Prevalence of malnutrition in a tertiary hospital in Turkey: overlooked subject?

Aims: The study evaluated children’s nutritional status at the moment of hospitalization. Patients and Methods: The nutritional status of 113 hospitalized patients was retrospectively evaluated at the time of hospitalization in the Clinic of Pediatric Gastroenterology between May 2013 and November 2014. During hospitalization, height for age, weight for age, and weight for height z scores were calculated. Results: Of the 113 patients in the study, 58 were female and 55 were male; the mean age was 59.59 ± 61.73 months and 67.87 ± 60.99 months, respectively. According to the World Health Organization standards, 33 (29.2%) underweight patients, 17 (15.0%) patients with acute malnourishment, and 21 (18.6%) patients with chronic malnourishment were detected. Based on weight for age data, 10 (8.8%) patients were severely malnourished, 22 (19.5%) patients were moderately malnourished, 27 (23.9%) patients were mildly malnourished, 40 (35.4) patients had normal weight, 8 (7.1%) patients were overweight, and 6 (5.3%) patients were obese. According to the Water low classifi cation, 14 (12.4%) children were stunted, 6 (5.3%) children were wasted-stunted, and 15 (13.3%) children were wasted. Conclusion: High rates of malnutrition were detected in hospitalized patients, therefore nutritional status should be carefully assessed at the moment of hospitalization to reduce the mortality rate, and patients should be given immediate nutritional support. The early diagnosis of mild or moderate malnutrition, and the timely start of treatment, will diminish the progression to severe malnutrition in developing countries like Turkey. Research Article Prevalence of malnutrition in a tertiary hospital in Turkey: overlooked subject? Yasin Sahin1*, Ahmet Rauf Goktepe2 and Evrim Ozen2 1Department of Pediatric Gastroenterology, Hepatology and Nutrition, Gaziantep University Medical Faculty, Gaziantep, Turkey 2Department of Pediatrics, Gaziantep University Medical Faculty, Gaziantep, Turkey Dates: Received: 22 May, 2017; Accepted: 30 May, 2017; Published: 31 May, 2017 *Corresponding author: Yasin Sahin, Department of Pediatric Gastroenterology, Hepatology and Nutrition, Cerrahpasa Faculty of Medicine, Istanbul University, Turkey, Tel: +90 212 414 30 00-21499; Fax: +90 0212 632 86 33; E-mail: ysahin977@gmail.com


Introduction
Malnutrition is a condition characterized by a defi ciency or excess intake of nutrients, or an imbalance of nutrients that has adverse effects on growth and development, and may increase morbidity and mortality. This term also includes obesity [1]. Malnutrition is reported to be directly or indirectly responsible for about 50-60% of childhood mortality worldwide [2]. The prevalence of malnutrition in hospitalized children has been reported as 5% in developed countries and up to 50% in developing countries [3][4][5].
The prevalence of malnutrition in hospitalized children has not decreased over the last 20 years [6]. Therefore, the Committee on Nutrition of the European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) has recommended the establishment of a nutritional support unit, especially in children's hospitals; the implementation of nutritional risk screening and providing adequate nutritional management to identify patients who require nutritional support; and the education of hospital staff and checking them regularly [7]. However, these recommendations have not been widely introduced into clinical practice.
While severe malnutrition is easily diagnosed, the diagnosis of mild or moderate malnutrition is often overlooked. Diagnosing mild or moderate malnutrition in the early period of hospitalization and starting treatment will diminish progression to severe malnutrition, so that the morbidity and mortality risk of malnutrition will be reduced. To our knowledge, this is the fi rst study on the prevalence of malnutrition in hospitalized children in the Clinic of Pediatric Gastroenterology. The aim of our study was to determine the prevalence of malnutrition at the moment of hospitalization in patients.

