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Prevalence of malnutrition in medical and surgical gastrointestinal outpatients
Clinical Nutrition ESPEN xxx (xxxx) xxx
Contents lists available at ScienceDirect
Clinical Nutrition ESPEN journal homepage: http://www.clinicalnutritionespen.com
Original article
Prevalence of malnutrition in medical and surgical gastrointestinal outpatients N. Kamperidis*, L. Tesser, P. Wolfson, C. Toms, K. Katechia, D. Robinson, J. Nightingale St Mark's Hospital, Harrow, Middlesex HA1 3UJ, UK
a r t i c l e i n f o
s u m m a r y
Article history: Received 27 January 2019 Accepted 2 October 2019
Background: UK NICE guidelines, state that patients attending an outpatient clinic for the first time, should be screened for malnutrition. Aims: To determine the prevalence of malnutrition in the medical and surgical gastroenterology outpatient department (OPD) using body mass index (BMI) and % weight loss (%WL) and to assess the physicians'/surgeons' response to malnutrition being detected. Methods: The BMI and the %WL were determined for every patient over a 2 week period before the clinician saw the patient. The BMI and %WL were scored as in the Malnutrition Universal Screening Tool (MUST). Results: 605 patients (316 females) of mean age 54 years were included. 150 (25%) were new patients. 519 (86%) had a normal BMI and %WL. 86 (14%) had a BMI <20 kg/m2 or had 5% WL. 61 (10%) were in MUST “medium risk” and 25 (4%) were in MUST “high risk” of malnutrition. 15 (60%) of the “high risk” patients were under the care of or had been referred to a dietitian compared to 19 (28%) of “medium risk” patients. The prevalence of malnutrition was independent of sex, age, history of previous surgery or underlying comorbidities. There was no difference in the prevalence of malnutrition between new and follow up patients. Malnutrition was more common in patients with IBD (38, 18%) vs non-IBD (48, 12%) and patients with cancer (11, 25%) vs non cancer (75, 13%) (p < 0.05). Conclusions: The prevalence of malnutrition in medical and surgical gastrointestinal outpatients was 14%. IBD and cancer patients had the highest prevalence. Most patients with malnutrition (52, 61%) were not being seen by a dietitian. © 2019 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd. All rights reserved.
Keywords: Malnutrition Outpatients Inflammatory bowel disease MUST
1. Introduction Malnutrition is both a cause and effect of ill health [1] and affects up to 34% of hospital inpatients [2]. Malnutrition affects all the systems in the body and causes multiple problems including impaired immune function (infections are more common and more severe), impaired wound healing (surgical wounds are less likely to heal and may become infected), impaired muscular strength (so the risk of chest infections, DVT and pressure sores may increase) and impaired cerebral function (poor concentration, depression, excessive sleep) [3]. Malnourished patients have a high risk of medical complications, a longer hospital stay with more
* Corresponding author. St Mark's Hospital, Watford Road, Harrow, Middlesex HA1 3UJ, UK. E-mail address: [email protected] (N. Kamperidis).
complications; they are more likely to be readmitted after discharge and have an 8 fold increase in mortality irrespective of pre-morbid status [4]. In order to improve the healthcare professionals' awareness and ensure that patients at risk of malnutrition are identified early during their clinical course, a simple scoring system, the Malnutrition Universal Screening Tool (MUST) was developed [5]. The MUST score risk stratifies the patients according to body mass index (BMI), % weight loss and an acute disease effect [5]. The incidence of malnutrition in patients admitted to hospital from the large UK BAPEN surveys is 29% [6] while the prevalence of malnutrition among medical inpatients has been reported as 35% according to BMI, % of weight loss or mid-arm circumference [7,8]. However, in the outpatient setting, the prevalence of malnutrition has been less extensively reported. A recent study, estimated that up to 22% of outpatients with COPD were malnourished [9]. There is little data about the prevalence of malnutrition in medical or
https://doi.org/10.1016/j.clnesp.2019.10.002 2405-4577/© 2019 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd. All rights reserved.
Please cite this article as: Kamperidis N et al., Prevalence of malnutrition in medical and surgical gastrointestinal outpatients, Clinical Nutrition ESPEN, https://doi.org/10.1016/j.clnesp.2019.10.002
2
N. Kamperidis et al. / Clinical Nutrition ESPEN xxx (xxxx) xxx
surgical gastrointestinal clinics even though it can significantly influence patient outcomes. In the UK, the guidelines of the National Institute for Health and Care Excellence (NICE) state in their ‘key priorities for implementation’ that ‘all outpatients at their first clinic appointment should be screened’ for malnutrition and this should be repeated ‘when there is clinical concern’ [1]. In this study we aimed to determine the prevalence of malnutrition in the outpatient department (OPD) of medical and surgical gastrointestinal clinics at St Mark's, Northwick Park and Central Middlesex Hospitals using body mass index (BMI) and % weight loss (%WL) as per MUST and to assess the physicians'/surgeons' response to malnutrition being detected. 2. Methods 2.1. Patients e Setting St Mark's, Northwick Park and Central Middlesex Hospitals provide outpatient care in their gastroenterology and gastrointestinal surgery outpatient clinics for 1.5 million adults living in Northwest London (Brent and Harrow). Additionally, St Mark's Hospital is a tertiary referral centre, accepting nationwide referrals mainly for patients with intestinal failure, Inflammatory Bowel Disease (IBD), functional bowel disorders and polyposis syndromes. All patients attending the medical and surgical gastrointestinal outpatient clinics of St Mark's, Northwick Park and Central Middlesex Hospitals over a random 2 week period were included in the study. 2.2. Assessments Prior to the study, the nursing staff working in the medical and surgical gastroenterology clinics across the Trust were trained to complete the nutritional screening. Posters of BMI charts, percentage weight loss charts and the agreed management guidelines were provided to the measurement rooms and clinic rooms on all sites. Consecutive patients (new and follow up patients) attending the outpatient clinic were screened for their risk of malnutrition. A specially printed yellow sticker was stuck into the patient's medical notes and the nutrition screening details and measurements were completed (Fig. 1). The yellow sticker included the following prompts: name, hospital number, date, current weight, weight 3e6 months ago, height, BMI, and % weight loss and MUST score. MUST is a five-step screening tool to identify adults who are malnourished or at risk of malnutrition. The individual steps are shown on Fig. 2. For the purpose of this study (making assessment quick), step 3 of MUST i.e. Acute Disease Effect score was omitted. The % weight loss was calculated according to the one documented on the previous clinical appointment for patients attending for a follow-up
PaƟents name Hospital number Date Current weight(kg): Weight 3 – 6 months ago(kg): Height(m): BMI(kg/m2): %weight loss: MUST score:
Fig. 1. Yellow sticker describing the nutrition screening details.
