Malnutrition and Associated Factors in Admitted adult Surgical Patients in Eastern Ethiopia

Background: Malnutrition in surgical patients is found to be associated with reduced wound healing, increased complication rates, length of hospital stay, mortality, and healthcare costs than normally nourished patients. There are higher magnitude was reported from surgical patients in different studies abroad. However, there is no study conducted in eastern Ethiopia. Therefore, this study was aimed to assess magnitude of malnutrition and associated factors among adult surgical patients. Methods: Hospital based cross sectional study was conducted among 398 consecutively admitted surgical patients in Jugel and Hiwot Fana Specialized University Hospital from December 20, 2018 to November, 2019.Data was collected using pre tested structured questionnaire. Anthropometric measurements and dietary diversity assessment were made at admission and discharge of the patient. Capillary blood sample was collected for hemoglobin measurement. Data were analyzed using SPSS 20 software. Result: A total87(21.9%) and 99(24.9%) study participants were underweight at admission and discharge. Being male (AOR=0.40; 95CI: 0.21, 0.75) , age groups 18-40 years (AOR=0.22; 95 CI: 0.08, 41-60 , :0.17, Non patients (AOR= 0.25; 95 CI:0.12, 0.48) were factors less likely to undernourished at admission. Being male (AOR= 0.39; 95% CI: 0.20, 0.76) ,age groups 18-40 (AOR= 0.14; 95 CI 0.04, 0.52) and 41-60 years (AOR=0.15; 95% CI: 0.04, 0.52) urban residents (AOR=0.26; 95 CI: 0.11, 0.57) , with elective type of surgery (AOR=0.34; 95% CI: 0.14, 0.82) less likely, participants with hospital stay less than 5 days (AOR=0.14; 95 CI 0.02, 0.69) were factors less likely to undernourished at discharge. Conclusion: malnutrition /under nutrition is highly prevalent among surgical patients. Sex, age, residence and anemia were common factors associated with under nutrition at admission and discharge. In addition, type of current surgery and length of hospital stay were identied factors at time discharge. Therefore, the hospital staff should apply nutritional assessment and nutritional counseling /support to surgically admitted patients considering the identied factors.


Introduction
Malnutrition is rampant around the world which is a burden on patients and health care facilities. Studies reported that up to 40% of patients are malnourished at the time of their admission and the majority of them continued to be nutritionally depleted throughout their hospital course. Surgery related causes of malnutrition are due hyper catabolism, postoperative fasting, stula, malabsorption syndrome, and intestinal obstruction (1)(2)(3)(4).
Malnourished patients have higher morbidity and mortality rates than normally nourished patients, with longer hospital admissions and increased health care cost. In a study conducted in Singapore found that magnitude malnutrition at admission was 29%; malnourished patients had longer hospital stays (6.9 ± 7.3 days vs. 4.6 ± 5.6 days) and was more likely to be readmitted within 15 days (5). In another study report from German found a 27% rate of malnutrition among hospitalized patients. Malnourished patients having a LOS 43% longer than well-nourished patients (6).
Malnutrition is also found additionally associated with reduced wound healing and increased complication rates. Lack of appropriate nutritional support during hospitalization may worsen patients' nutritional status and increases risk for infection, organ failure and suboptimal response to regular medical treatment. (7).
Nutritional status at hospital admitted patients compounded by primary malnutrition mainly re ecting poor social-economic condition and secondary malnutrition re ecting usually the impact of degenerative and chronic diseases (2).
The treatment of malnutrition rst requires identi cation of the patient as malnourished by means of nutrition screening or other type of assessment tool at admission. This procedure should be made compulsory by a health care team (8).
Magnitude of malnutrition among hospital admitted patients in Ethiopia was not widely well known and neglected. In one study conducted in Ethiopia among adult hospitalized patients the prevalence of malnutrition was 55.6% (9). The issue malnutrition among admitted patients is well studied other parts of the world (3,10,11). However, there is no published data in the current study area. Therefore, this study tried to assess magnitude malnutrition and associated risk factors among Surgical Patients in public hospitals in eastern Ethiopia.

