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ARE THEY BEING SERVED?
1491
haemoglobin released into the plasma by intravascular haemolysis. Indeed, increased mechanical red-cell destruction (as in march haemoglobinuria), has been suggested as an explanation for the reduced levels of serum haptoglobins1,7 and increased serum bilirubin,7 particularly during the initial stages of severe prolonged exercise. However, frank haemoglobinuria was rare even during several days of road running,8and haemolysis is unlikely to provide a complete explanation for the observed reduction in haemoglobin concentration: the bone marrow would normally be expected to increase red cell production and compensate completely for such limited red cell destruction. The finding of increased circulating interleukin-119 and
protein20 levels with severe exercise raises the of possibility an acute-phase inflammatory response limiting erythropoiesis during continuing severe exercise. An alternative suggestion by Hallberg and Magnusson21 is that oxygen delivery to tissues per unit of haemoglobin may be more efficient in trained athletes. Several studies in runners have shown an increase in concentration of red cell 2,3-diphosphoglycerate4,5,12 which, in favouring tissue oxygen delivery over long periods of exercise, might reduce the stimulus for erythropoietin production and thus limit any increase in red cell mass. However, measurement of the P50 of the oxygen dissociation curve has not revealed the expected "shift to the right". 5,12 The wealth of conflicting evidence concerning often marginal changes in circulating haemoglobin concentrations testifies to the concern of elite athletes to obtain a competitive edge. Increased red cell destruction may occasionally have a role in the aetiology of athletes’ anaemia. However, the minor changes in haematocrit are much more likely to represent a "physiological response to unphysiological exercise"21 and not a true reduction in total body haemoglobin. Iron therapy should be restricted to those rare patients with unequivocal evidence of subnormal iron supply for erythropoiesis. Extreme attempts to obtain marginal improvements in performance by infusion of red cells ("blood doping"22) are hazardous and should be condemned. C-reactive
ARE THEY BEING SERVED? THIS is the title of "an
investigation into the nutritional medical patients and the influence of ward organisational patterns on that care" sponsored by the Royal College of Nursing.’ It comes at a time when British hospital authorities are under pressure to review their food catering systems, largely in response to the widespread publicity given to the NACNE report2 and the 3 care
given by
nurses
to acute
COMA report on diet and cardiovascular disease.3 The study took place on four wards of two teaching hospitals. 51 male and 42 female acute medical patients were selected and investigated in groups offour for one week. Most patients were receiving an ordinary diet, 25 a reducing diet, and 17 a diabetic diet. Dietary intake of energy and protein,
19 Simon HB. The immunology of exercise. JAMA 1984; 252: 2735-38. 20. Strachan AF, Noakes TD, Kotzenberg G, Nel AE, De Beer FC. C reactive protein concentrations during long distance running. Br Med J 1984; 289: 1249-51. 21. Hallberg L, Magnusson B. The etiology of "sports anemia". Acta Med Scand 1984; 216: 145-48 22. Klein HG. Blood transfusion and athletics. Games people play. N Engl J Med 1985; 312: 854-56. 1. Coates VE. Are they being served? London: The Royal College of Nursing of the United Kingdom, 1985. 2. National Advisory Committee on Nutrition Education. Proposals for nutritional guidelines for health education in Britain. London: The Health Education Council, 1983. 3 Committee on Medical Aspects of Food Policy. Diet and cardiovascular disease. Report on Health and Social Subjets No 28. London: HM Stationery Office, 1984.