visit and was self-reported for patients attending for their first clinical review. Patients with a score of zero were classified as being at “low risk”, patients with a score of 1 as “medium risk” and patients with a score of 2 or more as “high risk”. Patients at medium risk (or above) were to be highlighted to the doctor and he/she could then refer the patient to a dietician. 2.3. Data collection Data on demographics (sex, age), disease specific characteristics (underlying condition necessitating the clinical appointment based on the conclusions after the clinical assessment, co-morbidities), appointment details (new or follow up patient) and the action taken by the reviewing physician or surgeon on the patients' nutritional status were collected retrospectively from the Electronic Clinical Information System (CIS) used by the Trust. The electronic system used by the dietitians, to record their activity was examined to determine if the patients identified as being at high or medium risk of malnutrition were seen by a Dietitian. 2.4. Ethical considerations Ethical approval was not sought as this project was an audit against the UK NICE standard. 2.5. Data analyses Continuous variables were expressed as mean (standard deviation of the mean) and qualitative variables were expressed as absolute number (% of the whole). Comparison of continuous variables between groups was performed using the student's t-test. Comparison of qualitative variables was performed using the chisquare test. All analyses were 2-tailed and a p value of less than 0.05 was considered as statistically significant. Statistical analyses were facilitated with the use of the Statistical Package for Social Sciences (SPSS version 16.0). All graphs presented in this paper were produced with the use of Graphpad Prism 6. 3. Results 3.1. Patients e Demographics During the study period 651 patients had the dedicated yellow stickers stuck into their medical notes. For 33 patients the sticker was uncompleted and 13 were found to be duplicates due to the patient having more than one OPD appointment during the study period. A total of 605 patients (289 (47.8%) male) were therefore taken as being included in the study, of whom 442 patients (73.1%) were attending for follow up appointments and 163 (26.9%) for an initial appointment. The mean (SD) age was 54.4 (18.3) years (Table 1). 3.2. Patients e Reason for consultation, co-morbidity From the patients attending the OPD, 208 (34%) had inflammatory bowel disease, 73 (12%) had anorectal issues, 54 (9%) upper GI symptoms or conditions, 44 (7%) cancer and 33 (6%) had liver disease (Table 1). 223 patients (37%) had previous abdominal surgery. 214 patients (35%) had co-morbidities: 107 (18%) cardiovascular, 91 (15%) endocrine, 45 (7%) musculoskeletal or connective tissue disorders, 38 (6%) respiratory, 21 (4%) non GI malignancies, 19 (3%) neurological and 10 (2%) psychiatric comorbidities.
Please cite this article as: Kamperidis N et al., Prevalence of malnutrition in medical and surgical gastrointestinal outpatients, Clinical Nutrition ESPEN, https://doi.org/10.1016/j.clnesp.2019.10.002
N. Kamperidis et al. / Clinical Nutrition ESPEN xxx (xxxx) xxx
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Fig. 2. The Malnutrition Universal Screening Tool (MUST). This figure is reproduced here with the kind permission of the British Association for Parenteral and Enteral Nutrition (BAPEN).
3.3. Malnutrition 519 participants (86%) had a BMI 20 kg/m2 and %WL less than 5%. 86 (14%) had a BMI <20 kg/m2 or had 5% WL. 61 (10%) were in MUST “medium risk” of malnutrition with mean [SD] BMI and %WL
of 23.1 [4.8] and 5.0 [4.1] respectively. Of these, 33 (54%) had low BMI as per MUST and 28 (46%) had lost 5e10% of their body weight. 25 (4%) were in MUST “high risk” of malnutrition with mean [SD] BMI and %WL of 20.1 [3.8] and 7.0 [4.5] respectively. Of these, 10 (40%) scored both for %WL and BMI, 11 (44%) had lost more than
Please cite this article as: Kamperidis N et al., Prevalence of malnutrition in medical and surgical gastrointestinal outpatients, Clinical Nutrition ESPEN, https://doi.org/10.1016/j.clnesp.2019.10.002
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N. Kamperidis et al. / Clinical Nutrition ESPEN xxx (xxxx) xxx
Table 1 Demographic and disease characteristics of patients included.