Methods
Children hospitalized in the Clinic of Pediatric Gastroenterology (tertiary center in Turkey) between May 2013 and November 2014 were included in the study. They were evaluated retrospectively from their records.
Patients who were admitted to intensive care or the emergency department were excluded and patients who were readmitted after discharge were excluded. Patients were also excluded if they were hospitalized for less than two days; had a history of premature birth or low birth weight; had congenital syndromes, such as Down syndrome, or oncologic diseases or chronic renal failure; or had no records of measurement of height and weight.
Anthropometric measurements are important in determining the risk of malnutrition in children in the early period of hospitalization. Therefore, measurement of the height and weight of newly hospitalized patients is required to calculate the necessary anthropometric values. On admission, the body length of children under the age of 2 years, standing height from the age of 2 years, and body weight were measured.
Multiple factors, such as low socioeconomic and educational level of the parents contribute to the development of malnutrition. Because of that, we used the socioeconomic and educational level of the parents.
We used different classifi cation systems for the defi ning of malnutrition; Gomez classifi cation, Waterlow classifi cation and World Health Organization 2006 classifi cation.
According to Gomez classifi cation, > 90% of the median of gender specifi c reference values of weight for age of this population were considered to indicate normal, 75-89% indicate mild malnutrition, 60-74% to indicate moderate malnutrition, and values <60% were defi ned as severe malnutrition [8].
Malnutrition was defi ned according to the criteria established by Waterlow. That is, 81-90% of the median of gender specifi c reference values of weight for height of this population were considered to indicate mild malnutrition, 70-80% to indicate moderate malnutrition, and values <70 % were defi ned as severe malnutrition [9].
Because there is a controversy in identifying malnutrition worldwide, the World Health Organization (WHO) has recommended the use of three indices; height for age z score (HAZ); weight for age z score (WAZ); and weight for height (W/H) z score [10]. The HAZ indicates the linear growth retardation among children; -2 SD is the median reference value according to the population, and a < -2 z score indicates chronic malnutrition. The WAZ is used to assess both acute and chronic malnutrition, and for the long-term evaluation of nutrition; a < -2 z score is referred to as underweight. A W/H z score (especially in children under the ages of 24 months) is used to identify children below -2 SD. Those below these values are accepted as weak (wasted), which is an indicator of acute malnutrition [10]. Based on the WHO classifi cation for malnutrition, children with < -3 z scores for W/H or H/A were considered to be severely malnourished (including severe wasting and severe stunting) [11]. Those with W/H or HAZ between -3 and -2 were classifi ed as moderately malnourished.
In April 2006, the WHO reported new standards for assessing the nutritional status of children under the ages of 5 years. These criteria have been developed in Europe, Africa, the Middle East, Asia, and Latin America and can be used internationally [12]. Children who have z scores between -1 SD and 2 SD are no longer considered as malnourished according to the WHO criteria [13].
In the present study, weight for age (W/A), H/A, W/H, WAZ, and HAZ were calculated separately using the WHO 2006 standards. In addition, the Gomez and Water low classifi cations were used to assess the nutritional status of the patients in our study.

Statistical analysis
The Mann-Whitney U-test was used for the comparison of groups of numerical variables. The relationships between categorical variables were analyzed using the chi-squared test.
A level of p < 0.05 was considered as statistically signifi cant.
The SPSS for Windows 22 software package was used in the analysis.

