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ORIGINAL ARTICLE
Abstract A nutritional supplementation trial (Vlaming et al., Clin Nutr 2001; 20: 517) enabled us to assess the nutrition
of 1561patients on emergency admission to hospital. Patients acutely admitted to the 15 relevant medical, surgical and
orthopaedic wards were identied. Mid upper arm circumference (MUAC) measurements were obtained in 95% (848 m,
635f) patients. For clinical reasons, Body mass index (BMI) was assessable in only 44% patients (408 m, 285f). Data on
three month weight loss were obtainable in 509 patients. These measurements combined to demonstrate that 18.3% of
patients were undernourished (At least one of : BMIo20 kg/m2 or MUACo25 cm or loss of weight Z10%).There was a
close relationship between BMI and MUAC. Regression equations (excluding age)were for men : BMI=1.01 MUACF
4.7, (R2=0.76), and for women BMI=1.10 MUAC6.7, (R2=0.76). After adjustment for age, weight loss Z10% was the
most signicant of the three as a predictor of mortality. Among patients in whom weight loss was not recorded MUAC
was a signicant predictor of mortality either alone (P=0.002) or after adjustment for BMI (P=0.007), but BMI was not
signicant. All three measures, even when adjusted for age and sex, were poor predictors of hospital stay although
MUAC was signicant in the larger group with a MUAC measure (R2=0.7% Po0.001). MUAC correlates closely with
BMI, is easier to measure and predicts poor outcome better.
r 2003 Elsevier Science Ltd. All rights reserved.
Key words: body mass index; mid upper arm circumference; weight loss; anthropometrics; nutritional assessment; nutritional screening
Introduction
Body mass index (BMI) and percentage weight loss are
recommended and widely used to assess the nutrition of
patients entering hospital. However it is not always
possible to measure weight or height in the acutely ill
because patients may not be able to stand or leave their
bed. A nutritional supplementation trial (1) gave us the
opportunity to assess the nutrition of 1561 patients on
emergency admission to medical (1097), surgical (335)
and orthopaedic (129) services of the Royal London
Hospital, a teaching hospital in Londons socially
deprived East End. We sought to compare measurements of the mid upper arm circumference with the BMI
and the percentage weight loss.
The purpose of such screening measures is to identify
patients likely to benet from enhanced nutritional care
by improved outcome. They will thus be of most use in
the acutely hospitalized patient if they can be shown to
relate to outcome. Because the benet of the nutritional
Methods
Two research dietitians employed for the purposes of a
nutritional supplementation trial (1), tried to include
all consenting patients admitted as an emergency to
General Medicine, Surgery or Orthopaedics on Sundays
to Thursdays, from June 1997January 1999. Patients
admitted to the 15 relevant wards were identied by lists
generated by the admissions department. Patients
electively admitted to medical or orthopaedic wards
were excluded. Patients were, whenever clinically possible, weighed and their height and mid non-dominant
upper arm circumference (MUAC) measured. An
estimate of weight 3 months prior to admission was
made from the notes and by questioning the patient and
their relatives, and percentage weight loss calculated.
Height was measured using Seca model 220 ward
307
308
Statistical methods
Results
MUAC, BMI and weight loss were compared independently for their ability to predict either death during the
period of hospital admission using multiple logistic
regression, or length of stay in hospital using multiple
regression. The strong effects of age over 60, and being
male and over 60 were adjusted for length of stayage
over 60 was adjusted for mortality.
Analyses were performed among patients with measures for both BMI and MUAC for comparison
purposes, and also among patients with MUAC alone
to show whether results for MUAC held in a larger data
set. Analysis was repeated among patients in whom
weight loss of more than 10% was not recorded.
Because length of stay was not normally distributed
and had signicant outliers, the regressions were
performed using values truncated at 21 days (so that
patients staying longer than this were reclassied as 21
days), and also using loge (length of stay).
BMIs of 20 and 18.5 are standard measures of
thinness. BMI of less than 20 is widely accepted as
underweight (2), particularly in well-developed countries
and 18.5 is recommended as a practical lower limit for
most populations representing the third centile of a
population with median BMI of 23 (3).
In order to establish MUAC values equivalent to
BMIs of 18.5 and 20 two regressions were performed,
BMI on MUAC and MUAC on BMI, separately by sex
and adjusted for age. The averages of the two predicted
MUAC values associated with BMIs of 18.5 and 20 were
calculated for 55 year olds were taken as the equivalent
MUAC value.