Age, Mean (SD) Male New appointment Inflammatory Bowel Disease Anorectal Upper GI Cancer Liver Disease
Low risk (n ¼ 519)
Medium risk (n ¼ 61)
High risk (n ¼ 25)
All (n ¼ 605)
p value
55.0 (17.8) 248 (47.8) 128 (25.3) 170 (32.8) 69 (13.3) 49 (9.4) 33 (6.4) 30 (5.8)
50.8 (22.0) 32 (52.5) 16 (26.2) 29 (47.5) 2 (3.3) 2 (3.3) 7 (11.5) 2 (3.3)
49.9 (17.3) 9 (36.0) 6 (24.0) 9 (36.0) 2 (8.0) 3 (12.0) 4 (16.0) 1 (4.0)
54.4 (18.3) 289 (47.8) 163 (26.9) 208 (34) 73 (12) 54 (9) 44 (7) 33 (6)
0.11 0.38 0.98 0.07 0.06 0.24 0.08 0.68
Values express n (%) unless otherwise stated. p values express differences between low, medium and high risk groups.
10% of their BW and 4 (16%) had a BMI of less than 18.5 (Table 2). 15 (60%) of the “high risk” were seen by a Trust Dietitian, compared to 19 (28%) of “medium risk” patients. 3.4. Risk factors associated with malnutrition The mean age of malnourished patients was lower than that of non-malnourished patients (50.5 vs 55.0 years, p ¼ 0.04) (Table 3). The prevalence of malnutrition was independent of sex, history of previous surgery and co-morbidity. There was no difference in the prevalence of malnutrition between new and follow up patients (Table 3). The proportion of malnourished patients attending the OPD according to the indication for their appointment is shown in Fig. 3 and the prevalence of malnutrition according to the indication for the outpatient attendance is shown in Fig. 4. 11 out of 44 patients with cancer were malnourished compared to 75 out of 561 non-cancer patients (25% vs 13%, p < 0.05) attending the OPD (Fig. 5). Similarly, 38 out of 208 patients with IBD were malnourished compared to 48 out of 397 patients without an underlying diagnosis of IBD (18% vs 12% p < 0.05) attending the OPD (Fig. 5). 3.5. Characteristics of malnourished IBD outpatients 38 IBD patients, 13 with Crohn's disease (CD) and 25 with Ulcerative colitis (UC) were malnourished. The prevalence of malnutrition did not differ between CD (16%, 13/83) and UC (21%, 25/120) (p ¼ 0.35). The mean (SD) age, age at diagnosis and disease duration of all malnourished IBD patients, were 40 (17) years, 27 (15) years and 11 (10) years respectively. 11 (30%) patients had undergone previous intestinal surgery (6 colonic and 5 small bowel ± colonic resections), 4 (11%) previous perianal surgery, 2 (5.4%) had a short bowel and 4 (11%) had a stoma. 23 (62%) patients were on 5-ASAs, 11 (30%) were on steroids, 17 (46%) were on thiopurines and 3 (8.1%) were on anti-TNF. 27 (71%) of malnourished IBD patients and 61 (36%) of non malnourished IBD patients (p < 0.01) had active disease at the time of assessment according to the physician's assessment. Among the malnourished IBD patients, 12 (31.6%) had mildly active disease and 15 (39.5%) had moderately active disease. Among the non malnourished IBD patients, 30 (17.6%) had mildly active disease, 28 (16.5%) had moderately active disease and 3 (1.8%) had severely active disease.
Table 2 MUST score components of malnourished patients.
n BMI % Weight loss Referred to dietician n, (%)
Medium Risk (MUST ¼ 1)
High Risk (MUST 2)
61 23.2 (4.8) 5.0 (4.1) 19 (28)
25 20.1 (3.8) 7.0 (4.5) 15 (60)
4. Discussion This is the first study to report the prevalence of malnutrition among patients attending medical and surgical gastrointestinal outpatient clinics. In this study 14% of the patients were malnourished with IBD and cancer patients being at the highest risk. Among IBD patients, malnutrition was associated with extensive disease phenotypes and stricturing/penetrating behavior in CD. Active disease was present in more than 70% of malnourished IBD patients. It is notable that 61% of the malnourished patients were not referred to or seen by a dietitian. The prevalence of malnutrition in our cohort of patients is less than that reported in patients with COPD [9]. This may relate to the difference in the overall pre-morbid status of the patients included in each study. Our study includes a proportion of patients newly referred to the OPD without confirmed pathology and some patients with conditions (reflux disease, irritable bowel syndrome, anorectal disorders) that do not cause catabolism like COPD [10]. This is further supported by the fact that the prevalence of malnutrition among IBD and cancer patients attending these clinics is comparable to that reported in COPD patients highlighting the impact of an underlying pro-inflammatory pathophysiology on a patients' nutritional status. The use of anti-TNF agents in our IBD patients is relatively low, as in the UK IBD patients are treated with a step-up approach, with immunosuppressive treatment being used prior to anti-TNFs according to the guidelines of the National Institute of Clinical Excellence [11]. The prevalence of malnutrition among patients with Crohn's disease has been previously reported between 45% [12] and 59% [13] and is related to disease activity. Among oncology patients malnutrition has been reported as high as 71% according to their MUST score [14] however, this estimate is based on patients attending oncology outpatients who are more likely to have more advanced malignancies, longer disease durations and may be undergoing chemotherapy (which itself may reduce calorific intake) [15]. Our lower rates of malnutrition among IBD and cancer patients are probably relevant to the fact that dietetics are an integral part of the IBD team ensuring easy access and early intervention when malnutrition is identified. Also, patients with advanced malignancies would be under the care of oncology and palliative care, rather than gastroenterology. Even in the setting of medical and surgical gastrointestinal OPD, malnutrition and its importance has been under-recognized as the majority of patients were not referred to the dietitian. A recent survey among gastroenterologists documented that only 41% of gastroenterologists are confident about their skills in IBD nutrition and only a third of them routinely screen their patients' nutritional status [16]. This study has several strengths. It has been conducted prospectively, using a validated tool in consecutive patients attending the outpatient department limiting the possibility of selection bias. In order to eliminate tertiary centre bias we included patients
Please cite this article as: Kamperidis N et al., Prevalence of malnutrition in medical and surgical gastrointestinal outpatients, Clinical Nutrition ESPEN, https://doi.org/10.1016/j.clnesp.2019.10.002
N. Kamperidis et al. / Clinical Nutrition ESPEN xxx (xxxx) xxx
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Table 3 Demographic and disease characteristics of patients stratified by risk.
