University of Nigeria Research Publications

Ngwu, Elizabeth kanayo

Aut

hor

PG/MSc/83/1825

Title

Observation of Some Indicators of Malnutrition in Hospitalized Adult Males at the University of Nigeria

Teaching Hospital (UNTH), Enugu

Facu

lty

Agriculture

D

epar

tmen

t

Home Science and Nutrition

Dat

e APRIL, 1986

Sign

atur

e

0 3 S ~ V h T I O i 3 S 03 SOME I N D I CATOBS OF M~;~~ITU'PL~ITIOM

ELI Zi;BhTIi KlLTJIYO M G W (PG/N. SC. /83/1825)

MR. D.O. NNfJvYELUG0

This pro jec t is hereby approved:

This day of , 1986.

TABLE OF CONTENTS

Page

TABLE OF CONTENTS

LIST OF PMVC.mAL TABLES

LIST DF:FXWW .

ACKNOWLEDGEPENTS ,

ABSTR?CT .

CHAFTER ONE: INTRODUCTION

Statement of t h e problem

Objectives of t h e study

CHAPTER TWO: LITERATURE REVIEW

Malnutri t ion i n hosp i t a l i zed p a t i e n t s .. 6

Prevalence of malnutr i t ion among hosp i t a l - iwpa t i en t s 8

Nutr i t ional assessment 11

Useful ind ica to r s 6f Malnutrition 1 2

CHA TER THREE: MATWALS AND METHODS

Select ion of sub jec t s

C l i n i c a l examination

Anthropmetric measurements

Biochemical measurements

Fol lowup examination

Food in take and ana lys i s

CHAPTER FOUR: RESULTS

Background information

C l i n i c a l examination

ii TABLE OF CONTENTS contd.

.- . . Page

Anthropometric measurements of p a t i e n t s

Biochemical Evaluation

Follow-up Evaluation

Dietary Evaluation

Nutrient supply

Energy and Prote in supply

Vitamin Supply

Minerals

Percent of requirements

CHAPTER FIVE: DISCUSSION 49

Ind ica to r s of malnutr i t ion i n hosp i t a l i zed p a t i e n t s 49

Anthropometric measurements 49

Biochemical Evaluetion

Follow-up Evaluation

F ~ o d Service t o p a t i e n t s

Summary and Conclusion

References

Appendices 66

Table 1 :

Table 2:

Table 3 :

Table 4:

Table 5:

Tab. e 6:

Table 7:

Table 8:

LIST OF PRINCIPAL TABLES

Page :

D i s t r i b u t i o n of p a t i e n t 6 i n v e s t i g a t e d by d i s e a s e ca tegory , age and occupation, 33

Anthropometric measurements of t h e p a t i e n t s s t ud i ed . The va lue s a r e shown as means + s t anda rd dev i a t i ons . Number of pa t i en t s - in each d i s e a s e ca tegory is shown i n pa ren thes i s . 34

Mean v a l u e s f o r h e i g h t , weight , mid-arm circum- f e r e n c e and t r i c e p s s k i n f o l d of t h e p a t i e n t s i n each d i s e a s e group accord ing t o age groups. 35

Percen tage overweight shown by t h e p a t i e n t s i n v e s t i g a t e d accord ing t o d i s e a s e category. Values a r e expressed a s pe rcen tage of i d e a l weight f o r he igh t . o n

Blood va lue s f o r g lucose , t o t a l p r o t e i n , serum albumin, g lobu l i n , haemoglubin and pyruva te accord ing t o d i s e a s e category. The va lues a r e shown a s means+ s t anda rd dev i a t i ons . Number of p a t i e n t s in-each d i s e a s e ca t ego ry a r e shown i n pa ren thes i s . .. . Mean va lue s f o r blood glucose , t o t a l p r o t e i n , albumin, g lobu l i n , and haemoglobin of t h e p a t i e n t s i n each d i s e a s e group acco rd ing t o age groups. . . . Mean v a l u e s f o r blood g lucose , t o t a l p r o t e i n , albumin, g l o b u l i n and haelnoglobin of t h e p a t i e n t s i n each d i s e a s e group by occupat iono Number of p a t i e n t s i n each occupa t ion is shown i n pa r en the s i s . . . .. 40

I n i t i a l and f i n a l mean va lue s of h e i g h t , weight mid-arm ci rcumference and t r i c e p s sk in - fo ld f o r l i v e r , r e n a h d i a b e t e s m e l l i t u s , h e a r t and miscel laneous diseases.: Means + s t anda rd devi- a t i o n s a r e i nd i ca t ed . Number OF p a t i e n t s i n each d i s e a s e group i s shown i n pa ren thes i s .

LIST OF PRINCIPAL TABLES ( ~ o n t d )

Table 9: I n i t i a l and f i n a l v a l u e s f o r blood g lucose t o t a l p r o t e i n , albumin, g l o b u l i n and haemo- g l o b i n f o r l i v e r , r e n a l , d i a b e t e s m e l l i t u s h e a r t and misce l l aneous d i s e a s e s . Means + s t a n d a r d d e v i a t i o n s a r e i n d i c a t e d . ~ u m b e F of p a t i e n t s i n each d i s e a s e group .iashown i n p a r e n t h e s i s . . . . . 42

Table 10: Mean d a i l y n u t r i e n t supp ly of t h e h o s p i t a l d i e t t o f o u r p a t i e n t s i n each d i s e a s e group, Means + s t a n d a r d d e v i a t i o n s a r e i n d i c a t e d * - 43

L\sT OF FIGURES

1. Fig . 1: I n i t i a l and f i n a l mean va lue s f o r weight , mid-arm ci rcumference and t r i c e p s sk in - fo ld of p a t i e n t s i n v a r i o u s d i s e a s e ca t ego r i e s , 45

2. F ig , 2: I n i t i a l and f i n a l mean va lue s f o r t o t a l p r o t e i n albumin and haernoglobin of p a t i e n t s i n v a r i o u s d i s e a s e c a t e g o r i e s rn 46

3. Fig. 3: Adequacy of energy, p r o t e i n , i r o n , and calc ium of d i e t s se rved t o p a t i e n t s a cco rd ing t o d i s e a s e category. . 47

4. Fig. 4: Adequacy of v i t amins of d i e t s se rved t o p a t i e n t s accord ing t o d i s e a s e category. 48

LIST OF BASIC TABLES

Aypendix Table 001 . . . a

Table OOla: I n i t i a l va lue s f o r blood glucose t o t a l p r o t e i n , albumin, g l o b n l i n h e i g h t , weight , kid-arm ci rcumference and t r i c e p s s k i n f o l d of l i v e r p a t i e n t s accord ing t o age groups. Means -I-

s t a n d a r d d e v i a t i o n s a r e i n d i c a t e x

Table 001b: I n i t i a l va lue s f o r blood g l u c ~ s c , t o t a l p r o t e i n , mid-arm c i r c u ~ f e r e n c e and t r i c e p s s k i n f o l d a? l i v e r p a t i e n t s b o c c u p a t i o n . Means -c s t anda rd d e v i a t i o n s a r e i n d i c a f e d

Table OOlc: I n i t i a l and f i n a l va lue s f o r e i g h t l i v e r p a t i e n t s f o r whom measurements were complete f o r blood g lucose , t o t a l p r o t e i n , albumin, g l o b u l i n and haemoglobin. Means + s t anda rd devia- - t i o n s a r e shown. .. 7 1

Table 001d: I n i t i a l and f i n a l va lue s f o r e i g h t l i v e r pa t i e n t e f o r whom measurements were complete f o r h e i g h t , weight , mid-arm ci rcumference and t r i c e p s - s k i n fo ld . Means $ s t anda rd dev i a t - i o n s a r e shown. . . 72

Appendix Table 002 . . . . 73

Table 002a: I n i t i a l va lue s f o r blood g lucose , t o t a l p r o t e i n , albumin, g lobu l i n , haemoglobin, h e i g h t , weight , mid-arm ci rcumference and t r i c e p s s k i n f o l d f o r r e n a l p a t i e n t s accord ing t o age groups. Means + s t anda rd d e v i a t i o n s - a r e i nd i ca t ed . . . 74

LIST OF BASIC TASLES (Contd.)

Table 002b: I n i t i a l va lue s f o r blood glucose , t o t a l p r o t e i n , albumin g lobu l i n , haemoglobin, h e i g h t , weight , hid-arm ci rcumference and t r i c e p s s k i n f o l d f o r r e n a l p a t i e n t s accord ing t o occupation. Means + s t anda rd d e v i a t i o n s a r e i nd i ca t ex . 76

Table 002c: I n i t i a l and f i n a l va lue s f o r s i x r e n a l p a t i e n t s f o r whom measurements were complete f o r blood glucose , t o t a l p r o t e i n , albumin, g lobu l i n , and hasmo- globin. Means + s tandard d e v i a t i o n s - a r e shown. . . 7 8

Table 002d: I n i t i a l and f i n a l va lues f o r s i x r e n a l p a t i e n t s f o r whom measurements were complete f o r h e i g h t , weight , mid-arm ci rcumference and t r i c e p s sk in - fo ld . Means + s t anda rd d e v i a t i o n s a r e shown 79 -

Table 003 . O 0 0 80

Table OO3a: I n i t i a l va lues f o r blood glucose , t o t a l p r o t e i n albumin, g l o b u l i n , haemoglobin, h e i g h t , weight , mid-arm ci rcumference, and t r i c e p s s k i n gold of d i a b e t i c p a t i e n t s accord ing t o age groups. Meam + s t anda rd d e v i a t i o n s . - a r e i nd i ca t ed . . . 8 1

Table OO3b: I n i t i a l va lue s fo? blood glucose , t o t a l p r o t e i n , albumin, g l o b u l i n , haemoglobin, h e i g h t , weight , mid- arm ci rcumference, and t r i c e p s s k i n f o l d of d i a b e t i c p a t i e n t s by occupa- t ion . Means + s t anda rd d e v i a t i o n s ' .

a r e indicated: . . 83

Table OO3c: I n i t i a l and f i n a l va lue s f o r n i n e d i a b e t i c p a t i e n t s f o r whom measure- ments were complete f o r blood glu- cose , t o t a l p r o t e i n , albumin, g l o b u l i n , and haemoglobin. Means + s t anda rd d e v i a t i o n s a r e i nd i ca t ed . - 85

LIST OF BASIC TABLES (Contd)

Page :

Table 003d:

Appendix Table 004:

Table 004% :

Table 004b :

Table 004c :

Appendix Table 005:

Table OO5a:

Table 005b:

I n i t i a l and f i n a l va lue s f o r n ine d i a b e t i c p a t i e n t s f o r whom measurements were complete f o r h e i g h t , weight , mid- arm circumference and t r i c e p s s k i n fo ld . Means + s t a n d a r d d e v i a t i o n s a r e - ind ica ted . . . . .

I n i t i a l va lue s f o r blood glucose , t o t a l p r o t e i n albumin, g lobu l i n , haemo- g l o b i n h e i g h t , weight , mid-arm circum- f e r e n c e and t r i c e p s s k i n f o l d & c a r d i a c p a t i e n t s accord ing t o age groups, Means + s t anda rd d e v i a t i o n s a r e i nd i ca t ed . 88

rn

I n i t i a l v a l u e s f o r blood g lucose , t o t a l p r o t e i n , albumin, g lobu l i n , haemoglobin, h e i g h t , weight , mid-arm ci rcumference and t r i c e r a s k i n f o l d of c a r d i a c p a t i e n t s accord ing t o occupation. Means + s t anda rd - d e v i a t i o n s a r e ind ica ted . . . 90

I n i t i a l and f i n a l va lue s f o r f o u r c a r d i a c p a t i e n t s f o r whom measurements were complete f o r blood glucose , t o t a l p r o t e i n , albumin, g l o b u l i n and haemo- globin. Means + s t anda rd d e v i a t i o n s - a r e shown. . . . .

I n i t i a l v a l u e s f o r blood g lucose , t o t a l p r o t e i n , albumin, g lobu l i n , haemoglobin, h e i g h t , weight , mid-arm circum'arence and t r i c e p s sk in - fo ld of miscel laneous d i s e a s e p a t i e n t s accord ing t o age groups. Means + s t anda rd d e v i a t i o n s a r e ind ica ted . 95

rn

I n i t i a l va lue s f o r blood glucose , t o t a l p r o t e i n , albumin, g l o b u l i n , haemoglobin, h e i g h t , weight , mid-arm ci rcumference and t r i c e p s sk in - fo ld of miscel laneous d i s e a s e p a t i e n t s accord ing t o occupation. Means + s t anda rd d e v i a t i o n s a r e i nd i ca t ed . 97 -

LIST OF BASIC TABLES ( ~ o n t d . )

Page :

T a b l e 005c: I n i t i a l and f i n a l v a l u e s dor s i x misce l l aneous p a t i e n t s f o r whom measurements were complate f o r blood g l u c o s e , t o t a l p r o t e i n , albumin, g l o b u l i n and haemoglobin. Means + s t a n d a r d d e v i a t i o n s a r e i n d i c a t e d T . .

T a b l e Q05d: I n i t i a l and f i n a l v a l u e s f o r s i x miscel- l a n e o u s p a t i e n t s f o r whom measurements were complete f o r h e i g h t , we igh t , mid- arm c i rcumference and t r i c e p s s k i n f o l d . Means + s t a n d a r d d e v i a t i o n s a r e i n d i c a t e d . 100 -

I wish t o express my profwnd g r a t i t u d e t o M r o D.O. Nnanyelugo

f o r h i s advice, support and encouragement a s my supervisor. I am

indebted t o M r . I. Gnwuamaeze and Dr . A. Ezeoke f o r t h e i r selfless

a s s i s t a n c e and f o r making ava i l ab le t h e f a c i f i t i e s of Univers i ty of

Nigeria Teaching Hospital (UNTH), Enugu throughout t h i s research

projec t . Especia l ly , I am g r a t e f u l t o D r , J.M. O l i f o r allowing

me u s e h i s pa t i en t s ,

I a l s o wish t o thank the s t a f f of Chemical Pathology, p a t i e n t s

i n t h e male medical wards, the doctors , nurses and d i e t i t i a n s

f o r t h e i r co-operation,

My most s ince re ly apprecia t ion goes t o my parents , husband,

and i r i e n d s f o r t h e i r moral and f i n a n c i a l support.

