Special Article - Malnutrition
Austin J Nutri Food Sci. 2019; 7(8): 1132.
Malnutrition and Their Association with Diabetes Complications Among Hospitalized Type 2 Diabetes Patients in Gaza Strip, Palestine
El Bilbeisi AH1,2,4*, El Afifi A3, Taleb M3, El Qidra R3 and Djafarian K4
1Department of Clinical Nutrition, Faculty of Pharmacy, Al Azhar University of Gaza, Palestine
2Department of Nutritional Sciences and Public Health (Academic Department), Palestine Technical College, Palestine
3Faculty of Pharmacy, Al Azhar University of Gaza, Palestine
4Department of Clinical Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, International Campus (TUMS- IC), Iran
*Corresponding author: El Bilbeisi Abdel Hamid, Department of Clinical Nutrition, Faculty of Pharmacy, Al Azhar University of Gaza, Gaza Strip, Palestine
Received: November 22, 2019; Accepted: December 18, 2019; Published: December 25, 2019
Abstract
Background: Malnutrition is a health problem of huge magnitude among hospitalized patients. However, the role of malnutrition in the origin of diabetes complications is not understood well. This study was conducted to evaluate the association between malnutrition and diabetes complications among patients with type 2 diabetes mellitus in Gaza Strip, Palestine.
Methods: This cross sectional study was conducted among a representative sample of Palestinian type 2 diabetes patients (both genders, aged 30-80 years), patients receiving care at Al Shifa Medical Complex in Gaza Strip, Palestine. Patients’ nutritional status was evaluated on the first day of admission using the nutritional risk screening tool (NRS 2002). Additional information regarding demographic-socioeconomic and medical history variables was obtained with an interview-based questionnaire.
Results: Based on the nutritional screening scores, 31.5% of the patients had malnutrition, (55.2% females, and 44.8% males). The prevalence of low risk, at risk, and high risk of malnutrition was 68.5%, 22.1%, and 9.4% respectively. After adjustment for confounding variables, patients with the low risk of malnutrition had a lower odds for (high blood pressure, eyes problems, kidney problems, heart problems, and extremities problems), (OR 0.063 CI 95% (.013-.305)), (OR 0.391 CI 95% (.225-.680)), (OR 0.431 CI 95% (.197-.942)), (OR 0.167 CI 95% (.050-.557)) and (OR 0.499 CI 95% (.281-.885)) respectively, (P value ‹ 0.05 for all), compared with those in the high risk of malnutrition.
Conclusion: The low risk of malnutrition are associated with a lower prevalence of diabetes complications among type 2 diabetes patients.
Keywords: Diabetes complications; Malnutrition; Palestine; Prevalence; Type 2 Diabetes Mellitus
Abbreviations
NRS: Nutritional Risk Screening Tool; DM: Diabetes Mellitus; T2DM: Type 2 Diabetes Mellitus; BP: Blood Pressure; WC: Waist Circumference; BMI: Body Mass Index; FPG: Fasting Plasma Glucose; IPAQ: International Physical Activity Questionnaire; SD: Stander Deviation; OR: Odds Ratio; CI: Confidence Interval; MET: Metabolic Equivalent
Introduction
Malnutrition is a health problem of huge magnitude among hospitalized patients [1]. It is associated with many adverse clinical outcomes including prolonged hospitalization, infections, muscle wasting, and impaired wound healing, and increased morbidity and mortality [2,3]. In addition, malnutrition increases health care costs, reduces productivity and slows economic growth, which can perpetuate a cycle of poverty and ill health [4]. Malnutrition refers to deficiencies, excesses, or imbalances in a person’s intake of energy and/or nutrients [5]. The World Health Organization estimates that, 1.9 billion adults are overweight or obese, while 462 million are underweight [6]. It is estimated that, the prevalence rate of malnutrition in hospitalized patients varies from 20% to 60% [7,8]. Furthermore, the developmental, economic, social, and medical impacts of the global burden of malnutrition are serious and lasting, for individuals and their families, for communities and for countries [9]. Every country in the world is affected by one or more forms of malnutrition, and these mostly occur in low- and middle-income countries [10]. Combating malnutrition in all its forms is one of the greatest global health challenges [6].
