Prevalence of malnutrition in surgical patients: evaluation of nutritional support and documentation

Clinical Nutrition (1999) 18(3): 141-147 © 1999 Harcourt Brace & Co. Ltd

Prevalence of malnutrition in surgical patients: evaluation of nutritional support and documentation L. I. BRUUN*, I. BOSAEUS*, I. BERGSTAD*, K. NYGAARD* *Department of Clinical Nutrition. Aker Hospital, Oslo, Norway, ~Department of Clinical Nutrition. Sahlgrenska Hospital, Gothenburg, Sweden (Correspondence to: LIB, Department of Clinical Nutrition, Aker Hospital, Trondheimsveien 235, 0514 Oslo, Norway) Abstract--Objectives: To assess the nutritional status of surgical gastrointestinal and orthopaedic patients, and to audit the practice and documentation of nutritional therapy used on these wards. Methods: Nutritional status was assessed in 244 patients using body mass index (BMI) and weight loss. Amount and length of nutritional therapy and records of the patients' nutritional state were noted from the patients' records. Results: 94 patients (39%) were mildly/borderline to severely malnourished. Sixty courses of nutritional support were given parenterally or by tube feeding. Twenty seven of these were given for less than a week. Of the remaining 33, the amount of energy given to 17 patients was less than 25 kcal/kg. There was no correlation between patient weight and energy administered. Twenty four patients received less than 1 gram aminoacids per kg bodyweight. Body weight was recorded in 59% of the patients records. Conclusion: New routines and staff education are needed.

admitted to the orthopaedic ward, and malnourished patients had significantly longer convalescence periods compared with normally nourished patients (16). It has been demonstrated that supplementary nasogastric tube feeding (17) or oral supplements (18) improve the clinical outcome in underweight patients admitted with fractured femoral neck. Nutritional support probably has to be given for at least 7 days in order to be of clinical beneft to the patient (14). Of the 200 malnourished patients identified in a study carried out in a British hospital (1), only 104 had nutritionat information in their case notes. In order to clarify why, and how often, malnutrition is unrecognized in Britain, the British Association of Parenteral and Enteral Nutrition (BAPEN) interviewed doctors and nurses on this issue (19). Two-thirds of the nurses weighed the patients, but only 11% measured their height, and approximately 80% of the results were recorded. Some nurses and doctors neither asked about nutrition nor performed measurements because they regarded this information as unimportant. A study performed by Mow6 and BOhmer (3) showed that of 121 (54%) malnourished patients, none were given a diagnosis of malnutrition in their journal synopsis. Multidisciplinary nutritional support teams are now well established in several countries. Results show that patients in need of nutritional support attain more energy, are more closely monitored and have fewer complications when treated by a team compared to a non-team approach (20-22). Team approach results in improved patient care, and therapeutic and economic benefits (23). In Norway formalized nutritional support teams do not exist. The individual physician is responsible for detecting malnutrition or risk of malnutrition in the patients, and for the consequent treatment of this. The purpose of this study was to assess the nutritional status of patients admitted to the gastrointestinal and

Key words: malnutrition; surgical patients; nutritional assessment; artificial nutrition

Introduction Malnutrition is still a largely unrecognized problem in hospitals in the Western world, as indicated by the recent findings of 40% undemutrition in a British hospital (1). During the last decades malnutrition and the use of nutritional support has also been highlighted in the Nordic countries. However, few surveys have been carried out regarding the incidence of malnutrition and the use of nutritional support in these countries, and the majority of these are 10 years or older. At the beginning of the 1980s, 11 small studies demonstrated a frequency of malnutrition between 22 and 35% among medical and geriatric patients and between 4 and 31% among different surgical patients (2). In 1988, a Norwegian study of elderly people (age > 70 years) admitted to a medical ward, showed a prevalence of malnutrition of 54% (3). One Swedish survey showed a prevalence of malnutrition of 29% among patients admitted to a long-term medical ward (4), and another Study showed a mean of 27% malnutrition among both medical and surgical patient (5). Malnutrition is associated with decreased muscle function (6), respiratory function (7), immune function (8) and quality of life (9), and impaired wound healing (10). These consequences lead to increased postoperative morbidity and mortality (11, 12), and duration and costs of hospital stay are significantly higher (13). Gastrointestinal problems are often associated with nutritional problems, and nutritional support can benefit some of these patient (14, 15). Malnutrition is more common in patients with fractured femoral neck than in other patients I41

142 PREVALENCEOF MALNUTRITIONIN SURGICALPATIENTS

orthopaedic wards of our hospital for more than 7 days. Furthermore to assess the practice and documentation of nutritional therapy in these wards, and to determine if this part of the treatment is given enough priority.

