Van Wayenburg - Fight Malnutrition

European Journal of Clinical Nutrition (2005) 59, Suppl 1, S81–S88& 2005 Nature Publishing Group All rights reserved 0954-3007/05 $30.00www.nature.com/ejcnORIGINAL COMMUNCIATIONNutritional deficiency in general practice: a systematicreviewCAM van Wayenburg 1 *, FA van de Laar 1 , C van Weel 1 , WA van Staveren 2 and JJ van Binsbergen 11 Department of General Practice, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands; and 2 Division of HumanNutrition, University of Wageningen, Wageningen, The NetherlandsObjective: Nutritional deficiency is an independent risk factor for mortality. Despite its clinical relevance, the prevalence in aprimary care setting is poorly documented. We performed a systematic review of reported prevalence and clinical assessment ofnutritional deficiency in general practice.Methods: From MEDLINE, Current Contents and EMBASE, we derived articles and checked the initially included ones forreferences on prevalence data. Of the eligible articles, we assessed the quality of research and results.Results: We finally included eight studies. The prevalence ranged from 0 to 13%. However, the study populations wereheterogeneous and all studies contained methodological flaws, especially selection bias. In addition, the clinical assessmentdiffered between studies.Conclusion: Literature on the prevalence of nutritional deficiency within general practice is rare and provides disputableprevalence assessments.Sponsorship: The Dutch Dairy Association, Zoetermeer.European Journal of Clinical Nutrition (2005) 59, Suppl 1, S81–S88. doi:10.1038/sj.ejcn.1602178Keywords: family practice; undernutrition; nutritional deficiency; prevalence; review literatureIntroductionIn modern Western society, an unbalanced eating patternhas far reaching health consequences (World HealthOrganisation, 2003). Obesity, a result of excess dietaryenergy compared to body expenditure, is well documentedand highly prevalent. This is in contrast to nutritionaldeficiency, which seems to be virtually unrecorded. However,particularly in the chronically ill elderly, the risk ofdeveloping nutritional deficiency is substantial (Akner &Cederholm, 2001).Unlike the term malnutrition, which implies a wide rangeof nutritional disorders, including deficiency or excess (or*Correspondence: CAM van Wayenburg, PO Box 9101, HAG 229,Nijmegen 6500 HB, The Netherlands.E-mail: c.vanwayenburg@hag.umcn.nlGuarantor: JJ van Binsbergen.Contributors: CAMvW: protocol development, searching for articles,abstract and article assessment for eligibility, quality assessment, dataextraction, and review development; FAvdL: protocol development,abstract and article assessment for eligibility, quality assessment, dataextraction, and review development; WAvS: review development(editing); JJvB: protocol development and review development;CvW: protocol development (advisor) and article development.imbalance) of energy, protein and other nutrients (Wahlqvistet al, 1995), nutritional deficiency specifies undernutrition inearly as well as advanced stages.Implications of nutritional deficiency vary from delayedwound healing (Deitch, 1995; Mathus-Vliegen, 2004), anddeterioration of muscle function (Engelen et al, 1994; Miyagiet al, 1994) to impaired immune function (Field et al, 2002).Undernourished patients show a higher consultation andprescription rate (Martyn et al, 1998), longer hospital stays(Naber et al, 1997), a reduced quality of life (Larsson et al,1995; Shoup et al, 1997; Mostert et al, 2000) and mostimportantly an increased mortality risk (Wilson et al, 1989;Ryan et al, 1995; Anker et al, 1997; Schols et al, 1998; Landboet al, 1999; Sullivan et al, 1999). Yet, the prevalence ofnutritional deficiency within primary care has not beensystematically reviewed.Particularly, the elderly are less capable of recovering fromweight loss (Fiatarone et al, 1994; Roberts et al, 1994).Therefore, nutritional deficiency should be treated in itsearly stages. Primary prevention belongs partly and secondaryprevention completely to the domain of primary healthcare. Furthermore, the general practitioner faces an increasingpopulation ‘at risk’ for nutritional deficiency. The