Methods And Materials
Study area, design and period Harar town is the capital city of Harari National Regional state, which is one of the regional states of Federal Democratic Republic of Ethiopia and located at East part of Ethiopia at distance of 515 km from Addis Ababa. It is one of the most popular historical towns in the eastern part of Ethiopia. The town has a projected total population of 203,438 in 2010. The region has 8 worades and 36 kebeles (the lowest administrative structure). There are three governmental hospitals (2 public and 1 police hospital), two private hospitals and four health centers in the town (Harari region 2010.This cross-sectional study was conducted in the two public hospitals in the region i.e. Hiwot Fana Special University Hospital and Jugel Hospital, from December 20, 2018 to November, 2019.

Population
All admitted patients older than 18 years old of age in HiwotFana Specialized University Hospital and Jugel Hospital during the study period were source population. All surgical patients older than age of 18 years admitted to surgical ward and stayed in the ward for at least 24 hours were the study population. Because it is di cult to look how admission affects nutritional status patients with less than 24 hours admission. Patient having di culty of communication and understanding, severe deformity, edematous patients, pregnant women, di cult to speak (on coma), who were not conscious, those who performed minor surgery and discharged before 24 hours, with recent surgery and re admitted again for another surgery (as these patients might have high malnutrition associated with previous surgery) were excluded from this study.

Sample size and Sampling techniques
Sample size was calculated using EPINFO version -software considering assumptions of power of 80%, ratio unexposed: Exposed of 1:1; the prevalence of malnutrition among not read and write and literate was 61.5% and 48.5%, respectively from study conducted among adult hospitalized patients at Amhara National Regional State, Ethiopia (9). The nal sample for this study was 390 plus 5% non-response rate 410. The nal Sample size was allocated proportionally based on average number of patients admitted to surgical ward in each hospital per month. Then all consecutive eligible patients were included from each hospital until the nal sample size reached. Hiwot Fana specialized university hospital has 70/month surgical admission with allocated sample size of 302; while Jugel Hospital has 25/month surgical admission with allocated sample of 108.

Data collection methods
Data were collected by the following methods A. Face to face interview: was made by trained rst degree in nursing as data collectors using pre-tested structured questionnaire which is prepared by reviewing related literatures (9,12). The questionnaire was used to collected data on socio-demographic information such as age, occupation, education, income, type of transport and distance to hospital. In addition, clinical information from patient records such as current type of disease diagnosed and comorbidity, duration of current disease, previous history of surgery, complications after surgery and type of surgery was reviewed. After completion of the above data collection process during admission, study participants were followed till discharged from the hospital.
B. Nutritional status assessments: were conducted at the time admission and discharge. Weight (W) patients was measured using a scale with a maximum capacity of 150 kg and accuracy of 0.1 kg. Weighing scale was checked for correctness after each patient measured. Height (H) was measured in standing position in stadiometer but for those confounded to bed, demi-span (outstretched arms, forwarded palm from the base of the middle nger to the sterna notch), knee height and ulnar length were used (9). Waist circumference (WC) was measured on the median line between the costal border and the iliac crest at the end of exhalation. The above measurements were taken in duplicates and an average was used if different in measurement.
C. Dietary diversity assessment: was made by using standard dietary diversity questionnaire at admission and at time discharge (13).
D. Hemoglobin test: blood was collected through nger puncture and hemoglobin was measured using HemoCue hemoglobin analyzer (HemoCue® Hb 301).

Operational de nition
Length of hospital stay is measured in days, from the day of admission to hospital to the time of discharge or death.

Malnutrition
Malnutrition can apply to various states; undernutrition, over-nutrition or de ciencies of speci c nutrients. In this study the term malnutrition refers to undernutrition.

Data analysis
Data was coded and entered using Epi Data software version 3. Individual Dietary Diversity Score was calculated as the sum of food groups consumed over 24 hours. By considering the mean individual dietary diversity score, participates with Individual dietary diversity Score above the mean were considered as good dietary diversity (diversi ed diet) or high and those below the mean Dietary Diversity Score were considered as low dietary diversity (undiversi ed diet) or low (13). Anemia was de ned for non-pregnant women (15 years of age and above) and men (15 years of age and above) with hemoglobin value of < 11 g/dl and ≤ 12 g/dl, respectively (17).