Patients and methods Patients This prospective investigation was carried out from August 1996 until May 1997 at the gastrointestinal and orthopaedic surgical wards at Aker hospital, a 630 bed university hospital in Oslo, Norway. During this period, consecutive patients aged 18 years or more, were included when they had stayed for at least 7 days. Patients who received nutritional support during the first seven days after admission were also included. The nutritional therapy given included total parenteral nutrition, partial parenteral nutrition and tube feeding containing a combination of carbohydrates, amino acids and fat. In total, 244 patients were included. Of these, 64 patients were reassessed once weekly regarding their nutritional state until they were discharged or entered a terminal state. Four of the 244 patients received nutritional support when they were readmitted, these four are included in the evaluation of nutritional support given. The reported evaluation of the nutritional state of the patients were only done during the hospitalization period when they were included in the study. Each patient gave informed consent to participate in the study.

weight loss between 5 and 10%. A BMI between 16 and 18, or a weight loss between 10 and 20% indicated moderate malnutrition and a BMI below 16 or weight loss more than 20% indicated severe malnutrition. The presence of oedema would affect BMI and was noted by the study-group. Patients were classified as 'oedematous' when pitting oedema of the limbs was evident. The patients were also interviewed using a simple nutrition risk score to evaluate their risk of malnutrition. This scoring system included weight loss during the previous 3 months, body mass index, appetite, ability to eat/retain food and stress factor (24). Patients who had a score of six or more were considered to have a high risk of becoming malnourished. Assessment of nutritional therapy Amount and duration of nutritional therapy were noted from the patients' records. Energy and nitrogen received per kg body weight were calculated. No attempts were made to influence the use of artificial nutrition during the study. Documentation of nutritional state and nutritional therapy from patient records After the patient was discharged, the patient records were reviewed for records regarding nutritional state. Body weight, height and comments on weight changes were looked for. Monitoring of nutritional therapy was reviewed. Statistics

Assessment of nutritional state At inclusion, each patient's nutritional state was determined and, if possible, this was repeated once weekly until discharge or they entered a terminal state. Data from the time of inclusion and from the last measurement were used in the evaluation. In order to evaluate nutritional state, the following parameters were used: weight loss during the previous 3 months (as recalled by the patient) and body mass index (weight (kg)/(height (m)2), BMI) at inclusion. Body weight was measured with a Seca electronic scale (Seca Mess und Wiegetechnik, Germany) or a Seca mechanical chair scale, and measured to the nearest 0.1 kg. Height was asked for. Patients were considered mildly/borderline malnourished if their BMI was between 18 and 20 or if they had had a

Table 1

Statistical analysis were carried out using the SPSS for Windows, SPSS Inc., Chicago. Statistical methods used were arithmetic mean, standard deviation, minimum and maximum values, percent, frequency, correlation and the Student's t-test. Results Nutritional state at inclusion Characteristics of the 244 patients who were assessed are outlined in Table 1. Gastrointestinal cancer, other cancers (including breast cancer) and inflammatory bowel disease were the most common diagnoses of the patients included from the gastrosurgical ward. From the orthopaedic ward fractured neck of femur and other fractures were the most common diagnoses.

