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Methods |
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Hospital in-patients in both acute medical and surgical wards were recruited for the study within 24 h of admission to Glasgow Royal Infirmary. The study was conducted in July 1998 over a 4-week period. The measurements (height, weight, mid-upper arm circumference and waist) were made between 9.00 am and 5.00 pm by two researchers who had received standard training in these methods.10 Patients could not be included if they were away for other investigations, being seen by a doctor, had been discharged already, were in obvious distress or post-operation, or if they had been measured already, as many patients were re-admitted for the same complaint during the period of the study.
When possible, anthropometric measurements were made for all in-patients (these measurements were not possible for patients who had to stay in bed because they were tired or in too much pain, or were unavailable at the time of investigation). Height was measured using a portable stadiometer (Castlemead), patient standing in bare feet, back to the stadiometer. Care was taken to ensure that the Frankfurt plane was kept horizontal. Feet were placed parallel with heels together. The moving arm of the stadiometer was lowered to touch the top of the head, and height was measured to the nearest 1.0 mm. Weight was measured to the nearest 0.1 kg using portable calibrated Seca scales. BMI was calculated from weight and height using the standard formula: mass/height2 (kg/m2). Mid-upper arm circumference and waist were measured according to standard methods.11
Patients with malnutrition were defined as those with BMI <18.5 kg/m2 in accordance with WHO guidelines,4 and those with a BMI between 18.5–20 kg/m2 who reported having lost more than 3 kg in the last 3 months.21,22 Information was obtained from medical records after discharge, for both malnourished and overweight patients, on weight measurements and weight change during hospital stay, mention of nutritional status in supporting the referral letter, assessment of nutritional status with appropriate biochemical indices, and plans for nutritional support and the medical discharge letter. The hospital dietetic department provided details on patients referred.
Data were analysed using the statistical package SPSS for Windows (release 6.0).
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Results |
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Observations were restricted to routine emergency medical admissions, which made up 36% of total medical admissions over the period. Surgical admissions were elective and emergency, and made up 6% and 29% of total surgical admissions respectively over the period. A total of 337 patients were included in the study. Table 1
presents the age and anthropometric measurements of males and females admitted to medical and surgical wards.
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Prevalence of nutritional problems |
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TopSummaryIntroductionMethodsResultsPrevalence of nutritional...Referral to dietetic departmentDiscussionReferences |
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Of the 337 patients included, 219 had BMI measured. More difficulties in measuring BMI were found in medical than surgical patients. BMI was <18.5 kg/m2 in 19 (9%) patients; of these, 12 (63%) reported having also lost >3 kg in the last 3 months. There were 21 (10%) patients with BMI 18.5–20 kg/m2, of whom nine (4%) reported having lost >3 kg in the last 3 months. A total of 40 (18%) patients had a BMI <20 kg/m2 which might have been considered to represent malnutrition under older definitions. According to our a priori criteria for defining malnutrition, 28 (13%) patients were malnourished on admission. Review of 26 (two could not be obtained) case records (medical and surgical) indicated that malnutrition was associated with gastro-intestinal disease in 13 patients, cardiovascular and psychological disease in two patients, respectively, respiratory disease in three patients, urological, endocrinological, and ear/nose/throat disease in one patient each, and three patients had cancer.
Mid-upper arm circumference was measured as a possible proxy for BMI. The measures were correlated, but not well enough for confident identification of BMI (Figure 1). Most malnourished patients had mid-upper arm circumference <22.25 cm for both men and women (sensitivity 98%) but there was an almost equal number of false positives with mid-upper arm circumference below this cut-off (specificity 65%). Waist circumference measured using standard methods was similarly unable to discriminate (Figures 2 and 3) (males: waist 75.7cm; sensitivity 94%, specificity 50%; females: waist 68.4cm; sensitivity 98%, specificity 50%).12 Malnutrition was found in occasional patients with waist as high as 80 cm in women or 90 cm in men. A total of 33 (15%) subjects had a BMI above 30 kg/m2 on admission (i.e. diagnosable as obese). Table 2 presents the distribution of patients in BMI categories by age ranges for both underweight and overweight patients, and the BMI profiles of people in the community aged 16–64 years.
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Review of 53 medical records (including patients with BMI >30 kg/m2) showed that weight had not been recorded for 8/17 (47%) patients with BMI <18.5 kg/m2 (two case notes could not be obtained), 6/9 (67%) of those with BMI between 18.5–20 kg/m2 and who reported having lost >3 kg in the last 3 months, and 18/27 (67%) patients with a BMI >30 kg/m2 (six case notes could not be obtained) during their hospital stay. None of the malnourished patients had a biochemical nutritional screen performed. Only five (18%) of the malnourished patients had mention of the nutritional status in their referral or medical discharge letters. Dietetic follow-up at home was not planned for any of the malnourished patients.