S82Nutritional deficiency in general practiceCAM van Wayenburg et alEuropean population is aging, as a result of a fertility falland longevity rise. Between 1995 and 2015, the populationaged over 65 y is expected to grow by 30%, for the very old(80 þ ), this will be 40%, as a consequence morbidity will rise(European Commission, 1999). For family practice, the effectof this will be re-enforced by the trend of home care, insteadof hospitalisation.We performed a systematic review to obtain a literatureoverview of the prevalence and clinical assessments of‘nutritional deficiency’ in general practice.MethodsInclusion criteria were cohort, cross-sectional, or nutritionsurveys concerning prevalence of nutritional deficiency. Thesubjects studied had to be adults (Z18 y), living in developedcountries (North America, Europe, New Zealand andAustralia) and recruited from primary health care. Weincluded study populations ‘at risk’ for nutritional deficiencyand all languages of publication. We excluded studiesconcerning eating disorders as well as studies of which nofull report was available (eg abstract or poster).We developed a sensitive search strategy that combined(key) words for general practice and synonyms, nutritionaldeficiency and synonyms and study type and epidemiologicalvariables (prevalence or incidence) (Table 1).In June 2003, we searched MEDLINE (1966–2003), CurrentContents (1996–2003) and EMBASE (1980 Week 25-2003).Two independent reviewers (CvWa, FvdL) read all titles and/Table 1Synonyms in search strategySettingGeneral practice/practitionerPrimary (health) careFamily practice/doctor/physician/medicineOther: outpatient care or primary medical care or private practiceVariable(Adolescent/under) nutrition (assessment/disorders)Weight loss/reductionEmaciationCachexiaKwashiorkorMarasmusWasting syndrome(Protein (calorie/energy)) malnutritionSarcopeniaUnderweightLow (/lean) body massLean body weightUndernourishThinnessNutritional support/status/requirementDiet therapyDietary intakeMuscle atrophyOther: diet/or feeding behaviour/or food/or food intake/or meal/ornutrient/or nutritional toleranceStudy type and epidemiological variablesCross-sectional studyPrevalence, incidenceEpidemiologyCohort (analyses/-studies)Nutrition surveyCRITERIAEXCLUSIONChildren (

or abstracts and scored them for eligibility by inclusion andexclusion criteria listed (Figure 1). In case of doubt, we readthe full contents of the article. We calculated the interrevieweragreement in article selection by kappa statistics.One reviewer (CvWa) checked initially included articles forreferences on prevalence values. And both reviewers (CvWa,FvdL) assessed possible suitable references and extracted datafrom all finally included articles by use of a pretested dataextractionmatrix.We determined the quality by the internal and externalvalidity. The internal validity refers to the degree of certaintythat the observed results are truthful, and depends on thestudy methodology. We evaluated selection bias (selectionmethods and/ or nonresponse bias) and information bias(abstracted data from medical files, interview bias, recallbias and reporting bias). The external validity is the extentto which we can extrapolate the results to the generalpopulation. It comprised gender and age distribution of thestudy population, country, study design, objective, inclusionand exclusion criteria, number of patients and of generalpractitioners participating.We compared the studies on the basis of the clinicalassessment of nutritional deficiency and external validity.ResultsFigure 1 shows the inclusion and exclusion pathways ofarticles. Searches in MEDLINE, Current Contents Archives/Weekly and EMBASE yielded 577, 436 and 871 records,respectively. Most articles dealt with obesity and its healtheffects and were excluded. Initially, we included 24 articles bytitle and abstract. After further analysis, we excluded 17 articles.The inter-reviewer kappa was 0.68 (95% confidence interval(CI): 0.54–0.83). From the references of the initially includedarticles, we included one additional study (Wissing & Unosson,1999). Articles were excluded because they did not describeprevalence studies (eg narrative reviews) or did not concern ageneral practice population (eg community dwelling).Table 2 gives an overview of the internal and partly theexternal validity of the articles included. Within studies, thepercentage of males differed from 25 to 100%. The mean agewas above 55 y. Description of selection methods in allstudies missed important aspects with regard to the