F ina l ly , I wish t o thank M r o E. Ugw f o r a l l t h e pa ins taken

i n typing and re typing t h i s work.

ABSTRACT - Ihe n u t r i t i o n a l s t a t u s of 97 male p a t i e n t s admitted f o r l i v e r , r ena l ,

d iabetes rnellitus and hea r t d i seases a t t h e Universi ty of Nigeria Teaching

Hospital , (UNTH), Enugu, were evaluated on t h e f i r s t day of hosp i t a l i za t ion .

A follow-up study was conducted on 33 ou t of t h e 97 p a t i e n t s a o stayed

two wt:-?k:; or ionger. The techniques used included severa l i n d i c a t o r s

o f malnutr i t ion (height , weight, mid-arm circumference, t r i c e p s skin-fold

thic?cric~ss, blood glucose, serum t o t a l prote in , a l h m i n , g lobul in , haemoglo-

bin and pyruvate l e v e l s ) , Five day weighed d i e t a r y in take study of hosp i t a l

d i e t was conducted on subsample of t h e p a t i e n t s , Resul ts showed high

prevalence of malnut r i t ion (40% o r more) i n a l l the p a t i e n t s by these

c r i t e r i a ( f o r e x a m ~ l e , weight/height 40%, skin-fold measurement 78%, and

serum albumin 5 5 % ) . Greater percentage of d i a b e t i c (75%) and l i v e r p a t i e n t s

(6x6) were mostly malnourished and less percentage of r ena l (13%) and

hzart ( F A ) p a t i e n t s were malnourished, A fol low up evaluat ion, showed

s i g n i L i c ~ n t inc reases i n t o t a l p ro te in , serum albumin and hamoglobin

for l i v e r and rcna l p a t i e n t s (P+0.0.1). There was however a s i g n i f i c a n t

deer.-;- c - Lust: - i n weight f o r r ena l p a t i e n t s (P4 OOO$). Hospital d i e t was found

low f o r scvera l important n u t r i e n t s p a r t i c u l a r l y r i b o f l a v i n and ascorbic

ac id compared with F A 0 requirements ranging from energy (67,6 t o 8104%),

calcium (67,O t o 73,3%), n iac in (37-6 t o 76.9%), r i b o f l a v i n (26.1 t o

40,0;:), ascorbic (2200 t o 28,7%). P a t i e n t s in takes f o r i r o n

(81.3 t o 102.9%) and r e t i n o l (9800 t o 100%) were marginally adequate-

Prote in in take (112.9% F A 0 requi ranents) for d i a b e t i c p a t i e n t s was

CIIPATER ONE

INTRODUCTION

STATLMENT OF THE PROBLEM

High incidence of malnutrition in hospitabi~cpatiente

whether hospital induced or other wise has been reported by

several workers(l)oll!et et al, 1973; Bistriar et &, 1974;

Bistrim et al, 1976; Hill , - et -s a1 1977; Nils et al, 1982).

This calls for a proper nutritional assessment of patients sinoe

malnutrition affects the medical course of patient6 as well as

having a direct bearing on morbidity and mortality (seltzer

et a1 1980; Ngwu and Nnanyelugo, 1984, 1985). The amelioration - .-La

of such malnutrition entails in the first instance awareness

of the existence and secondly the adoption of sound therapeutic

measures (~abadarios and Rossouw, 1981). The failure to survey

'the incidence and prevalence of protein calorie malnutrition

and examine its relationship to the prognosis of varioue

diseases cannot be consistent with good patient care (~istrian

and Blackburn, 1976).

According to Butterworth and Blackburn (1975) hospital

malnutrition is a prevalent health problem with serious

professional and legal implications regardless of etiology.

Nutrition has an important role to play in making expanded

medical services available to individuals as well as to the

communities (scrimshaw, lg"I)* Nutritional support of the

critically ill patient can improve health and organ function

and have a significant impact on survival lackbu burn et al, 1977). It is important that physicians,, dietitians, nurses

and all persons involved in patient care become aware of the

nutritional status of the hospital patients. A factor such

as the level of current food prices may cause more poor people

and indigent elderly to be undernourished before they are

admitted in the hospital. On the other han4, with the current

high costs of hospitalization, there should be every incentive

to shorten the period of confii-ement by preventing complica-

tions and hastening convale-scence, as proper nutritional

care of the patient will ensure.

Nutritional support is an integral part of management

since metabolic stabilization both precedes and facilitates

recovery (~occhio and Randal, 1974). Many factors may exert

a reciprocal impact on nutritional status of patients, and

eepasating their individual effects represents a difficult

clinical and research task (~occhio and Randal, 1974).

Moreover, when drugs are used in the treatment of diseases,

both the drugs and the diseases may affect metabolic processes

independently or jointly. They may alter dietary intake

either directly by inducing anorexia or indirectly by

necessitating therapeutic dietary restrictions (~abadarios

and Rossouw, 1981).

The requirements for specific nutrients in sick people

may be increased, reduced or un-changed from the normal

depending in general on the nutritional sta.tus of the patients

as well as the diseases themselves (~e~sted, 1970). For

example, the severe and prolonged stress of a major burn

increasl::~ nutritional requirements beyond those in other kinds

of trauma (~renshaw, 7973). On the other hand protein and

caloric intakes are reduced in liver failure and diabetes d

mellitus respectively, Obviously it will not be possible to

maintain nutritional equilibrum in every desperately ill,

hypercatabolic patient in the hospital still, the occufience

of severe protein depletion in 30% of a hospital population

. as reported by (~ollet and Owens, 1973; Prevost and Butter-

worth, 1974) seems inordinately high by almost any criteria

r utter worth, 1974). However, there is a general feeling

that diet should be generous in disease states. Tobias and

Van Itallie (1977) noted that many basic principles of nutri-

tional care of patients are neglected in the diagnosis and

care of hospital in-patients.

The basic principles such as obtaining the patients

weight and height by weighing and measuring the patients

instead of inquiring from the patient of his usual weight and

height should be part of the admitting process. Skin fold

thickness and mid-arm muscle circumference are also good

indicators of patientsv nutritional status (~istrian et L&, 1975;

NnLmyolugo and N w , I 9s) . . , I

e

In a well organised hospital such as Rust-Presbyterian,

St. Luke s Medical Centre (RPSLMC) Chicago, patients weights

and heights are obtained on admission and these are carried

out routinely to fellow bp patients' progress, dietary history

of patients is obtained, biochemical analysis is done when

indicated and dietitians give nutritional conselling to patients

regularly. In several industrialized countries, malnutrition

appiars to be an important yet, largely neglected, problem

in hospital-in-patients (~s~lund et al, l9.Y). The nutritional

status of patients in developing countries is however, largely

unknown. Little information ia available in Nigeria on the

nutritional status of hospitalized patients. . Nutritional services in Nigerian hospitals leaves much

to be desired (personal observation). It ia necessary to

evaluate current practices and standards with regard to the

nutritional care of hospitalized patients.

OBJECTIVES OF THE STUDY

The study has five main objectives:

To assess the nutritional status of hospitalized patients

based on clinical anthropometriwbiochemical and dietary

evaluations.

To assess the incidence of malnutrition and to define

the extent of malnutrition in the patients,

To describe and evaluate the food consumption pattern

and nutrient contribution of hospital food to

p ;t isnte meale.

'I0 investigate to what extent the hospital diets are

prepared w.ith reference to patients likes and dislikes,

To evaluate the contribution af hospital food t o nutrient

intake, w

CHAPTER TWO

LITERATURE REVIEW

MALNUTRITION IN HOSPITAL-IN-PATIENTS

Malnutrition is any disorder of nutrition or undesirable

health status due to either lack or excess of nutrient supply

ague & &, 1974). Bistrian -- et a1 (1975) defined protein

energy malnutrition as a lev~l of serum albumin below

3.5g/100 ml.

Mild to moderate cases of malnutrition which are usually

unrecopnised consti'tuts a . much larger proportions of

malnutrition in hospital-in-pat ients (~ntener et al, 1977).

Protein energy malnutrition in adults has received little

attention in great contrast to pediatric protein calorie mal-

nutrition, despite the obviously prevelent pre-conditions for

its development in many hospitslized patients, for example

during prolonged semi-starvation in patients with hyper cata-

bolic ,illness (~istrian et al, 1974). A substantial portion of

hospitalized patients suffer from protein energy malnutrition

acquired as a result of their illness, their semi-starvation,

dietary regimes or the combination of both, Many and probably

most patients become malnourished prior to hospitalization,

as a result of illne~s induced anorexia and the catabolic

response to the stress of disease. Likelihood of malnutrition

i n s ick people correlates with a longer hospital s tay and an

increased mortality r a t e ( ~ t e f f ee , 1980) lvhen energy needs

a r e not met by the d ie t , de f i c i t must come from body stress-

muscle or visceral protein and f a t ( ~ u t t e r w r t h and Blackburn,

1975). The association between, excessive morbidity and mactality

m d rn ihaur i~hed . ,s ta te- .:. i i n s ick people has been well esta-

blished ( ABel & 2, 1974) Bistr ian & aJ. (19751 noted tha t

f a i l u r e t o recognise the extent of protein u enexw mahi;rktion

i s the wide spread reliance on weight f o r h e i ~ l i t US routine meas-

ure of nut r i t iona l status. Additionally the significance of low

serum albumin levels as indicator of protein def ic i t i s not generally

appreciated. Daly ,et al ( 1978) have clear ly observed a relationship

between malnutrition and immune competence of ill patients. B i s t r i a n

e t a1 (1975) i n t h e i r study on ce1lula.r immunity i n semi-staved s t a t e s -- i n hospitalized adults noted reduction i n ce l lu l a r immunity as well as

protein energy malnutrition, 2 1 1 3 body defence mechani.sms - mechanical,

ce1lula.r a d humoral a re impaired ( ~ a w e t al, 1974). I n additio-e

body i s open t o infect ion a t a time when it i s l e a s t able t o cope with

it. It has long been recognised tha t malnutrition is frequently

associated with atrophy of lymphoid t i ssue (MC Farlane and Hamid,

7973; Law -- e t al, 1974). Studies suggest t ha t protein and energy

malnutrition i s associated with some impairment both of B and T

Cell - mediated immune functions (~bdou and Richter, 1970).

Inference drawn from the study by Weinsiner & & (1979)

on general medical patients on admission and during the course

of hospitalization have been that nutrition support is negle-

cted, that little attempt is made to reverse malnutrition and

that physicians lack concern for the nutritional status of

their patients. Although many reports have indicated that

malnutrition actually develops during the course of hospi-

talization, there have been no prospective studies to show

whether the reported prevalence of malnutrition is in fact,

hospital induced or simply a reflection of the patients nutri-

tional status upon hospit.q.1 admission utterwo worth, 1974).

PREVALENCX OF MALNUTRITION AMOKG --- - I I ~ S L l;CIAL-IN-PATIENTS --

Nutrition surveys in U.S and England have documented

the existence of malnutrition among hospitalized patients

(~ates - et -9 a1 1977; Woods, 1982). Also Bistrian et a1 (1977)

reported a malnutrition prevalence of 15% or more in Arnerlcan

hospitals. Kassiodou fi & (1978) have reported malnutrition

rate between 35 and 77% in patients hospitalized in Brazillian

hospitals. Similarly Will.-Cuts et (1978) have shown 65%

rate in a Suburban community hospital.

Presence of malnutrition of varied aetiology and

incidence has been rzported by Labadarols and Rub,ouw (1981)

in three hospital populatioqsurveyed with 50% of the patients

being moderately to severely wasted. Leevy and Co-workers

(1965) noted protein deficiency in selected groups of hospita-

lized patients. Nils, et a1 (1982), in Sweden, investigated

75 consecutive patients, acutely admitted to a general medical

ward and found protein under-nutrition as well as energy

deficiencyo , They equally found obesity in 9%

and under-nutrition in 22% of the patients on admission.

Antener et a1 (1977) in their study noted with amazement the

large number of patients found malnourished on admission.

Bistrian et a1 (1976) reported 44% prevalence of malnutrition

in generel medical patients in Boston City hospital by these

cziteria (weight height, 457& triceps skin fold, 76%; arm

muscle circumference, 55%; serum albumin, 44% and haematocrit

48%).

In a study by Weinsier ,et a1 (1979) a high likelihood

of malnutrition was found in 48% of the patients evaluated on

admission. They also noted that likelihood of malnutrition

increased with hospitalization in 69% of patients with paired

determinations compared to admission. At final followmp,

they still noted that a greater proportion of patients fell

into the depleted range of values for triceps skin fold,

weight/height9 and arm rnilscle oi-sumf ersnce. According to their

report, these perarneters worsened in over 75% of patients

admitted with normal values. Their findings demonstrate an

association, between nutrition status and hospital course and

a worsening trend during hospitalization.

Low intakes of energy and protein have been reported

among elderly patients and among patients on a liquid diet

(warnold et al, 1978). A study by Kaufman et a1 (1962) reported

that diet served to patients were generally low in prbtein,

vitamin A and ascorbic acid. Tobias and Vanitallie (1977) in

their survey of the nutritional problems of hospitalized patients

noted that sixty-one of the sixty seven patients studied were

actually or potentially malnourished. The same study revealed

that appropriate attention to nutritional status was paid to

thirteen of twenty eight patients with a history of ethanol

abuse, and only five of sixteen obese patients. Prevost and

Buttsrvorth (1974) also noted that nutritional counselling was

never ordered for patients, even those on therapeutic diet

neither were there plans for a fol!.ow-up of nutritional care

at discharge. Asplund et a1 (1981) reported low mean values

for weight, arm muscle circumference, serum albumin in 91

patients studied. Energy and/or protein under-nutrition was

found in 30% and obesity in 4%. When an intensive care unit

population was compared to the general hnspital. pop- lat ti on a

6-fold increase in albumin level depression (seltzer et al,

7 1.

1980) was noted. In Nigeria limited data are atvdlable on the

nutritional status of hospitalized patients.