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Referral to dietetic department |
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TopSummaryIntroductionMethodsResultsPrevalence of nutritional...Referral to dietetic departmentDiscussionReferences |
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Of those with a BMI <18.5kg/m2, 6/19 (31.5%) patients were referred to the dietitian; 2/21 (9.5%) patients with BMI 18.5–20kg/m2 (including one of the nine who reported having lost >3 kg in the last 3 months) were referred to the dietetic department. Of the 28 malnourished patients (BMI <18.5 kg/m2 and BMI 18.5–20 kg/m2 with weight loss), seven (25%) were referred to the dietetic department. A total of 9/33 (27%) patients with a BMI >30 kg/m2 were referred to the dietetic department during the course of their admission.
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Discussion |
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TopSummaryIntroductionMethodsResultsPrevalence of nutritional...Referral to dietetic departmentDiscussionReferences |
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The prevalence of malnutrition in hospital patients has been worrying for over 20 years.13–15 The present evidence suggests that malnutrition remains a significant problem in hospital admissions, and it may be going undiagnosed. The prevalence of malnutrition will obviously depend upon the criteria used to define this diagnosis, and differences in definitions partly account for the variations in prevalence quoted in the literature. Variations in diagnostic criteria make direct comparisons difficult. A recent study of 500 hospital admissions in Scotland reported that 40% of patients admitted were undernourished, but defined undernourished as BMI <20 kg/m2 and a triceps skinfold thickness or mid-arm muscle circumference <15th centile for mild undernutrition. Of these 500 patients, 67% lost weight during their hospital stay.16
In the present study, using stricter diagnostic criteria designed to be more clinically relevant, 13% of hospital admissions were malnourished and over 75% of them were not diagnosed as such. Of patients who fulfilled the strictest definition (BMI <18.5 kg/m2), 70% went undiagnosed, at least according to information recorded in the medical records. As might be expected, a low BMI was more common in sick people admitted to hospital than in the general population. The proportion of hospital admissions with BMI <18.5 kg/m2 is five times greater than in the community and BMI <20 kg/m2 is three times greater than in the community. Total admissions to the Glasgow Royal Infirmary amount to 47 000 per year and 37% (17390) as both medical and surgical emergencies. Therefore, it can be estimated that 2261 (13%) are malnourished emergency admissions. If a prevalence of 13% can be extrapolated to all admissions, i.e all subspecialities, elective and emergency, then up to 6110 malnourished patients may be admitted annually. Over the 12-month period 01/04/97 to 31/03/98, only one (E46) of the six International Classification of Disease codes for malnutrition or undernutrition was recorded, and this in only 28 patients.
Conducting the present study highlighted a number of practical issues. To obtain BMI, good measurements of height and weight are necessary, using regularly calibrated equipment, and by staff with some training. This should not be costly or onerous, but neither of these conditions are currently met in most hospital wards. In a relatively large number of patients, it is not possible to make these measurements (in the present study, BMI could only be obtained in two out of every three admissions). For bed-bound patients, a good proxy for height exists in the lower leg length8 from which to calculate BMI, but if weight cannot be measured, referral to dietitians must be made on other grounds. The mid-upper arm circumference, a useful epidemiological indicator of undernutrition,17 is inadequately specific to pinpoint BMI in hospital patients. Waist circumference were higher than expected for BMI in the present study by comparison with measurements in healthy adults,18 and could not be used to screen for malnourished patients (Figure 2).
Complicated scoring systems including functional outcomes are not specific to malnutrition and have not been shown to improve identification or management. However, failure to recognize malnutrition, and to take appropriate action to reverse the condition, leads to longer hospital stay, delayed recovery, and therefore to increased National Health Service costs. It has been estimated from a study carried out amongst undernourished patients in hospital that nutritional treatment could potentially save £266m each year in Britain.3 The outcome for individuals depends on underlying disease processes, but would generally be improved by providing appropriate nutritional support. Few studies have documented the benefits of nutrition intervention. Decreased mortality rate, potentially by 50%, was shown in a large well-conducted controlled study of routine nutritional supplementation in geriatric patients.8 A systematic review of randomized controlled trials of routine protein energy supplementation has reported improved nutritional status among adults, based on anthropometric indices.9 Nutritional support is seldom the whole solution, and may be inappropriate for a minority, but in some cases denying it may be contributing to distress and re-admission to hospital. There are guidelines regarding hospital food, suggesting methods of improvement;19 and the growing emphasis on quality in the Government White Paper stresses the importance of recognizing nutrition as part of clinical management.2 There are many reasons for weight loss during hospitalizations, e.g. having to fast for investigations, unpalatable foods, nausea, depression or feeding difficulties. These problems and the diagnosis of malnutrition may still go unnoticed by health professionals focussed on more technical, biochemical or pharmaceutical issues if routine evaluation of nutritional status is neglected.
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Acknowledgments |
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We are grateful to the ward staff and patients, Nutrition Sister Patricia McKeown, Lynda Murray and the dietetic department for their co-operation and help, and to Dr Thang Han for his contribution towards statistical analysis. Kelloggs is also gratefully acknowledged for providing funds for summer jobs for the two medical students (AC and DMcL). We thank the Data Archive Support by the University of Essex, the Economic and Social Research Council and the Joint Information System Committee for access to the Scottish Health Survey 1995.
A formal nutritional assessment has now been introduced into the routine admission procedures for all emergency admissions to Glasgow Royal Infirmary.
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References |
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