Characteristics of the patients

Number of patients Women Men Died in hospital Age, years, median (range) Duration of stay, days, median (range)

Total

Gastrosurgery

Orthopaedic

244 149 (61%) 95 (39%) 11 (4.5%) 70.0 (22-92) 14.0 (3-115)

178 101 (56.7%) 77 (43.3%) 10 (5.6%) 67.5 (22-92) 13.0 (3-115)

66 48 (72.7%) 18 (27.3%) 1 (1.5%) 76.0 (39-91) 14.5 (8-33)

CLINICAL NUTRITION

Table 2

Distribution of body mass index of all patients at inclusion. Number of patients (%)

Body mass index

Total

< 16.0 16.0-17.9 18:0-19.9 20.0--25.0 25.1-30,0 > 30

7 (2.9) 9 (3.8) 34 (14.2) 115 (48A) 56 (23,5) 18 (7.5)

Gastrosurgical

239*

4 (2.3) 5 (2.9) 28 (16.0) 90 (51.4) 39 (22.3) 9 (5.1) 175

3 (4.7) 4 (6.3) 6 (9.4) 25 (39.0) 17 (26.6) 9 (14,0) 64

Nutritional status evaluated by weight loss prior to admittance Number of patients (%)

Weight loss

Total

Gastrosurgical

Orthopaedic

> -- 20% 10-19.9% 5-9.9% < 5%

6 (2.5) 29 (12.1) 31 (12.9) 174 (72.5)

5 (2.9) 25 (14,3) 27 (15.4) 118 (67.4)

1 (1.5) 4 (6.2) 4 (6.2) 56 (86.1)

240*

175

65

*Four patients couldnot recall their weight loss during the previous3 months. One of five patients had a BMI of less than 20 (Table 2). Sixty six patients had lost 5% or more body weight during the preceding 3 months (Table 3). When both BMI and weight loss are taken into account, 39% of the patients were malnourished (Table 4). Figure 1 shows that 22 of the 94 patients had both a recent weight loss and low BMI. By calculating the nutrition risk score from the interview,

Table 4 Nutritional status of 244 patients at inclusion based on BMI and percent weight loss Number of patients (%) Total Severely malnourished Moderately malnourished Mildly/borderline malnourished Normally nourished

11 (4.5) 31 (12.7) 52 (21.3)

Gastrosurgical 8 (4.5) 24 (13.5) 44 (24.7)

34% of the patients were considered to be at high risk of malnutrition.

Orthopaedic

*Five of the patients were not possible to weigh on inclusion. Table 3

143

Orthopedic 3 (4.5) 7 (10.6) 8 (12.1)

150 (61.5)

102 (57.3)

48 (72.8)

244

178

66

Fig. 1 Patients borderline/mildly to severely malnourished according to BMI < 20 and weight loss _>5%.

Development of the nutritional status during the hospital stay A total of 64 patients were re-evaluated regarding their nutritional status during their stay. Eleven of these (17%) gained weight or were stable during their stay. Thirty-two patients (50%) lost up to 5% body weight, 16 (25%) lost between 5 and 10% and 5 (8%) lost between 10 and 15% body weight. However, 14 (21%) of the patients had oedema when their weight was first measured, and some of the weight loss could therefore be due to a correction of this. None of the five patients with weight loss of more than 10% were in this group. Two of the five patients who lost more than 10% body weight died from their primary illness. Of the 21 patients who had had a weight loss of 5% or more before admittance and who were re-evaluated by the study group whilst staying in hospital, 17 continued to lose weight during their stay. Of the group of patients who received nutritional therapy, 36 were re-evaluated, and 31 of these lost weight during their hospital stay.

Nutritional therapy Nutritional therapy was given to 56 patients, four of whom were re-admitted and received artificial nutrition also during their next stay. Total number of nutrition courses was thus 60, and in the following we have chosen to evaluate these individually. Gastrointestinal cancer was the most frequent diagnosis in patients who received nutri-fional support. Most patients received more than one type of artificial nutrition (partial parenteral nutrition, total parenteral nutrition and/or tube feeding). Twenty seven patients (45%) received nutritional support for less than a week, whereas 33 patients (55%) received such therapy for 7 days or more. Of the latter patients, 28 did not eat during their course of nutritional therapy due to a tack of appetite or nil by mouth orders, and the remaining five reported that they ate less than half of the food portion served. Six patients in the group given enteral nutrition continued artificial feeding after discharge or transfer to another hospital, whereas none of the patients receiving parenteral nutrition continued with this type of therapy after discharge. Half of the patients who received nutritional therapy for 7 days or more received less than 25 kcal/kg/day, and weight loss was greater in this group compared with those who received more (P < 0.05) (Table 5). Thirteen patients (39%) received between 25 and 40 kcal/kg, and three received more than 40 kcal/kg/day. Two of the latter patients reported oral intake in addition. There was no correlation between total energy intake fi:om nutritional support and the patients' body weight on inclusion of the study (Fig. 2). Twenty four (73%) of the patients who received nutritional therapy for 7 days or more, received less than 1.0 g

