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Original article:

The outcome of the severity of diarrhoea in adult hospitalized patients with the
assessment of nutritional and socioeconomic status

Islam A
1
, Daula AU

2

Abstract
Background: Diarrhoea is a leading cause of morbidity and mortality in developing countries. This study
observed the influences of nutritional status and age on the outcome of severe diarrhoea in adult male
patients. Methods and materials: Data were obtained through interview by arranged questionnaire. It is
a prospective longitudinal study, where one group of patient was well nourished and other group was
malnourished. Results: Significant differences were found in all study factors between malnourished and
well nourished diarrhoea patients. Patients with poor nutritional status had low body weight and muscle
mass index than well nourished patients. The stool volume was higher in malnourished patients than well
nourished patient. In addition mean duration of diarrhoea for malnourished patients was higher than well
nourished patients until discharge from hospital. Conclusion: Therefore, the diarrhoea of malnourished
and low socioeconomic status of adult patients is more severe, and the incidence of this disease can be
reduced by growing awareness as well as improve nutritional and socioeconomic status of those patient
groups.

Key words: Diarrhoea, nutritional status, BMI, malnourished and wellnourished patients

Introduction
Diarrhoea is an alteration in normal bowel move-
ment, characterized by increased frequency, vol-
ume, and water content of stools. The incidence of
diarrhoea was associated with 2.2 million deaths

worldwide
1
. Deaths due to diarrhoeal illness occur

predominantly in children, with an estimated 1.5
million deaths in under 5-year-olds each year,
making diarrhoeal illness the second leading cause

of death in this age group
2
. However, in developed

countries diarrhoea is a major public health prob-
lem and estimated to 21-37 million episodes of

diarrhea occurs annually
3, 4

. But, in low income
country about 6.9% death occurs due to diar-

rhoea
1
. All estimates derive from population-based

studies, including both adults and children.
Generally the cause of diarrhoea depends on geo-
graphical location, standards of food hygiene, san-
itation, water supply, and season. Commonly iden-
tified causes of sporadic diarrhoea in adults in low

income countries include Campylobacter,
Salmonella, Shigella, Escherichia coli, Yersinia,

protozoa, and viruses
5, 6

. In addition, the duration
and severity of acute diarrhoea increases in under-

nourished children
7
. Malnutrition contributes to

diarrhoea which is more severe, prolonged, and

possibly more frequent
8
. Low body mass index

(BMI), indicative of chronic energy deficiency
(CED) and malnutrition are associated with com-
promised immune function, increased susceptibili-
ty to infectious illnesses, and reduced survival of

people
9
. Although the incidence of diarrhoea is

more discussed for children but the severity of
acute diarrhoea of adults in low income countries
is largely unknown owing to the lack of large-scale
surveillance studies in these countries.

In the year 2007, around 11,000 diarrhoeal
patients attended to the Dhaka Hospital, and 44%
of them were adults, of whom 58.7% had severe

1. Alimul Islam, Department of Applied Nutrition and Food Technology, Islamic University, Kushtia-
Jhenidah, Bangladesh.

2. Asad Ud-Daula, Department of Applied Nutrition and Food Technology, Islamic University,
Kushtia-Jhenidah, Bangladesh.

Corresponds to: Asad – Ud- Daula, Assistant Professor, Department of Applied Nutrition and Food
Technology, Islamic University, Kushtia-Jhenidah, Bangladesh
E-mail: asad.uddaula@googlemail.com; ud-daula_bd@hotmail.de

Bangladesh Journal of Medical Science Vol. 12 No. 03 July’13

250



diarrhoea
10
. In recent years, the frequency and hos-

pitalization period of adult patients who suffering
from severe diarrhoea is increases significantly.
Therefore, the management of diarrhoea is becom-
ing increasingly difficult. In addition, less attention
has been given to adult with acute severe diarrhoea
compared to children; thereby deaths among adults
may increases during epidemic of acute severe
diarrhoea. All of these may significantly contribute
to economic loss (through daily weight loss) with
reduced disability adjusted life years (DALY).
There were many studies conducted on adult diar-
rhea based on used of antibiotic, ORS , zinc, other
medicines and micro nutrients

11-14
but not based on

nutritional status of adult diarrhoeal patients. The
previous study done on the basis of nutritional sta-
tus that related with severe diarrhoea in children.
Therefore, the purpose of this study is the determi-
nation of outcome of the severity of adult diar-
rhoeal patients based on nutritional status, age and
socioeconomic condition. This can help to deter-
mine the relationship between nutritional status and
outcome of diarrhoea in future. 

