Thesis Abstract

                ABSTRACT 

Orthopaedic injuries are common globally with the highest prevalence reported in the sub-Saharan region. In hospitals, malnutrition is a significant problem in both developed and developing countries, its prevalence ranging from 20 – 60%. Malnutrition is reported to be common among orthopaedic patients due to disease, inadequate nutrient intake and low diet satisfaction associated with quality of hospital food. Untreated malnutrition is detrimental to individuals, societies and economies of countries. Despite the high prevalence of malnutrition, the condition is under-diagnosed. There is limited literature on the nutrient intake, diet satisfaction and nutrition status of adult surgical orthopaedic patients. The purpose of this study was therefore to determine the nutrient intake, diet satisfaction and nutrition status of adult surgical orthopaedic patients admitted at the University Teaching Hospital in Lusaka, Zambia. It was a cross-sectional analytical study that collected both quantitative and qualitative data on a sample of 98 surgical orthopaedic patients. A researcher-administered questionnaire was used to collect data from individual patients. Key informant interviews were conducted with three hospital staff. Anthropometric measurements of mid-upper arm circumference were taken on admission and during data collection. Statistical Package for Social Sciences version 21.0 was used to analyze quantitative data. Nutrient intake data was first analyzed using NutriSurvey software (2005) based on recommended dietary intakes, then exported to SPSS for further analysis. P-values less than 0.05 were considered statistically significant. The findings on nutrient intake indicated that mean energy, protein, calcium, sodium, iron, zinc, folic acid, dietary fiber and vitamin C intake were all below the recommended values (1,919cal, 61.67g, 160.05mg, 222.91mg, 10.19mg, 2.55mg, 165.98µg, 20.09g and 22.60mg respectively). Further, 24.4%, 8.5%, 26.7%, 5.5% and 15.2% of the participants met the Recommended Dietary Intakes of energy, protein, iron, vitamin C and dietary fiber respectively. Hospital food contributed more than 60% of the total nutrient intake of energy, protein, folic acid and dietary fiber. With a mean overall satisfaction score of 2.33±0.61, the majority of orthopaedic patients were satisfied with the hospital diet on aspects of portion size, temperature and time of meal distribution (67.3%, 94.9%, and 56.1% respectively), while 76.5%, 96.9%, 71.4% and 65.3% were dissatisfied with the hospital diet on aspects of type, variety, taste and appearance respectively. Majority of the participants had normal nutrition status on admission (86.7%) and during data collection (82.7%). There was a significant difference between mid-upper arm circumference on admission and during data collection (Paired t-test; p<0.001). There was no significant association between nutrient intake of the selected nutrients and nutrition status (MUAC) among adult surgical orthopaedic patients (Pearson correlation; p>0.05), between nutrient intake of the nutrients and diet satisfaction (Pearson correlation; p>0.05) as well as between diet satisfaction and nutrition status (MUAC) (Pearson correlation, p>0.228). In conclusion, the mean consumption intake for all the selected nutrients was below the recommended dietary intakes and the majority of orthopaedic patients were not satisfied with hospital food. It is recommended that the Ministry of Health increase funding towards provision of nutritious meals at the University Teaching Hospital and that routine screening of hospitalized patients for malnutrition be done as standard practice.

