© Borgis - Postępy Nauk Medycznych 12/2012, s. 971-976
*Mirosław Jarosz, Jan Dzieniszewski, Ewa Rychlik
Niedożywienie szpitalne – ważny problem zdrowotny i ekonomiczny
Hospital malnutrition – important health and economic problem
Department of Nutrition and Dietetics with Clinic of Metabolic Diseases and Gastroenterology, National Food and Nutrition Institute, Warsaw
Head of Department: prof. Mirosław Jarosz, MD, PhD
Stan odżywienia pacjentów w szpitalach ma istotny wpływ na skuteczność leczenia, występowanie powikłań, długość hospitalizacji i koszty leczenia. Dlatego też niezmiernie ważna jest właściwa ocena stanu odżywienia pacjentów przyjmowanych do szpitali i na jej podstawie zastosowanie odpowiedniego sposobu żywienia. Pozwala to na skrócenie czasu gojenia się ran, zmniejszenie ryzyka rozwoju szpitalnego zapalenia płuc, zmniejszenie okresu hospitalizacji oraz zmniejszenie nawet o 30-50% całkowitych kosztów leczenia. Tymczasem, jak wskazują wyniki badań antropometrycznych oraz biochemicznych, objawy niedożywienia występują u 40-50% pacjentów przyjmowanych do szpitali. Co więcej, u dużego odsetka chorych objawy niedożywienia rozwijają się lub pogłębiają w czasie pobytu w szpitalu.
Nutritional status of patients in hospitals has a significant impact on the effectiveness of treatment, the incidence of complications, length of hospital stay and cost of treatment. Therefore an appropriate assessment of the nutritional status of patients admitted to hospitals is extremely important as well as a suitable diet applied on the basis of this assessment.
This procedure reduces wound healing time, decreases the risk of hospital-acquired pneumonia, reduces the period of hospitalization and reduces the total costs of treatment by 30-50%. However, as the anthropometric and biochemical studies show, symptoms of malnutrition are found in approximately 40-50% of patients admitted to hospitals. Moreover, symptoms of malnutrition develop or intensify during hospital stay in a large proportion of patients.
HOSPITAL MALNUTRITION – SCALE OF THE PHENOMENON
In the past decades hospital malnutrition has become a subject of numerous epidemiological and clinical studies. This is due to the fact that a considerable part of patients admitted to hospitals manifest clinical or biochemical symptoms of malnutrition (1, 2). In many patients the symptoms of malnutrition, ascertained while being admitted to hospital, become intensified in the hospitalisation period. Besides as the stay in hospital increases, the occurrence frequency of malnutrition tends to grow as well (3, 4). It was found that malnutrition in patients tends to increase the morbidity, prolongs the required stay in hospital, and also increases treatment costs (5, 6).
In Poland tests of the nutritional status of the patients staying in hospitals were undertaken under a Commissioned Research Project Development of the scientific basis for nutrition in hospitals, which was oriented at evaluating the hospitalisation influence on the nutritional status (2, 7). The research was of a multi-centred, prospective and randomised nature. It was performed in 16 Polish hospitals, in clinics or internal medicine, general surgery, otolaryngological, gynaecology, ophthalmology and neurology wards.
The tests were performed on each tenth patient admitted to particular clinics or wards in the period from 01.01.1999 to 31.12.2000 (2, 7). The tests comprised 3256 patients aged 16 to 100, including 1368 males (average age: 54 years) and 1888 females (average age: 53 years). For each patient qualified for testing, in the first 24 hours after admission an assessment was carried out of the nutritional status, and with regard to persons after surgery – also on the date of discharge from the hospital. On the other hand, as regards persons who did not undergo surgery the nutritional status testing was carried out during discharge only if they stayed in the hospital longer than 10 days. The evaluation of the nutritional status at discharge from hospital was carried out on 2673 patients. The nutritional status was evaluated with the use of anthropometric methods (Body Mass Index – BMI (kg/m2); arm circumference (cm)) and biochemical methods (red cells count (million/mm3), haemoglobin concentration (g/dl), white cells count (x103/mm3), lymphocyte count in peripheral blood (x103/mm3), and albumin concentration in blood serum (g/dl)). In in-depth tests on the nutritional status several biochemical tests were carried out, which comprised the determination of levels of antioxidant vitamins (A, E, C), B12 vitamin and folic acid in blood serum.