NUTRITIONAL ASSESSMENT

Nutritional assessment of the hospitalized patients has

been recognised as a valuable tool in defining the extent of

malnutrition (Seltzer et al, 7980) while some patients will

appear obviously wasted, with muscular atrophy, flaccid sub-

cutaneous tissue, and pallor, the majority will not seem to be

malnourished, despite underlying deficiencies u utter worth,

1974). Assessment of the nutritional status of every hospi-

talized patient should be fundamentally part of the workup

as listening to the heart or obtaining a urinary analysis

utterwo worth, and Weinsier, 1974). A variety of techniques a r e

available for assessment ranging from the complex and time-

consuming procedures described by Blackburn st a1 (1977) to

the more simple methods described by Jelliffee (1966).

Of the various means for assessing nutritional status,

body weight is considered to be one of the most important

factors. Butterworth and Blackburn (j975) in their clansic

paper on hospital malnutrition stated, "weight is perhaps the

single most important piece of information that can be

provlded as to the p~,tients nutritional status" (seltzer et al,

1981).

The provision of proper nutrition support to sick

patients represents the standard of nutritional oare in con-

temporary clinical medicine, such support is the obligation

of the clinical physician, pharmacist, nurse and dietitian

(seltzer, 7982). Patients with malnutrition, particularly

protein-energy malnutrition, do not tolerate illness well.

They tend to have delayed wound healing and greater-suscepti-

bility to infection and other complications. Thus early den-

tification of the patient at risk, and the assurance of adequate

protein and energy supplies, may serve to prevent a prolonged

and complicated, or even a catastrophic, hospital course

u utter worth and Weinsier, 1974).

USEFUL I N D I C A T O R S O F MALETUTRITION

1. Anthropometric measurements

(a) He'ight and weight: The measurement of height and weight

are by far, the most useful indicators of nutritional status.

In many cases they are the only indices available outside the

hospital bl utter worth and Blackburn, 1975). It has been

estimated that an acute 25-35% loss of body weight may be

associated with as high as a 90% mortality rate (~eltaer e& &

1981). A patient who is grossly obese may be above the

desirable weight for height standard ; yet suffer extreme protein

energy malnutrition u utter worth and Blackburn, 1975;. Oedema

is a common feature in protein energy malnutrition and may

give falsely high weight readings and this interferes with

nutritional assessment.

(b) Skin fold thickness: Body fat storeo cam be

estimated with good approximation by measuring skinfold thick-

ness with a large caliper Butterworth and Blackbum,

1975; Wright,'ly&l),. Skinfold thickness has been shown to be a

good indicator of calorie reserves being easily determined and

also a specifically nutrition related parameter ellif if fee,

1966; Weinsier et al, 1979; Nnanyelugo & Ngwu, 1985; Okeke,

Nnaayelugo and Ngwu, 1983).

( c) Arm muscle circumference : Arm-muscle circumference

has been shown to reflect mass of muscle protein which is

rapidily mobilised when calorie intake is inadequate (committee

report, 1970).

2. Biochemical measurements: Serum albumin

Studies have shown that an early effect of protein

deprivation is reduced albumin synthesis and hypoalbuminemia

(~irsch et al, 1968' Waterlow, 1969).

Hypoalbuminemia has been shown to be a key diagnostic

feature of protein energy malnutrition, heralding the

critical clinical and biochemical phase of kwashiorkor

(whitehead et al, 1973). Serum albumin levels are considered

a more reliable and sensitive index of protein nutritional

status than total protein levels (~auberlich & a& 1977).

Thurnberg (1981) in his study of 58 stable non-diabetic patieats

regarded serum albumin level normal at 3.5 to 5.!jg/dl, in

nild deficit at 3.0 to 3.5g/dl; in moderate deficit at 2.1 to

3.!Ig/dl and in aevere deficit if less than 2.1g/dl. Other

workcrs, (~ollet and Owens, 1973; Weinsier et al, 1979 and

Weisstcr~er et al, 1982) regarded normal level of serum albumin

to be 3.5g/dl and above,

Edosien (1965) reported a serum albumin level of 3,4g

and 3. 8g/1°0ml in healthy adult Nigerian and lhropoana living

in Nigeria respectively, According to Wright (1980) aerum

albumin concentration of less than 3.4g/dl in the absence of

liver disease, indicates protein malnutrition, Weisseberger.

et a1 (1982) reported that 46% of the men studied were -- admitted with a serum albumin of less than or equal to 3.0 gm

per deciliter. Butterworth (1974) reported hypoalbuminernia

to be present in 30 of 56 subjeots and in 15 (27%) of these,

serum albumin level was in the severely depleted rage

(less than 2,8g/100ml),

Haemo~lobin level

Blood haemoglobin levels have also been used extensively

to assess protein nutritional status. Variation exists in

the cormal haemoglobin levels for example Dacie and Lewis

(1975) gave normal level * as 13.5 to 18.0g percent while

lieissberger -- et a1 (1982) regarded normal value as 14.0 t o 1 8 . 0 ~

percent. The average haemoglobin value of a representative

group of Nigerian male adult is shown to be 22g percent

rantzing from 18-30g/100rnl (~dozien, 1965).

(c) Blood sugar

Screening for unsuspected diabetes is widely practised

in hospitals by testing for glucosuria on all in-patient

admissions. It has been noted that hyperglycaemia often

exists without glu'cosuria, especially where the proportion

of elderly people is high u utter field et al, 1967). Among

16 patients found to be diabetic, six had not had glu'cosuria

on routine testing and therefore could not have been detected

by clinistix (~ortham et &, 1982). The WHO Expert Committee

(1980) on diabetes mellitus recommends blood glucose deter-

rriination as the method of choice for screening for diabetes

mellitus since it has a higher diagnostic specificity than

urine testing. Northam et al, (1982) . included serum glucose

determination in the biochemical profile as an additional

screening procedure for the detection of unsuspected diabetes.

Also Whitehead (1973)' included serum glucose in the biochemical

profile on in-patient admissions to the Queen Elizabeth

Hospital, Birmingham, Normal range of blood sugar in fasting

subjects is given ( Ealsewood and Strookman, 1939):

.

Venous blood - 65-105mg/100ml; Capillary bload - 70-130mg/ 100ml.

Hospital Food

Poor food is certainly considered to be the most unpleasant

aspect of a stay in the hospital especially now that many

countries of the world are facing serious food shortages

(Feldrnan, 1962). Hospital diet is poor because menus are

monotonous, because food is badly cooked/sometimes scanty and

served cold obias as and Vm Itallse, 1977).

The history of provision of care for the sick gives

some clue to the problem, for the feeding of patients is

closely allied to the history of nursing (~albraith, 1975) .

Nursing developed under the auspices of the church, and its

guiding principle was charity which embraced the care of both

the sick and the poor. The standard of living of the people

was so low that no one troubled much about feeding in hospital,

It was left to the poor and sometimes degraded women .who

nursed them. Only a few hospital authorities gave little

thought to it but little importance was attached to food as

a means of restoring health. With the reforms started by

Florence Nightingale towards the end of the nineteenth century,

there was little improvement in the service of meals to the

patients; but nutritional values were etill not studied seriously,

Bollet and Owens (1973) have teported Wide spread lack of

appyeciation of the role of nutxition in clinical praotice

among people involved in patient see.

A study of dietary consultation sendoe in an Indiana

nursing home revealed that therapeutic diets prescribed by

physicians often were not served as ordered (~aufman & al,

1962). Similar picture may be seen in other hospital s e t up,

Physicians should have the blame for not insisting that the

needs of the patients are properly met. Adequately nourished

patient was defined as consumption of at least 30 kcal/kg

IBW (30 kcal per kg of ideal body weight and at least qg

protein per kilogram of ideal body weight (~hunber~, 1981),

CHAPTER THREE

MATERIALS AND METHODS

SELECTION OF SUBJECTS

Investigations were carried out on 97 adult male

patients admitted in two male wards of the University of

Nigeria Teaching Hospital (UNTH) medical service, Twenty

three of the patients were with liver diseases, twenty two

with cardiac problems, twenty with diabetes mellitus, sixteen

with renal problems while sixteen were miscellaneoue cases.

Essentially all patients admitted to the hospital were

believed to have serious illness of either an acute or chronic,

nature, Terminal cases are usually referred to the hospital,

Patients were first seen within two days of admission.

The ages of the patients ranged from 20 to 60 years. Informed

consent for the procedure was obtained from the patients or

from their relatives,

Five patients died during the period of the study,

Each patient was interviewed and weighed where pcmaible

Information concerning the patientsD ages, occupation, tribe,

medical and dietary history was obtained from the patient,

his relatives ox from his folder. Some of the patients were

confined to bed but most patients were up and about during the

study. All received the general hospital diet or the

therapeutic diet.

Clinical &amination

Patients were examined f o r wastina;, 0b8ity, m c i t i s and

od ema , Anthropometric Measurements

Body measurements - height, weight, mid-azm cirmaference

and t r iceps skinfold measurements were made according t o a

standardised precedure recommended by J e l l i f f e (1966), the

relevance of which has been detailed elsewhere ( ~ k e k e e t all,

1983; Nnanyelugo 2nd Ngwu, 1985).

Height - measured with "Nivotoise portable height measurett

graduated i n centimeters up t o 2 meters,

Weight - weighing was done i n a hospital clothing using a

salter weight scale graduated in kilogram up t o 120

kilo@;ramsr Ideal weight f o r height w a s derived from

Metropolitan Life Insurarice Table ( 1959).

M i d - m circumference - measurement was done with tape graduated in

centimeter at the mid upper l e f t asn.

Triceps skin-fold - skinfold over the t r iceps at the same position

f o r the l e f t mid-am circumference was made with the

Harpenden skinfold cal ipers t o the nearest mu. A l l

the measurements were made i n the morning between 8 and

12 noon by the investigator,

Biochemical Measurements

A sample of approximately 10 m l of fasting blood was

obtained from each pat ient by venipuncture and divided i n t o 4 clean t e s t tubes f o r laboratory analysis of serum protein,

albumin, haemoglobin, blood sugar and pyruvate,

Serum total rotei in and albumin --.- - Approximately 3 ml of blood wqg collected in a clean

glass centrifuge tube and left to clot. The blood sample was

centrifuged for five minutes at 2,000 r,p.m, At the end of

the five minutes the serum was removed into another clean

glass tube using a pasteur pipette, corked and stored in deep

freezer until ready to use.

Serum total protein and albumin were determined using

Biuret reagent (cornall et al, 1949) uith a photoelectric

colorirneter at optical Density 540 mm,

Haemogl obin

Two milliliters of blood were collected into a fluoride

bottle for fasting blood sugar determination. This was shaken

to mix well, Fasting blood sugar estimation is routinely

done in the hospital. The blood samples collected for the

purpo5es of this study were analysed using the methods by

Halse Wood (1939.

Blood Pyruvate

Three milliliters of blood was used for the estimation of

blood pyruvate. Blood was added to a clean centrifuge tube

containing 3 ml of tri-chloroacetic acid (TCA) solution

obtained by dissolving 100g of TCA in 0.5N hydrochloric acid.

The blood, TCA mixture was shaken immediately t o mix well. The

mixture was centrifuged f o r 15 minutes a t 2000 r.p.m. The c l ea r

supernatant formed was removed i n t o a clean tube with a pasteur

pipet te and then stored i n the deep freezer u n t i l ready f o r analysiG.

Blood pyruvate was estimated by methods of enzymatic analysis by

ZPK and Lamprechi ( 1974).

FOLLOW UP rnAMINATION

Thirty-three out of 97 patients seen on admission were re-

examined two weeks a f t e r admission. A l l the parameters measured Bn

first day were repeated on each pat ient seen two weeks a f t e r admission.

M)OD INTAKE

Several methods are used i n assessing the food intake of a group

of people which i s applicable t o hospitalized patients. The methods

include food account or record, food weighing, d i e t history and d i e t

recall . A l l these methods have t h e i r respective advantages and

disadvantages and based on tha t , food weighing method w a s chosen

f o r use i n t h i s study. Foods served t o sub-sample of pat ients i n

the d i f fe rent disease categories by the hospital ' s catering service

were weighed using Waymaster Dietary Scales (c.M.s. Weights Ltd,

on don) and recorded f o r f i v e days. Four pat ients aged 31-50

y e w s i n each disease category were chosen as sub-sample.

I

An a l i q o t sample of t h e hosp i t a l lood was co l l ec ted during each

meal, weighed and s tored i n a deep fr-er u n t i l ,ready t o use.

ANhLYSIS OF DATA

The cooked foods were ca lcula ted as raw q u a n t i t i e s using

water conversion fac to r s . Nutrient cont r ibut ion of h o s p i t a l d i e t

were then ca lcu le ted using food composit icp tdbl.es ( P l a t t , 1975;.

FAG, 1969)0 Means - + standard devia t ions w e r e ca lcu la ted f o r the

p a t i e n t s i n var ious d i sease groups and adequacy of t h e d i e t was

estimated a s percentage of FAO/WO (1961, 1967, 1970, 1973)

requirements,

rmthropometric measurements w e r e compared on group of p a t i e n t s

using i d e a l weight f o r he ight derived from the ,Metropolitan L i f e

Insurance Table (195910 Biochemical i n d i c a t o r s were evaluated a s

described by Duodu (1975) and Weinsier e t a1,(1579). Both the -- Duncan's mul t ip le range t e s t (1965) and paired t-test were used t o

compare means f o r l e v e l s of s ign i f i cance of i n d i c a t o r s amongst

t h e groups of p a t i e n t s invest igated.

CHAPTER FOUR

RESULTS

(a) Background Inf onation

Data were collected on admission from 97 adult male

medical patients admitted for Liver, Renal, Diabetes mllitus,

Heart and Miscellaneous diseases at the University of NigeriaTeaca

Uospital (UNTPH), . Enugu. Majority of the patients (90%) were

from the Eastern part of the countzy.

Table 1 shows the distribution of the patients investigded

according to disease category, age and occupation. This Table

reveals that majority of the patients (23) were admitted for

liver diseases. Also 32.99% of the patients were civil servants.

Thirty six yatients fell into the age group 41-50 years.