144 PREVALENCE OF MALNUTRITION IN SURGICAL PATIENTS Table 5 Energy provided by nutritional support in patients who received nutritional support more than 6 days Energy from nutritional support, kcal/kg

Number of patients (%)

Weight difference during hospitalisation (kg) (range) and number of patient weighed more than once

17 (51.1) 9 (27.3) 3 (9.1) 1 (3.0) 3 (9.1)

-4.5 (-8.8 - +2.1) 13 -2.7 (-7.9-+2.1) 8 -2.9(-3.7--2.0) 2 +3.7 1 ~).5 (-1.3-+0.9) 3

< 25.0 25.0-29.9 • 30.0-34.9 35.0-39.9 >40.0

2200, 00

ducted, and no fixed regime of parameters for monitoring nutritional support. Body weight'and laboratory measurements form the basis of monitoring nutritional support. In 15 of the patients (25%) body weight was not recorded in the notes, and in 14 (23%) the weight was only recorded on admission. Thus, 48% of the patients who received nutritional support, had no weight control during the period of nutritional support. However, in 31 of 33 patients who received nutritional support for 7 days or more, body weight was recorded. In nine of these patients weight was noted once, which in seven cases was on admission. Laboratory measurements were not reviewed.

~2000,

&

Discussion

o_

1800,

Assessment of malnutrition

g

:~ 1600,

O•

•

E 1400' 0

1200.

lOO0, 0

E 800 30

40

50

60

70

80

90

1O0

body weight, kg

Fig. 2 Mean energy provided by means of nutritional support related to the body weight of the patients at inclusion. Correlation coefficient 0.036.

aminoacids/kg/day, while 9 (27%) received between 1.0 and 1.5 g/kg. Five (46%) of the 11 severely malnourished patients received artificial nutrition, two of them for less than 7 days. Six patients in this group did not receive nutritional support. Eleven of the patients included in the study were referred to a dietitian for nutritional advice.

Documentation of nutritional state The prevalence of body weight and height found in the patients records were 142 (59%) and 123 (51%), respectively, out of 240 records 1. Although weight was not recorded in 98 patients (41%), comments regarding weight or weight changes were found in 31 of them (e.g. 'lost 10 kg' or 'no weight change'). When weight was registered it was noted once in 105 patients (75%), and in 68 of these (65%) it was asked on admission. Fifteen (16%) of the 94 malnourished patients had no weight recording or comments regarding nutritional state in their notes. Four of the malnourished patients were given a diagnosis of malnutrition in their discharge report.

Documented monitoring of nutritional support There was no written protocol for the use of nutritional support in the surgical wards where this study was con1Four of the patients records were missing