In patients for which the tests were carried out twice, it was found that during the stay in hospital a weight loss took place and consequently also the reduction of BMI, and arm circumference was reduced (2). In the tested blood the concentration of haemoglobin and albumins was reduced, and also the red cells count. Changes in the average lymphocyte count were not significant statistically.
The existence of a correlation was proven between the lengh of hospital stay and a change of certain nutritional indices (2, 7). As the number of days spent in hospital increased, a reduction of weight, BMI and arm circumference was noted (p < 0.05).
In a part of the patients the malnutrition risk was ascertained already during admittance to the hospital (tab. 1) (2). The value of BMI suggesting the possibility of protein-energy malnutrition was recorded in 4.2% of males and 4.4% of females. A decrease of lymphocytes count was recorded in the blood of 20% of males and 21.7% of females, and a deficient albumin concentration in the blood serum was noted in 23.1% of males and 18.6% of females. At discharge the percentage of persons with underweight was slightly higher, especially among males, nevertheless the differences were not of statistical significance. On the other hand, the percentage of patients, in which deficient albumin concentration was recorded, was significantly higher.
Table 1. Percentage of patients in which values of selected indices at admittance and discharge from hospital pointed to the risk of malnutrition.
|At admittance||At discharge||At admittance||At discharge|
|BMI (< 18.5 kg/m2)||1368||4.2||1064||5.5||1888||4.4||1594||4.5|
|lymphocyte count (< 1.5 x 103/mm3)||1365||20.0||715||19.0||1867||21.7||910||22.4|
|albumin concentration (< 3.5 g/dl)||1348||23.1||684||30.6*||1865||18.6||894||27.1*|
N – number of patients in which the given indicator was tested.
*Statistically significant differences in patients tested at admittance to and discharge from hospital (p < 0.05; test of difference between two structure indices).
The percentage of persons, in which at least one of the above parameters pointed to the risk of malnutrition, amounted to 39.5% among males and 37.9% among females at admittance to hospital and to 43.9% and 44.1% respectively at discharge (2).
Weight loss during hospital stay was recorded in 60.9% of patients (2). On average it equalled to 2.1% of weight measured at the time of admittance. This reduction also concerned other persons characterised by underweight, and tended to intensify during hospitalisation. This concerned 42.6% of patients from this subgroup, and their weight decreased on average by 2.6%.
In the majority of cases the risk of vitamin malnutrition concerned vitamin C and folic acid (2). At admittance to hospital the deficit concentrations of those vitamins were recorded in 51.8% and 32% respectively of patients qualified for in-depth study. At discharge from hospital those percentages grew insignificantly (lack of statistical significance): for vitamin C to 67.7% and for folic acid to 40%.
The BMI correlates relatively well with other health state indices. In the analysed tests the interpretation proposed by WHO was adopted, according to which values of BMI < 18.5 kg/m2 point to the risk of malnutrition (8). In the tested patient group BMI was clearly lower at discharge from hospital (2). Moreover, a strong interdependency was found to exist between the lengh of hospital stay and BMI reduction. The percentage of underweight persons already during admittance to hospital was higher in the general population, especially in older age groups (2, 9). During hospitalisation it even increased slightly (2).
During hospital stay arm circumference, another indicator of the protein-energy nutritional status decreased (2). The longer was the hospitalisation, the greater was the decrease in arm circumference.
The haemoglobin concentration is considered to be the most useful indicator in screening used to allow an evaluation of iron deficiency anaemia and an assessment of the nutritional status (7, 8). However, its values depend on the age of the tested persons, their gender and race and tend to change clearly during pregnancy. The haemoglobin concentration among tested patients during their stay in hospital clearly decreased (2).