Results
Of the 113 patients in the study, 58 (51.3%) were female, 55 Because the present study was retrospective, the data for breastfeeding and additional food given were obtained in only 90 (79.6%) patients; the mean time of breastfeeding and starting to receive additional food was 10.88 ± 9.41 months and 4.61 ± 3.33 months, respectively. In the current study, parents had low socioeconomic and educational level (Table 4).
According to the Gomez classifi cation, 10  weight, and the weight of 6 (9.8%) of them did not change.
There was no signifi cant difference between patients with and without nutritional support in terms of weight change (p > 0.05).   of them gained weight, and the weight of 6 (9.8%) of them did not change.
Exposure to negative factors, severe infections, especially during infancy when there is a signifi cantly higher growth rate, may cause severe and permanent changes in growth and developmental processes and may cause malnutrition [14,15].
In a study conducted in Turkey in 2008, one in every 10 children under the age of 5 years was malnourished and one-third of them were severely malnourished [16]. The deterioration in nutritional status in our country begins in the fi rst year of life, so early diagnosis and treatment of malnutrition is very important. Regarding age groups in the current study, the prevalence of malnutrition was 27.4% in the 0-24 month's age group. A high rate of detection of malnutrition in 0-24-monthold children is consistent with other studies [4,[17][18][19][20].
Malnutrition is fairly common in hospitalized children regardless of the presenting symptoms. Malnutrition is often overlooked when coping with the child's main disease.
Malnutrition rates vary depending on age and the underlying disease on admission to hospital [21][22][23].
The value of the protein-energy malnutrition in hospitalized children was reported as varying between 21% and 80% in proportion with the level of development of the countries [4,[24][25][26]. There is an inverse relationship between the number of patients with malnutrition and the level of development of a country [5,27,28]. In developing countries, it is known that malnutrition has been one of the primary causes of mortality in children under 5 years of age [29]. Mortality in children with severe malnutrition is 8.7 times more than in non-malnourished children. The mortality risk is up to 4.2 times in mild malnutrition and two-fold in moderate malnutrition [30].  [25].
It has been reported in multiple studies that the prevalence of acute malnutrition and chronic malnutrition is 10-71.2 %, and 7.7-21% respectively [17,26,31,33,34].According to studies conducted in different areas of our country, malnutrition rates in Turkey vary between 12-56.6% [19,23,[35][36][37]. In our Our fi ndings are consistent with the literature, but the rate of malnutrition is higher than in most of the studies. This rate may be attributed to the low socioeconomic level of our families and low educational level of the mothers. To our knowledge, although this is the fi rst study on the prevalence of malnutrition in hospitalized children in the Clinic of Pediatric Gastroenterology, malnutrition was overlooked even by us while coping with the main disease.
Multiple factors, such as low socioeconomic and educational level, lack of food resources, wrong eating habits, frequent infections, and poor hygiene conditions lead to the development of malnutrition in Turkey. In the present study, parents had low socioeconomic and educational level ( Table 4). This factors contribute to malnutrition. The most important factors of malnutrition in developing countries like Turkey are low socioeconomic and educational level.
Admission body weight and height records were reported in only 15.1-20.3% of the patients in different studies [3,17,32,38]. In one study, 346 (86.0%) of 402 children had their weight taken both on admission and at discharge [31]. In another study, discharge weights were available for 122 (76%) patients [18]. In our study, the discharge weights of 87 (77.0%) patients were available. Our study was compatible with these two studies. These reports showed that the measurement of weight and height, and evaluation of the malnutrition, was often overlooked in order to cope with the main disease. However, the fi ndings of the studies also indicated that nutritional status is evaluated more and better in recent years.
It has been reported that the prevalence of being overweight and obesity in hospitalized children was 20.4-25% [18,20].The prevalence of overweight and obese children in our study was 12.4%. The difference between the studies may be explained by different economic levels and region. With respect to gender, the overweight/obesity rate was higher in girls in the current study, which is consistent with Aurangzeb et al.'s study [20].
The calculation of energy intake is considered to be a key part of nutritional assessment. Indeed, the defi ciency of dietary intake, together with the increase of energy requirements, are the main causes of hospital malnutrition and may contribute to the worsening of malnutrition [39]. Poor nutritional status has been associated with higher rates of complications, an increased incidence of nosocomial infections, higher hospital costs, higher mortality rates, and longer lengths of stay in hospital [5,6]. These reports suggest that extra attention to nutritional status should always be given to the children in the high-risk group for malnutrition, and interventions should be started as soon as possible at admission.
There are some limitations of the present study. As it is a retrospective study, the discharge weights of some patients were not available. Because multiple factors such as underlying disease, disease duration and symptoms like vomiting, diarrhea affect the malnutrition rates, many patients were excluded from the study. So, we had a small number of patients.
The ideal screening tool should consist of a few easily obtainable data points, which might include both objective anthropometric parameters and subjective data points about disease state/food intake/nutrition history [39].
The incidence rate of malnutrition decreases with increasing socioeconomic levels and decreasing unemployment rates. In this regard, socioeconomic improvements are the fi rst priority in the prevention of malnutrition. Malnutrition is still a serious problem in developing countries, such as our country, and early diagnosis and treatment is very important. Starting from infancy, the regular monitoring of the growth and development of each child during childhood is of utmost importance, especially to diagnose mild and moderate malnutrition. Health professionals working in primary health care institutions should be educated about nutrition and be required to raise the mother's awareness, encourage breastfeeding for the fi rst six months alone, provide instructions for the transition to food and food selection, ensure regular monitoring of the healthy child, and teach housekeeping rules.

Conclusion
As a result of the fi ndings of the current study, to prevent hospital-acquired malnutrition, the nutritional status of hospitalized children should be carefully assessed during hospitalization to identify mild and moderate malnutrition in early life. If malnutrition is detected, the patient should be referred to begin further investigation, and to start timely treatment to prevent progression to severe malnutrition.