Dear Journal of the Academy of Nutrition and Dietetics,

We are submitting the manuscript “Impacts of an ICU visit and Number of Daily Medications on

Five Year Weight Change and Self-Reported Health in Patients Surveyed for Nutrition Day 2017

at Louis Stokes Cleveland Veteran Affairs Medical Center” for your review. Our findings

provide important insight into the usual nutritional profile of hospitalized patients on any given

day. Additionally, this study presents the benefits of participating in Nutrition Day, the

worldwide initiative to eradicate malnutrition in hospitals. Consistent involvement in Nutrition

Day will provide the framework for the development of effective malnutrition treatment and

prevention interventions. Publication in your journal will encourage and inspire healthcare

professionals to participate in this international initiative.

Thank you.
Introduction

Nutrition Day has proven to be a useful tool to assess malnutrition in hospitals. 1 One day

is chosen annually to be the data collection day, in which all participating hospitals complete an

audit using a standard screening template. The data is then anonymously imputed into an

international database to allow facilities, health care professionals and researchers to track trends

and make comparisons. 2 The data has become a springboard for the development of other

screening tools such as PANDORA. 3

Malnutrition in hospitals is common4 the information gathered through Nutrition Day

will provide us a snapshot of malnutrition rates on any given day, at any participating hospital.

Questions included in Nutrition Day ask patients about current health status and well-being and

also take into account past medical histories in order to identify where malnutrition is occurring

and what factors are contributing. By using information from Nutrition Day, we aim to establish

a link between ICU visits and weight. Whether the condition be acute or chronic, an admission to

the ICU is indicative that an individual is in a severely compromised state of health. However,

does an admission to the ICU pose a threat to future health status? We hypothesize that patients

who have visited the ICU will have experienced significant weight change in the past five years.

A patient’s self-rated well-being, while subjective, has been found to provide valuable

insight to a health care team. A study found that a patient’s answer to this one question provided

enough to information for a healthcare team to develop a suitable lifestyle intervention and

course of treatment.7 However, studies in the past have looked at how lifestyle factors such as

smoking status, alcohol consumption and weight status influenced self-reported wellbeing. The

association between this answer and number of medications a patient is receiving is something

we are looking to establish through Nutrition Day.6 This relationship is important to understand,
with there being thousands of medications with implications on nutrition- whether it be diet

suppression or food interactions. Studies into the effect of “polypharmacy”, which is defined as

the “use of five or more different prescription medications”8 have found it to be a growing

phenomenon. Our secondary objective using the information gathered through Nutrition Day will

be to assess whether the number of medications a patient is taking is related to their reported

well-being. We hypothesize that there will be an inverse relationship between number of

medications taken and self-reported feeling.

Methods

A one-day cross-sectional audit was conducted on select floors of Louis Stokes Cleveland

Veteran Affairs Medical Center (LSCVAMC). Information was collected by a research assistant

via printed questionnaires. Beyond the questionnaire, additional data collected included

structural information, hospital and staffing information, patient medical information, and thirty

day follow up data. Prior to surveying the patients, the structural information form was

completed by the unit’s supervisor and the hospital information was entered by hospital

management. Patient medical information was obtained by researchers after patient consent

through electronic medical record review and outcome was collected thirty days later by a

researcher also through electronic medical record review.

Questionnaires were filled out individually by consented patients. Consent was obtained

verbally and HIPPA authorization was received through patient signature. If a patient was unable

to complete the form on their own, assistance was provided by researchers. The questionnaire

included questions regarding health and nutritional status. Data was collected by researchers and

imputed into a password protected excel file on the day of the audit. All patient information was

recorded anonymously and identifiable information was replaced by a three digit code. The
primary investigator, researchers and coinvestigators were the only individuals aware of the

password. The data was transmitted electronically to the University of Vienna when completed

for long term storage in a secure database.

Descriptive statistics such as age, gender and BMI were recorded as continuous values.

The variable of percent weight change in five years was recorded as a continuous value and was

calculated by taking the patient’s weight from five years ago on sheet six and subtracting it from

their current weight then dividing by their five-year weight and multiplying by one-hundred.

Percent weight change was further assessed by creating groups within the data set of percent

weight change in patients that had gained weight and percent weight change in patients that had

lost weight; these values were also recorded as continuous. All continuous data results were

represented through mean and standard deviation. Previous ICU admission was recorded

categorically in groups of either yes or no, information was obtained from sheet two. Self-

reported health was recorded as a categorical variable, with answers being taken from sheet

seven. The number of medications a patient was on was obtained from sheet three and recorded

as a categorical variable. All categorical data was represented through n and percent.

Participants with missing data were retained in the data set and included in pairwise

analyses. Patients under the age of 18, displaying signs of cognitive impairment, non-English

speaking, admitted and discharged same-day or with inability or unwillingness to consent were

not included.

Statistical analysis was completed through JMP Pro 13 software. We used an independent

t-test to determine whether percent weight change was statistically different between those who

had been admitted to the ICU verses those who were not. We used a chi-square test to compare
the proportion of patients in each self-reported health group and the number of medications they

were taking. Statistical significance was set at p<0.05.