Age, Mean (SD) Male New appointment Previous surgery Comorbidity
Present Number of systems involved, Median (range)
Low Risk MUST ¼ 0 (n ¼ 519)
Medium/High Risk MUST 1 (n ¼ 86)
p value
55.0 (17.8) 248 (47.8) 128 (25.3) 192 (38.5) 184 (36.3) 0 (0, 5)
50.5 (20.6) 41 (47.7) 22 (25.6) 31 (36.0) 29 (33.7) 0 (0, 4)
0.04 0.54 0.53 0.38 0.37 0.36
Values represent n, (%) unless otherwise stated.
Fig. 3. Indication for review in the outpatient department.
attending both tertiary clinics and general medical and surgical gastrointestinal outpatient clinics in 3 hospitals. This study also has limitations. It is possible that our study underestimated the prevalence of malnutrition among outpatients. We studied only clinic attendees and there is a possibility that nonattendees (i.e. patients who were invited for a clinical review but did not attend their appointment) may be more likely to be malnourished. Also 33 labels were not completed. Secondly, although the BMI is a robust objective measure, the % weight loss was self-reported by 150/605 patients (25%) and it is possible that this may have been intentionally or not, over or under reported. Finally, the inclusion of patients attending home parenteral nutrition (HPN) or complex nutritional clinics may pose a degree of interpretation bias. However, only ten such patients were included.
Fig. 5. Malnutrition is more prevalent among patients with IBD and cancer. (The numbers in the columns represent the proportions of patients of each group in absolute numbers).
Knowledge about malnutrition among medical staff is poor [17] but improving as teaching about malnutrition and its consequences is now incorporated into the undergraduate and postgraduate medical curriculums. The recognition, prevention and treatment of malnutrition do not fit solely into any one specialty because malnutrition does affect the outcome of patients in all specialties. As the gut is responsible for digestion and absorption of nutrients and as gastroenterologists commonly insert enteral tubes they have in most hospitals taken the lead in providing appropriate safe nutritional support. As the treatment of malnutrition is beneficial and results in a shorter hospital stay, lower intensity nursing and fewer complications [18] the detection and treatment of malnutrition is vital in obtaining good outcomes from hospital admissions. In conclusion, this study shows that malnutrition is prevalent (14%) among the outpatients attending the medical and surgical gastrointestinal outpatient department. Unfortunately, the treating physicians or surgeons frequently fail to recognize or act upon it. The identification of risk factors associated with outpatient malnutrition (cancer and IBD) helps direct attention towards these patients who may benefit from dietetic assessment and advice including active nutritional support. Declaration of Competing Interest None. Acknowledgments
Fig. 4. The prevalence of malnutrition between different patient groups.
The study was designed by JN and LT and supervised by JN. PW, CT, KK, DR and LT collected the data for the study. NK analyzed the
Please cite this article as: Kamperidis N et al., Prevalence of malnutrition in medical and surgical gastrointestinal outpatients, Clinical Nutrition ESPEN, https://doi.org/10.1016/j.clnesp.2019.10.002
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data and prepared the manuscript. No grants or funding were received for this work. References [1] NICE. Quality standard for nutrition support in adults. 2012. [2] collaborators, C.A.R.a.M.E.o.b.o.B.a.. Nutrition screening surveys in hospitals in the UK, 2007e2011. A report based on the amalgamated data from the four Nutrition Screening Week surveys undertaken by BAPEN in 2007, 2008, 2010 and 2011. 2014. [3] Stroud M, Duncan H, Nightingale J. Guidelines for enteral feeding in adult hospital patients. Gut 2003;52(Suppl 7):vii1e12. [4] Felder S, Lechtenboehmer C, Bally M, Fehr R, Deiss M, Faessier L, et al. Association of nutritional risk and adverse medical outcomes across different medical inpatient populations. Nutrition 2015;31(11e12):1385e93. [5] Todorovic V, Russell C, Elia M. The MUST explanatory booklet. A guide to the Malnutrition Universal Screening Tool (MUST) for adults. BAPEN; 2011. [6] Russell CA, Elia M. Nutrition screening surveys in hospitals in the UK, 2007e2011. A report based on the amalgamated data from the four Nutrition Screening Week surveys undertaken by BAPEN in 2007, 2008, 2010 and 2011. 2014. [7] Nightingale JM, Walsh N, Bullock ME, Wicks AC. Three simple methods of detecting malnutrition on medical wards. J R Soc Med 1996;89(3):144e8. [8] Middleton MH, Nazarenko G, Nivison-Smith I, Smerdely P. Prevalence of malnutrition and 12-month incidence of mortality in two Sydney teaching hospitals. Intern Med J 2001;31(8):455e61. [9] Collins PF, Elia M, Kurukulaaratchy RJ, Stratton RJ. The influence of deprivation on malnutrition risk in outpatients with chronic obstructive pulmonary disease (COPD). Clin Nutr 2018;37(1):144e8.