Thesis Overview

1.0 INTRODUCTION 

1.1 BACKGROUND TO THE STUDY

Orthopaedic conditions are physical injuries that affect the musculoskeletal system of an individual (Martinez-Diaz & Coughlin, 2007). Woolf and Pfleger, (2003), report that orthopaedic injuries are common globally, affecting hundreds of millions of people. In the United States of America, orthopaedic injuries account for more than 20% of patient visits to health care facilities (Adegbehingbe et al., 2009). In Africa, the majority of the orthopaedic patients are people under the age of 60 years (Gabriel et al., 2007). The most prevalent orthopaedic conditions in the world are those associated with sprains, dislocations and fractures (Muthuuri, 2012). A study conducted in India reported that fractures are the most common type (68.6%) of orthopaedic injuries (Sharma et al., 2014). Orthopaedic patients might end up admitted in hospital where they become partially or totally dependent on hospital food for their nourishment. The Department of Health report, (2014), of the United Kingdom documents that hospital food plays a major role in the nutritional care of inpatients. It has been observed that meal services in hospital can significantly influence patients’ recovery (Muraal & Davas, 2014). In order to meet the  nutrient requirements of inpatients, hospital food must be of good quality (Agency for clinical innovation, 2011). Hospital food must therefore provide all the nutrients required for a specific medical condition. The key nutrients required for wound healing and bone health in orthopaedic conditions are: energy, protein, carbohydrates, fats, vitamin A, C, D, E, K, zinc, copper, iron, calcium, phosphorous, flouride, magnessium, vitamin B6 and vitamin B12 (Angello, 2015; Greyling, 2010). For these nutrients to be available in the right amounts to the patients, hospital menus must be prepared in accordance with daily recommendations for inpatients (Agency for Clinical Innovation, 2011). Studies have revealed that malnutrition in hospitals is a huge problem globally among surgical patients and is common among orthopaedics (Ben-Ishay et al., 2011; Deren et al., 2012; Gottraux et al., 2004). According to the British Association of Parenteral and Enteral Nutrition (BAPEN), malnutrition refers to a situation of deficiency, excess or imbalance of energy, protein and other nutrients resulting in adverse effects on functionality, body tissue and clinical outcomes (Elia, 2003). In developed and some developing countries, hospital malnutrition is prevalent (Kim et al., 2010). For example, the prevalence of hospital malnutrition in most of the European countries is estimated at 37% (Kondrup & Sorensen, 2009). A recent study conducted in regional hospitals in Ethiopia, Africa revealed a prevalence of 55.6% (Haile et al., 2015).

In a study conducted in Paraguay, it was reported that malnutrition is a common condition on admission among trauma patients. According to the study, trauma was the leading cause of hospital admission of young people (Goiburu et al., 2006). A study in a tertiary hospital in Spain on nutritional control revealed that the nutrition status of patients with hip and knee prosthesis deteriorated while in hospital (Garcia et al., 2008). This observation is supported by Gottraux et al., (2004), who noted that the risk of malnutrition among patients increases while in hospital. Therefore, a patient who presents with normal nutrition status may develop malnutrition if they stay longer in hospital. Malnutrition can also lead to longer hospital stay (Kondrup & Sorensen, 2009). In health care facilities, where orthopaedic patients might be admitted, there are many factors that contribute to malnutrition and among them is inadequate food intake (Agarwal et al., 2012). Henry et al., (2002) and Kenny, (2000) as cited in Hartwell, (2004), indicate that patients in hospital do not meet their recommended energy and protein intakes. Evidence indicates that nutrition disorders among surgical patients develop due to reduced food intake associated with surgical precautions or anorexia in combination with metabolic stress of injury (Jensen et al., 2009). It means that malnutrition in hospital may result from interplay of disease condition, depressed nutrient intake, anorexia and hospital procedures.

Malnutrition in hospitals may also be associated with poor quality of hospital food and food services (Abdelahafez et al., 2012). Patients including those with orthopaedic injuries who are not satisfied with hospital food may eat less because they do not like it or find the food unacceptable or source food from elsewhere such as outside the hospital. Nonetheless, it has been mooted by Wright, Connelly and Capra as cited in Aljaziri, (2011), that one of the strategies that can be employed to address malnutrition is observation of patient satisfaction with hospital food. It has been noted that as diet satisfaction declines, the risk of malnutrition tends to rise. There are multiple factors that may contribute to diet satisfaction and one important predictor is the patient’s relationship with food (Messina et al., 2012). It was against this background that this study was conceptualized. 

1.2 Problem statement 

Malnutrition is reported to be common among orthopaedic patients but is underdiagnosed (BAPEN, 2012; Deren et al., 2012). Despite the high prevalence of malnutrition in hospital (20 – 60%), close to 80% of malnourished patients remain unidentified (Ben-Ishay et al., 2011). Lack of identification of malnourished patients in hospital can lead to patients not receiving appropriate nutrition interventions. Their condition may thus deteriorate while in hospital. Most of the statistics on prevalence of hospital malnutrition are derived from studies conducted in developed countries such Ireland, Australia and the United States of America. Huong et al., (2014), however, note that regardless of the countrys’ economic status, hospital malnutrition is a common problem. Henry et al., (2002), and Kenny, (2000), as cited in Hartwell, (2004), have reported that patient’s nutrient intake of energy and protein in hospitals is inadequate to meet their requirements. This is according to studies conducted in Hong Kong and Great Britain respectively. Sub-optimal food intake among hospital inpatients including those with orthopaedic injuries is one of the factors that contributes to malnutrition (Agarwal et al., 2012). As such, patients are unable to meet both their macro and micro-nutrient requirements. Inadequate oral intake of food coulped with severity of injury and anorexia can result in malnutrition among inpatients.

