AMONG HOSPITALIZED GASTROENTEROLOGICAL PATIENTS

Background / Aims. Risk factors for malnutrition of patients during hospitalization have not been precisely determined. The aim of the study was to determine these factors in hospitalized gastroenterological patients. Methods . Nutritional status (NS) of 650 gastroenterological patients was assessed on admission and at discharge by the six parameters: unintentional weight loss, lymphocyte counts, serum albumin concentration, body mass index, triceps skinfold thickness and mid-upper arm muscle circumference. The influence on NS at discharge was tested for ten factors: gender, age, affected organ, the nature, severity and complications of the disease, the lenght of hospitalization, mobility worsening during hospitalization, Karnofsky score and NS on admission. Primary and secondary risk factors were defined among the factors influencing significantly the malnutrition. Results . Seven factors were found to be the independent predictors for malnutrition in hospitalized gastroenterological patients. NS on admission was considered as primary risk factor (Forwald: Wald multivariate logistic regression analysis, p<0.001 for five applied assessment parameters). The other factors, obtained in the evaluation according to 1-3 parameters, were considered as secondary risk factors: severe disease activity, malignancy, the existence of complications, male gender, hospitalization >14 days, and mobility worsening during the hospitalization (Forwald:Wald multivariate logistic regression analysis, p from 0.001 to 0.027). Conclusion . There are seven risk factors for malnutrition among gastroenterological patients during hospitalization. Timely nutritional support in these patients can prevent the development of intrahospital malnutrition and its negative influence on clinical outcome.


INTRODUCTION
Malnutrition is a serious health problem that affect more than 20% patients on hospital admission. [1][2][3] It significantly contributes to the many adverse outcomes, such as cardiovascular and infective complications, increased morbidity and mortality, prolonged hospitalization, increased hospitalization costs and increased re-admission rates after discharge from the hospital. [4][5][6][7][8] Although these consequences of poor nutritional status are well known, malnutrition is often undiagnosed on hospital admission. Furthermore, some patients have deterioration of the nutritional status and become malnourished during hospitalization, regardless of their initial nutritional status, but this change often remains unrecognized by the medical staff. 7,9,10 If we keep in mind that malnutrition can potentially be prevented and treated, identification and definition of risk factors for malnutrition is of particular interest. Many studies investigated the risk factors for malnutrition among the patients on hospital admission. 1,[11][12][13] However, there is a lack of data regarding the prevalence and risk factors for malnutrition during hospitalization. Some authors highlight gender, age, malignant tumors, reduced food intake, prolonged therapeutic fasting, as factors associated with malnutrition, but the significance of these factors has not been precisely determined. 14,15 This study presents our experience with risk factors for malnutrition among hospitalized gastroenterological patients. As well, information is presented how to recognize a risky patient who is a candidate for nutritional intervention..

Study design and patient population.
A prospective study included 650 gastroenterological patients, treated in our clinic during a fifteen months period. The criteria on inclusion were: age of eighteen years or more, admission Karnofsky score > 40 and length of hospital stay for at least seven days. The study protocol was approved by the local Ethics Committee, and each patient gave written informed consent before entering the study. NSAPs were qualified as the primary, while those that have been obtained by estimation according to the 1-3 NSAPs were qualified as the secondary risk factors.

Statistical analysis..
Statistical analysis was performed using SPSS 11.5 for Windows software (SPSS, Inc., Chicago, IL), and p value of < 0.05 was considered to be statistically significant. The Student's t-test for parametric data, and the Mann-Whitney U-test for categorical data, were performed to compare characteristics between two groups. Correlation between two variables was tested by binary logistic analysis. Prediction of malnutrition at discharge was determined using Forwald: Wald multivariate logistic regression analysis. • Mobility worsening during the hospital stay. Malnutrition at discharge was significantly more common in the patients with mobility worsening during the hospital stay than in the patients without mobility worsening. The differences were not statistically significant only if the assessment parameters was TSF (Binary logistic analysis p>0.05).

Characteristics
• Karnofsky score on admission. The average Karnofsky score on admission and at discharge was always significantly lower in patients who were malnourished at discharge (Mann Whitney test; p<0,001). Regardless of the NSAP applied, malnutrition at discharge was significantly more common in the patients with admission Karnofsky score  80, than in the patients with admission Karnofsky score >80 (Binary logistic analysis; p0.001).
•Nutritional status on admission. Malnutrition at discharge was more common in the patients who were malnourished on admission, than in the patients who were non-malnourished on admission. These differences were not statistically significant only, if the assessment parameters was WL(Binary logistic analysis p>0.05).

