Scandinavian Journal of Gastroenterology. 2015; Early Online, 1–8
ORIGINAL ARTICLE
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Nutrition impact symptoms, handgrip strength and nutritional risk in hospitalized patients with gastroenterological and liver diseases
ANNE WILKENS KNUDSEN1, ASTRID NAVER1, KAREN BISGAARD1, INGE NORDGAARD-LASSEN1, ULRIK BECKER1,2, ALEKSANDER KRAG3 & FRODE SLINDE4 1
Gastrounit, Medical Division, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark, 2National institute of Public Health, University of Southern Denmark, Copenhagen, Denmark, 3Department of Gastroenterology and Hepatology, Denmark. Odense University Hospital, University of Southern Denmark, Odense, Denmark, and 4 Department of Internal Medicine and Clinical Nutrition, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
Abstract Objective. Malnutrition is common among patients with diseases of the liver and gastrointestinal tract. Nutritional intake may be negatively affected by nutrition impact symptoms (NIS). Therefore, the aims were to assess: 1) the prevalence of NIS in this group of patients and 2) the relationship between NIS and nutritional status as well as nutritional risk. Material and methods. We performed a cross-sectional study among patients with liver disease, inflammatory bowel disease, cancer or pancreatitis. Nutritional risk was assessed by the NRS-2002. Nutritional status was assessed by body mass index (BMI) and handgrip strength (HGS), which were both measured within 5 days after admission. NIS were assessed by the Eating Symptoms Questionnaire (ESQ) and the Disease-Related Appetite Questionnaire (DRAQ). Results. In total, 126 patients were included (women 39%) with a mean BMI of 24 ± 5 kg/m2. The prevalence of low HGS was 38%, and the prevalence of those at nutritional risk was 58%. The number of NIS reported by 50% of the patients were 4 or more in the ESQ and 5 or more in the DRAQ. Patients who were both at nutritional risk and had a low HGS more frequently reported difficulties swallowing, poor appetite, feeling full after having one-fourth of the meal and food tasting bad. Conclusions. NIS that preclude food intake are very frequent among patients with diseases of the liver and gastrointestinal tract. Specific NIS are associated with low HGS, weight loss and being at nutritional risk.
Key Words: appetite, gastrointestinal cancer, inflammatory bowel disease, liver disease, pancreatitis, stomachache
Introduction The risk of malnutrition ranges between 20% and 50% in hospitalized patients depending on the type of department and method used to assess nutritional risk [1,2]. Detection and treatment of malnutrition is very important in hospitalized patients because malnutrition is associated with loss of muscle strength, increased morbidity, increased length of stay and increased mortality [3–6]. Despite this, malnutrition is often unrecognized and treated insufficiently due to
lack of knowledge regarding identification and planning of nutritional therapy [7–9]. Nutritional risk can be identified by nutritional screening tools such as the NRS-2002 [10]. Patients identified to be at nutritional risk should be treated with relevant nutritional therapy to ensure sufficient protein and calorie intake [3]. When planning nutritional therapy, patients are sometimes asked about underlying causes known to affect nutritional intake, but these causes are not systematically assessed and handled. The eating symptoms questionnaire (ESQ)
Correspondence: Anne Wilkens Knudsen, MSc, RD, Gastrounit, Medical Division 360, Copenhagen University Hospital Hvidovre, DK-2650 Hvidovre, Denmark. Tel: +45 3862 6477. E-mail: [email protected]
(Received 6 February 2015; revised 5 March 2015; accepted 8 March 2015) ISSN 0036-5521 print/ISSN 1502-7708 online 2015 Informa Healthcare DOI: 10.3109/00365521.2015.1028994
Scand J Gastroenterol Downloaded from informahealthcare.com by East Carolina University on 04/23/15 For personal use only.
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A. Wilkens Knudsen et al.
and the Disease-Related Appetite Questionnaire (DRAQ) are two questionnaires developed to systematically assess underlying causes that can preclude nutritional intake [11]. These underlying causes are referred to as “nutrition impact symptoms” (NIS). The identification of NIS can be helpful in identifying the etiology of the nutritional diagnosis and, in that context, may lead to a more individual and optimized nutritional therapy. Both nutritional risk from the NRS-2002 and low handgrip strength (HGS) have been found to be related to mortality [12,13]. The ESQ and DRAQ have been shown to correlate with body composition in an outpatient population with chronic obstructive pulmonary disease (COPD) [11]. However, the questionnaires may also be useful in other patient populations. Therefore, the aim of our study was to assess: 1) the prevalence of NIS among hospitalized patients with gastrointestinal and liver diseases and 2) the relation between NIS and NRS-2002 or nutritional status as determined by HGS or body mass index (BMI).