[10] Sanders KJ, Kneppers AE, Van de Bool C, Langen RC, Schols AM. Cachexia in chronic obstructive pulmonary disease: new insights and therapeutic perspective. J Cachexia Sarcopenia Muscle 2016;7(1):5e22. [11] Excellence, N.N.I.o.C. Infliximab and Adalimumab for the treatment of Crohn's disease. 2010. [12] Sandhu A, Mosli M, Yan B, Wu T, Gregor J, Chande N, et al. Self-screening for malnutrition risk in outpatient inflammatory bowel disease patients using the malnutrition universal screening tool (MUST). JPEN J Parenter Enteral Nutr 2016;40(4):507e10. [13] Vadan R, Gheorghe LS, Constantinescu A, Gheorghe C. The prevalence of malnutrition and the evolution of nutritional status in patients with moderate to severe forms of Crohn’s disease treated with Infliximab. Clin Nutr 2011;30(1):86e91. [14] Shaw C, Fleuret C, Pickard JM, Mohammed K, Black G, Wedlake L. Comparison of a novel, simple nutrition screening tool for adult oncology inpatients and the Malnutrition Screening Tool (MST) against the Patient-Generated Subjective Global Assessment (PG-SGA). Support Care Cancer 2015;23(1):47e54. [15] de Vries JHM, de Vries YC, Van Den Berg MMGA, Boesveldt S, de Kruif JTCM, Buist N, et al. Differences in dietary intake during chemotherapy in breast cancer patients compared to women without cancer. Support Care Cancer; 2017. [16] Tinsley A, Ehrlich OG, Hwang C, Issokson K, Zapala S, Weaver A, et al. Knowledge, attitudes, and beliefs regarding the role of nutrition in IBD among patients and providers. Inflamm Bowel Dis 2016;22(10):2474e81. [17] Nightingale JM, Reeves J. Knowledge about the assessment and management of undernutrition: a pilot questionnaire in a UK teaching hospital. Clin Nutr 1999;18(1):23e7. [18] Excellence, N.I.o.C.. Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition. 2006.
Please cite this article as: Kamperidis N et al., Prevalence of malnutrition in medical and surgical gastrointestinal outpatients, Clinical Nutrition ESPEN, https://doi.org/10.1016/j.clnesp.2019.10.002
Contents lists available at ScienceDirect
Clinical Nutrition ESPEN journal homepage: http://www.clinicalnutritionespen.com
Original article
Prevalence of malnutrition in medical and surgical gastrointestinal outpatients N. Kamperidis*, L. Tesser, P. Wolfson, C. Toms, K. Katechia, D. Robinson, J. Nightingale St Mark's Hospital, Harrow, Middlesex HA1 3UJ, UK
a r t i c l e i n f o
s u m m a r y
Article history: Received 27 January 2019 Accepted 2 October 2019
Background: UK NICE guidelines, state that patients attending an outpatient clinic for the first time, should be screened for malnutrition. Aims: To determine the prevalence of malnutrition in the medical and surgical gastroenterology outpatient department (OPD) using body mass index (BMI) and % weight loss (%WL) and to assess the physicians'/surgeons' response to malnutrition being detected. Methods: The BMI and the %WL were determined for every patient over a 2 week period before the clinician saw the patient. The BMI and %WL were scored as in the Malnutrition Universal Screening Tool (MUST). Results: 605 patients (316 females) of mean age 54 years were included. 150 (25%) were new patients. 519 (86%) had a normal BMI and %WL. 86 (14%) had a BMI <20 kg/m2 or had 5% WL. 61 (10%) were in MUST “medium risk” and 25 (4%) were in MUST “high risk” of malnutrition. 15 (60%) of the “high risk” patients were under the care of or had been referred to a dietitian compared to 19 (28%) of “medium risk” patients. The prevalence of malnutrition was independent of sex, age, history of previous surgery or underlying comorbidities. There was no difference in the prevalence of malnutrition between new and follow up patients. Malnutrition was more common in patients with IBD (38, 18%) vs non-IBD (48, 12%) and patients with cancer (11, 25%) vs non cancer (75, 13%) (p < 0.05). Conclusions: The prevalence of malnutrition in medical and surgical gastrointestinal outpatients was 14%. IBD and cancer patients had the highest prevalence. Most patients with malnutrition (52, 61%) were not being seen by a dietitian. © 2019 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd. All rights reserved.
Keywords: Malnutrition Outpatients Inflammatory bowel disease MUST
1. Introduction Malnutrition is both a cause and effect of ill health [1] and affects up to 34% of hospital inpatients [2]. Malnutrition affects all the systems in the body and causes multiple problems including impaired immune function (infections are more common and more severe), impaired wound healing (surgical wounds are less likely to heal and may become infected), impaired muscular strength (so the risk of chest infections, DVT and pressure sores may increase) and impaired cerebral function (poor concentration, depression, excessive sleep) [3]. Malnourished patients have a high risk of medical complications, a longer hospital stay with more
* Corresponding author. St Mark's Hospital, Watford Road, Harrow, Middlesex HA1 3UJ, UK. E-mail address: [email protected] (N. Kamperidis).
complications; they are more likely to be readmitted after discharge and have an 8 fold increase in mortality irrespective of pre-morbid status [4]. In order to improve the healthcare professionals' awareness and ensure that patients at risk of malnutrition are identified early during their clinical course, a simple scoring system, the Malnutrition Universal Screening Tool (MUST) was developed [5]. The MUST score risk stratifies the patients according to body mass index (BMI), % weight loss and an acute disease effect [5]. The incidence of malnutrition in patients admitted to hospital from the large UK BAPEN surveys is 29% [6] while the prevalence of malnutrition among medical inpatients has been reported as 35% according to BMI, % of weight loss or mid-arm circumference [7,8]. However, in the outpatient setting, the prevalence of malnutrition has been less extensively reported. A recent study, estimated that up to 22% of outpatients with COPD were malnourished [9]. There is little data about the prevalence of malnutrition in medical or
https://doi.org/10.1016/j.clnesp.2019.10.002 2405-4577/© 2019 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd. All rights reserved.