Low diet satisfaction is a common problem in both developed and developing countries associated with poor quality of hospital food (Abdelahafez et al., 2012). Dissatisfied patients are likely to develop malnutrition, as they eat less of the hospital food and especially if there is no provision for sourcing of food elsewhere. Despite the importance of measuring diet satisfaction to improve hospital services, there is paucity of literature on the subject in health care institutions in Zambia (Abdelahafez et al., 2012). Orthopaedic patients who are undernourished are more likely to suffer from infections, reduced functionality and take longer to recover thereby lengthening hospital stay (Huang et al., 2013). Malnutrition may increase the risk of complications, morbidity and mortality (Loh et al., 2012). Thus, orthopaedic patients of productive age may lose valuable time due to slower healing rates and incur higher healthcare costs. In the long run, the country’s national development may be negatively affected, posing a challenge to meeting the Sustainable Development Goals (SDG’s) and Zambia’s vision 2030. There is limited literature on nutrient intake, diet satisfaction and nutrition status of adult surgical orthopaedic patients in sub-Saharan Africa, in Zambia and specifically in Lusaka province. 

1.3 Purpose of the study

The purpose of this study was to determine the nutrient intake, diet satisfaction and nutrition status of adult surgical orthopaedic patients admitted at the University Teaching Hospital (UTH) in Lusaka province, Zambia.

1.4 Objectives of the study 

The specific objectives of this study were to: 1. Determine the demographic and socio-economic characteristics of adult surgical orthopaedic patients admitted at UTH. 2. Determine the nutrient intake of adult surgical orthopaedic patients admitted at UTH. 3. Assess the diet satisfaction among adult surgical orthopaedic patients admitted at UTH. 4. Determine the nutrition status of adult surgical orthopaedic patients admitted at UTH. 5. Establish the relationships among nutrient intake, diet satisfaction and nutrition status among adult surgical orthopaedic patients admitted at UTH. 

1.5 Hypotheses 

H01: There is no significant association between nutrient intake and nutrition status among adult surgical orthopaedic patients. 

H02: There is no significant association between nutrient intake and diet satisfaction among adult surgical orthopaedic patients. 

H03: There is no significant association between diet satisfaction and nutrition status among adult surgical orthopaedic patients.

1.6 Significance of the study 

The findings of this study are significant to stakeholders such as UTH, Ministry of Health (MoH) and non-governmental organizations (NGOs) concerned with quality of hospital meals and nutrition care of inpatients in Zambia. The study identified deficiencies in the diet provided to inpatients as well as their level of satisfaction with the diet. The results of this study may inform other hospitals on nutrient intake of inpatients and preparation of hospital meals in line with daily recommendations. In addition, this study should contribute to literature on nutrient intake, diet satisfaction and nutrition status of adult orthopaedic patients in Zambia. This study found limited published literature on associations between nutrient intake and diet satisfaction as well as between diet satisfaction and nutrition status.

1.7 Delimitation of the study 

Participation in this study was delimited to adult orthopaedic patients 18 to 64 years of age, admitted at University Teaching Hospital in Lusaka province, Zambia. Generalization of the findings therefore can only to be done to areas and patients of similar characteristics. 

1.8 Limitations of the study 

Mid-upper arm circumference was used in determining the nutrition status of adult orthopaedic inpatients. This was because other anthropometric indices such as body mass index could not be taken on all patients owing to injuries. The Parenteral and Enteral Nutrition Group recommends the use of MUAC in situations where body mass index   cannot be determined (The Parenteral and Enteral Nutrition Group, 2011). Further, studies point out that there is no tool in clinical practice that is considered a gold standard for identifying malnutrition among such patients (Cant, 2011;Velasco et al., 2011)