Further distributions of patients according to disease categories

and age or occupation are shown in Tables 001-005 (appendaged).

(b) Clinical Examination

Aecitie and Odema were common clinical features observed

in renal and cardiac patients. Leaness or weight boss was oornnon

among .;liver and diabetic pcrtisnts.. ~nfunaation(e) obtained from

the history of their sickness indicated that most of the patients

were referred to the College of Medicine from other hospitals

and the liver patients had gone to native doctors before going

to other hospitals from where they were referred.

24,

( c ) Anthropometric -.m-easurements of t h e Q a t i e n t s

The mean va lues f o r he igh t , weight, mid-arm ciroumference

and t r i c e p s skin-fold of t h e p a t i e n t s on t h e day of admission

a r e summsrised i n Table 2 accord ing t o d i s ea se ca tegor ies .

This Table po r t r ays an even d i s t r i b u t i o n f o r he igh t , mid-arm

c i r c m f e r c n c e and t r i c e p s s k i n f o l d of a l l t h e d i s e a s e

ca t ego r i e s . Disease d i f f e r e n c e s exe r t ed h i g h l y s i g n i f i c a n t

e f f e c t on t h e mean weight of t h e p a t i e n t s ( ~ 4 0 . 0 1 ) . D iabe t i c

p a t i e n t s appear t o be s i g n i f i c q t . l y more dep l a t ed accord ing t o

weight f o r he igh t c r i t e r i o n (P <;0,01).

Also d i a b e t i c p a t i e n t s appeared t o be most ly dep le ted by

weight f o r he igh t and mia-arm c i rc~ lmference c r i t e r i a i n 20 t o

30 and 41 t o 50 yea r s age groups (Table 3). I n 31-40 y e a r s age

group miscel laneous d i s e a s e p a t i e n t s were most ly dep l e t ed by

weight f o r he igh t c r i t e r i o n whereas r e n a l d i s e a s e p a t i e n t s were

most ly dep l e t ed i n 51 t o 60 y e a r s age group.

Frequency of over-weight among p a t i e n t s accord ing t o

d i s e a s e groups i s presen ted i n Table 4. The t a b l e shows t h a t

87.50% ( 14) of r e n a l p a t i e n t s were 100 percent o r more o f : the i r

i d e d weidht f o r hoight fol lowed by h e a r t d i s e a s e

p a t i e n t s (50~6)d Nine ou2 'of 23 l i v e r d i s e a s e p a t i e n t s

were 100 percent o r mom of their i dea l weight f o r height.

Conversely t h e d i a b e t i c p a t i e n t s were most s eve re ly dep l e t ed (90%)

25

with only two patients exceeding t h e i r ideal weight far heig;ht by

0.70 mid i&~. This i s followed by miscellaneous disease pat ients

( 7 ) . Only f wl: miscellaneous patients were 10Q6 o r more of e e i r

i d o d weight f o r height.

( d ) $iochcmical Evaluation ..-" I

T d l s 5 summarises the mean values f o r blood glucose, t o t a l

protcir:, serum albumin, globulin, haemoglobin and pymvate of the

pr~ticz~ts i n the various disease categories. The number of patients

j-il aw:l disc!,zse cctsgory i s indicated. I n the Tab% the mean to t a l

protcin :or t h z pntients i n different diseczse s tz tus ranges from

5.2F(~.l.25 t o 7.11~0.90g/100rnl. It could also ba s e m from the gable

%hat p ~ ~ t i c n t s admitted with renal disense showed thc leas t mean value

(2,54~0.96g/100rnl) f o r serum albunin followed by p ~ t i e n t s admitted

witb l i v e r d i s ~ a s e (3.12~0.64g/100ml). Significant d i s ~ a s e differences

WE.W i f imtif ied (P 9 . 0 1 ) by means of the Duncan's I4ultiple Range

l ~ s t . u y t h i s t e s t analysis, renal patients were significantly

severely malnouriehed by 611 : the c r i t e r i a evaluatcxi. Differences

along disease exerted highly s ignif icant ( ~ 4 0 , 0 1 ) dl"ect on serum

albumin lcvcls of the patients ,although the differences were

si;;il;ific,mt among the heart , diabetic and m i s c e l l ~ ~ c o ~ r s diseases.

On the.; 1;~holc 53 ('&.6&.) out of 97 pationts had scruni dbumin

1c.i 'bclow 3,Sg/100ml on admission. Also s ignif iccnt differences

(P 4~j.01) were observed on the haemoghbin level of the

disease groups but not between l i v e r

and renal di3eases; diabetes mellitus (13.72L2.43g/100m1)

heart (1 3.97+2,47g/100ml) - and miscellaneous (13.44t2. 69g/100ml)

diseases. The Table shows also that dirlbetes mellitus exerted

the greatest influence on the patientst blood glucose

(1 32.45~41 .65mg/l00rnl) while no statistical significant

difference was observed Dong the other disease categories .

(~b0.05). fill the diabetic patients were on insulin therapy,

Renal disease also exerted the greatest influence on the

p.?.tientst total protein level. The influence of the other

disease categories on the total protein level of the patients

were not statistically different (P k-0.05). Similarly the

differences in the globulin levels of the disease groups were

not statistically significant (P* 0.05).

Only 48 blood pyru7rate values .were available on study The number In each disease category is indicate

patients on admission a able 5) M e w values for each disease L group showed liver patients as having the hi&est v d e s

(h5.59-~17.0~~g/100ml), - followed by renal patients (63. 33219.80

p)lg/lOOml). The least value was presented by miscellaneous

patients (50.82~9. 15ug/100ml). Diabetic 4 4 heark

disease patients have 56,7l+_l8,lg and 55. 29+l5.Ol ~g/lo~rnl

respectively. hihen the data was pooled, the mean value for all

the 2atients was 58.35+17,2? nq/l00d.

The mean values f o r blood glucose, t o t a l pro te in , serum

albumin, gl.obulin and haemoglobin were r eca lcu la t ed according

t o age groups a s shown i n Table 6. I n a l l t he age groups,renal

diseuse p a t i e n t s c o n s i s t e n t l y showed lowest mean value f o r

t o t a l pro te in , serum albumin, g lobul in and haemoglobin except

f o r age group 51-60 years where l i v e r p a t i e n t s showed t h e ,

l e a s t value f o r t o t a l p ro te in (6,07+~.72~/100ml, albumin ( 3 . 3 0 ~

0.56 g/100ml) and haemoglobin ( 1 1.29+2.75g/100ml). S t a t i s t i c a l

d i f fe rence between age groups showed no e f f e c t (P~ .~ ! .o ' ) ) on

t h e mean l e v e l s of t h e parameters.

When the mean values f o r the blood cons!i i tuents were

r e c ~ . l c u l a t e d (Table 7) by occupation groups, r ena l d isease

p a t i e n t s c o n s i s t e n t l y presented the l e a s t value f o r t o t a l p ro te in

i n a l l the groups except f o r miscellaneous d isease group where

no r e n a l p a t i e n t s appear t o be present.

( e ) Follow-up Evaluation

Of the 97 p a t i e n t s examined on admission, 33 (34%) p a t i e n t s

remained i n the h o s p i t a l two ,weeks o r longer and had follow-up

evaluat ions (Table 8 and Fig. 1). Relat ionship between the

i n i t i a l and f i n a l (2 weeks) mean values i n each parameter was

examined using pa i red t - t e s t . Resul t s showed t h a t two weeks

of h o s p i t a l i z a t i o n was assoc ia ted with s i g n i f i c a n t l y h igher

mean values of t o t a l pro te in , serum albumin' and haemoglobin

f o r l i v e r and r ena l d isease p a t i e n t s (PCO.OIT,) whereas d i a b e t i c

and miscellaneous disease patients renained statisticallfthe

sx:e for all the parameters.

The result of the follow-up evalu2.tion of the anthropome-

tric measurements on the patients as shown in Table 9 and Fig. 2

indicates that mean weight, mid-arm circumference and triceps

skin fold thickness increased in all disease categories at two

weeks of admission exept that for renal patients which fell

from 72.06kg to 62.75kg for weight, 26.67cm to 26.45cm for mid-

arm circumference and from 5.17mm to 4.98mm for triceps skin

fold. This shows a significant (F 40.01) loss in weight for

renal patients.

Dietary Evaluation

Hosp&$dl. food supplied to patients was estimated in sub-

sa~ilpl~ (4) of patients 31-50 years of age in the various

disease conditions for five days. Observation showed that the

hospital served three main meals to patients every day. Snacks

were rarely served even to diabetic patients who were on

insulin, Patients were asked to buy their own biscuits for

between meals, Twelve patients were independent of hospital

food. They have relatives who cooked their foods, Majority

of the patients (75%) were dissatisfied with food served in the

hospital. Greater percentage (80%) of those who disapproved

of hospital food come from the farmers followed by business-

men. More of Civil Servants and students appeared to give a

29 . positive answer to the question 'Do you like the good served?'

On further questioning 100% of all the patients agreed to be

fauiliar with food served in the hospital. The food likes and

dislikes of the patients were hardly ascertained. Only 10% of

the patients who needed to be seen by a dietitian reported

having been visited by one.

The r~aults of the mean daily nutrient supply by the

hospital diet is shown in Table 10.

NUT~IENT sumx

Levels of adequacy of nutrient supply is shown in FQa 3

and 4 as percentage of FAO/WHO requirements (1961, 1967, 1970,

1973).

Ener~y and Protein supply

As shown in Table 10 the daily mean supply of energy

and protein for patients in the various disease conditions

ranges from 2027.34~199~21 to 2441.94~333~81 Kcal ar,d 39.9&

5.66 to 59.8422.66g respectively. The least energy served

was to the diabetic patients (2027.34~199 ~cal) while the

highest energy served was to miscellaneous disease patients

. . (2w.943~3.81). On the contrary &I oqected diab&ic ' , '

' , .,. . . 72tients were served tho highest-" protein. Generglly, t. . - ,+ ( :

ener2Y sup?ly of the hospital diet were below thet . ' .

rcc .., !.:ended for hU::althye pe ,pie . I .

within the same age group (FAO/WHO, 1973). Whereas only food

served t o d i a b e t i c p a t i e n t s met and exceoded the requirement

f o r p ro te in (59.8422.66g) per day. This i s s t a t i s t i c a l l y

( ~ 4 0 . 0 5 ) g r e a t e r than t h a t served t o the r e s t of the pa t ien ts .

Table 10 a l s o shows t h a t d i a b e t i c p a t i e n t s were served meals

which suppl ied energy more t h e l e v e l (2,000 ~ c a l ) prescr ibed

by t h e physician on four days out of t h e f i v e days of d i e t a r y

survey.

Vitamin Supplg

The mean d a i l y vitamin supply was below requirement f o r

most of the p a t i e n t s i n d i f f e r e n t d isease categories . Ret ina l

supply f o r a l l t he d isease groups ranges from 735.03+_38.23&g f o r

hea r t d i sease group t o 754.39241.4721g f o r miscellaneous d isease

pa t ien ts . These l e v e l s appear t o be c lose t o t h e FAO/WHO

(1967) requirement f o r vitamin A. The thiamine l e v e l s were

below requirement f o r a l l p a t i e n t s except d i a b e t i c p a t i e n t s

(1,29+0.17mg). The h o s p i t a l d i e t s were found t o be s e r i o u s l y

d e f i c i e n t i n r i b o f l a v i n and ascorbic ac id (Fig. 4). The

l e v e l s obtained from h o s p i t a l food were below41% of FAO/WRO

requirement f o r a l l ca tegor ies of pa t i en t s . The l e v e l s f o r

n i ac in were ? 5 e ? , 5 e 5 2 m f o r l i v e r p a t i e n t s * 9 - 3 f o r r e n a l pa t i en t s ; 8.8i2. Inj f o r d i a b e t i c

31. *g

p a t i e n t s ; 7 . 4 4 ~ 1 . 8 z f o r h e a r t p a t i e n t s ; and 17.69~5.71mg f o r

n!iscellaneous d i s e a s e p a t i e n t s . A l l t h e se a r e below f equhemen t

l e v e l s f o r h e a l t h y people.

Minerals ---- The mean d a i l y supply f o r calcium i n a l l t h e d i s e a s e

groups i s below t h e FAO/WHO (1961) requirements f o r h e a l t h y

people. The mean d a i l y i r o n supply t o p a t i e n t s were 9.26+_1.27mg mg mg

f o r l i v e r ; 7.70+1.58f f o r r e n a l ; 8.61+2.66Lfor d i a b e t i c s ;

7.38-1.1.40 - 3 o r h e a r t and 8 . 8 8 ~ 2 . 8 4 g f o r miscel laneous p a t i e n t s .

These a r e lower than t h e rccomnended i n t a k e s f o r h e a l t h y people

of t h e same age group except f o r l i v e r p a t i e n t s (FAO/WHC, 1970)

Perccn t o f requirement -..-.-...

The l e v e l s of n u t r i e n t s u p p l i e s t o p a t i e n t s by t h e h o s p i t a l

catc.;ring s e rv i ce ; were compared wi th FAO/WHO requirement8 (1961,

1967, 1970, 1973). F igure 3 shows l e v e l s of adequacy of t h e

h o s p i t a l d i e t f o r ene rp j , p r o t e i n , calcium and i ron . The

energy supply ranges from 67.58 t o 81.39 percent . Only t h e

p r o t e i n supply t o d i a b e t i c s w a s above 160% of requirement.

I n F igure 4, l e v e l s of adequacy of v i t amins a r e shown.

A l l p a t i e n t s i n t h e va r ious d i s e a s e cond i t i ons had r e t i n o l

supy:ly above 90% of requirement. Also th iamin supply was above

90% f o r a l l t h e d i s e a s e groups except f o r l i v e r p s t i e n t s

(73*33%). The l e v e l s of d e a c a c y f o r r i b ~ f l a v i n and

ascorbic acid were below 307; o x c e ~ t f ~ r miscellaneous p z t i e n t s

who had 40% r i b o f l a v i n supply. The n iac in suppl ies t o a l l

ca tegor ies of p a t i e n t s were below 80 percent . FA0 requirements.

Table 1: Distribution of the patients investigated : i I

by disease oategory, age range and occupation.