Please cite this article as: Kamperidis N et al., Prevalence of malnutrition in medical and surgical gastrointestinal outpatients, Clinical Nutrition ESPEN, https://doi.org/10.1016/j.clnesp.2019.10.002
2
N. Kamperidis et al. / Clinical Nutrition ESPEN xxx (xxxx) xxx
surgical gastrointestinal clinics even though it can significantly influence patient outcomes. In the UK, the guidelines of the National Institute for Health and Care Excellence (NICE) state in their ‘key priorities for implementation’ that ‘all outpatients at their first clinic appointment should be screened’ for malnutrition and this should be repeated ‘when there is clinical concern’ [1]. In this study we aimed to determine the prevalence of malnutrition in the outpatient department (OPD) of medical and surgical gastrointestinal clinics at St Mark's, Northwick Park and Central Middlesex Hospitals using body mass index (BMI) and % weight loss (%WL) as per MUST and to assess the physicians'/surgeons' response to malnutrition being detected. 2. Methods 2.1. Patients e Setting St Mark's, Northwick Park and Central Middlesex Hospitals provide outpatient care in their gastroenterology and gastrointestinal surgery outpatient clinics for 1.5 million adults living in Northwest London (Brent and Harrow). Additionally, St Mark's Hospital is a tertiary referral centre, accepting nationwide referrals mainly for patients with intestinal failure, Inflammatory Bowel Disease (IBD), functional bowel disorders and polyposis syndromes. All patients attending the medical and surgical gastrointestinal outpatient clinics of St Mark's, Northwick Park and Central Middlesex Hospitals over a random 2 week period were included in the study. 2.2. Assessments Prior to the study, the nursing staff working in the medical and surgical gastroenterology clinics across the Trust were trained to complete the nutritional screening. Posters of BMI charts, percentage weight loss charts and the agreed management guidelines were provided to the measurement rooms and clinic rooms on all sites. Consecutive patients (new and follow up patients) attending the outpatient clinic were screened for their risk of malnutrition. A specially printed yellow sticker was stuck into the patient's medical notes and the nutrition screening details and measurements were completed (Fig. 1). The yellow sticker included the following prompts: name, hospital number, date, current weight, weight 3e6 months ago, height, BMI, and % weight loss and MUST score. MUST is a five-step screening tool to identify adults who are malnourished or at risk of malnutrition. The individual steps are shown on Fig. 2. For the purpose of this study (making assessment quick), step 3 of MUST i.e. Acute Disease Effect score was omitted. The % weight loss was calculated according to the one documented on the previous clinical appointment for patients attending for a follow-up
PaƟents name Hospital number Date Current weight(kg): Weight 3 – 6 months ago(kg): Height(m): BMI(kg/m2): %weight loss: MUST score:
Fig. 1. Yellow sticker describing the nutrition screening details.
visit and was self-reported for patients attending for their first clinical review. Patients with a score of zero were classified as being at “low risk”, patients with a score of 1 as “medium risk” and patients with a score of 2 or more as “high risk”. Patients at medium risk (or above) were to be highlighted to the doctor and he/she could then refer the patient to a dietician. 2.3. Data collection Data on demographics (sex, age), disease specific characteristics (underlying condition necessitating the clinical appointment based on the conclusions after the clinical assessment, co-morbidities), appointment details (new or follow up patient) and the action taken by the reviewing physician or surgeon on the patients' nutritional status were collected retrospectively from the Electronic Clinical Information System (CIS) used by the Trust. The electronic system used by the dietitians, to record their activity was examined to determine if the patients identified as being at high or medium risk of malnutrition were seen by a Dietitian. 2.4. Ethical considerations Ethical approval was not sought as this project was an audit against the UK NICE standard. 2.5. Data analyses Continuous variables were expressed as mean (standard deviation of the mean) and qualitative variables were expressed as absolute number (% of the whole). Comparison of continuous variables between groups was performed using the student's t-test. Comparison of qualitative variables was performed using the chisquare test. All analyses were 2-tailed and a p value of less than 0.05 was considered as statistically significant. Statistical analyses were facilitated with the use of the Statistical Package for Social Sciences (SPSS version 16.0). All graphs presented in this paper were produced with the use of Graphpad Prism 6. 3. Results 3.1. Patients e Demographics During the study period 651 patients had the dedicated yellow stickers stuck into their medical notes. For 33 patients the sticker was uncompleted and 13 were found to be duplicates due to the patient having more than one OPD appointment during the study period. A total of 605 patients (289 (47.8%) male) were therefore taken as being included in the study, of whom 442 patients (73.1%) were attending for follow up appointments and 163 (26.9%) for an initial appointment. The mean (SD) age was 54.4 (18.3) years (Table 1). 3.2. Patients e Reason for consultation, co-morbidity From the patients attending the OPD, 208 (34%) had inflammatory bowel disease, 73 (12%) had anorectal issues, 54 (9%) upper GI symptoms or conditions, 44 (7%) cancer and 33 (6%) had liver disease (Table 1). 223 patients (37%) had previous abdominal surgery. 214 patients (35%) had co-morbidities: 107 (18%) cardiovascular, 91 (15%) endocrine, 45 (7%) musculoskeletal or connective tissue disorders, 38 (6%) respiratory, 21 (4%) non GI malignancies, 19 (3%) neurological and 10 (2%) psychiatric comorbidities.