Results

A total of twenty-nine patients were included in the study. The average age of

participants was 68 ± 8.9 years, the average BMI of participants was 30.2 ± 6.6 and our

population was predominately male (93%). The average five-year percent weight change in all

surveyed patients was 0.9%. Among the surveyed patients, there were 11 patients with five year

weight gain and 14 with five year weight loss. The mean percent weight gain was 12.9% in

patients that gained weight, whereas the mean percent loss was 11.8% in patients that lost

weight. The majority of patients recruited were on greater than five home medications daily prior

to hospitalization (75%). Additionally, 42% of recruited patients rated their health as fair on a

scale of very poor to very good, zero participants rated their health as very good. (Table 1)

Patients who had an ICU stay had a higher mean percent weight change in five years

(0.39%) than those without an ICU stay (0.02%), however these results are not statically

significant (p=0.52). Refer to Table 2. Of patients taking three to five home medications daily,

the most common response for self-rated health was “fair”. For patients taking greater than five

home medications daily, there were equal responses for “fair” (38.1%) and “good” (33.3%) self-

rated health. However, these results are not significantly significant (p= 0.46). (Table 3)
Table 1: Characteristics of Patients Recruited at LSCVAMC for Nutrition Day 2017

Characteristic N Measured Mean ± SD or n %

BMI 29 30.2 ± 6.6
Age 28 68 ± 8.9
Percent Weight Change in Five 27 0.9 ± 15.8
Years
Average Percent Weight Gain In 11 12.9 ± 9.9
Patients that Gained Weight
Average Percent Weight Loss in 14 -11.8 ± 9.9
Patients that Lost Weight
Gender - Male 29 27 (93% )
ICU Visit During Admission 29
Yes 2 (6%)
No 27 (93%)
Number of Home Medications 28
Daily
None 0 (0%)
1-2 0 (0%)
3-5 7 (25%)
>5 21 (75%)
Self-Reported Health 28
Very Poor 1 (3%)
Poor 5 (17%)
Fair 12 (42%)
Good 10 (35%)
Very Good 0 (0%)
Amount of Hospital Food 23
Consumed for Lunch
None 5 (19%)
¼ 6 (23%)
½ 7 (26%)
All 8 (30%)

Table 2: Comparison of Mean Percent Weight Loss Based on ICU visit During Nutrition Day 2017 at
LSCVAMC

With ICU stay (n=2) Without ICU stay P value by 2 Sided

(n=25) t-test
% Weight Loss Mean and SD 0.39 ± 0.57 0.02 ± 0.22 0.52
 Table 3: Comparison of Number of Home Medications Taken Per Day and General Health Rating in
Patients Surveyed for Nutrition Day 2017 at LSCVAMC

No Home 1-2 Home 3-5 Home >5 Home Unknown

Medications Medications Medications Medications Home
(n=0) (n=0) (n=7) (n=21) medications
(n=0)
Feel Very 0% 0% 0% 0% 0%
Poor (n=1)
Feel Poor 0% 0% 0% 5 (23.8%) 0% P= 0.46
(n=5)
Feel Fair 0% 0% 4 (57.1%) 8 (38.1%) 0%
(n=12)
Feel Good 0% 0% 3 (42.9%) 7 (33.3%) 0%
(n=10)
Feel Very 0% 0% 0% 0% 0%
Good (n=0)

Discussion

Our hypothesis that patients that visited the ICU would have significant weight change in

the past five years is inconclusive. The small sample size of our study limited our ICU visit

results; with 93% of patients answering no to having visited the ICU, and only two patients total

answering yes- despite the hospital having three ICU wards. This population was therefore

under-represented in our sample set. Several years of Nutrition Day information has already

provided evidence showing underfeeding is a concern for ICU patients 8 and that an ICU

admission is a risk factor for developing a multitude of health issues, including malnutrition.

This can lead us to assume that if we had a larger number of eligible patients who had visited the

ICU, our results would have shown a higher percent weight loss. This population especially

would benefit from more Nutrition Day representation. We did not see a significant difference in

five-year percent weight change. We believe this is due to the number of outliers in our sample.

Individuals who gained weight and those who lost weight in the five-year period cancelled each

other out, leading to a small value.

 Additionally, our secondary objective of observing the relationship between the number

of daily home medications a patient is taking and their self-reported well-being was inconclusive.

Our sample size restricted our ability to compare groups; as there were zero participants in two

of the categories: “none” and “1-2”. Furthermore, of collected data, results were contrary to our

hypothesis. Individuals taking greater than five medications rated their health equally as “fair” or

“good”. This is against existing literature that has linked polypharmacy with an increased overall

mortality risk and decrease in functionality in activities of daily living. 7, 9, 10 However, without

any participants on the lower end of the spectrum, there is no way to compare these findings. In

addition to being skewed, the results are not statistically significant.

This data is limited by the small sample size of twenty-nine, many participants were not

included due to exclusion criteria or denial of consent. In the future, a more effective method of

obtaining consent should be implemented to increase the number of participants. Furthermore,

the inconsistency with weight change among surveyed patients impacted our results. The

findings of percent five-year weight change were unimpressive due to participants who have

gained weight and those who have lost weight cancelling each other out. Our attempt to remedy

this issue by assessing the two groups separately, in percent weight change in those who lost

weight and percent weight change who gained weight was unsuccessful, as it reduced the already

small sample size even greater. The separation of those who had lost and those who had gained

weight was not in our original data analysis plan, but is logical and would be helpful to include

in future applications. Moving forward, the study should be conducted again at LSCVAMC, but

with a larger sample size to achieve significance.

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