studypopulation and/or the general practice characteristics.Furthermore, the participant rate, the number, characteristicsand reasons of nonparticipants were not described.Information bias was mainly caused by self-reported data onheight and weight or unclear definitions of under-nutrition.Table 3 gives an overview of the external validity andresults. Four studies were conducted in the United Kingdom(UK), the others in Denmark, the United States of America(USA) and the Netherlands. Six studies were cross-sectionaland two were retrospective. Most articles failed to describethe exclusion criteria, as well as the number of generalpractitioners participating. The prevalence of nutritionaldeficiency ranged from 0 to 13% depending on the studyNutritional deficiency in general practiceCAM van Wayenburg et alpopulation and clinical assessments. Only two studies(Edington et al, 1996; Edington et al, 1997) presented aprevalence with CI. There was a large variation in recruitmentmethods (patients visiting the general practitioner orcontacted for research participation), in mean age of thestudy population and in the presence of comorbidity.We divided study populations into three groups: (1) illpatients (cancer, chronically ill, postsurgery), (2) elderlypopulation (Z65 y) and (3) a general population. Fourstudies concerned the ill patients, three the elderly and onethe general population.We classified three categories of clinical assessments ofnutritional deficiency: (1) the body mass index (BMI), with/or without triceps skin-fold thickness (TSF) or mid-armmuscle circumference (MMC), (2) presence of weight loss intime and (3) the Mini Nutritional Assessment (MNA). TheBMI was calculated by body weight divided by height 2 (kg/m 2 ) and the MMC by mid-arm circumference (cm) 0.314TSF (mm). TSF was measured with skin-fold calipers. TheMNA is a questionnaire of four categories (a total of 18questions), concerning anthropometric measurements (egweight loss), a global assessment (eg questions related tolifestyle), dietary questions (eg number of meals) and asubjective assessment (eg self-perception of health). Thecalculated score estimates the (risk of) nutritional deficiency.In four studies, the BMI, with or without TSF or MMC, wasused as clinical assessment for nutritional deficiency. Thelargest study (Martyn et al, 1998) found a prevalence of13% of nutritional deficiency in chronically ill patients.Another study (Edington et al, 1996) reported prevalences of8 and 10% in chronically ill and cancer patients, respectively.They combined BMI with TSF or MMC. The same clinicalassessment method was applied in patients after majorsurgery, resulting in a prevalence of 11% (Edington et al,1997). One study did not specify the cutoff point of BMI forclassifying nutritional deficiency, but reported a percentageof 12% (DeVore, 1993).In two studies (Wannamethee et al, 2000; Kruizenga et al,2003), weight loss was used to assess the nutritional status.Wannamethee et al (2000) reported unintentional weightloss in 11% of males, but unintentional weight loss was notpredefined quantitatively. The other study (Kruizenga et al,2003) defined undernutrition as weight loss more then10% in 6 months and ‘at risk’ between 5 and 10% weightloss. The study was conducted from a dietitians’ point ofview with patients from several health settings. The generalpractitioner referred 7% of the patients included, of whicha total of 5 or 6% (data not equal in text and table) wereundernourished.Two studies assessed the risk of nutritional deficiency withthe MNA; however, the study populations differed. Oneconcerned not acutely ill elderly visiting their generalpractitioner (Beck et al, 2001), and the other reported elderlywith foot ulcers contacted for research purposes (Wissing &Unosson, 1999). The prevalence of undernutrition was 0 and3%, respectively.S83European Journal of Clinical Nutrition