Materials and methods
Study design
It is a hospital based prospective longitudinal study
and conducted in Dhaka hospital of International
Center for Diarrhoeal Diseases Research,
Bangladesh (ICDDR,B). The duration of the study
was conducted from September 2010 to January
2011. There are two criteria:  inclusion & exclu-
sion criteria were selected for this study. Inclusion
criteria includes adult male patients with age of 20-
50 years, two group of patient (wellnourished and
malnourished), basal metabolic index (BMI), dehy-
dration (severe or some according to Dhaka
Method) and stool characteristics/volume. Stool
characteristics/volume (volume/frequency/consis-
tency) was observed for 4 hours prior to study.
Written informed consent was taken from every
patient. Exclusion criteria include patients with
bacillary dysentery (presence of visible blood in
stool) and unconscious or patients with medical
emergencies. This study was also counted major
indicators of patients such as malnourishment

(BMI less than 18.5), well nourishment (BMI
greater than 18.5), income, weight, height, mean
BMI, housing condition, leaving own or rent
house, educational status, duration of diarrhoea,
stool volume and IV fluid requirement. Total sam-
ple size was 130 in which 65 malnourished and 65
well nourished. This research was approved by
ethics Committee of ICDDR,B.

Method of data collection
To reduce observer variation, a standardized form
was used at the Dhaka hospital for assessment of
dehydration. This is a minor modification of the
WHO guidelines, known as the Dhaka method, as
presented in the Table 1. Patients who fulfill the
selection criteria of “Dhaka Method” was admitted
to the ward of Dhaka hospital of ICDDR,B and
BMI was calculated after measuring the height and
weight of patients. Duty nurses were measured and
recorded vital signs (pulse and respiratory rates,
temperature and blood pressures). Physicians took
their detailed medical history and performed thor-
oughly physical examination, including assessment
of dehydration using the “Dhaka Method”.
According to the dehydration status, patients was
either initially re-hydrated by introduce intra-
venous fluid (patients with severe dehydration and
frequent vomiting) or drinking ORS solution (those
with some dehydration and able to drink), and then
observed for next 4 hours. Patients stool and urine
was separately collected by attendant and patients
were allowed to drink water and food as their abil-
ity. At the end of the 4 hour observation period,
stool volume was measured and the patients who
fulfill the selection criteria i.e. having watery stool
volume of 5 ml/kg/hour or more (20 ml/kg/4-hour
observation period) were selected for this experi-
ments and cordially asked for their consent to par-
ticipation questionnaire of “Dhaka Method” in this
study. The selected patients were received a single
1.0 gm dose of azithromycin antibiotic orally.
Stool and urine was collected separately, measured
and recorded for each 6 hour-period of the study
until resolution of diarrhoea. The intake of intra-
venous and ORS solutions, water and other fluids
(e.g. milk) was similarly measured. Patients who
developed any complication during study was con-
sidered as failures and withdrawn from the study.

Outcome of the severity of diarrhoea in adult

251



Statistical analysis
Data were coded, scrutinized and put on to entry
using statistical package for social science (SPSS).
Nutritional status was calculated by WHO Anthro
software. Data were expressed as mean±SD and
number (percent). Unpaired Student’s-‘t’ ‘chi-
squared and Mann Whitney Rank Sum tests were
performed as applicable. A p value <0.05 was
taken as level of significance. 

Results
A total number of 130 adult male patients with
severe diarrhoea were included in the study of
them 65 were malnourished (BMI <18) and 65
wellnourished (BMI>18). The major indicator of
patient’s were age, monthly income, housing con-
dition, leaving own or rent house, weight, height,
mean BMI, educational status, duration of diar-
rhoea, stool volume and IV fluid requirement. 

Age, monthly, housing and leaving condition of
the patients
Mean age of malnourished and well nourished
group was 28 years and 33 years respectively
which demonstrated that malnourished group was
significantly younger (p<0.001). The monthly
mean income of malnourished and wellnourished
patients was Tk 4953/- and Tk 6938/- respectively
and the difference was statistically significant
(p<0.02) (Table 2). 

Well nourished patients (29.2%) had their own
house compared to the malnourished (12.3%) and
the distribution did not show statistical significant
difference (p=ns).