weight, height, triceps skinfold thickness, upper arm circumference, arm muscle circumference, and 3-day urinary nitrogen excretion were measured. The wards differed with regard to the method of nursing practice; two practised team nursing, one patient allocation, and one primary nursing. Although the sample was small, the period of study short, and the methods used subject to technical error and problems of interpretation, the main conclusions do give rise to considerable concern if they are representative of acute medical patients in general. Depending on the criteria used for assessment, at least 25% and at most 36% of patients were diagnosed as having some degree of protein energy malnutrition, in line with previous reports. By weight/height assessment 29% were obese. However, too much reliance should not be placed on these figures since the methods are imprecise. Attention is now being given to the importance of frame size and distribution of body fatS when categorising people as under or over nourished. Patients on the ordinary diet were all consuming less than the recommended intake of energy and two-thirds less than the recommended protein intake. Only 18 patients were judged to be in positive nitrogen balance. Although the 20 patients on a 1000 kcal diet received approximately the prescribed amount, 5 other patients on different calorie restricted diets received considerably more than intended, while all diabetic patients received less energy than recommended. A detailed analysis of the operation of each of the different systems of nursing practice employed revealed no significant differences between the wards as far as nutritional care was concerned. It was observed that all wards operated with fewer nurses than the numbers recommended for the
different systems. The report rightly draws attention to the need for greater emphasis on nutrition in the nursing curriculum if the profession is to play its proper part in nutritional care of patients, and rather despairingly points out that things seem to be no better now than they were 20 years ago when Platt and his colleagues made their survey.This deserves to be widely read and inwardly digested by the hospital-based nursing profession, for there is little doubt that improvements can be made despite nursing shortages. The feeding of patients is a complex matter in which nurses are only one, albeit very important, link in a long chain-going all the way from the placing and implementation of contracts, local purchasing, catering, and portering to the final nursing duty of seeing that the patients get the appropriate meals and eat them. The NHS has some of the largest contracts with the food industry in the country. Even so the average hospital patient has to be fed for as little as about [, 1.30 per day. This leaves the catering manager very little room for manoeuvre-especially when the more nutritionally desirable varieties of foods, such as those with more fibre, less saturated fat,
or
less salt tend to be more
expensive. Where do doctors
come
in? The
widespread use of
enteral
occasion, parenteral nutrition is slowly bringing general recognition that the provision of adequate nutrition is and,
on
essential adjuvant to all forms of treatment in hospital. It be an enlightening and salutary experience to sit down with a hospital administrator, nursing officer, dietitian, and catering manager and find out exactly how one’s patients are being fed. an
can
4. Frisancho AR. New standards ofweight and body composition by frame size and height for assessment of nutritional status of adults and the elderly. Am J Clin Nutr 1984; 40: 808-19. 5. Editorial. The shape of fatness. Lancet 1984; i: 889. 6 Platt BS, Eddy TP, Pellett PL. Food in hospitals. Oxford: Oxford University Press, 1963.
haemoglobin released into the plasma by intravascular haemolysis. Indeed, increased mechanical red-cell destruction (as in march haemoglobinuria), has been suggested as an explanation for the reduced levels of serum haptoglobins1,7 and increased serum bilirubin,7 particularly during the initial stages of severe prolonged exercise. However, frank haemoglobinuria was rare even during several days of road running,8and haemolysis is unlikely to provide a complete explanation for the observed reduction in haemoglobin concentration: the bone marrow would normally be expected to increase red cell production and compensate completely for such limited red cell destruction. The finding of increased circulating interleukin-119 and
protein20 levels with severe exercise raises the of possibility an acute-phase inflammatory response limiting erythropoiesis during continuing severe exercise. An alternative suggestion by Hallberg and Magnusson21 is that oxygen delivery to tissues per unit of haemoglobin may be more efficient in trained athletes. Several studies in runners have shown an increase in concentration of red cell 2,3-diphosphoglycerate4,5,12 which, in favouring tissue oxygen delivery over long periods of exercise, might reduce the stimulus for erythropoietin production and thus limit any increase in red cell mass. However, measurement of the P50 of the oxygen dissociation curve has not revealed the expected "shift to the right". 5,12 The wealth of conflicting evidence concerning often marginal changes in circulating haemoglobin concentrations testifies to the concern of elite athletes to obtain a competitive edge. Increased red cell destruction may occasionally have a role in the aetiology of athletes’ anaemia. However, the minor changes in haematocrit are much more likely to represent a "physiological response to unphysiological exercise"21 and not a true reduction in total body haemoglobin. Iron therapy should be restricted to those rare patients with unequivocal evidence of subnormal iron supply for erythropoiesis. Extreme attempts to obtain marginal improvements in performance by infusion of red cells ("blood doping"22) are hazardous and should be condemned. C-reactive