There is no 'gold standard' for identification of malnutrition, and several parameters should be considered. Body weight is important, and should be related to height, as BMI. The criteria we used to determine limits for BMI were derived from McWhirter and Pennington (1). Body weight can be inaccurate if oedema, ascites or fluid balance derangements are present, resulting in falsely high BMI measurements. Fluid shifts with extracellular volume expansion is a regular feature of severe illness and systemic inflammation. This complicates the interpretation of body weight measurements as well as changes in body weight during therapy. Another disadvantage of using BMI is that patients with equal BMI's may have significantly different fat free masses. Percent ideal body weight (PIW) is an other parametre that might be used; but different reference populations will, however, give different interpretations of the results. In most cases PIW will relate to a BMI of 22-23; and BMI might therefore be as valuable as PIW. Weight loss less than 10% does not seem to affect physiological function to a degree that is clinically important. It is, however, important to prevent further weight loss in such patients. If 20% of body weight is lost, protein-energy malnutrition (PEM) with impaired physiological function will always be present. Patients between these two limits could have clinically significant PEM (25). As illustrated in Figure 1, patients evaluated as malnourished judged by their BMI, are not always identical with those considered malnourished from weight loss alone. Mean BMI among elderly people in Scandinavia is 26 (26). In this group a weight loss of more than 20% may take place before BMI falls below 20. Low BMI and recent weight loss are both important parameters in the evaluation of malnutrition, and both these factors should be taken into account. The prevalence of 39% mild/borderline to severe malnutrition in patients staying for more than seven days in hospital confirms the severity of this problem. It is important to identify these patients and be aware of nutritionally related complications which may occur. Appropriate intervention may improve nutritional status in such cases. The nutrition risk score (NRS) is a simple way of identifying patients at risk of malnutrition, which is applicable

CLINICAL NUTRITION

to all patient categories and ages. This scoring system can be a useful tool in identifying 'at risk patients' and should be linked to recommendations for appropriate action. Low blood albumin level has been the main laboratory criterion for identification of malnutrition. The specificity of this parameter is low due to altered distribution in metabolic stress or inflammation, or because of changes in hydration. The albumin concentration is rather a nonspecific marker of inflammatory disease than a marker of undernutrition. Prolonged starvation in absence of disease has been shown to produce only small changes in circulating albumin concentration, and values within the normal range are seen in patients with anorexia nervosa (27). Albumin as a malnutrition risk parameter was therefore not evaluated in this study. Triceps sldnfold (TSF) and midarm muscle circumference (MAMC) are commonly used for diagnosing malnutrition. However, the use of different reference populations significantly affects the interpretation of these parameters. This was confirmed in an evaluation of validity of British anthropometric reference data for assessing the nutritional state of elderly people in Edinburgh (28). This study suggested that existing reference data for anthropometric nutritional assessment of elderly people in Britain are not representative of all populations, ~ d TSF measurements may be an inappropriate method for nutritional screening in this patient population TSF and MAMC were therefore not used for evaluation of malnutrition in the present study.

Nutritional development during hospital stay A total of 64 patients were re, assessed during their hospital stay, and 8 3 % of them lost weight whilst admitted. Although this may have been due to correction of fluid overload in some patients, the majority probably lost body cell mass. Even though 3 6 o f the re-evaluated patients had received nutritional therapy, 31 of these still lost weight during hospital stay. The reasons for this may be that they received inadequate amounts of energy and amino acids in comparison to requirements, and/or that they received nutritional therapy for a too short period Thirty: eight patients had advanced malignant disease. Cachexia is a frequent complication in this patient group, and deSpite aggressive nutritional intervention, reversal of this syndrome cannot be achieved in the majority of cases (29): The goal for such patients should therefore be to limit the wasting process and improve the quality of life and survival time (30).

Nutritional therapy If the recommendations for perioperative artificial nutrition made b y the French speaking society for parenteral and enteral nutrition are taken into account (14), the following evaluation is made: There is no documentation of any benefit from nutritional support when the duration of artificial feeding is less than