Disease Cateaorx

Liver

Renal

Diabetes mellitus

Heart

Miscellaneous

Total

Age rang5

20 - 30

31 - 40

41 - 50 51 - 60 Total

Occupation

Civil servants

Business men

Farmers

Students

Miscellarieo~s

Total

Table 2: Anthrapometric measurements of the patients etudied. The values are shown as Means.-& Standard deviations. Number of patients in each disease category is shown in parenthesis,

Disease Mid a r m Tricep Category Height Weight Circumference skinf old

( c d (kg) (cm> ( m d

Liver (23) 16831 60.99 25.18 5*78 + + + 6T77 9T24 3T90 2*41

Renal (16) 168.62 + 4T98

Heart (22) 171e22 + 3 3 5

Miscellaneous 169.87

Table 3: Mean values fo r height , weight, m i d - a r m circumference and t r iceps skin f o l d of the p a t i e n t s i n each d isease group according t o age groups

AGE GROUPS \ -

- - -

Mid-arm Triceps sk in Circumference f o l d

( cm) (m)

20 - 30 Liver d isezse (I) ~ ~ O , ~ O J ~ O , O O Renal disease (4) 166-93&33 Diabetes mel l i tus(2) 172020&5.94 Heart d isease (1) 172.30+0,00 Miscellaneous diseaseg2) 173,50z2.12

31 - 40 Liver disease(8) 168.69.7.75 Renal disease(7) 171,19+6.32 Diabetes mell i tus(7) 173.27710.38 Heart disease ( 168.92z5-07 Miscellaneous glsea~eg(~)l70.90+2.72

41 - 50 Liver disease( 10) 167,36+7.80 Renal d isease 166.70~3.18 Diabetes me l l i 163.9057045 Heart d isease 7 171.86+3,50 Miscellaneous $>!eases (7)168.17z55. 17

51 - 60 Liver disease(&) 169.4522- 55 Renal disease(1) 165,10+0,00 Diabetcs mellitus(3) 167.3s7.60 Heart disease(9) 171 *90+_3*52 Miscellaneous d iseases (3) 170,03+4. 32

Table 4: Percentage over weight shown by the patients investigated according to disease category. Values are expressed as percentage of ideal weight f o r height.

Disease Grou~s Percentage (%) of Ideal Weiaht a

a b _ - - c d - = e B a r" 100% of ideal weight

Liver disease 14 9 b = 100-110% of ideal weight ( 2 3)

Renal disease (16)

- a = 121-130%' I! I) I! CLabetes Mellitus 1 8 1 - - - 1 (20)

e 3 131-14096 11 II

Reart disease (22)

Miscellaneous diseases 12 4 - - - - - g = 151-160% " I1 11

( 1 6 )

Table 5 2 Blood values for &u,me,total protein, serum albumin, globulin, haemoglobin and pyruvate according to disease category, The values are shown as mean 2 standard deviations, Number of patients in each disease category are shown in parenthesis,

~ - -

Disease Tot a1 Serum Haemo- Blood Category BloodgZ~c~e protein albumin , G l o b u l i n globin pyruva t e

(mg/100ml) (g/100ml) (g/l(j~ml) (g/100ml) (g/lO~ml)

Liver (23)

Diabetes mellitus (20)

Heart (22)

Miscellaneous

(16)

z I-'. [I] 0 (D P

F (D

0 !z

t' P. C (D H a I-'. [I] (D

E

F E P P, Y d

CG ct

a co I-'-'. U) [I]

(D 5' '$ ,-J

0 Y '% [3: [I] * (D

3; P. [I] 0 CD w P

8 (D

F : P P Y d et .m

rt a co P m [I] (D

%' 3 L a I-'. [I]

a I-'. m (D

r n m , - J 0 0 I-'. n a$.rtcz

; - F : [I] 0 (D

w n

E OD v

m

h r 0 (D P.

a& ctp r e

[I] g w - . - [I] n 4 w 0 3 u - - r - l m P - b I U I U C n 0 . m e . A w l . - l A

- b o . C D N * . A w l . 4 0 N wl 4 -A

ch

\ O O r u o * u o o o u o o If I+ 0 I& I& U P 1 & 0 3 ,

0 0 3 , 0 P O * W O P \D 0

\D

u r n . m a O O - l c h C D

I& 1: 1% I& \ D W - P W W . . A W * W 0 3 P O W N C L ,

W

Table 6 contd,

~ W t j W t c td r- co r- (D r. d w p p o y d ~ c o '1, I-l

(D d - ( D P H

Table 8: Initial and final mew --dues of heaght, weight, mid-arm circumference, triceps skin fold t for liver, renal, diabetes mellitus, heart and miscellaneous d i s = , - a ~ . Means standard deviations are indicated. Number of patients i n each disease group is shown in parenthesis.

- - -

Disease Height Groups ( 4

- --

Mid-m circumference (m)

Trice s akin-fold Pmd

Init ial i n I n i t i a l Final I n i t i d - i n Init ia l F ind -

E 2

n Y

m a - P, U) n,

l? 0

e' Owl 0

A

V)

I -4

CD 0

I+ -4

4 Out a

* . A ' Table 10: Mean daily nutrient supply of the hospital diet t o four patients in each disease @;roup. * Means 2 standard deviations are indiczted

- - - - - - - - - - - - - - - - - -- - - - -

C arboh- Thia- Ribof- Ascor- Disease Category Days Energy Protein Fat ydrate Calcium Iron Retinol mine 1 avin Niacin bic acic

(kcal) (ma) ( m g ) 1 ( mg)

(i) Liver -

Mean 2 ' S , d

(3 ) Diabetes Mellitus 1 2

Mean 2 S.d

Table 10 contd.

Carboh- Thia- Ribof- Ascor- .Disease Category Days Ener Protein Fat ydrate Calcium I ron Rctinol mine lavin Niacin bia amid

(d (d Ge 1 (mg> (mg) *) (mg) (me1 (Qd 8)wu

Mean 2 S.d 2097.73 39.96 42.92 - 389.01 330.04 7.32 735.03 1-72 0.52 7.44 1-26 + + + + + + + + + + +

K - 9 5 5 3 6 3T92 13564 3:79 1140 38y23 oT43 0T26 1,82 0T66

T r i c c ~ s :.kin-f o ld -

Mid-arm Circumf c r ~mre

Weiqht

m e l l i t u s sneou s

Fig. 1: i n i t i c 1 1 dnd f i n a l 61 ruearl v a l u e s for weigh t , mi (~--,,KKI i-lrcurnt ererice ;]nri tr< ceps skin-f old of p, t I e n t c i n v a r i o u s d i :)c2,,sc c<,teyories.

Haermogl obin

L i v e r

Serum ~ l h u m i z -

Renal Pj.ahc.tes Heart Flj.scel1- m e l l i t u s a n e m s

Fiq. 2: ~ n i t i d m . . a n d f i n a l . 0 mean v a l u e s for t o t a l p r o t e i n , al.bumin and haemonlobin of p a t i e n t s i n various disease categwies.

CHAPTER FIVE

~ I s c u s s ~ o ~ ~

Indicators for Malgtritionin Hospital Patie-

Assessment of the rutritional status relies, inter alia,

on the specificity and the sensitivity of the indicators used

(~s~lune et 1 I ) In this study, nine parameters

(weightiheight, mid-arm circumference, triceps skinf old thick-

ness, blood glucose, total. protein, serum albumin, globulin,

haemoglobin and blood pyruvate) were selected for the evalua-

tion of nutritional status of hospitalized patients. When

combined, these measurements have a satisfactory specificity as

indicators for malnutrition (~elliffe, 19665 Mcfarlane. et al,

39698 Blackbxw d,&, 1977; Hill et al, 1977; Asplund eta, 1981). The iimitatims of these parameters for use on hospital

population have been dztailed elsexhere (~einsier: et al, 1979;

Wooda, 1982). ,.<

Anthroponetric M ~ : ~ r e m c ; : C s

weight/height has been used as a basic yet complementary, *--4

measure of energy support (~istriar et al, 1976; Weinsier

et a1 1979; Woods, 1982)- Triceps skin fold thickness-was - -* used as an indicator of calorie reserves being easily deter-

*- mined and also a specifically nutrition related parameter

(~istrian et al, 1976; Weinaier. et ale 19798 Woods, 1982).

Mid-arm circumference i s used to calculate the muscle tissue

(~einsier & a& 1.979). There is some controversy about the

validity of using universal anthropmetric standards on

different population Croups (~eissber~er, et al, 1982)

For the purpose of categorising the de3rees

of aaln~trition~cut off levels for severe and moderate subst-

andard of the two anthropometric measurements were chosen as

sho~rn by Weinsier et al, 1979. Severe t o ' moderate depletion

were defined by a triceps skin fold less than 20% and 60% of

standard respectively. ~eight/height less than 80% and 90% of values,

stendarg-respectively, On the basis of weight/height criterion

39 (40.21%) out of 97 patients were moderately to severely wasted

on adni,ssion with the highest number coming from diabetic patients.

The renal patients appeared to be least affected. Recent weight

loss is a cardinal manifestation of malnutrition unless an other

wise normal individual has voluntarily restricted energy intake

in an attempt to reduce weight (~irie et al, 1981). Triceps

skin fold volues showed that non of the patients was severely

malnourished on admission, however 76 (78.35%) out of 97 patients

were found to be moderately malnourished on admission, The

fact that no patient was found to be severely malnourished

by triceps skin fold criterion is possibly as a result of the

cut-off level used for severe substandard value which is below

that previously reported by Bistrian et a1 (1976) and

Yates -- et al, ( 7 9 7 7 ) . Comb ning weight/height and trj.ocpc skin

fold as indicators of malnuiritlun, 7576 (15) dizbetic, 60 a 87%

(14) liver, 43.75% (7) miscellaneous, 12.5% (2) renal, and 4.55%.

(1) heart patients were identified as being moderately mal-

nourished on admission. The high prevalence of.wasting present

in diabetic and liver patients on admission emphasises the

insidiuos nature of the effects of chronic diseases on nutrient

requirements and further the importance of instituting and

maintaining optimal nutritional status as soon as pos::ible

after the on set of the illness. Such measures would imply

understanding of the underlying mechanisms predisposing to

wasting which may be lacki2g or may be inapparent in view of

the possible lnultifactorial naturs of the disease (~abadarios

and Rossouw, 1981). However poor dietary intake is a major

cause of wasting ( ~ e ~ s and Grande, 1973).

The high an-thropome ti-i 2 measurexent s yotrayed by renal

and cardiac patients in this study is in line with the nature

cf their illnesses, Oedena and ascitis are common features in

them thereby elevating the values of their body measurements,

This therefore will complicate the interpretation of their

nutritional status based on anthropometry.

52,

Biochemical Evaluation

Hypo-albuminemia has been sho~~i to be a key diagnostic

feature of protein - calorio ~alnutri-tion, (V~oas, 1982).

In this study a high pruvalence of hypo-albuminemia is

indicated among patients admitted for renal and liver problems.

This is in agreement witk findicgs of Rollet and Owens, (1~73)~

and Bistrian & al, (1976)~ Low serum albumin can have multiple

causes, although inadequate protein intake has been associated

with a rapid drop in al.bumin level (~uodu, ,1975): . . , . Non nutritional factors such as impaired hepatic synthesis of

albumin and increased 1 3 s ~ of protein (~roteinuria) have been

in,!-i-cated ii~ liver and renal problems respectively. Since

protein synthesis is affected in liver disease, caution has

to be taken in using serum albumin as a marker of nutritional

statns for patients with liver di::ease (NW and Nnanyelugo,

1984).

The relatively good nutritioxl status of the diabetic

patients in terms of serum albumin is in line with that found

by Ballet and Owens (1973) who had mean serum albumin and haemo-

globin levels of 4.1 lg/'~OOi~~l and I 3.9g/100ml respectively.

The high level of blcod glucose seen in diabetic patients is

not surprising since the ~atients vere zdmitted for control

such as glucosuria.

53.

Follow-up Evaluation

The failure of the patients admitted for liver, rend,

heart and miscellaneous diaeasee to reach a mean level equal or

greater thsn 3.5c/106m1 for albumin at two weeks of admission

(Table 8 and Fig. 1) raises some questions such as whether

patients receive inadequate nutrition support or whether the

parameters worsen regardless of nutrition support on the basis

of the underlying disease process or necec:sary hospital

practices. It is noteworthy that all the liver patients had a

slight increase in their individual al.bumin level at 2 weeks

compared with the levels on admission representing a net mean

gain of 12.34%. This is also true of renal patients representing

an increase of 51,50%. Two out of nine diabetic patients had

a mean fall of l.3lg/100ml0 On? cat of four cardiac6 fell to 3.5g/100ml

from 4.53g/100rnl while 3 of six miscellansous patients had a L mean fall. of 0,73~/100rnl. The fall in the m a n albumin level

of miscellaneous patients from 3.59g/100ml on admission to

3.4g/100ml st 2 weeks cf admission suggests a redaced nutrient

intake and development of hospital malnutrition during hospita-

lization although serum al-bumin level of 3.4g/100ml was found

to be the highest level obtained from healthy adult Nigerians

(~dozien, 1965)- Likelihood of increase2 incidence of mslnutrftion

with prolonged hospital siay has been reported by sev,lrl

investigators (~ollet and Ovens, 1973; Eistrian et al, 1974;

Bistrian, et al. 1975; Bistrian et al, 1976; Bistrian . 7 ' : -- 1977; Weinsier; -- et al. 1979). Malnutrition reduces t h ~ incane-

competence of patients ( ~ a w & aJ, 1974).

Reduction in weight, mid arm circumference and triceps

skin fold of the renal patients at two weeks of admission is

expected since odema and ascitis disappear as recovery progresses.

The net improvement in the weight, triceps skin fold, mid-arm

circumferenca, serum albumin and haemoglobin levels of diabetic

patients might be due to better handling of carbohydrate

resulting from insulin administration with proper therapy and

probably reduction in breakdown of protein and fat stores. It

has been observed thst insulin response to the combined stimulus

of catabolic stress and carbohydrate feeding reduces the mobili-

zation of protein and fat stores (wagstaff et al, 1977).

