Disease and malnutrition in British hospitals.

The development of disease may be accompanied by the loss of appetite, metabolic changes leading to tissue wasting and, in some cases, intestinal malfunction associated with the impaired absorption of nutrients. Thus, in many patients there is an inadequate supply of nutrients which, in combination with the influence of inflammatory mediators, leads to tissue wasting and defective organ function. This process is characterized by the term malnutrition. Unfortunately, satisfactory tools for the measurement of malnutrition in the clinical context are not yet available. Reliance is placed on structural change determined by anthropometry. Laboratory markers such as the concentration of serum proteins and immunological indices are influenced by other factors, not least of which is the activity of the disease process. Consequently, many of these variables reflect the severity of illness rather than the degree of nutritional depletion (Sitges-Serra & Franch-Arcas, 1995). Impaired organ function may precede measurable changes in structure (Lopes et al. 1982; Jeejeebhoy, 1988). Whereas there are some clinical measurements of function, such as muscle dynamometry (Webb et al. 1989), the variability and lack of specificity for nutritional depletion limit their value in nutritional assessment, although they do correlate with increased surgical risk. Malnutrition is common in hospital patients (Bistrian et al. 1974; Bastow et al. 1983a; Larsson et al. 1990; McWhirter & Pennington, 1994). There is a lack of awareness of the importance of the problem amongst clinical staff (McWhirter & Pennington, 1994; Lennard-Jones et al. 1995). Consequently it escapes recognition in the majority of affected patients (Hill et al. 1977; McWhirter & Pennington, 1994). Many malnourished patients are deprived of treatment from which they may benefit and increasing nutritional depletion is common during hospital stay. The effect of malnutrition on the patient and the outcome of disease is significant and sometimes fatal. Reduced muscle strength and stamina affects muscles of respiration as well as muscles of locomotion (Arora & Rochester, 1982). Reduced immune function (Hill, 1992; Animashaun & Heatley, 1994) exposes the patient to increased risk of infection. Increased surgical mortality has long been recognized in the malnourished patient. Techniques for nutritional support are now available for the prevention or treatment of malnutrition. Reversal of nutritional depletion may not be possible in all patients, especially in patients who are stressed on account of sepsis, bums, or trauma, at least until the underlying disease process has been treated or controlled (Askanazi et al. 1980). Even