ARE THEY BEING SERVED? THIS is the title of "an
investigation into the nutritional medical patients and the influence of ward organisational patterns on that care" sponsored by the Royal College of Nursing.’ It comes at a time when British hospital authorities are under pressure to review their food catering systems, largely in response to the widespread publicity given to the NACNE report2 and the 3 care
given by
nurses
to acute
COMA report on diet and cardiovascular disease.3 The study took place on four wards of two teaching hospitals. 51 male and 42 female acute medical patients were selected and investigated in groups offour for one week. Most patients were receiving an ordinary diet, 25 a reducing diet, and 17 a diabetic diet. Dietary intake of energy and protein,
19 Simon HB. The immunology of exercise. JAMA 1984; 252: 2735-38. 20. Strachan AF, Noakes TD, Kotzenberg G, Nel AE, De Beer FC. C reactive protein concentrations during long distance running. Br Med J 1984; 289: 1249-51. 21. Hallberg L, Magnusson B. The etiology of "sports anemia". Acta Med Scand 1984; 216: 145-48 22. Klein HG. Blood transfusion and athletics. Games people play. N Engl J Med 1985; 312: 854-56. 1. Coates VE. Are they being served? London: The Royal College of Nursing of the United Kingdom, 1985. 2. National Advisory Committee on Nutrition Education. Proposals for nutritional guidelines for health education in Britain. London: The Health Education Council, 1983. 3 Committee on Medical Aspects of Food Policy. Diet and cardiovascular disease. Report on Health and Social Subjets No 28. London: HM Stationery Office, 1984.
weight, height, triceps skinfold thickness, upper arm circumference, arm muscle circumference, and 3-day urinary nitrogen excretion were measured. The wards differed with regard to the method of nursing practice; two practised team nursing, one patient allocation, and one primary nursing. Although the sample was small, the period of study short, and the methods used subject to technical error and problems of interpretation, the main conclusions do give rise to considerable concern if they are representative of acute medical patients in general. Depending on the criteria used for assessment, at least 25% and at most 36% of patients were diagnosed as having some degree of protein energy malnutrition, in line with previous reports. By weight/height assessment 29% were obese. However, too much reliance should not be placed on these figures since the methods are imprecise. Attention is now being given to the importance of frame size and distribution of body fatS when categorising people as under or over nourished. Patients on the ordinary diet were all consuming less than the recommended intake of energy and two-thirds less than the recommended protein intake. Only 18 patients were judged to be in positive nitrogen balance. Although the 20 patients on a 1000 kcal diet received approximately the prescribed amount, 5 other patients on different calorie restricted diets received considerably more than intended, while all diabetic patients received less energy than recommended. A detailed analysis of the operation of each of the different systems of nursing practice employed revealed no significant differences between the wards as far as nutritional care was concerned. It was observed that all wards operated with fewer nurses than the numbers recommended for the
different systems. The report rightly draws attention to the need for greater emphasis on nutrition in the nursing curriculum if the profession is to play its proper part in nutritional care of patients, and rather despairingly points out that things seem to be no better now than they were 20 years ago when Platt and his colleagues made their survey.This deserves to be widely read and inwardly digested by the hospital-based nursing profession, for there is little doubt that improvements can be made despite nursing shortages. The feeding of patients is a complex matter in which nurses are only one, albeit very important, link in a long chain-going all the way from the placing and implementation of contracts, local purchasing, catering, and portering to the final nursing duty of seeing that the patients get the appropriate meals and eat them. The NHS has some of the largest contracts with the food industry in the country. Even so the average hospital patient has to be fed for as little as about [, 1.30 per day. This leaves the catering manager very little room for manoeuvre-especially when the more nutritionally desirable varieties of foods, such as those with more fibre, less saturated fat,
or
less salt tend to be more
expensive. Where do doctors
come
in? The
widespread use of
enteral
occasion, parenteral nutrition is slowly bringing general recognition that the provision of adequate nutrition is and,
on
essential adjuvant to all forms of treatment in hospital. It be an enlightening and salutary experience to sit down with a hospital administrator, nursing officer, dietitian, and catering manager and find out exactly how one’s patients are being fed. an
can
4. Frisancho AR. New standards ofweight and body composition by frame size and height for assessment of nutritional status of adults and the elderly. Am J Clin Nutr 1984; 40: 808-19. 5. Editorial. The shape of fatness. Lancet 1984; i: 889. 6 Platt BS, Eddy TP, Pellett PL. Food in hospitals. Oxford: Oxford University Press, 1963.