Nutritional Assessment at the Crossroads

Abstract

&dquo;Sciences not underpinned by theory are not much more than kitchen arts.&dquo; Sir Peter Medawar &dquo;The Art of the Soluble&dquo;Necessity is the mother of invention, and it was the general recognition of two quite separate but widespread malnutrition problems that gave birth to interest in nutritional assessment. Malnutrition is any disorder of nutrition and besides that relating to protein and energy may also concern a number of vitamins and essential elements. In both the problems referred to below, protein-energy malnutrition (PEM) is the major concern and attention here will be confined to this.The first problem is that of PEM as the major form of childhood malnutrition throughout developing countries and at any one time affects hundreds of millions of preschool age children. Growth failure is its earliest manifestation and various schemes, based on weight, height, and other measurements have been used to assess the extent of the problem in population groups' and to classify the degree of PEM in sick children.2, 3 Several simple lessons have been learned from this experience. The application of standards based on crosssectional data should be confined to large population groups. Longitudinal growth data should be collected for the individual child and any failure to maintain its own growth tract should sound a warning of impending PEM. The severe degree of PEM is characterized not only by growth failure but also by biochemical abnormalities and clinical signs. Depending on the pathogenesis' these changes vary markedly, resulting in a spectrum of syndromes composed of marasmus, kwashiorkor, and intermediate forms, marasmic-kwashiorkor 5.1The second problem contributing to the impetus to nutritional assessment has come more recently from the general recognition that a considerable proportion of hospitalized surgical and medical adult patients throughout the world is also suffering from PEM, secondary to their underlying diseases. The proportions have been varyingly reported to be anywhere between 20 and 65%, but as will be seen later, these figures should be regarded with considerable skepticism as the tests and the ways in which they have been used in making the diagnosis are open to criticism.It is doubtful the current interest would have been generated if effective means of preventing or alleviating PEM under these circumstances had not been developed. Parenteral nutrition and improved enteral nutrition have provided the necessary spur. Unfortunately, the lessons to be learned from the childhood PEM experience have in general been overlooked, and as we shall see the area of adult medicine has many additional problems of its own. GENERAL POINTSNumbers are usually small in clinical studies, and hence, standards meant for large population groups are not applicable. Hospitalized patients form very heterogeneous groups with wide variations in age, types, and stages of disease, modalities of treatment, complications, etc.In surgical patients especially, the judgmental basis for the decision to operate will...

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