On the other hand, the prevalence of diabetes mellitus (DM) is steadily increasing everywhere, most markedly in the world’s low and middle-income countries [11]. DM is recognized as an important cause of premature death and disability [12]. Globally, more than 422 million adults were living with DM, and about 1.6 million death are directly attributed to DM each year [13]. Most of DM deaths (More than 80%) occur in low and middle-income countries [12]. In Palestine, the prevalence rate of DM was 10.5% in the West Bank and 11.8% in the Gaza Strip among the registered Palestinian refugees [14]. When DM is uncontrolled, it has dire consequences for health and well-being [14]. Moreover, DM and its complications impact harshly on the finances of individuals and their families and to health systems and national economies through direct medical costs and loss of work and wages [15]. Complications can arise as the disease progresses. Long term complications such as coronary heart disease which can lead to a heart attack, cerebrovascular disease which can lead to stroke, retinopathy which can lead to blindness, nephropathy which can lead to kidney failure and the need for dialysis, and neuropathy which increases the chance of foot ulcers, infection and the eventual need for limb amputation may be attenuated by dietary interventions [14].
Although measurement of malnutrition varied depending on the hospital setting and method of nutritional assessment [16]. In the present study, the Nutritional Risk Screening tool (NRS 2002) was used on the first day of admission to evaluate the nutritional status of type 2 diabetes mellitus (T2DM) patients [17]. The NRS 2002, documented by a retrospective analysis of 128 randomized controlled trials of nutritional supports, is a reliable, easily applied and reproducible tool for identifying patients at nutritional risk [18]. It contains the nutritional components of malnutrition universal screening tool, and in addition, a grading of severity of disease as a reflection of increased nutritional requirements [19]. The NRS 2002 appears to have higher sensitivity and specificity for predicting complications than other nutritional assessment tools [17,19].
In conclusion, the etiology of DM complications is poorly understood [14]. In addition, malnutrition is highly prevalent in hospitalized patients, and is associated with many adverse clinical outcomes, including longer length of stay, increased morbidity and mortality, and increased hospital costs. Furthermore, in Palestine the prevalence of malnutrition in hospitalized patients is not well studied. However, few studies have explored the relationship between malnutrition and DM complications. Therefore, understanding the association between malnutrition with DM complications may be helpful in reducing DM related premature mortality and improve outcomes among T2DM patients. To our knowledge, this is the first study, which examined this association among T2DM patients in Gaza Strip, Palestine. Our study was conducted to evaluate the association between malnutrition and DM complications among hospitalized patients with T2DM.
Methods and Materials
Study population
This cross sectional study was conducted in the years 2019 among a representative sample of Palestinian T2DM patients, selected by a cluster random sampling method. A total of 213 hospitalized patients, aged 30 to 80 years receiving care in medical and surgical departments at Al Shifa Medical Complex in Gaza Strip, Palestine, were included in the study. The total number of medical and surgical departments at Al Shifa Medical Complex is eleven, with 224 beds [20]. The medical and surgical beds were distributed in each department as follows (twentyfour, eighteen, ten, twenty-two, nineteen, twenty-two, twenty-five, twenty-one, twenty-seven, eighteen and eighteen beds respectively). The study sample was distributed according to the number of beds in each department as follows (23, 17, 9, 21, 18, 21, 24, 20, 26, 17 and 17 patients respectively). Pregnant, lactating women and patients with other types of serious illness such as cancer, thyroid diseases, acute myocardial infarction, or end-stage kidney disease were excluded from the study.
The study protocol was approved by the Ethics Committee of Al Azhar University of Gaza and by the Palestinian Health Research Council (Helsinki Ethical Committee). Moreover, written informed consent was also obtained from each participant.
Assessment of nutritional status
The NRS 2002 was used on the first day of admission to evaluate the nutritional status of T2DM patients [17]. The NRS 2002, documented by a retrospective analysis of 128 randomized controlled trials of nutritional supports, is a reliable, easily applied and reproducible tool for identifying patients at nutritional risk [18]. The purpose of the NRS-2002 tool is to detect the presence of undernutrition and the risk of developing undernutrition in the hospital setting [17]. It contains the nutritional components of malnutrition universal screening tool, and in addition, a grading of severity of disease as a reflection of increased nutritional requirements [19]. The NRS 2002 appears to have higher sensitivity and specificity for predicting complications than other nutritional assessment tools [19]. It includes four questions as a pre-screening for departments with few at risk patients [17]. Furthermore, according to the NRS 2002, nutritional risk is evaluated by three components: Nutritional status, severity of disease and patient age. It contains a total of 7 points. Impaired nutritional status is scored from 0 - 3 according to changes of BMI, weight loss and food intake. Severity of disease is scored 0 - 3 according to different kinds of disease. If age ≥ 70 years: add 1 to the total score [18]. In the present study, patients are classified as being at nutritional risk (score 4), high risk (score 5 to 7), or not (score 3 or less) according to the total score obtained [17].
