C. R. PENNINGTON

Department of Gastroenterology and Clinical Nutrition, Ninewells Hospital andMedical School, Dundee, Scotland, UK (Correspondence to: CRP,Department of Gastroenterology and Clinical Nutrition, Ninewells Hospital andMedical School, Dundee,
DD19SY Scotland, UK)

Introduction

        The subject of ‘Clinical Nutrition’ received little attention in the undergraduate curricula of many medical schools until recently, and neither did it commonly feature in post-graduate medical education. Evidence of lack of knowledge in the subject of nutrition amongst doctors and nurses is not surprising (1–3). Thus, nutritional depletion was often ignored until patients became severely malnourished when tissue wasting was obvious and frequently severe. In many centers this problem continues (4–6). Patients who are developing disease-associated malnutrition need to have their nutritional needs recognized so that they can receive appropriate treatment before severe malnutrition develops. Those who are at risk of developing malnutrition also need to be monitored, where possible before any malnutrition occurs, permitting safer and less expensive potential management. This is important especially because of changing clinical practice in which the length of Hospital stay is reduced with new surgical developments, and an increase in the demands on patient beds in the hospitals of many countries. The reduced duration of the patient stay within hospital is another reason why clinicians can no longer focus nutritional management exclusively in the hospital setting. Against this background, consideration must be given to nutritional management before, during, and after hospital treatment. There is a further issue that may require addressing in the future. The rapid increase in the elderly population, particularly those over the age of 75 years, has been identified (7). Recent information emphasizes the reduced cell mass for given body mass index in this group. Thus, such subjects may be at risk of developing disease, for example falls and infection (8). Under these circumstances, identifying potential malnutrition depletion out with the current accepted ranges and recognition, and certainly before illness develops and illness occurs is another area that needs to be addressed.

The patient journey

        The stages in the journey of a patient who requires abdominal surgery for gastrointestinal disease are illustrated in Figure 1. Much of the time may be spent with the development of symptoms and thus referral leading to the investigation and diagnosis and subsequent hospital admission. Within hospital there is assessment and surgery and recovery, ultimately leading to discharge for convalescence and recovery. The duration of the stages in patient’s journey is uncertain (Fig. 2). In many countries such as the UK the National Health Service is slowin terms of delayed investigation and admission; however, there is little information about duration and availability of referral in many countries. The conventional hospital stay is now reduced, often below1 week after surgical treatment. Studies indicate that post-surgical episodes can take 3–6 months for recovery to occur (9, 10). Under these circumstances, it is no longer acceptable to focus nutritional management exclusively within the hospital; rather attention is needed throughout the patient journey.

        A significant number of patients already suffer from established malnutrition on admission to hospital having become depleted in the community. Large groups of patients with a range of disorders including surgery, demonstrate malnutrition in 20–40% of subjects studied shortly after admission (4–6). There is no mechanism in many health-care systems for identifying patients at nutritional risk within the community and the pre-hospital setting. Nutritional deficiencies are defined using body mass index (BMI) accompanied by anthropometry and the history of weight loss. Weight loss is often not measured and identified. Increasing BMI within the population may be a reason why the incidence of low BMI values was reduced in two recent studies, one specifically for elective surgery (11, 12). Nevertheless, other recent reports include lowBMI values on admission (4–6). Weight loss may well be important before admission, significant loss of 10% of the body weight could occur within current BMI ranges (13). Furthermore, a significant number of patients who are admitted also suffer from vitamin deficiencies whether or not BMI or weight loss occurs (14). There is an additional issue. There is a significant increase in elderly subjects and a significant increase in the very elderly are nutritionally depleted (15). Thus, the treatment of malnutrition reflect three factors which relate to lowBMI , weight loss and starvation before, during and after admission. The omission of food with starvation during admission is currently recognized as an important therapeutic area, and is receiving attention. This ignores the implications of the brief hospital stay for the majority, and the adequacy of micronutrients, although there are long stay advantages in the elderly age groups. Nevertheless, there are broader implications.

        Even within many hospital settings, there is no agreed widely applicable screening tool. Currently, many patients do not even get weighed. Less than 30% of moderate–severely malnourished patients who remain in hospital for more than 7 days are diagnosed as suffering from malnutrition and referred for nutritional management (4–6). However, new technologies and economic pressures mean that the hospital stay represents a decreasing part of the patient journey. There is insufficient time to correct nutritional deficiencies during the hospital stay (16). Furthermore, anthropometric and weight reduction is a feature that commonly follows traditional surgery (12). When post-operative patients with less that 20% BMI and more than 5% of body weight loss after surgery were followed as out patients, progressive weight loss for 8 weeks after discharge were
observed in contrast to the subjects who were randomized to nutrition supplements (17).