Blackburn et al, (1977) observed that fat mobilization is

inhibited by insulin. Also adiposity is significantly related

to improvement in glucose tolerance. Total protein and globulin

were highest in the diabetics than in patients in the rest of

the disease groups poseibly resulting from polyphagia which ia

associated vith diabetics and so can lead to more intake of

various nutrients (Good hart and Shils, 1973). The fall in

blood glucose is also due to insulin adninistration which leads

to proper utilization of glucose. The mean low haemoglobin

l e v e l seen among p a t i e n t s on admission and 2 weeks of admission

may i n p a r t be due t o t h e chron ic blood l o s s a s i n haemolyt ic

d i s ea se . U n a v a i l a b i l i t y of necessa ry n u t r i e n t s may s e r i o u s l y

a f f e c t t h e haemoglobin l e v e l of p a t i e n t s . Also t h e volume o f

blood r e q u i r e d f o r l a b o r a t o r y t e s t s may a f f e c t t h e haemoglobin

l e v e l s of p a t i e n t s .

The mean pyruvate l e v e l s o f t h e p a t i e n t s i n t h e va r ious

desease c o n d i t i o r ~ s i s w i t h i n t h e range as ob t a ined by Annan

(1975) and Oeand e t a1.(1975)3 64.75219.50pg/100ml and 3 6 . 4 8 ~ /

100ml r e s p e c t i v e l y , a l though f i v e p a t i e n t s had va lues

l e s s than 36pg/1"0m1, Blood pyruvate l e v e l was es t imated t o

i n d i r e c t l y a s s e s s t h e th iamin l e v e l of t h e p a t i e n t s . Thiamin

de f i c i ency has been a s s o c i a t e d wi th e l eva t ed l e v e l s o f blood

pyruvat e ,

Phys io log i ca l chani:es t h a t l e d t o m a l n u t r i t i o n among t h e

p a t i e n t s cannot be a t t r i b u t e d s t r i c t l y t o age range, occupat ion,

educa t i ona l b a c k g r x n d and marital s t a t u s .

Food Se rv i ce t o P a t i e n t s

Food served i n t h e h o ~ p i t a l ' h a s been r e p o r t e d t o be t h e

main problem of h o s p i t a l s t a y o obi as and Van I t a l l i e , 1977).

The d e f e c t s of t h e h o s p i t a l d i e t from t h e p a t i e n t s po in t of

view a r e mul t ip le . Not on ly i s t h e fooa o f t e n poor ly cooked,

and g e n e r a l l y r a t h e r co ld , bu t t h e r e i s l i t t l e weekiy v a r l e i y

56. !

and seldom m y choice of d ishes , Suck okservatione have been recorded

previously ( A n n O n ~ . ' '945) P a t i e n t s pay well f o r h o s p i t a l

care and they have a r i g h t t o expect t o be f ed well i n return.

The condit ion of a p a t i e n t with poor a p p e t i t e w i l l be more

c r i t i c a l when he i s offered inspid o r even r e p e l l e n t food.

Food may be cold when i t reaches a p a t i e n t b e c a u s e ' i t i s t r a m

sported along co r r ido r s on o ld fashioned open t r o l l e y s , i n s t ead

of i n the heated t r o l l e y s . Since the buying of food i s the

r enpons ib i l i t y of one o f f i c e r , and the cooking the r e s p o n s i b i l i t y

of m o t h e r , and the d i s t r i b u t i o n perhaps of a t h i r d , it i s

d i f f i c u l t t o achieve a high uniform standard through out h o s p i t a l

feeding. However, attempt should be made t o improve t h e

s tandard of food given t o pa t ien ts . The two primary gozls i n

n u t r i t i o n a l i n t e rven t ion a r e f i r s t t o meet the energy demands of

the indiv idual so t h a t no energy deficit e x i s t s and second, t o

provide amino ac ids i n amounts s u f f i c i e n t t o support optimal

r a t e s of p ro te in synthes is ( ~ t e f f e e , 1980). This w i l l only be

achieved i f food i s consumed by pa t ien ts . The n u t r i e n t supply

of enerc;y, pro te in , calcium, i ron , r e t i n o l , thiamine,riboflavin,

n i a c i n and ascorbic ac id t o p a t i e n t s i n the h o s p i t a l was below

t h a t xeco~rmnded f o r hea l thy ind iv idua l s except i r o n and r e t i n o l

f o r l i v e r and miscellaneous p a t i e n t s respect ively. However,

energy supply t o d i a b e t i c p a t i e n t s was more than the normal

d i a b e t i c allowance prescr ibed by phyei .dan and prote in i r r fab w- 113%' of FA0 requirement. There have been

. .. .. .

57 s i m i l a r r e p o r t s of d i a b e t i c s being given the wrong food o r

food being o f fe red i n wrong q u a n t i t i e s and of p a t i e n t of a l l

kinds going hungry because they could not fancy t h e i r food

( ~ n n o n ~ m . 1945). The i n v e s t i g a t o r observed t h a t foods served

t o d i a b e t i c s were not weighed i n the wards before being given

out t o ensure t h a t co r rec t amount of food i s being given t o

the r i g h t pa t i en t . There were jus t l a b e l s of names on high

p ro te in and d isease condit ion but not on quan t i ty t o be

given. It has been suggested t h a t d i e t a r y adequacy of ill

p a t i e n t s should be r e l a t e d t o the d isease process r a t h e r than

t o t h e recommended in t ake f o r the normal population ( ~ a b a d a r i o s

and Rossouw, 1981). Considering the reduced a c t i v i t y of

hosp i t a l i zed p a t i e n t s , it could be concluded t h a t the food

given t o p a t i e n t s i f consumed was enough t o meet t h e i r nu t r i -

t i o n a l needs except f o r ascorbic ac id and r i b o f l a v i n although

low t o t a l pro te in , albunin and haemoglobin among miscellaneous

p a t i e n t s a t two weeks of hospi ta . l iza t ion suggest low

n u t r i e n t intake. Also f a i l u r e of a l l t h e p a t i e n t s except

d i a b e t i c p a t i e n t s t o a t t a i n mean albumin l e v e l equal t o o r

above j.5g/100ml at 2 weeks of admission suggests low n u t r i e n t

i n t ake

S ~ ~ ~ A R Y AND CONCLUSION 58

There is evidence of malnutrition of varied aetiology and

incidence in the patients investigated both on admission and

2 weeks after admission. The quality of food served to petients in

the h0spj.t r t l 1-eaves much to be desired, The general nutritional

care given to patients is wanting, Analysis of patients charts

indicated that only weight and not height was recorded for

patients making it impossible to assess relative weight,

Furthermore weight was often not monitored. There seems to

be lack of communication between staff physicians and dietitians

in the hospital. Nutritional counseling was seldomly given to

patisn-ts even when it is indicated by the physicians, This may

be &trfbuted to shortage . of dietitlam :in the hospital. The

investigator does not believe that these findings are unique

to the institution of study. The types of patients admitted

and the quality of care yrovidua is likely to be representative

of most hospitals in Nigeria. Sucil sitxation has been reported

elsewhere outside Nigeria,

Teaching hospitals tend to be the last x e s o ~ m d to

receive seriously ill patients. Patients staying two weeks

or more are likely to be the sickest and in such a population,

it is possible that both nutritional and non-uutritional'

parameters of health may deteriorate despite optimsl care.

It is the investigator's opinion, that people concerned with

patients care become aware of the nutrLtional surveillance

of hospital in-patients. All these have direct bearing on

morbidity and mortality and also c s l l s for closer co-operation

of the physician, dietitians and nurses for effective

therapy.

Abel, R.M., Fisher, J.E., Buck1 ey, M.J. Hyperalimentation i n cardiac surgery: A review of s ix ty four patients. J. Thorac. Cardiov. Surg. a 294-300, 1974.

Abdou, N.1 , and Richter, M. Role of the bone-marrow in the immune response. Adv. Immunol. 32 201, 1970.

Antener, I., Verwilghen, A.M., Vm Geertcand Maumn, J. Biochemical study of malnutrition - si tuat ion before treatment. Acta Tropica 34: 331-354, 1977.

Asplund, K., Normark, M, and Pettersson, V. Nutritional Assessnient.of Psych@sriatric patients. Age and Ageing, I0 87-94, 1981. - Annan, W.A. Method f o r the determination of blood l ac t a t e and pyruvate using an LKB 8600 reaction r a t e analyser. Ned. Lab. Tech. 2 287-294, 1975.

Anonymous. What i s wrong with hospital diet , Hospital Food Lancet 61-62, 1945.

?istrim, B.R., Blackburn, G e L , , Hallowellp E e , and Heddle, Re Protein s t a tus of general surgical patients. JAMB A ' 858-860, 1974.

Bistrian, B.R., Blackburn, G.L., Scrimshaw, N.S., and F l a t t , J. Ccll.ular Immunity i n semi starved s t a t e s i n hospitalized adults, 28 1148-11559 1975. - Bistr ian, B.R,, Blackburn, G.L., Vitale, J., Ccchran, D. and Naylor, J. Prevalence of mdnutr i t ion i n general medical patients. JPMA 1567-70, 19';6.

Bistr ian, B.R. Nutritional assessment and therapy of protein-calorie malnutrition i n the hospital. Research 393-397 9 1977

Blackb~irn, G.L. and Bistr ian, B..H, Nutrit ional care of injured and/or s e r t i c pat ier t . Symposium on Response t o infection and injury. 1195-1225, 1976.

Blackburn, GoL. and Bist i ran, B.R. Careers i n nutr i t ion fram the c l i n a l view po.@ts. Nutr. Rev. 2 97, 1976.

Blackburn, G.L. andMaini, B.S., Pierce, E.C.. Nutrition i n .I;.

the c r i t i oa l ly ill patienta. hes thes i cdo 42 181-194, l 9 n .

Bollet , A.J. and Owens, S. Evaluation of nut r i t iona l s ta tus of selected hospitalized patients. h. J m Clin. Nutr. 26 9L1-938 9 1973.

Butterworth, C.E. The skeleton i n the h o s p i t d closet. Nut. Today 4 4-8, 1974.

Butterworth, C.E. and Blackburn, G.L. Hospital Malnutrition. Nutrition Today. 2 8-18, 1975.

Butterworth, C.E. and Weinsier, RoLe Malnutrition i n hospital In-Patients. Assessment and Treatmentr Nutrition in Health and Disease, 6-th ed. 667-684, 1980.

Butterf i e l d , W. J .He, Keen, H. and Whichelow, M O J O Renal glucose threshold variations w i t h age. Br. Med. J o 4 505-507, 1967.

Committee Report. Assessment of protein nutr i t ion s ta tus Am. J e Clin Nutr. 23 807, 1970.

Cornall, A.G.9 Bardawill, CoJm and David, M.K. Recent advances i n c l in ica l pathology. 2nd Ed. J. Biol. Chem, a 7519 1949.

Crenshawo C. Nutrit ional support f o r bum patients. *TAKE perspectives in c l in i ca l Nutrition. Eaton Laboratorie.: , 1973.

Daly, J.M., Dudrick, S.J. and Copeland, E.M. Effects of protein depletion and repletion on c e l l mediated immunity i n experimental animals. Ann. Surg. 188 791-796, 1978.

Dacie, J.V. and Lewis, S.M. Pract ical haamatology. 4th &a 12, 1975.

Duodu, TmAe Biochemical methods of 4t. t a o t i q , margind malnutrition. YheD. Thesis Univ. of Lcndon, 1975.

Edozien, J o C . Biochemical evaluation of the s t a t e of nut r i t ion i n Nigeria. J. West Africa Sci. Assoc. Vol. 10 NO. 22-38, 19650

FA0 Food composition tables f o r use i n Africa, Food and Agriculture Organisatioq' Rome, 1969.

FA0 /K~o. Calcium requirements. Report of FAO/WHO Report mmp, Rome 1961.

FAO/WHO requirements f o r vitamin A, thiamine, riboflavin and niacin. Tech. Report Series No. 362, Geneva; 1967.

FAO/WHO. Bequirements of Ascorbic acid, vit . D. V i t . Blp, f o l a t e and iron. Technical Heport ser ies No. 452, 1970.

FAO/WHO, Ehergy and protein requirements. RepoH, of a joint F'AC/WEO ~d Hoc. Expert Commiteee No. 522, Geneva, 1973.

Feltlmti?, J .J. Pat ients opinions of Hospital Pood. J U . 4O 325-3251, 1962. -- .- Galbraj . th , E. D. Hospital d i e t e t i c s in t rans i t ion JADA 6'J, 4399U9 1975.

Goodhmt, R.S. and Shi l l s , M.E. Modem Nutrition i n Health and disease. 5 t h ed. 1012-1036, 1973.

IIegsted, D.M. Nutritional requirements. JADA, 303-37, 1970.

Hill, G,L., Blackett, R.L., Pickford, I., Burkinshaw, L., Young, G. A., Warren, J .V, , Schorah, C.J. and Morgan, D.B. Malnutrition in surgical patients8 an unrecognised protein problem Lancet 1, 689-92, 1977.

Halsewood, G.A.D. and Strookman, T.A. Glucose in blood and CSF. Biochem. J. 3 92, 1939.

J e l l i f f e e , D.B. The assessment of nutr i t ional s ta tus of the community. WE0 monograph se r i e s No. 53, Geneva, 1966.

Kaufman, M., Dunham, M.A. and Sanders , L A e The Challenge of Nursing Home food service: A study of Diet= consultation service. JADA & 313-317, 1962.

Keys, A., Grande, P. Body weight, body composition and calor ie status. In modern nut r i t ion i n Health and Disease. 5 t h ed. Good hart , RS. and Bhills, M.E. 1-279 1973.

Kassiodu, A. Domingos, J.C., Vianna9 R. Malnutrition i n general medical and surgical patients. J.P.E.N. 2, 199, 1978.

Kirsh, R.L., Fr i th , E., Black, El and Hoffenberg, R. Regulation of albumin synthesis and catabolism by a l te ra t ion of dietary protein. Nature. 2lJ 578, 1968.

Law, D.K., Dudrick, S.J., Abdou, N.I. The ef fec ts of protein calor ie malnutrition and immune competence of the surgical patients. Surg. Gynecol. Obst. 139 257-66, 1974.