Assessment of anthropometric measurements and blood pressure (BP): Height, weight, and waist circumference (WC) were measured in all patients using standard methods [21]. Then, the standard formula, weight (kg) divided by height (m2), was used to calculate body mass index (BMI) [22]. In addition, BP was measured from the left arm (mmHg) by mercury sphygmomanometer. Three readings on different days, while the patient was seated after relaxing for at least fifteen minutes in a quiet environment, empty bladder. The average of three measurements was recorded [23].
Biochemical analysis: After 12 hours fasting, venous blood samples (4.0 ml), were collected from all patients by well-trained and experienced nurses and was used for blood chemistry analysis. Serum was separated immediately, and the extracted serum was investigated for fasting plasma glucose (FPG) mg/dl. Mindray BS-300 chemistry analyzer instrument was used for blood chemistry analysis [24].
Assessment of other variables: Additional information regarding demographic socioeconomic, DM complications and medical history variables was obtained with an interview-based questionnaire. Diagnosis and classification of DM complications was defined according to Palestinian guidelines for diagnosis and management of DM criteria [25]. Past history of DM complications and any previous treatment for these complications was recorded by doctors on the patients files. In the present study, reports and all relevant documentation, including medical records were checked. Additionally, data on physical activity were obtained using the International Physical Activity Questionnaire (IPAQ short version) [26]. Pilot study was carried out on thirty patients to enable the researcher to examine the tools of the study. The questionnaire and data collection process were modified according to the result of the pilot study. The data was collected by six qualified data collectors who were given a full explanation and training by the researcher about the study.
Statistical analysis
All statistical analysis was performed using SPSS version 20. Data are expressed as means ± stander deviation (SD) for continuous variables and as percentage for categorical variables. The chi-square test was used to determine the significant differences between different categorical variable. The differences between mean were tested by independent samples t-test and one-way ANOVA. Finally, the odds ratio (OR) and confidence interval (CI) for the DM complications across categories of nutritional screening scores were tested by binary logistic regression. P value less than 0.05 was considered as statistically significant.
Results
Baseline characteristics of the study population by sex
A total of 213 hospitalized patients with T2DM, aged 30 to 80 years old (61.0% females, 39.0% males) were included in the present study. Table 1 show the characteristics of the study population by sex. The findings of this study demonstrated that the mean age (years) for male patients was 51.7±10.5 vs. 54.0±10.6 for females. In addition, for the following variables (educational level, employment status, history of smoking, type of DM medications used, multivitamin supplement use, and BMI (kg/m²)), the difference was statistically significant in both sexes (P value ‹ 0.05 for all).
Variables
T2DM
(n=213)
Male
(n=83)
Female
(n=130)
P
Value