Housing condition of the patients divided into three
types such as khaca, sami pacca and pacca. Among

these patients 38.46% malnourished and 23% well-
nourished were lived in khaca house, 33.85% mal-
nourished and 43% wellnourished were lived in
samipacca house, and 27.7% malnourished and
33.86% wellnourished were lived in pacca house
respectively (Table 2). 
Table 2: Age, monthly income, housing and
leaving condition of the study subjects  

Data were expressed as mean±SD and number
(percent) as applicable. 
Unpaired Student’s-‘t’ test and chi-squared tests
were performed as applicable to calculate statisti-
cal difference and/ or association between groups. 

Height, weight and BMI of the patient
Mean height (cm) of the malnourished group
(162.68 cm) and well nourished Group (162.38
cm) was almost similar (p=0.781). Mean weight
(Kg) of the malnourished and well nourished
Groups was 45.00 and 56.26 respectively which

Islam A, Daula AU

252

Table 1: Dhaka method for the assessment severity of dehydration/diarrhoea 

Assessment of dehydration 
Condition* Normal Irritable/Less active* Lethargic/ Comatose* 
Eyes Normal Sunken  
Mucosa Normal Dry  
Thirst* Normal Thirsty* Unable to drink* 
Skin turgor* Normal Reduced*  

 
 
Assess 

Radial pulse* Normal  Uncountable or Absent* 
Diagnose  No sign of 

Dehydration 
If at least 2 signs 
including one (*) sign 
present, diagnose 
"some dehydration" 

If "some dehydration" plus 
one of these (*) signs are 
present, diagnose "severe 
dehydration" 



showed significant statistical difference (p<0.001)
as depicted in Table 3. 
Table 3: Weigh, height and BMI of the study
subjects 

Data were expressed as mean±SD. 
Unpaired Student’s ‘t’ test was performed to calcu-
late statistical difference between two groups.

Educational status of the patients
Educational status of the study subjects evaluated
in the form of illiterate, attended primary school
but did not complete (<Class 5), high school
attended (<SSC), SSC passed and, HSC and
above. Education attainment of the respondent’s
showed that 23.07% malnourished and 15.38%
wellnourished patients were illiterate. The distribu-
tion in the two groups for <Class 5 was 30% and
20%, <SSC 35.38% and 38.46%, SSC 5 (7.69%)
and 7 (10.76%) and, HSC and above 3.07% and
7.69% respectively (Table 3). Over all distribution
showed statistical significant association
(p<0.001) (Table 4).

Table 4: Educational status of adult diarrhoea
patients admitted in the hospital

Data were expressed number (percent). 
Chi-squared test was performed to calculate statis-
tical association.

Stool volume during 4 hour observation before
get admission
Stool volume determines the severity of diarrhoea.
The mean stool volume of malnourished and well-
nourished patient was 38.95 ml and 32.4 ml
respectively. The value was showed that in mal-
nourished group the volume was 20% higher than

the well nourished counterpart during the 4 hours
observation period. The value was significantly
different between two groups (<0.001).
Duration of diarrhoea, stool volume and IV
fluid volume required for the study subjects
Duration of diarrhoea of the malnourished group
was 48.85 hrs and wellnourished 36.13 hrs that is
malnourished group had 33.5% time hour longer
diarrhea [duration in the two groups was signifi-
cantly different, p<0.004]. The total stool volume
[(median (range); ml/kg body weight) was 310 and
230 for malnourished and well nourished group
respectively which showed that it was 34.7% high-
er in malnourished group compared to well nour-
ished counterpart (p<0.002). 
Intravenous (IV) fluid is requires to re-hydration
the diarrhoea patients. Median (range) IV fluid
(ml/Kg BW) required for the malnourished and
well nourished group was 222 and 213 respective-
ly (p<0.001) (Table 5).

Table 5: Duration of diarrhoea, stool volume
and IV fluid requirement of the study subjects

Data were expressed as mean±SD and median
(range) as appropriate. 
Statistical difference between two groups was cal-
culated using unpaired Student’s-t test and Mann
Whitney Rank Sum tests as applicable. 

Discussion
The previous study, Islam et. al. reported that
households having a higher socioeconomic status

showed the low incidence of diarrhoea in adult
15
.

But they did not assessed nutritional status with
severity of adult diarrhoea. However, this study
assess the outcome of severity of adult diarrhoea
patients according to their nutritional status consid-
ering some indicators who come to the Dhaka hos-
pital of ICDDR,B  seeking treatment of diarrhoea.