Lagua, R.T., Claudio, V.S. and Thiele, VeFo Nutrition and Diet Therapy: Reference Dictionary. 2 &. 146, 1974.

Labadarios, D.B. and Rossouw, J.E. Malnutrition in three hospital population. South African Med. J. 60, 213-216, 1981.

Leevy, C.M., Cardi, L., Frank, 0. Incidence and significanoe of hypo vitaminemia i n a randomly selected municipal hospital population. Am. J. Clin. Nutr. 17 259-263, 1965.

Mc Farlsne, II. , Ogbeide, M.I., 2 6 d d ~ , S., Adcock, K.J., Adeshina, H., Gurney, J.M., Cooke, A., Taylor, G.O. and Mordie, J.A. Biochemical assessment of protein calor ie malnutrition. Lancet 1 392-5, 1969.

Mc Farlane, H. and Hamid, J. Cell-mediated immune response i n malnutrition. Clin. Dcp. Immunol. 153, 1973.

Metropolitan Life Insurance Co. Stat is . Bull. 4 &. Nov.-Dec, 1959

N i l s , A., Asplund, K. and Bjenner, L. Nutrit ional s ta tus of medical pat ients on emergency admission t o hospital. Acta. Xed. Scand. 2 1 2 8 157-156, 1982.

Ngwu,E.K. and Nnanyelugo, D.O. Biochemical evaluation of hospitalized pat ients admitted at University of Nigeria Teaching Hospital (UNTH), Enugu. Paper presented a t annual conference of Nutrition Society of Nigeria, Port-Hacourt, 1984.

Nnanyelugo, D.O. and Ngwu, E.K. Differences i n growth patterns of children i n f ive geographical sub-aivisionk cf Anambra State, Nigeria. Nig. J. Nutr. Sci. f? 1-14, 1985.

Northam, B.E., Smith, J.A. and Fitzgerald, M.G. Value of serum glucose assay as part of the biochemical prof i le in screening f o r diabetes. Ann. Clin. Biochem, 2 412-415, 1982.

Ozand, D.T. Hawkins, R.L., Collins, R.M., Tildon, J.T. and Cornblath, M. A micro-antoanalytic procedure developed

-

f o r the determination of ketone bodies, gluconeogenic amino acids, pyruvate, l ac t a t e and glucose i n metabolic studies. Biochem. Medicine & 170-183, 1975.

Okeke, E.C., Nnanyelugo, D.O. and Ngwu, E. The prevalence of obesity i n Adults by age, sex and occupation in hambra State, Nigeria. Growth. &Z 263-27 1, 1983.

P i r ie , P., Jacobs, D., Jeffrey, R. Distribution i n se l f reported height and weight data. JADA 2 601-606, 1981.

Prevost, E.A. and Butterworth, C.E. Nutrit ional care of hospitalized . 'patients. Am. J. Clin. Nutr. 2J 432, 1974.

P l a t t , B.S. Table of representative values of foods commonly used i n t ropical countries. Med. Res. Counc, Rep. Ser. No. 302 (seventh impression), HMSB London, 1975.

Rocchio, M.A. and Randal, H.T. Nutrition i n inflametory disease of the bowel, WUKEt Perspeotive i n Clim Nutrs f91L. Seltzer , M.H., Fletcher, H.S., Slocum, BOA. and Engler, P.E., Techniques, material, and devices I ~ s t a n t nutr i t ional assesameitt i n the intensive care unit. J P ~ A 70-72, 1980.

Seltzer, M.H., Fletoher, H.S., Slocum, B.A. and Engler, P.E. Techixiques, materials and devices. Instant nutr i t ional assessment i n the intensive care unit. JPEN 5 70-72, 1981.

Sel tzer , M.R. Presidential address. Specialized nutr i t ion uuppoz-c. 1h6 s i , adad 3; c a x . t 1d5-m I@, 1982.

Sauberilich, H.E., Rowdy, R.P. and SkaJa, J.H. Laboratory Tests f o r the assessment of n u t r i t i o n d status. CRC Press .fno* P ... 22-27 and 9+94, 1977.

Scrimshaw, N.S., Taylor, C.E. and Gordon, J.E. Interactions of nut r i t ion and infection. WHO monograph Series No. 57, 1968.

Steffee, W.P. Special communication: Malnutrition i n hospitalized patients. JdU, - 2 4 : 2630-2635, 1980.

Thurnberp, B.J., Swamy, A.P. and Cestear, R,~.M. Cross-section and l o n g i t u d m , ', ,: l p u t r i t ional measurements i n maintenance of haemocilysis patients. Am. J . Clin. Nutr. .- 348 2005-2'012, 1981.

Tobias, A amd Van I t t d i e , T.B. N u t r i t i m d problems of hospi t& zed patients. A preliininary survey. J . A.D. A. a 253-257 , 1977

Waterlow, J.C. The assessment of protein calorie malnutrition and metabolism i n the whole animal with special reference t o man. I n Mammalian protein metabolism edited by HoN. Munro. New York Acedemic Press, 1325, 1969.

Idagstaff, M.A. Nutrition and infection i n the hospital. im. J. Clin. Nutr. 2 562, 1977.

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Weissberger, L.E., Sowa, D. and Weddle, D. Clinical Nutritional assessment: A two month evaluation "perspective i n p r a c t i ~ e . ~ JADA. 81, No. 1, 1982.

Flill-Cutts , H., Driscoll, J J Reed, B. Paxenteral nut r i t ion and nut r i t ional assessment. 200, 1978.

Whitehead, R.G., Coward, W.A. and Lunn, P.G. Serum albumin concentrdtion and the onset of kwashiorkor. Lancet 1 63, 1973.

WHO expert Committee on Diabetes mellitus. Second Report. WHO Tech. Rept. Ser. 646, 1980.

Woods, H.F. Biochemical methods i n nutr i t ional assessment. Proc. ~ u t . SOC. & 419424, 1982.

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,L VALUES FOR B ;LoOD GLUCOSE, TOTAL PROTEIN, . ALBUMIN, GLOBULIN, IIAEMOGLOBIN, HEIGHT, WZIGHT,

'MID-ARM CTSCUMFERENCE AND TRICEPS SKIN-FOLD OF LIVER PATIENTS ACCOR3ING TO AGE GROUPS.'mmS $ STANDARD DEVIATIONS ARE INDICATED.

; t- W Appendix Table 001ar I n i t i a l values fo r blood glucose, to ta l protein, albumin, globulin, -

. haemoglobin, height, weight, mid-axm circumference and triceps skin-fold of l i ve r patients according t o age groups, Means 2 Standard

20-30 (PSI 1 Deviations are indicated.

Mid-arm Pats* Blood Total Haemo- Circum- Tricep

- . glucose ., protein Albmin Globulin globin Height Weight Zerence skin-fold ~ / N c r (mg#100ml) (g/lOOml) (g/100ml (g/100ml) ( g / l O O m l ) (cm) (kg) ( c d ( m d

Means 80.88 6-44 + + + . 2 3 8 8 0T6 9

Appendix Table OO1a contd. . .

-

Mi d-arm PatB, Blood Tot a1 Haemo- Circum- Triceps S/NG glucose protein Albumin Globulin globin 3eight Weight ference skin-fold

mg/ 100ml g/'l~~ml g/?~~ml g/l 00ml g/100ml cm (kg) (cm) (mm)

Means 2 86.10 6.28 2.74 3-54 9.49 767-36 62.30 25.93 6-56 Sod. +26.81 - - +Om 76 - +O 4 1 - +O. 76 - +1.74 27.80 - +10.42 23.89 23.10

2 ' 2 2

0\ u . . ' " + - ! " a ? b , . ,

0 -4 '3 IU P I0 o p v l o o o

* .

ch03"Ppfy b . . .

Appendix Tabla: 001b contd, v

Pats. Blood T o t a1 Haemo- Mid-arm Triceps Circuni- skin-

s/N~, glucose p ro te in Albumin Globulin g lobin Height .Weight fe rence f o l d m g / 1 0 0 m l d l 00nl a/l00ml dl 0 0 m l 00ml ( cm) ( ka) ( cm) (m)

FARMERS

Means 71-57 6.38 2.92 3-46 10.20 167.47 58.46 24-89 5.13 + + + + + + + + + +

s .;f. .27:26 oT79 K3rl 0-5-7 1 2r74 6,35 9.66 4 3 5 2.0 1

Means 75.33 6-61 3.56 3.05 12-81 169.50 65-07 27.53 6.50 + + + + + + + + f, +

sya . 1 4 3 5 1:06 oT64 oT5 1 3335 35? 1 4T8 5 3.54 2 3 3

T *In i t i a l : arid F i n a l Values f o r Eight LIVER P a t i e n t s f o r whom dppendix Table 001~: kLasurements were complete f o r Blood Glucose, T o t a l p ro t e in ,

Albumin, Globul in and Haemoglobin. M,S,D 2 a r e shown.

Pats. Blood g lucose T g t a l p r o t e i n Albbn Glo'bulin Haemoglobin S/NO. mg/l 00ml 8;/100ml ~ / 1 0 0 m l g/!100ml gf 1 00ml

1 I n i t i a l 85 F i n a l 107

2 , I n i t id 10 4 F i n a l 9 0

3 - I n i t i a l 138 F i n a l 106

4. I n i t i a l 117 F i n a l 8 6

5. I n i t i a l 65 5.85 2.93 2.92 9-43 F i n d 65 7.45 3.16 4.29 10.38

6. I n i t i a l 64 7-67 3-50 4-17 11.80 F i n a l 60 7.62 3.29 4.33 70.90

7. I n i t i a l 54 F i n a l 64

8 I n i t i a l 65 F i n a l 6 0

Appendix Table OOld8 I n i t i a l and F i n a l Values f o r E igh t LIVER P a t i e n t s 72. f o r whom Measurements were complete f o r Height , Weight, Mid-arm Circumference and T r i ceps skin-fold.

Means 2 Standard Devia t ion a r e shown. -.

Pals. Mid-arm T r i c e p s

s/m Height Weight Circumference sl-in-fold (cm)! . (kg) : cm . h ~ m .

1. I n i t i a l 1'74.20 57.70 21.00 3.0 F i n a l 174.20 55.40 20.80 3.6

2. I n i t i a l 166.20 44.20 20.00 4.2 F i n a l 156.20 44.20 20.00 4,4

3. I n i t i a l 154.80 50.30 27.00 7.2 F i n a l 154.80 51 .oo 26.80 7 .o

5. I n i t i a l 182.40 60.00 23.50 6 .OO F i n a l 182.40 61.00 23.00 6.20

6. I n i t i a l 156.20 44.20 19.40 4 0 F i n a l 156.20 46.00 20.20 5.0

7. I n i t i a l 173.30 56.10 23.00 4.0 F i n a l 173.30 56.00 24.00 5.2

8 I n i t i a l 172.00 56.10 22.00 4.5 F i n a l 172.00 56.00 23.60 5.1

APPENDIX 002

I N I T I A L VALUES FOR BLOOD GLUCOSE, TOTAL P R O T E I N , ALBUMIN, GLOBULIN, HAEMOGLOBIN, H E I G H T , WEIGHT, I I I L A R M CIRCUMFERENCE AND TRICEPS SKIN FOLD FOR RDIJAL PATIEN~S ACCORDING TO AGE GROUPS. MEANS - + STANDARD D D V I A T I O N S ARE .TBUICATED.

Appendix Table W2a: In i t ia l values for blood glucose, tota l protein, albumin, globulin, 2 C I - 7 - haemoglobin, height, weight, mid-amcircuroferences and triceps

skin fold for renal patients according to age groups. Means 2 20 - 30, ( y e w s ) Stddard deviations are indicated. 4

Mid-arm Triceps Pats. Blood Total Haemo- Circum- skin S/N o glucose protein Albumin Globulin globin Height Weight ference fo ld

mg/100ml j/100ml g/100ml d100rnl _8;/100ml (cm) (kg) ( cm) (mm

14 5 8 4-94 1.17 3.77 3-77 169.70 79.93 25-50 5.20 2. 56 7.00 3-91 3-09 14.50 168.00 66.00 30.50 5.40

3 906 4.94 3.09 1-85 9-64 165.10 49.50 25-50 3-80 4. 106 5.97 7-71 2.26 33.67 164.90 64.80 25.50 5-00

Means 87.50 5.71 2.97 2.74 10.40 166-93 65.06 26.75 4.85

a

E Appendix Table 002s contd.

41 - 50 (~rs)

Mid-arm Triceps Total Circum- skin Pats, Blood Haem02 I

S/:JQ~ g lucose pro5ein Albumin Globulin globid 3eight Weight f erence f o l d ma/lO@ml gf100ml g/100ml pfj00ml g / l O O m l ( cm (kg) cm (m)

Means 72.75 + +

sTa. 18577

fdlh mt Initial Values for Blood Glucose, Total protein, Albumin, Globulin, Haemoglobin, bight, Weight, Mid-am Circumference and Triceps skin-fold of REmAl Patients according to Occupation, Means S.D. aze indicated.

d : . .

CIVIL SERVANTS Mid-arm Triceps

Pats,. Blood Total Haemo- ~ircum- skin .S/Nf - glucose protein ~lbumin Globulin globin Height Weight f erence fold

. ? . - _ mg/100ml ~/100ml af100nJ. B/100ml a/100ml ( cm) (kd ( cm) (mm)

1; 77 ' 7.82 2.50 4. 32 43-70 183-50 92.24 30.00 13.00

Means 73.60 5.55 2.72 2 -03 . 11.11 170.06 70.47 27.32 6-94

BUSINESS MEN

Means 81.00 5-97 3-50 2.47 7.27 166.55 57.75 28.00 4.60 + - + + + + + + + + + S,C. 35736 1T46 ~ : 5 8 0T88 5T9 1 2T05 1C67 3T54 133

FARMERS

~ppfx'&X Table: 002b contd.