No. (%)
No. (%)
No. (%)
Age (years)
Mean±SD
53.1±10.6
51.7±10.5
54.0±10.6
0.744
Marital status
Married
209.0 (98.1)
82.0 (39.2)
127.0 (60.8)
0.492
Unmarried
4.0 (1.9)
1.0 (25.0)
3.0 (75.0)
Educational level
Low education
104.0 (48.8)
31.0 (29.8)
73.0 (70.2)
0.005
High education
109.0 (51.2)
52.0 (47.7)
57.0 (52.3)
Family size
Less than five
67.0 (31.5)
29.0 (43.3)
38.0 (56.7)
0.234
Five or more
146.0 (68.5)
54.0 (37.0)
92.0 (63.0)
Employment status
Yes
40.0 (18.8)
22.0 (55.0)
18.0 (45.0)
0.017
No
173.0 (81.2)
61.0 (35.3)
112.0 (64.7)
Monthly income
= 2000 (NIS)
182.0 (85.4)
69.0 (37.9)
113.0 (62.1)
0.284
> 2000 (NIS)
31.0 (14.6)
14.0 (45.2)
17.0 (54.8)
History of smoking
Yes
24.0 (11.3)
24.0 (100.0)
0.0 (00.0)
0.001
No
189.0 (88.7)
59.0 (31.2)
130.0 (68.8)
History of alcohol intake
No
213.0 (100.0)
83.0 (39.0)
130.0 (61.0)
-
Diabetes duration (years)
Less than five
37.0 (17.4)
15.0 (40.5)
22.0 (59.5)
0.304
Five to ten
83.0 (39.0)
37.0 (44.6)
46.0 (55.4)
More than ten
93.0 (43.7)
31.0 (33.3)
62.0 (66.7)
Use diabetes medications
Yes
213.0 (100.0)
83.0 (39.0)
130.0 (61.0)
-
Type of diabetes medications used
Diabetes pills
82.0 (38.5)
42.0 (51.2)
40.0 (48.8)
0.012
Insulin injections
114.0 (53.5)
37.0 (32.5)
77.0 (67.5)
Pills & injections
17.0 (8.0)
4.0 (23.5)
13.0 (76.5)
Received diabetes care instructions
Yes
103.0 (48.4)
43.0 (41.7)
60.0 (58.3)
0.253
No
110.0 (51.6)
40.0 (36.4)
70.0 (63.6)
Number of meals per day
Less than 3 meals
59.0 (27.7)
20.0 (33.9)
39.0 (66.1)
0.793
Three meals
104.0 (48.8)
42.0 (40.4)
62.0 (59.6)
More than 3 meals
50.0 (23.5)
21.0 (42.0)
29.0 (58.0)
Have a meal plan for diabetes
Yes
99.0 (46.5)
37.0 (37.4)
62.0 (62.6)
0.381
No
114.0 (53.5)
46.0 (40.4)
68.0 (59.6)
Who describe diet regimen
Physician
70.0 (32.9)
28.0 (40.0)
42.0 (60.0)
0.641
Self-reading
29.0 (13.6)
9.0 (31.0)
20.0 (69.0)
Do not fellow diet regimen
114.0 (53.5)
46.0 (40.4)
68.0 (59.6)
Multivitamin supplement use
Yes
98.0 (46.0)
5.0 (5.1)
93.0 (94.9)
0.001
No
115.0 (54.0)
78.0 (67.8)
37.0 (32.2)
Body mass index (kg/m²)
Mean±SD
31.02±6.40
28.2±4.6
32.8±6.7
0.001
Waist circumference (cm)
Mean±SD
106.1±15.3
100.3±13.0
109.7±15.7
0.167
Fasting plasma glucose (mg/dl)
Mean±SD
166.1±29.6
163.1±24.8
168.0±32.3
0.068
Physical activity (Total MET)
Mean±SD
1145.6±1255.8
1438.1±1403
958.8±1117
0.170
Systolic blood pressure (mmHg)
Mean±SD
131.5±12.5
130.3±12.1
132.3±12.7
0.411
Diastolic blood pressure (mmHg)
Mean±SD
83.8±7.7
83.4±7.7
84.0±7.8
0.882
Data are expressed as means ± SD for continuous variables and as percentage for categorical variables. The differences between means were tested by using independent sample t test. The chi-square test was used to examine differences in the prevalence of different categorical variable. P value less than 0.05 was considered as statistically significant. SD, stander deviation.
Table 1: Characteristics of the study population by sex.
The nutritional screening scores for the study population by sex
As shown in Table 2, based on the nutritional screening scores, 31.5% of T2DM patients had malnutrition (55.2% females, and 44.8% males). The prevalence of low risk, at risk, and high risk of malnutrition among T2DM patients was 68.5%, 22.1%, and 9.4% respectively. No statistically significant associations was found between the different categories of nutritional screening scores in both sexes (P value = 0.267).
