Elsevier

Clinical Nutrition

Volume 23, Issue 4, August 2004, Pages 551-559
Clinical Nutrition

ORIGINAL ARTICLE
Value of body mass index in the detection of severe malnutrition: influence of the pathology and changes in anthropometric parameters

https://doi.org/10.1016/j.clnu.2003.10.003Get rights and content

Abstract

Background & aims: We have estimated the prevalence of severe malnutrition in groups of patients hospitalized for different medical causes and assessed the sensitivity of BMI in the diagnosis of severe malnutrition.

Design: A prospective study enrolled 1052 patients: 396 patients with liver cirrhosis including 165 non-ascitic patients (NAP), 124 patients with mild ascites (MAP), 107 patients with tense ascites (TAP), 251 patients after cardiac surgery (SCP), 81 patients with cardiac diseases (MCP), 85 patients with stroke (SP), 36 patients with degenerative neurological diseases (DNP), 68 patients after surgery of a hip fracture (HFP), 91 patients with palliative care for cancer (CP) and 44 elderly patients with medical affections (EP). BMI, mid-arm muscular circumference (MAMC) and triceps skinfold thickness (TST) were measured within 48 h after admission. Patients with MAMC and TST below the 5th percentile of a reference population when aged ⩽74 or the 10th percentile when aged ⩾75 were defined as severely malnourished. Sensitivity of BMI<20 to detect malnutrition was assessed.

Results: The prevalence of severe malnutrition was the highest in TAP (39.1%) HFP (25.6%) and MAP (24.3%) and the lowest in SCP (4%), SP (4.8%), DNP (5.7%) and MCP (7.4%) (P<10−4). In multivariate analysis, low TST was associated with female gender (P<10−4) mild and tense ascites (P=0.038, P=0.0004), low MAMC with male gender (P<10−4), low BMI with female gender (P=0.0082), hip fracture (P=0.0407) and cancer (P=0.0059). The sensitivity of BMI to detect severe malnutrition was the highest in HFP, CP and EP (100%, 80% and 100% respectively) and the lowest in TAP, MCP and SP (40%, 33.3% and 50% respectively). After exclusion of TAP, sensitivity of BMI to detect malnutrition correlated significantly with the coefficient of correlation between MAMC and TST observed in each group (r=0.821, P=0.0066).

Conclusion: Ascitic cirrhotic patients and elderly patients after surgery of hip fracture had the highest prevalence of severe malnutrition. BMI had the highest sensitivity when both TST and MAMC were damaged to the same extent. BMI<20 has a high sensitivity in the diagnosis of severe malnutrition in elderly and cancer patients but not in cirrhotic patients with tense ascites, cardiovascular and neurological patients.

Introduction

There is a growing awareness that malnutrition must be recognized in hospitalized patients because malnutrition in these patients is still frequent and affects outcome and costs. Furthermore, recent reports of disease-related malnutrition have demonstrated that too few patients receive appropriate nutritional support.1., 2., 3., 4. There is no universally accepted definition of malnutrition, diagnosis of malnutrition is usually based on the association of recent weight loss, inadequacy of dietary intake, low body mass index (BMI) and the presence of disease damaging nutritional status.5 BMI is a simple tool which can be universally used, and when <20, is admitted as a marker of malnutrition. However, whereas it is well known that overt fluid retention is a limiting factor in the interpretation of BMI, little is known about the value of BMI in the detection of malnutrition in various clinical conditions where changes in body composition may vary according to the nature of pathology. It should be important to determine in what conditions BMI may be used as a single tool or must be associated with other anthropometric or biological parameters to recognize malnutrition.

The primary objective of this study was to estimate the prevalence of severe malnutrition in homogenous groups of patients hospitalized in a rehabilitative care hospital for different medical causes. The second objective was to assess the sensitivity of low BMI with a cutoff of 20 in the diagnosis of severe malnutrition in these patient populations. The diagnosis of severe malnutrition was based on sharp decrease in two anthropometric parameters reflecting muscular and fat masses. We chose to measure mid-arm circumference (MAC) and triceps skinfold thickness (TST) and to calculate mid-arm muscle circumference (MAMC) because these parameters can be measured with a minimum of equipment, effort and time and are more frequently used in surveys of nutritional status of patient populations and they can be evaluated according to sex- and age-specific standards of reference. Sensitivity of BMI was assessed regarding each parameter and the association of them.

Section snippets

Patients and methods

The departments of Liver and Digestive Diseases, Cardiovascular Disease, Neurological Diseases and Internal Medicine of Albert Chenevier hospital participated in the study. 1052 patients consecutively admitted into our hospital from January 1, 2001 to December 31, 2001 were enrolled. Hospital Albert Chenevier is a rehabilitative medical institution and receives patients from other hospitals in the area of Paris after medical or surgical treatment. All these patients require long-term care and

Statistical analysis

Results of quantitative variables are given as mean±SD. Comparison of quantitative variables among several groups were performed using ANOVA. When ANOVA showed a statistically significant difference, comparisons between two groups were performed using Bonferroni Dunn's test. Comparisons of qualitative variables were performed using X2 test. Correlations was calculated according to the least-square regression analysis. Multivariate analysis was done using a stepwise logistic regression model.

Results

The demographic characteristics of the population are shown in Table 1. The three groups of cirrhotic patients were younger than the other groups (P<10−4) except NAP and TAP when compared with DNP. HFP and EP were older than the other groups (P<10−4). Males were predominant in all the groups except in HFP and EP groups.

All anthropometric values differed significantly among the eight groups (Table 2). Patients with hip fracture (HFP) and cancer patients (CP) showed the lowest values of BMI (HFP

Prevalence of malnutrition

Patients included in this study had various pathologies exposing them to a high risk of malnutrition. It is well known that liver cirrhosis, advanced cancers, hip fracture and age are major causes of malnutrition in hospitalized patients.9., 10., 11., 12., 13. Patients with recent cardiac surgery, cardiovascular diseases and acute stroke are also exposed to malnutrition.14., 15., 16., 17. Our study shows that the prevalence of malnutrition and changes in body composition are different according

Acknowledgements

The authors thank Mme Valérie Miranda for efficient secretarial assistance.

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