B-score and a potential age-score. If the total-score is ‡3, is the patient considered at nutritional risk. The A-score refers to BMI and/or nutritional intake and the B-score refers to the patient’s disease [10]. The study was waived by the Danish National Committee on Biomedical Research Ethics (ref. no. H-3-2012-156) and registered at the Danish Data Protection Agency (ref. no. 02001 HVH-2012-056). Statistical analysis Data are presented as the mean ± standard deviation or as a number and percentage unless otherwise stated. Unpaired data were analyzed by Student’s t-test. For difference in distributions, the c2 test was used. Correlations were determined using the Pearson’s or Spearman’s correlation coefficient as appropriate. A p-Value < 0.05 was considered statistically significant. The statistical analyses were carried out using SAS version 9.3 (SAS Institute, Cary, NC, USA). Results
Methods Patients with known or suspected liver disease, cancer, inflammatory bowel disease or pancreatitis that were admitted to Hvidovre University Hospital or Odense University Hospital were included from December 2012 to February 2014. Exclusion criteria were hospitalization above 5 days, change in diagnosis and inability to cooperate. Within 5 days of admission, NIS were assessed by two questionnaires: the ESQ and the DRAQ. Both questionnaires are newly developed by a Swedish group from Gothenburg, for the purpose of investigating NIS mainly in patients suffering from, or at risk of, developing malnutrition [11]. The questionnaires were afterwards translated into Danish and retranslated back to Swedish in order to check the Danish translation. Body weight was measured to the nearest 0.1 kg. Height was recorded to the nearest 0.1 cm and was used to calculate BMI (kg/m2). Low BMI was determined as BMI
ORIGINAL ARTICLE
Scand J Gastroenterol Downloaded from informahealthcare.com by East Carolina University on 04/23/15 For personal use only.
Nutrition impact symptoms, handgrip strength and nutritional risk in hospitalized patients with gastroenterological and liver diseases
ANNE WILKENS KNUDSEN1, ASTRID NAVER1, KAREN BISGAARD1, INGE NORDGAARD-LASSEN1, ULRIK BECKER1,2, ALEKSANDER KRAG3 & FRODE SLINDE4 1
Gastrounit, Medical Division, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark, 2National institute of Public Health, University of Southern Denmark, Copenhagen, Denmark, 3Department of Gastroenterology and Hepatology, Denmark. Odense University Hospital, University of Southern Denmark, Odense, Denmark, and 4 Department of Internal Medicine and Clinical Nutrition, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
Abstract Objective. Malnutrition is common among patients with diseases of the liver and gastrointestinal tract. Nutritional intake may be negatively affected by nutrition impact symptoms (NIS). Therefore, the aims were to assess: 1) the prevalence of NIS in this group of patients and 2) the relationship between NIS and nutritional status as well as nutritional risk. Material and methods. We performed a cross-sectional study among patients with liver disease, inflammatory bowel disease, cancer or pancreatitis. Nutritional risk was assessed by the NRS-2002. Nutritional status was assessed by body mass index (BMI) and handgrip strength (HGS), which were both measured within 5 days after admission. NIS were assessed by the Eating Symptoms Questionnaire (ESQ) and the Disease-Related Appetite Questionnaire (DRAQ). Results. In total, 126 patients were included (women 39%) with a mean BMI of 24 ± 5 kg/m2. The prevalence of low HGS was 38%, and the prevalence of those at nutritional risk was 58%. The number of NIS reported by 50% of the patients were 4 or more in the ESQ and 5 or more in the DRAQ. Patients who were both at nutritional risk and had a low HGS more frequently reported difficulties swallowing, poor appetite, feeling full after having one-fourth of the meal and food tasting bad. Conclusions. NIS that preclude food intake are very frequent among patients with diseases of the liver and gastrointestinal tract. Specific NIS are associated with low HGS, weight loss and being at nutritional risk.