Variables
T2DM
(n=213)
Male
(n=83)
Female
(n=130)
P
Value
No. (%)
No. (%)
No. (%)
Initial Screening: If “Yes” to any, proceed to final screening
BMI < 20.5 kg/m²
Yes
38.0 (17.8)
22.0 (57.9)
16.0 (42.1)
0.008
No
175.0 (82.2)
61.0 (34.9)
114.0 (65.1)
Weight loss within 3 months
Yes
56.0 (26.3)
23.0 (41.1)
33.0 (58.9)
0.412
No
157.0 (73.7)
60.0 (38.2)
97.0 (61.8)
Reduced dietary intake in the last week
Yes
119.0 (55.9)
44.0 (37.0)
75.0 (63.0)
0.298
No
94.0 (44.1)
39.0 (41.5)
55.0 (58.5)
ICU patient
Yes
0.0 (0.0)
0.0 (0.0)
0.0 (0.0)
-
No
213.0 (100.0)
83.0 (39.0)
130.0 (61.0)
Final Screening: addition of the selected points
Nutritional impairment:
None
0 points
0.0 (0.0)
0.0 (0.0)
0.0 (0.0)
0.225
Mild: weight loss > 5% in 3 months or food intake < 50 - 75% of normal requirement in the preceding week
1 point
148.0 (69.5)
53.0 (35.8)
95.0 (64.2)
Moderate: weight loss > 5% in 2 months or BMI 18.5 - 20.5 plus impaired general condition or food intake 25 - 60% of normal requirement in preceding week
2 points
45.0 (21.1)
19.0 (42.2)
26.0 (57.8)
Severe: weight loss > 5% in 1 month (> 15% in 3 months) or BMI < 18.5 plus impaired general condition or food intake 0 - 25% of normal requirement in preceding week
3 points
20.0 (9.4)
11.0 (55.0)
9.0 (45.0)
Severity of disease:
Normal nutritional requirement
0 points
0.0 (0.0)
0.0 (0.0)
0.0 (0.0)
0.017
Hip fracture, chronic illness (may have acute complications, e.g. cirrhosis or COPD), chronic dialysis, diabetes, cancer
1 point
113.0 (53.1)
36.0 (31.9)
77.0 (68.1)
Major abdominal surgery, stroke, severe pneumonia, hematologic malignancy
2 points
100.0 (46.9)
47.0 (47.0)
53.0 (53.0)
Head injury, bone marrow transplant, ICU patient with APACHE >10
3 points
0.0 (0.0)
0.0 (0.0)
0.0 (0.0)
Age:
< 70 years
0 points
203.0 (95.3)
82.0 (40.4)
121.0 (59.6)
0.049
= 70 years
1 point
10.0 (4.7)
1.0 (10.0)
9.0 (90.0)
Nutritional screening scores: interpretation
0-3
Low risk
146.0 (68.5)
53.0 (36.3)
93.0 (63.7)
0.267
4
At risk
47.0 (22.1)
19.0 (40.4)
28.0 (59.6)
5-7
High risk
20.0 (9.4)
11.0 (55.0)
9.0 (45.0)
Data are expressed as percentage for categorical variables. The chi-square test was used to examine differences in the prevalence of different categorical variable. P value less than 0.05 was considered as statistically significant.
Table 2: The nutritional screening scores for the study population by sex.
Distribution of diabetes complications for the study population by sex
On the other hand, Table 3 shows that 74.2% of the patients had high BP (≥130/85 mmHg) or treatment of previously diagnosed hypertension, 62.4% of the patients had eyes problems, 12.2% had kidney problems, 7.0% had heart problems, 27.2% had extremities problems, and 96.2% of the patients had neurological problems. Moreover, for the following variables (high BP or treatment of previously diagnosed hypertension, and eyes problems), the difference was statistically significant in both sexes (P value ‹ 0.05).
Variables
T2DM
(n=213)
Male
(n=83)
Female
(n=130)
P
Value
No. (%)
No. (%)
No. (%)
High BP (=130/85 mmHg) or treatment of previously diagnosed hypertension
Yes
158.0 (74.2)
53.0 (33.6)
105.0 (66.4)
0.005
No
55.0 (25.8)
30.0 (54.5)
25.0 (45.5)
Eyes problems
Yes
133.0 (62.4)
41.0 (30.8)
92.0 (69.2)
0.001
No
80.0 (37.6)
42.0 (52.5)
38.0 (47.5)
Kidney problems
Yes
26.0 (12.2)
6.0 (23.1)
20.0 (76.9)
0.057
No
187.0 (87.8)
77.0 (41.2)
110.0 (58.8)
Heart problems
Yes
15.0 (7.0)
3.0 (20.0)
12.0 (80.0)
0.096
No
198.0 (93.0)
80.0 (40.4)
118.0 (59.6)
Extremities problems
Yes
58.0 (27.2)
24.0 (41.4)
34.0 (58.6)
0.387
No
155.0 (72.8)
59.0 (38.1)
96.0 (61.9)
Neurological problems
Yes
205.0 (96.2)
80.0 (39.0)
125.0 (61.0)
0.619
No
8.0 (3.8)
3.0 (37.5)
5.0 (62.5)
Data are expressed as percentage for categorical variables. The chi-square test was used to examine differences in the prevalence of different categorical variable. P value less than 0.05 was considered as statistically significant.