145

7 days. In 27 (45%) of our patients, artificial nutrition was administered for less than 1 week. indicating that the planning of artificial nutrition could have been done more carefully. For some patients, artificial nutrition should not have been implemented, and in many of those requiring such treatment, it should have been continued for a longer period. The longer the duration of nutritional therapy, the more important it is for patients to receive adequate and balanced nutrition. As seen in Table 5, 51% of the patients who received artificial nutrition for more than 6 days had a mean daily intake of less than 25 kcal/kg. A careful registration of ordinary food intake was not performed. However, a review of the period the patients received artificial nutrition was compared with their answers in the nutritional risk score and their clinical state. This showed that of the 33 patients who received artificial nutrition for more than 6 days, 28 were not able or not allowed to eat. Energy and amino acids supplied from nutritional support were therefore probably inadequate according to their requirements. This is also reflected in the weight loss, which was significantly greater in the group receiving low amounts of energy per kg body weight. When inadequate nutritional support is given, the starvation process will continue, causing increased morbidity and length of hospital stay. The highest energy intakes (> 40 kcalNg) were in small, female patients, although they were not in an extreme stress situation. Two also ate in addition to the nutritional support. Overfeeding may lead to serious complications as for instance refeeding syndrome, hyperglycemia, hypertriglyceridemia and hepatic steatosis (31). In order to evaluate the nutritional needs of the patients, body weight should always be considered. In this study there was no correlation between body weight and amount of energy given to the patient as illustrated in Figure 2. This indicates that body weight was not sufficiently considered when prescribing nutritional support. Patients with severe malnutrition will benefit from artificial nutrition. An average duration of 10 days and a minimum of 7 days should result in an improvement in nutritional state demonstrated by weight gain. Of a total of 11 severely malnourished patients, five received nutritional support. Two of these patients received this for less than 7 days, both of whom probably could have benefitted from a longer period of nutritional therapy Six severely malnourished patients did not receive any nutritional support. One of them was expected to regain her nutritional status quickly after medical intervention. One was very old, and although the patient had a low BMI, quality of life was good. The remainder, two patients from the gastrointestinal ward and two orthopaedic patients, would probably have benefitted from nutritional support.

Documentation of nutritional state According to internal guidelines at Aker hospital, body weight should be measured on admission and on regular basis once weekly. In 40% of the patients included in this

146 PREVALENCEOF MALNUTRITIONIN SURGICAL PATIENTS.

study, no recording of body weight was done, and in 65% of the remaining cases, weight was asked for on admission, and not actually measured. Patients in need of nutritional support may be overlooked if weight and/or weight loss are not recorded. McWhirter and Pennington (1) showed that 50% of the malnourished patients in their study lacked nutritional information in their case notes. In our study, 16% lacked such information, which indicates a better awareness of the importance of this issue. Only four patients had diagnoses related to malnutrition in their discharge notes. As Mow6 and BChmer states (3): 'if this occurs regularly, it may lead to the misconception that undemutrition is no longer a medical problem in the developed countries'.

Documented monitoring of nutritional support Artificial nutrition forms a vital part of the care for certain surgical patients and can improve their prognosis. Its objective is only fully achieved when the prescription is adapted to the patient's needs and is regularly monitored (14). During the first days of artificial feeding daily weighing and examination for oedema form the basis for clinical monitoring. Forty eight percent of our patients were not weighed during the period of nutritional support, indicaring that regular weighing of patients on artificial nutrition was not performed on the wards included in the study. A review o f blood sample monitoring ordered by the physician was not performed. However, n o protocol stipulating which blood tests, and the necessary frequency of these, existed on the wards included in the study.

Conclusion This study shows that malnutrition was a significant problem in surgical patients staying for more than 1 week in the wards included. The goals of nutritional therapy in this patient group are at present not well defined. There was no correlation between the individual patient's energy requirements and amount actually administered, and in many cases inadequate amounts of aminoacids were given. In a number of cases, the duration of this therapy was shorter than desirable and, in others, it might as well have been omitted. Furthermore, the monitoring of nutritional therapy should be better. New routines and staff education are needed in order to improve the understanding and practice of nutritional therapy. Establishment of a mulfidisiplinary nutritional support team may be a way to achieve this. Tasks for such a team would be development of protocols, advicing physicians on correct nutritional therapy, adequate monitoring and continuous education. A mnltidisiplinary team can focus on the nutrition needs of each individual patient. It is to be hoped that such measures may contribute to improvement of the standards regarding nutritional support.

Acknowledgement -The authors wish to thank dietitian Marianne ]unli for initiation of the project and the development of a preliminary protocol, dietitian Thomas French for help regarding the development of the protocol and the inclusion of patients, dietitian Nina S,ether for help regarding inclusion of patients and dietitian Susan Hendrie SCdal for help in preparation of this manuscript. The authors also wish to thank Aker Hospital Pharmacy and the Norwegian Society of Proprietory Pharmacist for providing financial support for conducting the study.

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CLINICAL NUTRITION 147

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Submission date: 28 July 1998 Accepted: 4 January 1999

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