Outcome of the severity of diarrhoea in adult

253

Variables  Malnourished 
Group 
(n=65) 

Well 
nourished 

Group 
(n=65) 

P value 

Height  (cm) 162.68±5.78 162.38±6.34 0.781 

Weight  (kg) 45.00±4.48 56.26±8.36 <0.001 

Variables  Malnourished 
Group (n=65) 

Well nourished 
Group (n=65) 

P value 

Illiterate 15 (23.07%) 10 (15.38%) 

<Class 5 20 (30%) 13 (20%) 
Under SSC 23 (35.38%) 25 (38.46%) 
SSC pass 5 (7.69%) 7 (10.76%) 
Over HSC 2 (3.07%) 5 (7.69%) 

 
 
<0.001 

 

Indicators Malnourished 
Group 
(n=65) 

Well 
nourished 

Group 
(n=65) 

P value 

Duration in 
hours  

48.85 
±24.25 

36.13±23.66 <0.004 

Stool 
volume 
(ml/kg BW)   

310 (30-
1250) 

230 (83-
1260) 

<0.002 

Intravenous 
fluid (ml/kg 
BW)  

222 (0-1055) 213 (0-1350) <0.001 



The measured factors age and incomes of the
patients were essential due to maintaining hygiene
and ensuring proper balanced diet. In addition, the
factors weight and height determines nutritional
status of the patients, BMI determines malnourish-
ment and well nourishment of patients, house con-
dition determines the hygienic condition of leaving
place of patients, education determines the social
status of the patients, and stool volume, duration
and IV fluid requirement determines the severity of
diarrhoea of the patients. The above factors togeth-
er indicate the socioeconomic condition and sever-
ity of diarrhoeal adult patients. This study exhibits
that the malnourished patient was significantly
younger as compared to wellnourished patients.
The monthly income of wellnourished patients was
more compared to the malnourished one. The mal-
nourished diarrhoeal patients weighed 25% less
compared to the well nourished subjects. The mean
height of the malnourished patients was almost
similar to well nourished patients (162.68 cm vs.
162.38cm). This study also showed that the mean
BMI of malnourished patient was lower than the
wellnourished patient. Education pattern of well-
nourished patients was better that malnourished
patient. The malnourished patient’s stool volume
(ml) per kg body weight within 4 hours was more
compared to the well nourished patients. The stool
volume of malnourished study subjects was 20%
more than the wellnourished patients because mal-
nourished patients had been found to have exten-
sive mucosal injury and more intestinal infection
thus causes severity of diarrhoea and excess stool

volume
7
. Therefore, the diarrheal duration of mal-

nourished patients was high then the wellnourished
patients malnourished patient may be due to the
extensive mucosal injury which changes in intestin-
al functions in malnourished patients may be one

of the factor contributing to the intestinal infection
and causes of diarrhoea as a result prolonging diar-
rhoea of the malnourished patients, 33.5% higher
than the wellnourished patients. Literature study
also showed that the duration of diarrhoea of
underweight children was found to 33% higher

than wellnourished children.
16

Malnourished chil-
dren suffer zinc deficiency, and its supplementa-
tion led to significant decrease in diarrhoea dura-

tion (6.2 vs. 4.7 days)
7, 17

as well as, the supple-
mentation of zinc to the adults diarrhoea patients
led to significant reduction (30%) in stool volume.
In addition, this study indicates that wellnourished
patients group requires less IV fluid than malnour-
ished patient require more IV fluid. Therefore the
malnourished patients require more IV fluid to get
rehydrated.

Conclusions
In conclusion (i) Severity of diarrhea and require-
ment of intravenous fluid to rehydrate these
patients are increased by the nutritional status of
the patients; (ii) Area of their residence, in a way
the household hygiene, also associated in contact-
ing the disease and influenced by educational sta-
tus; and (iii) to reduce the burden of the diarrhoeal
disease in the community residence of the people
at risk needs to be addressed further and also the
improvement of the awareness.

Acknowledgement
The authors would like to express deep gratitude
and thanks to the hospital authority of ICDDR,B,
Dhaka. Authors also wants to thanks to duty doc-
tors, nurses and other attendance who were
responsible for managements of the patients in the
hospital of ICDDR,B. 

Islam A, Daula AU

254



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