Data quality
Two days training was given for data collectors and rst-degree holder public health o cers supervisors how to collect and supervise. The questionnaire was rst prepared in English then translated to local language and back translated to English to maintain the consistency of the questionnaire. Data collection instrument were pre-tested on 5% of the study participants at Dil Chora Hospital and appropriate modi cations were made it. All the anthropometric measurements were taken using standard procedures and calibrated equipment by the data collector. Daily supervision, spot checking and reviewing completed questionnaire were conducted to follow for completeness and consistency of the data by the supervisors.

Socio-demographic characteristics
A total of 398 study participants were included in this study with response rate of 97.1%. Majority of them were from HiwotFana Specialized University Hospital (73.6%). The mean age of the study participants was 35.6 (SD ± 15.5) years and 279(70.1%) of them were in the range of 18-40 years. Most of the study participants were male (66.1%) and rural resident (58%). One hundred sixty-ve (41.5%) and 142(35.7%) of the participants were unable to read and write in educational status and farmers in their occupational status, respectively. Majority (88.4%) of the participants earn < 3000 birr per month (Table 1). Clinical characteristics of the patients Majority study participants (72.6%) have with the current diseases of < 2 weeks duration. Only 30 (7.5%) of participants had history surgery. A total of 215(54.0%) and 183 (46%) were on emergency and elective surgery, respectively. Forty-three (10.2%) of study participants had co-morbidities other than the current disease they admitted. Diabetes mellitus was the commonest co-morbidity followed by hypertension. Sixty-two (15.6%) patients developed complications after surgery and surgical site wound infection was the commonest complication followed by sepsis. The median length of stay of study participants in the hospital was 9.3 days and majority (77.1%) of them stayed 5-15 days. The mean hemoglobin concentration was 12.7 (SD ± 1.9) g/dl. Most of the study participants were admitted due to digestive tract diseases (39.7%) and trauma (29.1) ( Table 2). A total of 392 (98.5%) and 6 (1.5%) of the study participant were healed and referred out at time discharge, respectively.     Malnutrition is a frequent concomitant of surgical illness. A study reported that up to 40% of patients were malnourished at the time of their admission and majority of these patients continued to be nutritionally depleted throughout their hospital course (18). Similarly, in the current study the magnitude of under nutrient increased from 21.9-24.9%. A similar unintentional weight loss was reported in a study conducted in Netherlands (19). In the current study, there is also signi cant mean weight depletion after the patients admitted to hospital. A signi cant weight loss was reported three months before admission in Ethiopian study (9).
The possible reasons for the continued under nutrition and weigh loss might be due diseases speci c factors like loss of appetite, in ammation, swallowing di culties, hyper catabolism; treatment related factors, such as episodes of fasting, side effects of treatment ; psychological factor (anxiety, depression, loneliness) or social factors (such as poverty) (1) and their clinical condition like stula, malabsorption syndrome, intestinal obstruction and gastric atony (20,21). The above condition can reduce dietary intake, absorption of macro-and/or micronutrients, increased losses or altered requirements, increased energy expenditure (in speci c disease processes) (21,22). In the current study majority of the patient were admitted for digestive tract surgery. A similar report indicates patients who undergo gastrointestinal surgery are at risk of nutritional depletion from inadequate nutritional intake and the stress of surgery both preoperatively and postoperatively (21).
Malnutrition is associated with poor tolerance to treatment decreased quality of life, and increased health care costs (23). In the current study, there is the longer duration of under nourished patients and septicemia and wound infection are the commonest complications. Malnourished patients have delayed in wound healing and longer length of stay reported in India (7). All the complications developed in the current study seems infectious which might acquire from hospital environment possibly drug resistance. Some studies had shown that infections are a classical complication of malnutrition and under feeding (24,25).
The magnitude under nutrition before admission was 21.9%. This was similar to study conducted from Despite the high prevalence of malnutrition, nutritional therapy was seldom prescribed to patients, thus reinforcing the fact that nutrition-related issues are not part of the patients' routine care in the current study. This increase in under nutrition and length of hospital stay after admission which can be possibly due to low awareness on hospital malnutrition among medical staff, low attention to given nutritional support medical staff, less application nutrition course given at 2nd year of medical students training in our country university curriculum. In the current study setting, there is no weight and height scale which might simply use their physical judgment for nutritional assessment.
Routine evaluation of nutritional status was proposed which allows the identi cation of patients at risk of complications, particularly in the postoperative setting (28,29). These patients should be targeted for speci c nutritional support (30). However, only 16.8% of those with elective surgery before two weeks of admission and 43.5% of those who did surgery obtained nutritional support/counseling from the health professional. There are no o cial guidelines concerning hospital nutrition and the practice of nutritional therapy in the current study setting which can worsen the condition.
Different factors were identi ed to be associated with under nutrition. The magnitude malnutrition was signi cantly higher in the age group > 60 years. Similar signi cant report of malnutrition were reported among old age/elderly in studies from Albania (2), Spain (10), Taiwan (31), multi centered study from several Latin American countries (32) and Brazil (26,3). That elder patient might have different condition which can impede or restrict nutritional intake like loose of appetites, co morbidities with chronic diseases. Diabetes mellitus and hyperextension are some of the chronic condition which requires nutritional restriction. Other reasons might be loneliness, depression, poor dentition and impairment of cognitive function, or secondary systemic disease. The magnitude under nutrition continues to increase from 47.1-52.1% among those with age greatest than 60 after surgery in this study. There is a need for nutritional support to elderly patients.
In the current study, males were less likely to undernourished. This is similar to study conducted from Brazil (33). The current study cannot establish cause-effect relationship because it's cross-sectional nature. However, this fact might be due to the physiology of female aging and the decline of anthropometric variables with age is also considerably higher in women than in men.
Length hospital stay was identi ed associated with increased under nutrition in the current study. This was similar to studies conducted from Brazil (3,33), Australia (22) and multi centered study from Latin America (32).
Reducing length of hospital stay (LOS) has the potential to decrease health care cost, risk of infections and other hospital acquired diseases, and to improve patients' quality of life. Prolonged hospital stay may predispose a patient to skin colonization with more virulent hospital-based pathogens. Hospitals with reduced LOS are said to have done better than others with longer stay (22,34,35). Reductions in postoperative length of stay may produce cost savings that can be invested in other areas of surgical patient care (36).
Those patients with emergency surgery are possibly under nourished than elective surgery in the current study. However, malnutrition was not related to the type of hospital admission (emergency or elective) or to the gender in other study (2).
This study used some basic nutritional assessment tool and biochemical assessment (hemoglobin).
However, it did not include subjective assessment tool and other biochemical tests. This might provide additional information about the magnitude of the problems in the studied hospital.