Please cite this article as: Kamperidis N et al., Prevalence of malnutrition in medical and surgical gastrointestinal outpatients, Clinical Nutrition ESPEN, https://doi.org/10.1016/j.clnesp.2019.10.002
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Fig. 2. The Malnutrition Universal Screening Tool (MUST). This figure is reproduced here with the kind permission of the British Association for Parenteral and Enteral Nutrition (BAPEN).
3.3. Malnutrition 519 participants (86%) had a BMI 20 kg/m2 and %WL less than 5%. 86 (14%) had a BMI <20 kg/m2 or had 5% WL. 61 (10%) were in MUST “medium risk” of malnutrition with mean [SD] BMI and %WL
of 23.1 [4.8] and 5.0 [4.1] respectively. Of these, 33 (54%) had low BMI as per MUST and 28 (46%) had lost 5e10% of their body weight. 25 (4%) were in MUST “high risk” of malnutrition with mean [SD] BMI and %WL of 20.1 [3.8] and 7.0 [4.5] respectively. Of these, 10 (40%) scored both for %WL and BMI, 11 (44%) had lost more than
Please cite this article as: Kamperidis N et al., Prevalence of malnutrition in medical and surgical gastrointestinal outpatients, Clinical Nutrition ESPEN, https://doi.org/10.1016/j.clnesp.2019.10.002
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Table 1 Demographic and disease characteristics of patients included.
Age, Mean (SD) Male New appointment Inflammatory Bowel Disease Anorectal Upper GI Cancer Liver Disease
Low risk (n ¼ 519)
Medium risk (n ¼ 61)
High risk (n ¼ 25)
All (n ¼ 605)
p value
55.0 (17.8) 248 (47.8) 128 (25.3) 170 (32.8) 69 (13.3) 49 (9.4) 33 (6.4) 30 (5.8)
50.8 (22.0) 32 (52.5) 16 (26.2) 29 (47.5) 2 (3.3) 2 (3.3) 7 (11.5) 2 (3.3)
49.9 (17.3) 9 (36.0) 6 (24.0) 9 (36.0) 2 (8.0) 3 (12.0) 4 (16.0) 1 (4.0)
54.4 (18.3) 289 (47.8) 163 (26.9) 208 (34) 73 (12) 54 (9) 44 (7) 33 (6)
0.11 0.38 0.98 0.07 0.06 0.24 0.08 0.68
Values express n (%) unless otherwise stated. p values express differences between low, medium and high risk groups.
10% of their BW and 4 (16%) had a BMI of less than 18.5 (Table 2). 15 (60%) of the “high risk” were seen by a Trust Dietitian, compared to 19 (28%) of “medium risk” patients. 3.4. Risk factors associated with malnutrition The mean age of malnourished patients was lower than that of non-malnourished patients (50.5 vs 55.0 years, p ¼ 0.04) (Table 3). The prevalence of malnutrition was independent of sex, history of previous surgery and co-morbidity. There was no difference in the prevalence of malnutrition between new and follow up patients (Table 3). The proportion of malnourished patients attending the OPD according to the indication for their appointment is shown in Fig. 3 and the prevalence of malnutrition according to the indication for the outpatient attendance is shown in Fig. 4. 11 out of 44 patients with cancer were malnourished compared to 75 out of 561 non-cancer patients (25% vs 13%, p < 0.05) attending the OPD (Fig. 5). Similarly, 38 out of 208 patients with IBD were malnourished compared to 48 out of 397 patients without an underlying diagnosis of IBD (18% vs 12% p < 0.05) attending the OPD (Fig. 5). 3.5. Characteristics of malnourished IBD outpatients 38 IBD patients, 13 with Crohn's disease (CD) and 25 with Ulcerative colitis (UC) were malnourished. The prevalence of malnutrition did not differ between CD (16%, 13/83) and UC (21%, 25/120) (p ¼ 0.35). The mean (SD) age, age at diagnosis and disease duration of all malnourished IBD patients, were 40 (17) years, 27 (15) years and 11 (10) years respectively. 11 (30%) patients had undergone previous intestinal surgery (6 colonic and 5 small bowel ± colonic resections), 4 (11%) previous perianal surgery, 2 (5.4%) had a short bowel and 4 (11%) had a stoma. 23 (62%) patients were on 5-ASAs, 11 (30%) were on steroids, 17 (46%) were on thiopurines and 3 (8.1%) were on anti-TNF. 27 (71%) of malnourished IBD patients and 61 (36%) of non malnourished IBD patients (p < 0.01) had active disease at the time of assessment according to the physician's assessment. Among the malnourished IBD patients, 12 (31.6%) had mildly active disease and 15 (39.5%) had moderately active disease. Among the non malnourished IBD patients, 30 (17.6%) had mildly active disease, 28 (16.5%) had moderately active disease and 3 (1.8%) had severely active disease.