Risk factors for malnutrition during hospitalization.
There are 9 factors that may influence NS during hospitalization (

Risk factors for malnutritionon during hospitalization
Gender and age. According to our results, male gender is a secondary risk factor for malnutrition during hospitalization. This is in accordance with the results obtained by the other authors. 14,19,20 The result of our study could be explained by the higher prevalence of malignancies among men and greater weight loss in men than in women during hospitalization. Although malnutrition often accompanies older age, and older patients are at increased risk for malnutrition at both, admission and discharge, 8,21-23 in our patients average age was similar for malnourished and non-malnourished patients at discharge. In the study of Kang, malnutrition was higher in the patients over 70 years, while Zhu showed that malnutrition at discharge was significantly higher at age 65 and older. 2,3 The difference in results between our and the other studies is probably related to the specificity of our series, which consisted of gastroenterological patients only, while most other studies included patients with various internal and neurological diseases.
Affected organ. Generally, in the patients with gastroenterological diseases, the prevalence and the risk of hospital malnutrition is higher than in patients with other diseases, due to impaired digestion and absorption, loss of appetite, prolonged therapeutic fasting and increased nutritional requirements. [24][25][26][27] Following the changes in the nutritional status of his patients, Cui found a significant reduction in the body weight and calf circumference in the patients with benign digestive tract disease at their discharge from the hospital. 15 In our study malnutrition was more common in the patients with intestinal disease and LBD disease, probably due to the higher prevalence of malignant diseases in these patients, but they were not found to be independent predictors for malnutrition during hospitalization.
This result is similar to the results of some other studies. [28][29][30] Severe disease activity and malignant disease. In our series severe disease activity and malignancy were secondary risk factors for malnutrition among hospitalized patients.
Severe disease activity is thought to cause increased nutritional requirements due to stress metabolism. [31][32] Therefore, many authors agree that the risk of intrahospital malnutrition correlates with the severity of the disease and that malnutrition is more pronounced in advanced stages of the disease. 13,29,33,34 There is no doubt regarding the association between malignant disease and nutritional status. It is known that numerous metabolic disorders and negative energy balance in malignancies lead to malnutrition and cachexia. 35,36 According to the results of other studies, the prevalence of hospital malnutrition is high in oncology patients. 22,37,38 Pirlih pointed to malignancy as one of three independent predictors of malnutrition on hospital admission. 39 However, in the current literature, association between malignant disease and malnutrition during hospitalization has been less studied.
We found that malignancy is risk factor for malnutrition during hospitalization. Similar results were published by some other authors. 15,40 An interesting result of Panella is that nutritional status is not associated with the stage of malignancy. 41 Complications of the disease. In our patients the presence of complications was a secondary risk factor for malnutrition during hospitalization. There is evidence in the literature that most of these conditions are characterized by hypermetabolism, due to the action of proinflammatory cytokines. 42,43 Unlike many clinical and epidemiological studies, that define malnutrition as a risk factor for infection and poor outcome, [44][45][46] studies that define clinical complications as a risk factor for malnutrition are rare. Pinchcofsky and Kinyoki considered persistent fever a risk factor for deteriorating nutritional status of adult hospitalized patients and children under the age of 5 years respectively. 47,48 The results of some studies indicate that the presence of infection adversely affects nutritional satatus in surgical and nonsurgical patients. 14,37,49 The lenght of hospitalization. Most authors agree that prolonging hospitalization increases the risk of malnutrition. 49,50,51 In his study Pinchcofsky found significant decreases in nutritional parameters after three weeks of hospitalisation. 47 Weinsier demonstrated that hospitalization longer than 14 days was critical for the onset of malnutrition. 52 This is the result obtained in our series also. The authors consider that patients during hospitalization have higher nutrient needs and lower apetite due to inflammatory processes associated with the disease. 53 Mobility worsening during the hospital stay. Although recommended in various tests for initial nutritional status screening, mobility worsening has been less discussed in studies to date. According to our results mobility worsening is a risk factor for hospital malnutrition.
This result is in line with the results of some other studies. 25,37,54 It is not surprising, since mobility is a component of a patient's functional ability, substantial for performing daily ativities independently.
Karnofsky score on admission. In our study malnutrition at discharge was significantly more common in the patients with admission Karnofsky score  80, but we did not find that it is an independent predictor for malnutritiuon . Although the results of some other studies show that malnutrition is associated with a lower Karnofsky score, none of them pointed the Karnofsky score as a risk factor for malnutrition. [55][56][57] In these studies a low Karnofsky score could be a consequence, rather than a cause of malnutrition.
Nutritional status on admission. According to our results, nutritional status on admission is the only primary risk factor for malnutrition at hospital discharge. Doctors must be aware that patients may already be malnourished on admission and that 35%-70% of hospitalized patients do not consume enough calories to meet their nutritional needs. 58 In the study by McWhirter patients who were severely malnourished on admission had the greatest weight loss at discharge. 59 Similar results have been published by some other authors. 5,15,17,60 Conclusion. Considering these limitations, the next study should certainly be designed to be multicenter and to include a wider patient population.    Table 3. Received on June 5, 2020.

Risk factors for malnutrition at discharge
Revised on July 22, 2020.