European Journal of Clinical NutritionTable 2Internal validity and external validity (gender distribution, mean age and number of GP participating)Study Male (%) Mean age (y) Selection methods Selection bias Information biasIll patientsEdington et al (1996) 58 68 (range 22–93) 25 GPs with computerised records Selection method of GPs not specified RandomIncluded a random sample of patients, Stratification only for the first 20 practicesstratified by gender and practicePatients actively contacted; participant rate: Nonparticipants not described by age and80%genderReasons of nonparticipation describedEdington et al (1997) 60 64 (range 23–90) 24 GPs with computerised records Selection method of GPs not specified RandomRegistered patients includedNo stratification, no random samplePatients actively contacted; participant rate Nonparticipants not specified by number,unknownreason of refusal, age and genderKruizenga et al Unknown 64.5 (range 18–102) 91 teams of dietitians in different fields (GP: Selection method of dietitians not specified Height self-reported or measured (not(2003)n ¼ 22 locations)described)?Patient selection not specifiedNonparticipants not specified by number, Unintentional weight loss was askedreason of refusal, age and genderParticipant rate unknown923 patients excluded because ofincomplete dataSupplementary information (eg kind ofillness) obtained from medical recordsNumber of participants in primary andhome care not equal between tablesPrevalence of nutritional deficiency inprimary and home care not equal betweenMartyn et al (1998) 45 55.7 (range 18–96) General Practice Research Database (4500 No stratification, no random samplepractices)Selection of people whose weight andIncluded registered patients who visited the height was previously measuredGPtable and textRandomS84Nutritional deficiency in general practiceCAM van Wayenburg et alElderly population (with (-out) comorbidity)Beck et al (2001) 30 75 Patients included at GP consultationParticipant rate: 65%(95% CI 72–79) Nonparticipants and participants similar inage and genderSelection method and number of GPs notspecifiedHeight and weight self-reported in 98% ofthe participantsMNA: neuropsychological problems basedon subjective impressionDeVore (1993) 25 78 One GP included visiting patients, inclusion Informed consent is not mentioned Weight and height self-reported orcriteria unclearmeasured (not described)?Participant rate: 100%Definition of underweight unclearWissing et al (1999) 28 79 (76.5) Nine primary care areasNurses identified included patients;Selection methods of participants withulcers unclearHeight and weight measured (except twopatients who could not stand. Of them selfreportedparticipant rate: 64%Nonparticipants and participants did notdiffer in age and genderdata were collected of last hospitalInclusion by nurses is doubtful reproduciblePatients under care of a specialist were also stay or clinic visit)includedReasons of nonparticipation describedGeneral populationWannamethee et al(2000)100 67 (range 57–78) 24 general practices in different townsIncluded random sample of patients,stratified by town and age, selected froma age–gender registerPatients actively contacted: participant rate:78%Towns were selected by regional variationin cardiovascular disease and water qualityIncluded patients had to report weightinformation in two subsequentlyquestionnairesDefinition of weight loss not furtherspecifiedBody weight self-reported

Table 3External validity and resultsStudy Design Objective Inclusion ExclusionSubjects(n)Clinical assessment ofnutritional deficiencyResultsIll patientsEdington et al (1996),UKCross-sectionalEdington et al (1997), Cross-sectionalUKKruizenga et al (2003), Cross-sectionalThe Netherlands GP (7%, n ¼ 533 or558?)H (81%), I (11%), U(1%)Martyn et al (1998), UK Retrospective cohortFollow-up: 2.4 y, s.d.1.5 yPrevalence ofmalnutrition, etcPrevalence ofmalnutritionPrevalence of diseaserelatedmalnutritionRelation use health careresources andnutritional stateZ18 y, comorbidity a Not described 441 Deficient: BMI o20 ANDTSF or MMC oP15418 y, surgery b within6 weeksNot described9% (CI 6.3–11.8%)Cancer: 10% (CI 6.2–14.5%)Chronic disorder: 8%(CI 4.3–11.5%)Not described 123 See Edington et al (1996) (1) 10.6% (CI 5.0–16.1%)o18 y, patients whocould not be weighed418 y with diagnosis ofchronic disease c BMI o15 and BMI 440in further analyses7606 Unwanted weight lossduring the last 6 months:(1) Deficient: 410%(2) At risk: 5–10%11 494 (1) BMI o15(2) 15rBMI o20Population of a GP:(1) 5 or 6%? (n ¼ 31)(2) 7% (n ¼ 40)(1) 0.4%(2) 12.1%Elderly population (with (-out) comorbidity)Beck et al (2001), Cross-sectionalDenmarkFrequency nutritionalrisk, etcDeVore (1993), USA Cross-sectional Prevalence ofoverweight/obesity, etcWissing et al (1999),SwedenGeneral populationWannamethee et al(20000, UKCross-sectionalRetrospective