Key Words: appetite, gastrointestinal cancer, inflammatory bowel disease, liver disease, pancreatitis, stomachache
Introduction The risk of malnutrition ranges between 20% and 50% in hospitalized patients depending on the type of department and method used to assess nutritional risk [1,2]. Detection and treatment of malnutrition is very important in hospitalized patients because malnutrition is associated with loss of muscle strength, increased morbidity, increased length of stay and increased mortality [3–6]. Despite this, malnutrition is often unrecognized and treated insufficiently due to
lack of knowledge regarding identification and planning of nutritional therapy [7–9]. Nutritional risk can be identified by nutritional screening tools such as the NRS-2002 [10]. Patients identified to be at nutritional risk should be treated with relevant nutritional therapy to ensure sufficient protein and calorie intake [3]. When planning nutritional therapy, patients are sometimes asked about underlying causes known to affect nutritional intake, but these causes are not systematically assessed and handled. The eating symptoms questionnaire (ESQ)
Correspondence: Anne Wilkens Knudsen, MSc, RD, Gastrounit, Medical Division 360, Copenhagen University Hospital Hvidovre, DK-2650 Hvidovre, Denmark. Tel: +45 3862 6477. E-mail: [email protected]
(Received 6 February 2015; revised 5 March 2015; accepted 8 March 2015) ISSN 0036-5521 print/ISSN 1502-7708 online 2015 Informa Healthcare DOI: 10.3109/00365521.2015.1028994
Scand J Gastroenterol Downloaded from informahealthcare.com by East Carolina University on 04/23/15 For personal use only.
2
A. Wilkens Knudsen et al.
and the Disease-Related Appetite Questionnaire (DRAQ) are two questionnaires developed to systematically assess underlying causes that can preclude nutritional intake [11]. These underlying causes are referred to as “nutrition impact symptoms” (NIS). The identification of NIS can be helpful in identifying the etiology of the nutritional diagnosis and, in that context, may lead to a more individual and optimized nutritional therapy. Both nutritional risk from the NRS-2002 and low handgrip strength (HGS) have been found to be related to mortality [12,13]. The ESQ and DRAQ have been shown to correlate with body composition in an outpatient population with chronic obstructive pulmonary disease (COPD) [11]. However, the questionnaires may also be useful in other patient populations. Therefore, the aim of our study was to assess: 1) the prevalence of NIS among hospitalized patients with gastrointestinal and liver diseases and 2) the relation between NIS and NRS-2002 or nutritional status as determined by HGS or body mass index (BMI).
B-score and a potential age-score. If the total-score is ‡3, is the patient considered at nutritional risk. The A-score refers to BMI and/or nutritional intake and the B-score refers to the patient’s disease [10]. The study was waived by the Danish National Committee on Biomedical Research Ethics (ref. no. H-3-2012-156) and registered at the Danish Data Protection Agency (ref. no. 02001 HVH-2012-056). Statistical analysis Data are presented as the mean ± standard deviation or as a number and percentage unless otherwise stated. Unpaired data were analyzed by Student’s t-test. For difference in distributions, the c2 test was used. Correlations were determined using the Pearson’s or Spearman’s correlation coefficient as appropriate. A p-Value < 0.05 was considered statistically significant. The statistical analyses were carried out using SAS version 9.3 (SAS Institute, Cary, NC, USA). Results
Methods Patients with known or suspected liver disease, cancer, inflammatory bowel disease or pancreatitis that were admitted to Hvidovre University Hospital or Odense University Hospital were included from December 2012 to February 2014. Exclusion criteria were hospitalization above 5 days, change in diagnosis and inability to cooperate. Within 5 days of admission, NIS were assessed by two questionnaires: the ESQ and the DRAQ. Both questionnaires are newly developed by a Swedish group from Gothenburg, for the purpose of investigating NIS mainly in patients suffering from, or at risk of, developing malnutrition [11]. The questionnaires were afterwards translated into Danish and retranslated back to Swedish in order to check the Danish translation. Body weight was measured to the nearest 0.1 kg. Height was recorded to the nearest 0.1 cm and was used to calculate BMI (kg/m2). Low BMI was determined as BMI