In malnutrition the lymphocyte count in peripheral blood decreases (7, 8). The total lymphocyte count equalling to 1.5 x 103/mm3 is considered to be correct. Values ranging between 0.9-1.5 x 103/mm3 may indicate moderate nutritional disorders, while values below 0.9 x 103/mm3 – severe malnutrition. However, the number of lymphocytes depends on numerous factors, such as septic states, stress, the administration of adrenal steroids, as well as coexistent infections. The evaluation of the total count of lymphocytes is a good measure of the immunity of the body and may only be used as an indirect measure of the nutrition status. A considerable part (ca. 20%) of tested patients was characterised by an insufficient lymphocyte count (2). Neither the average number of lymphocytes nor the percentage of patients in which it remained below the recommended values underwent substantial changes during the stay in hospital.
A frequently used index of the protein nutritional status are blood albumins (7, 8). There are many factors that affect the concentration of albumins in the blood serum, such as hepatic diseases, hypothyroidism (impaired production), diseases of the gastrointestinal tract and the kidneys (intensified albumins loss), injuries, stress, infections (change in the distribution of white cells in particular sections of the body), pregnancy (by dilution), in dehydration states (haemoconcentration). The albumin concentration of 3.5 g/dl was found to be the lowest admissible one, which can be accepted as being correct, while values ranging between 2.8-3.5 g/dl indicate to the possibility of protein malnutrition, and below 2.8 g/dl point to severe protein malnutrition. During hospitalisation the average concentration of albumins in the blood serum of the patients decreased considerably, and simultaneously quite a clear increase was recorded (by ca. 8 percentage points) of the percentage of patients, in whom this concentration was deficit (2).
Similar observations concerning the anthropometric indices of the nutritional status were made in patients admitted to one of the university hospitals in Scotland at the beginning of the nineties (3). The studied persons were characterised by an inferior nutritional status already at their admittance to the hospital as compared to the general population. Moreover, at the time of admission 39% of the group of patients with a correct weight had a lower weight during discharge, while in the group of underweight patients it became reduced in as much as 75%.
Among patients of 9 Swedish hospitals, who were studied in 2007, the risk of malnutrition (defined on the basis of low BMI, weight loss and improper nutrition) occurred in 22-34% of patients, and was the highest in the largest facilities (10).
Tests performed in 2006 in one of the Brazilian hospitals pointed to an extremely difficult situation (11). On the basis of the “Mini Nutritional Assessment” (MNA) malnutrition was recorded in 29.1% of elderly persons, and the risk of malnutrition in 37.1%.
In research related to the nutritional status of patients in Polish hospitals studies extended by biochemical indices were carried out, the objective of which was to allow discovering specific states of malnutrition (2). Very low vitamin concentration (with the exception of vitamin E) occurred with a similar frequency both in underweight patients, as well as with the normal weight, overweight and obesity. This implies that the risk of deficiency of many vitamins and minerals concerns not only underweight patients, but in many cases also those with the normal weight or overweight. The high percentage of patients with lower vitamin concentrations in the blood serum in hospitals than values considered to be correct may be connected not only with the disease, but may also reflect the relatively low intake of those vitamins.
A characteristic phenomenon for Polish hospitals is additional alimentation of patients by their families, as a large part of the patients declared supplementary alimentation apart from the hospital meals. However, in both patient groups, i.e. one obtaining additional food and the one that obtained no additional food, a similar trend was recorded of a reduction taking place of the tested indices of the nutritional status during the stay in hospital (2, 7).
The conducted research has shown that in Poland in more than 4% of patients admitted to various rank hospitals underweight was recorded (2). Reduced values of biochemical indices, indicating the impaired nutritional status (the concentration of albumins in the blood serum, the lymphocyte count in peripheral blood), occur in ca. 20% of persons admitted to hospitals. On the other hand, taking into consideration the above analysed parameters, it was found that at least one of them occurs in almost 40% of patients admitted to hospitals. The percentage of patients characterised by the risk of malnutrition becomes considerably intensified if one takes into account results of in-depth studies. The risk of vitamin malnutrition is recorded in more than half the patients admitted to hospitals, and the most frequent deficiencies concern vitamin C and folic acid.
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