STUDENTS

Mid-arm Triceps Pats. Blood Total Haemo- Circum- skin S / N ~ glucose protein Albumin Globulin globin Height Weight ference fold

rnR/100ml g/100ml g/100rnl g/100ml a/100ml ( cm (kg;) ( cm) mm)

e

Means 72.88 4.79 2.05 2.74 9.22 168.68 72-36 26.73 5.30 + + + + + + + + + +

s 2. 18T50 0T89 0:9 7 0 2 9 - 3 3 1 3T37 6T40 lTl7 0T56

Appendix Table 002c: I n i t i a l and F i n a l Values f o r s i x RENAl , 78. P a t i e n t s f o r whomri'easurements were complete f o r Blood Glucose, T o t a l p r o t e i n , Albumin, Globul in , and Haemoglobin. Means 2 S.D. a r e shown.

. . P a t e . Blood Tot a1 Haemo- S/NO. glucose p r o t e i n Album$n Globul in g lob in

m g / 100ml g / l O O m l g/l00ml g/100ml ~/100rnl

1

2 . 3.

4.

5.

6.

Means . .I.

I n i t i a l F i n a l

I n i t i a l F i n a l

I n i t i a l F i n a l

I n i t i a l F i n a l

I n i t i a l F i n a l

I n i t i a l F i n a l

fnittal

F i n a l

Appendix Table: 002dt I n i t i a l and F i n a l Valuou f o r six Renal P a t i e n t a f l.9 f o r whom ieasurements were oqmple.te for Height, Weight, Mid-arm Circumference and Tr i ceps skin-fold. Means S.D. a r e shown.

Mid-arm Tr i ceps Height Weight c i rcumference s k i n f o l d

(cm) (kg) ( cm) (mm)

1 I n i t i a l 169.70 79.93 25.50 5.20 F i n a l 769.70 77.80 26.00 9.20

2 I n i t i a l F i n a l

3. I n i t i a l F i n a l

4. I n i t i a l F i n a l

5. I n i t i a l F i n a l

6, I n i t i a l F i n a l

Means I n i t i a l 168.62 72.06 26.67 5.17 i-3.83 414.18 21.37 - - +o .71

F i n a l 168.62 62.75 26.45 4-98 +3.83 49.42 21.24 - +O. 78 -

I 80.

APPENDIX 003 -

I N I T I A L VALUES FOR BLOOD GLUCOSE, TOTAL PROTEIN, ALBUMIN, GLOBULIN, HAEMOLOBIN HEIGHT, WEICW, ,.

MILARM CIRCUMFERENCE AND TRICEPS SKIN FOLD OF DIABhTIC PATIENTS ACCORDING TO AGE CROUPS. m A N S - + STANDARD DEVIATIONS ARE INDICATED.

Initial values for blood glucose, total protein, albumin, 0 r

. Appendix Table 003a8 globulin, haemoglobin, height, weight, mid-- circumference ac) and triceps skin fold of digbetic patients acconiing

. - to age groups. Means + Stand& Deviations are indicated. 20 - 30 ( ~ r s )

Mid-arm Pat& Blood Tot a1 Haemo- Sircum- Triceps S/NO. glucose protein Albumin GlobdLin globin Height Weight ference skinfold

m~/100ml g/100ml g / 1 0 0 m l g /100ml a/100ml ( cm) (kg) ( cm) (m)

G . cO

Appendix Table C03a contd.

40 - 50 (-'= 1)

- - Mid-arm Pat 6- Blood To ta l Haemo- Circum- Tr iceas

S/NO. glucose p r o t e i n Albumin Globulin e lob in Height Weight ference skin-icld mg/100ml g/~00rnl g / l ~ ~ ) m l g/100ml g/100rnl ( cm) (kg) ( cm) (mm~-

1 . 2.

3 e

4. 5. 6.

7. 8.

Means + -

S.d.

Means 134.33 + +

s:d . 7 4 3 9

Appendix Table 003b contd.

CL FARMERS

Mi d-arm PatS .. Blood Total Eaemo- C i r c m Triceps S/NO. glucose protein Albumin Globulin globin Height Weight ference skin-fold

m~/100ml g/100ml ~/100ml &/100ml g/¶ 00m1 ( em) (kg) (cm) (mm)

Means 129.50 8.24 3-97 4-33 9.70 172.20 54.25 21.55 5.15 + + + + + + + + + +

s .;a 28T99 0T59 0T8 8 1T46 0T30 5T94 22y27 4T31 0T2 1

Append* ~ h l ~ ~3~ I n i t i a l and F i n a l Values fo r H.lne Uabetie s* P a t i e n t s f o r whomdi'easurements were complete f o r Blood Glucose, T o t a l p r o t e i n , Albumin,

Globulin. and Haemoglobin. Means 2 S.D. are ind ica ted .

Pats . Blood T o t a l Haemo- S/NO g lucose p r o t e i n A l b u d n Glob l in g l o b i n - m g / l O O m l dl OOml a / l O O m l &loom1 g/100ml

- -

1.

2.

3.

4

5.

6.

7.

8 . 9 .

Means + -

S o d .

I n i t i a l F i n a l

I n i t i a l F i n a l

I n i t i a l F i n a l

I n i t i a l F i n a l

I n i t i a l F i n a l

I n i t i a l F i n a l

I n i t i a l F i n a l

I n i t i a l F i n a l

I n i t i a l F i n a l

I n i t i a l

F i n a l

Appendix Table r 003dr I n i t i a l and F ina l Values f o r ! kne Diabe t ic P a t i e n t s f o r whomLteasurements were complete 86, f o r Height, Weight, Mid-arm Circumference and a

Triceps skin-fold, Meam 2 SOD a r e ind ica ted .

Mid-arm Pate. . Circum- Tr iceps

S/NO . Height Weight f erence skin-f o ld ( cm) (kg) ( cm) mm

1. ~ n i t i a l 168.0 38.5 18.5 5 .o F i n a l 168.0 38.7 18.8 5.2

2 I n i t i a l 170.0 103.8 33.5 18.4 Fina l 178 0 100.1 33.5 18.6

3. I n i t i a l 181.1 64.7 22.5 4.0 Fina l 181.1 62.2 23.6 4.2

5. fnitlal 160.5 43.0 24.2 6.2 Fina l 160.5 44 2 23.5 6.4

6, I n i t i a l 156.1 43.35 23.8 4.8 Fina l 156.1 46.68 23.6 6 .O

7. I n i t i a l 151.6 50.10 24.4 7.0 Fina l 161.6 58.3 26.0 9 0

8 I n i t i a l 165.9 51.15 26.6 7.4 F i n a l 165.9 54 25.5 7.4

I N I T I A L VALUES FOR BLOOD GLUCOSE, T O T A L P R O T E I N , ALBUMIN, G L O B U L I N , HAEMOGLOBIN, H E I G H T , WEIGHT, MID-ARM CIRCUMFERENCE AND T R I C E P S SKIN-FOLD O F CARDIAC P A T I E N T S ACCOBDING TO AGE GROUPS. M E A q A STANDARD D E V I A T I O N S ABE I N D I C A T E D .

Appendix Table oo4at Ini t ial values for blood glucose, t o t a l p r o t e k , albumin, - globulin, haemoglobin, height, weight, mid-arm circumference as' m and t r iceps skin-fold o f cardiac pat ients according t o age

gmups. Means standard deviations are indicated.

20 - 30 ( . X ~ - c i i ~ ) - Mid-am

Pats. Blood Tota l Haemo- Circum- Triceps C,/NQ. glucose p ro te in Albumin Globulin g lobin Height Weight fe rence skin-fold

mg/ lOOml g/100ml g/100nl g/:00ml gf 100ml ( cm) (kg). ( cm) mm

Means 54.57 6.54 3.72 2.82 + 14.8) 171.86 71.02 27.64 9.21 - 2 + + + + + 2 + +

S. d, 7.85 072 8 0T6 8 0T5 6 3 3 7 3T50 11.69 2T90 2T5 3

. Appen;' LX Table Initial values for blood glucose, total protein, albumin, globulin, 0 <n - - 004b: haemoglobin, height, weight, mid-arm circumference and triceps ski;?-fold

of CARDIAC patients according to occupation, Means f stmdard deviations are indicated.

CIVIL SERVANTS - Mid-arm

Pats, 51003 Total Haemo- Circum- Triceps S/KO glucose protein Albumin Globulin globin Height Weight ference skin-fold

mg/100ml g+100ml g/100ml g/100rnl a/100nl cm (kg) cm ( m m L

1 49 6.18 2.68 3.50 11.45 169.80 60.00 23.00 7.00

Means 56.00 6-37 3-47 3-09 13-82 171.80 69.99 25.64 8'84

Means 59-50 6.56 3.53 5-03 13-71 170.70 66-38 25-58 6.00

cn \0 O O W O o o 8 0 r U m o

w Q ) C D w w w m . . . . . I .

L n c n P R ) 0 3 0 3 - - . O O O O O G O

92. LiyxndLx Table : 004c: I n i t i a l an2 final values f o r FOUR

CARDIAC p s t i e n t s for whon measurements were complete for blood g lucose , t o t d protein, albumin, g l o b u l i n ,and heemoglo bin , Means 2 s t zndard d e v i a t i m s are shown.

2, .h.i t ia1 Final

. . . ' t d I11 .L l ‘*J.

F i n a l

F i n a l

Append- Table: 004dr I n i t i a l and f i n a l values f o r CARDIAC q3'

p a t i e n t s f o r whom measurements were complete f o r height , weight, mid-arm circumference and t r i c e p s skin-fold. Means 2 standard devia t i jns a r e shown.

Mid-arm Triceps Height Weight Circum, skin-fold ( c d (kg) ( cm) (mm)

1. I n i t i a l F ina l

2 . I n i t i a l F ina l

3 . Ipi t i a l F ina l

4. I n i t i a l F ina l

Means I n i t i a l

-b - s .'d.

Final

I N I T I A L VALUES FOR BLOOD GLUCOSE, TOTAL P R O T E I N , ALBUMIN, GLOBULIN, HAEMOGLOBIN, HEIGHT, WEIGHT, MID-ARM CIRCUMFERENCE AND T R I C E P S SKIN-FOLD O F NISCELLANEOUS D I S E A S E P A T I E N T S ACCOR- JII??S T3 AGE GROUPS. MEANS - + STANDARD D E V I A T I O N S ARE INDICATED.

-. - . - L A 3 4 - 4 4 c n 4

IU 0 0 - . 0 3 P . * . * I + $ O - r O L n 4 nJ 0 0 0 0 0

rn z (D

at+ V)

J 4 W P kl+ > P O

0 cn I+ IU 0 P 0

O W I+

cn N Vl N

0 nJ I+

2 2

A Ln A

I+ W 4 03 03

4

4 I U W I + * A Ln nJ 0

Ul m 03

I+ W 4 03

IU W W I+ J N C3 Ln

0 Ln I+

U l o 4 0

.- V) m Appendix Table: 005a contd.

- 51 - 60 ( r s ~ . ) . Mid-arm

Pate, Blood Total Haemo- Circum- Triceps S / N ~ glucose protein Albumin Globulin globin Height Weight f erence skin-fold

rng:/100ml g/100nl g/lO~ml g/100ml g/lOOml cm) (kg) ( cm) mm

Neans 78.00 6.93 3-97 2-97 13-37 170.03 64-70 24.17 5-50 + + + + + + + + + +

s .x 9T5 4 015133 0 2 7 0779 1T9 6 4T32 5<65 2:5)3 2:o 1

%&en- I n i t i a l va lues f o r blood glucose, t o t a l protein, al'umin, globulin, ~ ~ b l ~ w s t haemoglobin, height, weight, mid-arm cirmuference and t r i c e p s skin-fold . of MISCELLANEOUS DISEASE P a t i e n t s according t o Occupation. Means 4 * '' m Standard Deviations a r e indicated.

Mid- arm Pats. Blood Tota l Haemo- Circum- Triceps S/N, glucose pro te in Albumin Globulin globin Height Weight ference skin-fold

m,q/100ml g / l @ ~ m l g/l00ml a/100ml g/100ml ( cm (kg) cm (m>

Means 86.71 6 97 4.06 2.92 14.37 169.41 57.27 23.2G 4-50

BUSINESS MEN

1. 84 6.17 3.68 2.49 16-00 177.00 65.50 25.50 4.60

2 117 8-24 4.74 5-50 16.40 168.00 47-40 22.80 3.60

3. 5 7 6 0 59 3-50 3.09 11.30 171.10 72-20 30.00 11.00

4. 69 6-56 4-34 2.22 15 40 174.60 63.00 22.00 5-13

5. 77 7 -00 4.12 2.88 11-50 169.50 71.00 27-50 7.40

Means 80.80 6.91 4.08 2.84 14.12 171.04 63.82 25.56 6.34

9% . ..

Appendix Table : Wjc: I n i t i a l and f i n a l va lue s f o r MISCELLANEOUS DISEASE P a t i e n t s f o r whom measurements wsre complete f o r Blood gluoose, t o t a l p ro t e in , Albumin, Globul in and Haemoglobin. Means + Standard d e v i e t i o n are ind ica ted . -

Pats* Blood Tot a1 Haemo- s/%. gl.ucoae p r o t e i u A l b u a n G?obula~ g l o b i n

r n g / l G ~ m l a/100ml g/l00ml g/l00ml g/700ml

1.

2.

3.

4 . 5.

6.

Means + - . - ,

S.d.

I n i t i a l F i n a l

I n i t i a l F i n a l

I n i t i a l F i n a l

I n i t i a l F'i n a1

I n i t i a l F i n a l

I n i t i a l F i n a l

I n i t i n 1

F i n a l

Appendix Table

. , . I n i t i a l and F i n a l Values f o r s i x MISCELLANEOUS DISEASE P a t i e n t s f o r wham m4asurernents were complete f o r Height, Weight, Mid-arm Circumference, and t r i c e p s skin-fold. Means; Et@@ Deviat i ,>n a r e i nd i ca t ed .

Mid-arm Tr iceps I!ei;zht Weiyht Circun. skin-fold

( c ) (kg) ( c 4 (mm)

1. I n i t i a l F ina l

2. I n i t i a l F i n a l

3. I n i t i a l F i n a l

4. I n i t i a l F i n a l

5. I n i t i a l F ina l

6. I n i t i a l F i n a l

I n i t i a l

Means + .

s .X. F i n a l