Table 3: Distribution of diabetes complications for the study population by sex.
Characteristics of the study population in relation to the categories of nutritional screening scores
Then, the characteristics of the study population in relation to different categories of nutritional screening scores are shown in Table 4. Our results revealed that, the mean age (years) for patients with low risk of malnutrition was 43.5±11.0 vs. 55.0±9.4 for patients with high risk. In addition, for the following factors (age, educational level, employment status, monthly income, DM duration, received DM care instructions, BMI, WC, FPG, and physical activity (Total MET)), the difference was statistically significant across different categories of nutritional screening scores (P value ‹ 0.05 for all).
Variables
T2DM (n=213)
P
Value
Low risk
At risk
High risk
No. (%)
No. (%)
No. (%)
Age (years)
Mean±SD
43.5±11.0
51.0±11.4
55.0±9.4
0.001
Marital status
Married
144.0 (68.9)
46.0 (22.0)
19.0 (9.1)
0528
Unmarried
2.0 (50.0)
1.0 (25.0)
1.0 (25.0)
Educational level
Low education
82.0 (78.8)
17.0 (16.3)
5.0 (4.8)
0.005
High education
64.0 (58.7)
30.0 (27.5)
15.0 (13.8)
Family size
Less than five
43.0 (64.2)
14.0 (20.9)
10.0 (14.9)
0.172
Five or more
103.0 (70.5)
33.0 (22.6)
10.0 (6.8)
Employment status
Yes
22.0 (55.0)
10.0 (25.0)
8.0 (20.0)
0.025
No
124.0 (71.7)
37.0 (21.4)
12.0 (6.9)
Monthly income
= 2000 (NIS)
131.0 (72.0)
36.0 (19.8)
15.0 (8.2)
0.032
> 2000 (NIS)
15.0 (48.4)
11.0 (35.5)
5.0 (16.1)
History of smoking
Yes
16.0 (66.7)
3.0 (12.5)
5.0 (20.8)
0.086
No
130.0 (68.8)
44.0 (23.3)
15.0 (7.9)
Diabetes duration (years)
Less than five
17.0 (45.9)
11.0 (29.7)
9.0 (24.3)
0.003
Five to ten
58.0 (69.9)
18.0 (21.7)
7.0 (8.4)
More than ten
71.0 (76.3)
18.0 (19.4)
4.0 (4.3)
Use diabetes medications
Yes
146.0 (68.5)
47.0 (22.1)
20.0 (9.4)
-
Type of diabetes medications used
Diabetes pills
54.0 (65.9)
17.0 (20.7)
11.0 (13.4)
0.419
Insulin injections
80.0 (70.2)
25.0 (21.9)
9.0 (7.9)
Pills & injections
12.0 (70.6)
5.0 (29.4)
0.0 (0.0)
Received diabetes care instructions
Yes
60.0 (58.3)
24.0 (23.3)
19.0 (18.4)
0.001
No
86.0 (78.2)
23.0 (20.9)
1.0 (0.9)
Number of meals per day
Less than 3 meals
38.0 (64.4)
16.0 (27.1)
5.0 (8.5)
0.653
Three meals
76.0 (73.1)
20.0 (19.2)
8.0 (7.7)
More than 3 meals
32.0 (64.0)
11.0 (22.0)
7.0 (14.0)
Have a meal plan for diabetes
Yes
65.0 (65.7)
23.0 (23.2)
11.0 (11.1)
0.630
No
81.0 (71.1)
24.0 (21.1)
9.0 (7.9)
Who describe diet regimen
Physician
47.0 (67.1)
16.0 (22.9)
7.0 (10.0)
0.856
Self-reading
18.0 (62.1)
7.0 (24.1)
4.0 (13.8)
Do not fellow diet regimen
81.0 (71.1)
24.0 (21.1)
9.0 (7.9)
Multivitamin supplement use
Yes
73.0 (74.5)
20.0 (20.4)
5.0 (5.1)
0.095
No
73.0 (63.5)
27.0 (23.5)
15.0 (13.0)
Body mass index (kg/m²)
Mean±SD
32.3±5.0
30.2±8.5
22.8±0.85
0.001
Waist circumference (cm)
Mean±SD
109.4±12.2
104.2±19.3
86.1±9.1
0.001
Fasting plasma glucose (mg/dl)
Mean±SD
156.3±30.1
167.9±27.1
169.0±29.4
0.037
Physical activity (Total MET)
Mean±SD
2410.2±1215
1366.4±1277
901.30±1139
0.001
Systolic blood pressure (mmHg)
Mean±SD
132.5±12.2
129.3±13.5
130.0±11.6
0.268
Diastolic blood pressure (mmHg)
Mean±SD
84.1±7.8
82.5±7.9
84.0±6.8
0.459
Data are expressed as means ± SD for continuous variables and as percentage for categorical variables. The differences between means were tested by using one-way ANOVA. The chi-square test was used to examine differences in the prevalence of different categorical variable. P value less than 0.05 was considered as statistically significant. SD, stander deviation.