Table 2 MUST score components of malnourished patients.
n BMI % Weight loss Referred to dietician n, (%)
Medium Risk (MUST ¼ 1)
High Risk (MUST 2)
61 23.2 (4.8) 5.0 (4.1) 19 (28)
25 20.1 (3.8) 7.0 (4.5) 15 (60)
4. Discussion This is the first study to report the prevalence of malnutrition among patients attending medical and surgical gastrointestinal outpatient clinics. In this study 14% of the patients were malnourished with IBD and cancer patients being at the highest risk. Among IBD patients, malnutrition was associated with extensive disease phenotypes and stricturing/penetrating behavior in CD. Active disease was present in more than 70% of malnourished IBD patients. It is notable that 61% of the malnourished patients were not referred to or seen by a dietitian. The prevalence of malnutrition in our cohort of patients is less than that reported in patients with COPD [9]. This may relate to the difference in the overall pre-morbid status of the patients included in each study. Our study includes a proportion of patients newly referred to the OPD without confirmed pathology and some patients with conditions (reflux disease, irritable bowel syndrome, anorectal disorders) that do not cause catabolism like COPD [10]. This is further supported by the fact that the prevalence of malnutrition among IBD and cancer patients attending these clinics is comparable to that reported in COPD patients highlighting the impact of an underlying pro-inflammatory pathophysiology on a patients' nutritional status. The use of anti-TNF agents in our IBD patients is relatively low, as in the UK IBD patients are treated with a step-up approach, with immunosuppressive treatment being used prior to anti-TNFs according to the guidelines of the National Institute of Clinical Excellence [11]. The prevalence of malnutrition among patients with Crohn's disease has been previously reported between 45% [12] and 59% [13] and is related to disease activity. Among oncology patients malnutrition has been reported as high as 71% according to their MUST score [14] however, this estimate is based on patients attending oncology outpatients who are more likely to have more advanced malignancies, longer disease durations and may be undergoing chemotherapy (which itself may reduce calorific intake) [15]. Our lower rates of malnutrition among IBD and cancer patients are probably relevant to the fact that dietetics are an integral part of the IBD team ensuring easy access and early intervention when malnutrition is identified. Also, patients with advanced malignancies would be under the care of oncology and palliative care, rather than gastroenterology. Even in the setting of medical and surgical gastrointestinal OPD, malnutrition and its importance has been under-recognized as the majority of patients were not referred to the dietitian. A recent survey among gastroenterologists documented that only 41% of gastroenterologists are confident about their skills in IBD nutrition and only a third of them routinely screen their patients' nutritional status [16]. This study has several strengths. It has been conducted prospectively, using a validated tool in consecutive patients attending the outpatient department limiting the possibility of selection bias. In order to eliminate tertiary centre bias we included patients
Please cite this article as: Kamperidis N et al., Prevalence of malnutrition in medical and surgical gastrointestinal outpatients, Clinical Nutrition ESPEN, https://doi.org/10.1016/j.clnesp.2019.10.002
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Table 3 Demographic and disease characteristics of patients stratified by risk.
Age, Mean (SD) Male New appointment Previous surgery Comorbidity
Present Number of systems involved, Median (range)
Low Risk MUST ¼ 0 (n ¼ 519)
Medium/High Risk MUST 1 (n ¼ 86)
p value
55.0 (17.8) 248 (47.8) 128 (25.3) 192 (38.5) 184 (36.3) 0 (0, 5)
50.5 (20.6) 41 (47.7) 22 (25.6) 31 (36.0) 29 (33.7) 0 (0, 4)
0.04 0.54 0.53 0.38 0.37 0.36
Values represent n, (%) unless otherwise stated.
Fig. 3. Indication for review in the outpatient department.
attending both tertiary clinics and general medical and surgical gastrointestinal outpatient clinics in 3 hospitals. This study also has limitations. It is possible that our study underestimated the prevalence of malnutrition among outpatients. We studied only clinic attendees and there is a possibility that nonattendees (i.e. patients who were invited for a clinical review but did not attend their appointment) may be more likely to be malnourished. Also 33 labels were not completed. Secondly, although the BMI is a robust objective measure, the % weight loss was self-reported by 150/605 patients (25%) and it is possible that this may have been intentionally or not, over or under reported. Finally, the inclusion of patients attending home parenteral nutrition (HPN) or complex nutritional clinics may pose a degree of interpretation bias. However, only ten such patients were included.
Fig. 5. Malnutrition is more prevalent among patients with IBD and cancer. (The numbers in the columns represent the proportions of patients of each group in absolute numbers).
Knowledge about malnutrition among medical staff is poor [17] but improving as teaching about malnutrition and its consequences is now incorporated into the undergraduate and postgraduate medical curriculums. The recognition, prevention and treatment of malnutrition do not fit solely into any one specialty because malnutrition does affect the outcome of patients in all specialties. As the gut is responsible for digestion and absorption of nutrients and as gastroenterologists commonly insert enteral tubes they have in most hospitals taken the lead in providing appropriate safe nutritional support. As the treatment of malnutrition is beneficial and results in a shorter hospital stay, lower intensity nursing and fewer complications [18] the detection and treatment of malnutrition is vital in obtaining good outcomes from hospital admissions. In conclusion, this study shows that malnutrition is prevalent (14%) among the outpatients attending the medical and surgical gastrointestinal outpatient department. Unfortunately, the treating physicians or surgeons frequently fail to recognize or act upon it. The identification of risk factors associated with outpatient malnutrition (cancer and IBD) helps direct attention towards these patients who may benefit from dietetic assessment and advice including active nutritional support. Declaration of Competing Interest None. Acknowledgments
Fig. 4. The prevalence of malnutrition between different patient groups.
The study was designed by JN and LT and supervised by JN. PW, CT, KK, DR and LT collected the data for the study. NK analyzed the
Please cite this article as: Kamperidis N et al., Prevalence of malnutrition in medical and surgical gastrointestinal outpatients, Clinical Nutrition ESPEN, https://doi.org/10.1016/j.clnesp.2019.10.002
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Please cite this article as: Kamperidis N et al., Prevalence of malnutrition in medical and surgical gastrointestinal outpatients, Clinical Nutrition ESPEN, https://doi.org/10.1016/j.clnesp.2019.10.002