andprospective cohortFollow-up: notdescribedNutritional status inpatients with leg andfoot ulcers, etcCharacteristics andhealth status of menwho lost weight withaging465 y, not acutely ill Not described 61 (1) Deficient: MNA o17 (1) 0%(2) At risk:17rMNAr23.5Z65 y None 122 (1) Underweight BMI(cutoff point unclear)Z65 y, own home,treated for leg and footulcers d , contacted forparticipationMen, aged 40–59 y,contacted forparticipation(2) 38%(1) 11.6%Men: 16.7%Women: 6.5%Not described 70 (1) Deficient: MNA o17 (1) 3%Severe mental orphysical disability(2) At risk:17rMNAr23.54534 (1) Weight lossIntentionalUnintentional(2) 46%(1) 18%7%11%Nutritional deficiency in general practiceCAM van Wayenburg et alEuropean Journal of Clinical NutritionCI ¼ confidence interval; s.d. ¼ standard deviation; FL ¼ free living; GP ¼ general practitioner; H ¼ hospital; I ¼ institution; MNA ¼ Mini Nutritional Assessment; U ¼ unknown; MMC ¼ mid-arm musclecircumference; TSF ¼ triceps skin-fold thickness.‘Supplementary information is available at http://www.nature.com/ejcn/.a Cancer of the lung, prostate or gastrointestinal tract, and chronic diseases of the lung, gastrointestinal tract or neurological system.b Orthopaedic, cardiothoracic, gastrointestinal or genitourinary.c Respiratory, gastrointestinal and neurological disease, including Chronic Obstructive Pulmonary Disease (COPD), chronic bronchitis, emphysema and bronchiectasis, cirrhotic liver disease, chronic liverdisease, chronic hepatitis, Crohn’s disease, ulcerative colitis, chronic pancreatitis and chronic intestinal malabsorption, Parkinson’s disease and multiple sclerosis and recorded since January 1988.d Foot ulcers open for more then 1 month, not expected to heal within 6 weeks.S85

S86Nutritional deficiency in general practiceCAM van Wayenburg et alDiscussionLiterature on the prevalence of nutritional deficiency ingeneral practice is rare and gives a disputable prevalenceassessment. The prevalence ranged from 0 to 13%. Owing tofailure to adjust for possible confounders (eg gender-, ageandnutrition-related illnesses) within studies, reportedprevalence must be interpreted as crude. The overall qualityof the included articles was poor, with selection bias theweakest link. Edington et al (1996) stratified for gender andgeneral practice to compare the chronically ill and cancerpatients. Kruizenga et al (2003) reported data concerningpatients referred to a dietitian. Hence, these results cannot beinterpreted as the prevalence of disease-related malnutritionin primary care setting.This reported prevalence of nutritional deficiency inprimary care is low, compared to nursing homes, 10–40%(Fockert, 1991) and hospitals, 20–62% (McWhirter &Pennington, 1994; Naber et al, 1997; Edington et al, 2000).The general practitioner refers patients for more diagnosticsor intensive treatment or care to these care settingsdaily. This selection partly explains the difference in theprevalence of nutritional deficiency between hospital andprimary care.Although patients in hospital have been studied moresystematically, these studies suffer from the same methodologicalproblems. McWhirter et al and Edington et al assessedprevalence of nutritional deficiency on admission, based onBMI and TSF or MMC (McWhirter & Pennington, 1994;Edington et al, 2000), which were 40 and 20%, respectively.Naber et al (1997), on the other hand, reported a prevalenceof 45, 57 and 62%, according to the Subjective GlobalAssessment (physical examination and questionnaire), theNutritional Index (eg calculation formula with blood levels)and the Maastricht Index (eg calculation formula with bloodlevels), respectively, on admission of (gastro) intestinalpatients. The study of Edington et al illustrates theimportance of reporting nonparticipation in estimatingnutritional deficiency, because nearly half of the patientsrefused or could not participate. They were too ill andit is likely that many of them suffered from nutritionaldeficiency.Studies in the open population show a prevalence of0–34% with the same clinical evaluations as mentioned inTable 2 (Gregory et al, 1990; French et al, 1995; Beck et al,1999; Saletti et al, 1999; Perissinotto et al, 2002). This is morein line with our findings and suggests that the populationregistered in general practice is comparable to thecommunity.There is no universal agreement on the definition