Table 4: Characteristics of the study population in relation to the categories of nutritional screening scores.
OR and CI for the diabetes complications across categories of nutritional screening scores
Finally, we computed the OR and CI for the DM complications across different categories of nutritional screening scores (Table 5). Our results revealed that, after adjustment for confounding variables, patients with the low risk of malnutrition had a lower odds for (high blood pressure, eyes problems, kidney problems, heart problems, and extremities problems), (OR 0.063 CI 95% (.013-.305)), (OR 0.391 CI 95% (.225-.680)), (OR 0.431 CI 95% (.197-.942)), (OR 0.167 CI 95% (.050-.557)) and (OR 0.499 CI 95% (.281-.885)) respectively, (P value ‹ 0.05 for all), compared with those in the high risk of malnutrition. No statistically significant association was found between the low risks of malnutrition with the neurological problems.
Low risk
At risk
High risk
P value
OR (95%CI)
High BP (=130/85 mmHg) or treatment of previously diagnosed HTN (74.2%)
79.7
19.0
1.3
0.058
0.190 (.034-1.058)
Adjusted*
0.001
0.063 (.013-.305)
Eyes problems (62.4%)
73.7
18.8
7.5
0.139
0.841 (.668-1.058)
Adjusted*
0.001
0.391 (.225-.680)
Kidney problems (12.2%)
80.8
11.5
7.7
0.231
0.834 (.619-1.123)
Adjusted*
0.035
0.431 (.197-.942)
Heart problems (7.0%)
86.7
13.3
0.0
0.361
0.641 (.247-1.663)
Adjusted*
0.004
0.167 (.050-.557)
Extremities problems (27.2%)
79.3
20.7
0.0
0.130
0.833 (.657-1.055)
Adjusted*
0.017
0.499 (.281-.885)
Neurological problems (96.2%)
70.2
21.5
8.3
0.145
0.290 (.055-1.534)
Adjusted*
0.295
0.422 (.084-2.119)
The OR and CI for the diabetes complications across categories of nutritional screening scores were tested by binary logistic regression. *Adjusted for age (years), educational level, employment status, monthly income, diabetes duration (years), received diabetes care instructions, body mass index (kg/m²), waist circumference (cm), fasting plasma glucose (mg/dl), and physical activity (total met). P value less than 0.05 was considered as statistically significant. OR, odds ratio; CI, confidence interval.
Table 5: Odd ratio and confidence interval for the diabetes complications across categories of nutritional screening scores.
Discussion
Malnutrition is a health problem of huge magnitude among hospitalized patients [1]. It is associated with many adverse clinical outcomes including prolonged hospitalization, infections, muscle wasting, and impaired wound healing, and increased morbidity and mortality [2,3]. However, DM and its complications impact harshly on the finances of individuals and their families and to health systems and national economies through direct medical costs and loss of work and wages [15]. In addition, research consistently demonstrates that malnutrition is a hidden cause of poor health outcomes, rising health care costs, increased utilization of resources, increased length of hospital stay, increased re-admission rates, and contributes to higher morbidity and mortality [10]. To the best of our knowledge, this is the first study, which describes the malnutrition among T2DM patients and its association with DM complications in Gaza Strip, Palestine. The findings of the present study revealed that, based on the nutritional screening scores, 31.5% of hospitalized T2DM patients had malnutrition, (55.2% females, and 44.8% males). The prevalence of low risk, at risk, and high risk of malnutrition was 68.5%, 22.1%, and 9.4% respectively. Many of the previous studies demonstrated that, at least one third of hospitalized patients in developed countries are malnourished on admission to the hospital, and if left untreated, approximately two thirds of those patients will experience a further decline in their nutrition status during their hospitalization [7,8]. Lovesley et al. show that, malnutrition is serious but under-diagnosed problem among hospitalized patients as approximately one-third patients may become malnourished during their stay [27]. In addition, according to previous studies, the prevalence rate of malnutrition in hospitalized patients varies from 20% to 60% [7,8]. The results of our study support these findings.
