Page mackup-Final.qxd 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 (