andclinical assessment of nutritional deficiency and this hamperscomparison of studies. This reflects the complexity ofthe genesis of nutritional deficiency. From a medical point ofview, nutritional deficiency results from loss (eg vomiting),decreased food intake/tissue storage (eg protein)/intrinsicproduction (eg vitamin D) and/or increased demand. Despitethese different aetiologies, they all cause measurable adverseeffect on body shape/composition/function, and have anegative influence on clinical outcome. For example, anenergy intake below 1500 kcal (6.3 MJ) can serve as adefinition of inadequate in the elderly (Lowenstein, 1982),eventually resulting in weight loss. A daily intake of less than1500 kcal is not only insufficient of macro- but as well assome micronutrients.The methods for this review were adapted from Cochraneguidelines (Alderson et al, 2004). However, in contrast toCochrane reviews, this review concerned prevalence studiesinstead of randomised clinical trials or controlled clinicaltrials. Still we aimed to apply similar rigorous methods tominimise observation and selection bias.We conclude that better quality data on nutritionaldeficiency, and a clear definition is needed. In order tounderstand the impact in primary care better. Data must bepresented in different gender, age and/or illness categories toestablish an accurate prevalence and to identify ‘at-risk’populations.AcknowledgementsWe thank the Dutch Dairy Association for the financialsupport, Rob Scholten for the EMBASE contribution andCaroline Roos for translating the Spanish articles.ReferencesAkner G & Cederholm T (2001): Treatment of protein-energymalnutrition in chronic nonmalignant disorders. Am. J. Clin. Nutr.74, 6–24.Alderson P, Green S & Higgins JPT (2004): Cochrane Library, Issue 1.Chichester, UK: John Wiley & Sons Ltd.Anker SD, Ponikowski P, Varney S, Chua TP, Clark AL, Webb-PeploeKM, Harrington D, Kox WJ, Poole-Wilson PA & Coats AJ (1997):Wasting as independent risk factor for mortality in chronic heartfailure. 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S88Nutritional deficiency in general practiceCAM van Wayenburg et alDiscussion after Van WayenburgKolasa: Could you explain in more detail how the codingwas done? The patient who may come to see you gets adiagnostic code? Are you encouraged or paid to do morethan one? Because in the USA that would impact how manycodes we see.Van Wayenburg: I can only answer that question for myselfwhen I am working in the general practice. I only try to aimat one illness, and to relate most complaints to that illness.But nutrition deficiency or weight loss does need a specifictreatment, so it could be an entity on its own, like we discussalso obesity. We say someone has heart disease or cancer, andwith that illness comes nutritional deficiency.Helman: I guess that weight loss is seen as a symptomfor which another diagnosis would be sought. I think thelast thing that would occur to a GP is a nutritionaldeficiency.Van Wayenburg: If you look at nutritional deficiency asbeing an independent risk factor for mortality, should wethen be more aware to treat it as a separate illness? What doyou think?Helman: If most GPs understood the prevalence of deficiencyin hospitals and nursing homes and they understood theimpact on morbidity and mortality we would be a long way.Van Wayenburg: So our next question will be in COPDpatients to see how many of the patients are nutritionallydeficient. That would be maybe good to emphasise it.Pond: Picking up on this from the Australian point of view.We now have a 75 þ y health assessment, and we have a GPversion of a scale for being at risk of nutrition deficiency,which includes whether they eat alone, how many mealsthey eat a day and so on. I think the studies up till now aretaken up very well by GPs, but so far we have not been ableto prove that they act on this information. And there is noinformation on what to do.Van Wayenburg: The definition of nutritional deficiencyis unclear, and for that reason also not workable in practice.So that is something that we should maybe work on, tomake this definition more clear. For example, it has beensaid that weight and height, BMI should be registered just asblood pressure, but I should say we should also define weightloss in the electronic system, so we get a better picture.European Journal of Clinical Nutrition