Conclusion
In the current study the malnutrition /under nutrition is highly prevalent among surgical patients. Sex, age, residence and anemia were common factors associated with under nutrition at admission and discharge.
In addition, type of current surgery and length of hospital stay were identi ed factors at time discharge.
About one fth and less than half percentage of patients obtained nutritional support before admission and at discharge. Therefore, the hospital staff should apply nutritional assessment and nutritional counseling /support to surgically admitted patients considering the identi ed factors. The hospital in which study conducted or the regional health bureau should also reinforce nutritional assessment and nutritional counseling /support/therapy through guideline development, training and monitoring its application. The regional health bureau should also work on implementable strategies considering the identi ed factors. Further studies should be conducted by using different nutritional assessment tool (subjective and objective), biochemical assessment and unidenti ed factors on different type's patients in the country. In addition, there is need for assessment on level nutritional counseling and factors associated with it among health professional working in the hospital. Committee (IHRERC) of Haramaya University. Letter support was written to Harari Regional Health Bureau from College of Health and Medical Sciences, Haramaya University. All methods were performed in accordance with the relevant guidelines and regulations. The objectives, risk and bene ts of the study was explained to head of each hospitals and study participants. Written and signed informed consent were obtained from each study participants. The study participants' clinical records were reviewed anonymous. Information obtained during the study was kept con dential and only intended for research purpose.

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Competing interests
All the authors declare that they have no competing of interest associated with the publication of this manuscript.

Funding
No funding Availability of data and materials The authors declare that all the necessary data are fully described within the manuscript.

Authors' contributions
Zelalem Teklemariam participated in proposal writing, data collection, analysis, interpretation and critical review of the manuscript. Fitsum Weldegebreal participated in proposal writing, data collection and critical review of the manuscript. Habtamu Mitiku participated in proposal writing, data collection, analysis and critical review of the manuscript. All authors read and approved the nal manuscript.