Furthermore, measurement of malnutrition varied depending on the hospital setting and method of nutritional assessment [16]. In the present study, the NRS 2002 tool was used to evaluate the nutritional status of hospitalized T2DM patients. The NRS 2002 documented by a retrospective analysis of 128 randomized controlled trials of nutritional supports, is a reliable, easily applied and reproducible tool for identifying patients at nutritional risk [18]. It contains the nutritional components of malnutrition universal screening tool, and in addition, a grading of severity of disease as a reflection of increased nutritional requirements [19]. Moreover, the NRS 2002 appears to have higher sensitivity and specificity for predicting complications than other nutritional assessment tools [17,19]. Hospitalized patients, regardless of their BMI, usually suffer from undernutrition because of reduced nutrient intake due to illness-induced poor appetite, gastrointestinal symptoms, reduced ability to chew or swallow, or nil by mouth for diagnostic and therapeutic procedures. In addition, they may have increased energy, protein, and essential micronutrient needs because of inflammation, infection, or other catabolic conditions [27]. In our study, the high prevalence of malnutrition may be related in part to the burden of living with DM and its complications which may plays an important role in the etiology of malnutrition [14]. Malnutrition predisposes patients to disease, delays recovery from illness, and adversely affects body function, wellbeing and clinical outcome [2,3]. Moreover, people with DM are already at risk of poor healing and poor health outcomes because of the complications of the disease [28].
On the other hand, the main findings of this study indicate that, after adjustment for confounding variables, patients with the low risk of malnutrition had a lower odds for (high blood pressure, eyes problems, kidney problems, heart problems, and extremities problems), compared with those in the high risk of malnutrition. In fact, very few studies have explored the relationship between malnutrition and DM complications in patients with T2DM, which made the comparison of our results with previous studies difficult. Most studies have examined the associations between malnutrition and one of DM complications [29-31]. Laghari et al. in a cross sectional study show that, there was a close relationship between malnutrition, and risk of hypertension, and myocardial infarction in patients with T2DM [29]. Daien et al. show that, malnutrition was identified as an additional factor associated with retinopathy [30]. In addition, Saxena et al. show that, medical nutritional management is important for the prevention of malnutrition, which associated with diabetes nephropathy [31]. Furthermore, Little et al. show that, nutrition assessment and intervention can help patients with diabetic foot ulcers and maximize their nutritional status to promote wound healing [32]. The results of our study support these findings.
Additionally, the findings of our study revealed that, 74.2% of the patients had high BP (≥130/85 mmHg) or treatment of previously diagnosed hypertension, 62.4% of the patients had eyes problems, 12.2% had kidney problems, 7.0% had heart problems, 27.2% had extremities problems and 96.2% of the patients had neurological problems.
Diabetic patients have an increased risk of developing complications such as coronary heart disease, heart attack, cerebrovascular disease and stroke. However, complications such as retinopathy, nephropathy, and neuropathy can have a distressing impact on patient’s quality of life and a significant increase in financial burden [14]. The prevalence reported from studies conducted worldwide on DM complications showed varying rates. According to previous studies, the prevalence of retinopathy was 17-50%, nephropathy 17-28%, cardiovascular complications 10- 22.5%, neuropathy 19-42%, and foot problems 5-23% [33,34]. In Palestine, El Bilbeisi et al. show that, 64.25% of T2DM patients had high BP (≥130/85 mmHg) or treatment of previously diagnosed hypertension, 57.8% of the patients had eyes problems, 10.8% had kidney problems, 7.25% had heart problems, 22.0% had extremities problems and 92.1% of the patients had neurological problems [14]. The results of our study support these findings. In the present study, increasing DM duration, and patients’ age could contribute to these results. Furthermore, our study not adjusted for other confounding variables such as genetics factors, and different diagnostic methods and criteria used, which could contribute to these results. Actually, the relationship between malnutrition with DM complications need more studies in the future.
The main limitations of this study is its cross sectional design; the causal relationship could not be determined, and it limits the generalizability of our results. The main strength of our study was its being the first study, which describes the malnutrition among T2DM patients and its association with DM complications in Gaza Strip, Palestine.
Finally, we conclude that the low risk of malnutrition are associated with a lower prevalence of DM complications among T2DM patients. Further future multi-center studies are required to confirm these findings.
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