Because we were interested in those who had lost
weight or were underweight or thin, and these were a
Table 1 Distribution of mid upper arm circumference measurements compared with a general population (7)
Total n 1483
o25
2527.5
2730
3032.5
432.5
217
268
315
321
362
Male n 848
(14.6%)
(18.1)
(21.2%)
(21.6%)
(24.5%)
106
152
195
209
186
(12.5%)
(17.9%)
(23%)
(24.7%)
(21.9%)
Female n 635
3
14
28
31
24
111
116
120
112
176
(17.5%)
(18.3%)
(18.9%)
(17.6%)
(27.7%)
14
27
27
17
15
Table 2 Body mass index measurements: study population vs the general population (10)
BMI kg/m2
Total
Study group
n=692
r=20
42025
42530
430
116
254
208
114
(16.8%)
(36.7%)
(30%)
(16.5%)
Male
Study group
n=408
67
150
134
57
(16%)
(37%)
(33%)
(14%)
Female
Gen pop
n=3114 (%)
6
40
42
12
Study group
n=285
49
105
74
57
(17%)
(37%)
(26%)
(20%)
Gen pop
n=3430 (%)
8
47
29
16
CLINICAL NUTRITION
309
Table 3 Numbers and percentages classied as undernourished using three parameters alone or in combination: weight loss Z10%,
BMIo20 kg/m2, MUAC o25 cm
Number with data in
category n=1561
% of population
classied
undernourished
BMI alone
MUAC alone
wt loss alone
693
1483
508
115/1561 (7.4%)
217/1561 (13.9%)
50/1561 (3.2%)
41 (2.6%)
99 (6.3%)
143 (9.2%)
199 (12.7%)
33 (2.1%)
31 (2.0%)
BMI or MUAC
BMI or wt loss
MUAC or wt loss
any of three
1551
870
1541
1553
258/1561
149/1561
249/1561
286/1561
37 (2.4%)
137 (8.8%)
28 (1.8%)
(16.5%)
(9.5%)
(16.0%)
(18.3%)
40
40
35
35
MUAC
MUAC
Measure
30
25
20
20
20
25
30
35
15
20
25
30
35
BMI
BMI
Fig. 1. MUAC vs BMIall patients.
30
25
15
MUAC
35
30
25
20
15
20
25
30
35
BMI
Fig. 3. MUAC vs BMImales.
310
MUAC Z25 cm
MUAC Z23.5 and
o25 cm (thin)
MUAC o23.5 cm
(very thin)
BMIZ20
kg/m2
BMIZ18.5 and
o20 (thin)
BMIo18.5
(very thin)
474
17
29
11
2
9
13
29
Table 5
(a) Predictive power of being categorised undernourished by weight loss Z10%
Subjects with valid weight loss measures n-509
Length of stay (days) truncated at 21 days and adjusted being older than 60 years and being male and over 60
Coefcient
P-value
Coefcient
P-value
added R2
(95% CI)
(95%CI)
added R2
Estimatedn
values
0.066
0.2%
1053
P-value
added
pseudo-R2
Estimatedn
values
0.015
1.1%
1053
Length of stay (days) truncated at 21 days and adjusted being older than 60 years and being male and over 60
Coeff
P-value
coeff
P-value
added R2
(95% CI)
(95% CI)
added R2
Estimatedn
values
BMI o20
MUAC o25
0.035
0.001
0.8%
added pseudo-R2
7.0%
(b) Predictive power of being categorised with low MUAC or BMI in those without a measured weight loss of 410%
Subjects with both BMI and MUAC measures n=590
0.42
0.12
0.10
0.002
0.1%
0.4%
added pseudo-R2
2.0%
7.5%
0.38
o0.001
0%
0.7%
868
78
Odds ratio
(95% CI)
P-value
added
pseudo-R2
Estimatedn
values
0.63
o0.001
0.5%
4.5%
Number of cases with missing informationreclassied as weight losso10%, BMIZ20 and MUAC Z25 respectively.
868
78
CLINICAL NUTRITION
Discussion
Undernutrition in hospital patients is often unrecognized and there is a need for a simple means of screening
to facilitate targeted nutritional intervention. BMI has
been emphasized as an objective anthropometric criterion
(4). The British Association for Parenteral and Enteral
Nutrition (BAPEN) recommends that the measurements
used for screening are based upon the patients weight for
height (BMI) and their percentage weight loss (5). This
study conrms the high prevalence of undernutrition
among patients admitted to acute services though the
proportions with weight loss, low BMI, or low MUAC
are less than those observed elsewhere (6).
An important nding in this study was the difculty
our dietitians had in obtaining BMI soon after admission in many of these acutely ill patients. This was
despite dedicated time, and strong motivation by virtue
of the clinical study being undertaken. The reason was
nearly always that patients could not be taken out of
their beds for weighing or could not stand for height
measurement. Thus BMI has major drawbacks in the
early assessment of the acutely ill.
Our study was conned to the rst days of acute
hospital admission. During early acute illness missing
data can be expected to be associated with poor outcome
because we cannot estimate BMI and weight loss in those
too sick to be weighed or have their height measured.
Missing values can be established from Table 3.
Reecting the difculties of measuring the sickest
patients, missing BMI in this cohort was clearly
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312
3.
Acknowledgements
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10.
References
1. Vlaming S, Biehler A, Hennessy E M et al. Should the food intake
of patients admitted to acute hospital services be routinely
Submission date: 25 September 2002 Accepted: 20 January 2003