Original Article

Journal of the
ASEAN Federation of
Endocrine Societies

Association between Degrees of Malnutrition and Clinical Outcomes

among Non-critically Ill Hospitalized Adult Patients
with Type 2 Diabetes Mellitus*
Freyja Diana Ramos,1 Joy Arabelle Fontanilla,1,2 Reginna Emiliene Lat2

Center for Diabetes, Thyroid and Endocrine Disorders, St. Luke’s Medical Center, Global City, Taguig, Philippines
1

2
Center for Weight Intervention and Nutrition Services, St. Luke’s Medical Center, Global City, Taguig, Philippines

Abstract

Introduction. Malnutrition among hospitalized patients is highly prevalent. This adversely affects outcomes with longer
length of stay (LOS), higher treatment costs and increased mortality. People with diabetes mellitus (DM) are particularly
vulnerable to malnutrition and its consequences.

Objective. To determine the association of nutritional status with LOS and mortality among adults with Type 2 DM.

Methodology. This was a retrospective study of 439 adult patients with type 2 diabetes admitted in the medical ward of a
tertiary hospital from January 1, 2018 to December 31, 2018. Demographics, anthropometrics, feeding route, LOS and
outcomes were taken from the Clinical Nutrition Service database; biochemical data were taken from the Healthcare
System, and were analyzed.

Results. In our analysis, 83.8% were found to be malnourished with 50.3% moderately-malnourished (MM) (Nutrition
risk level 1-2) and 33.5% severely-malnourished (SM) (Nutrition risk level ≥3). BMI category and malnutrition were the
significant confounders for LOS. After controlling for BMI, LOS was longer by a mean of 2.2 days in SM compared
to well-nourished (WN) patients (95% CI=0.49-3.95, p=0.012). Of the malnourished patients, 6.1% of SM and 0.5%
of MM patients died. None of the WN patients died. Feeding route, admitted for neoplasm, low albumin levels and
malnutrition were the confounding factors associated with mortality. After controlling for these factors, SM had higher
odds of dying compared to MM patients [adjusted OR=8.91 (95% CI=1.04-76.18, p=0.046)].

Conclusion. Among hospitalized non-critically ill adult patients with type 2 diabetes, SM patients but not MM patients
had significantly longer LOS compared to WN patients, and greater degrees of malnutrition were associated with
higher mortality.

Key words: malnutrition, hospital outcome, diabetes mellitus

INTRODUCTION due to illness-induced poor appetite, gastrointestinal

symptoms, reduced ability to chew or swallow, or nil
Malnutrition, as defined by the World Health Organization per-os status for diagnostic and therapeutic procedures.3
(WHO), refers to deficiencies, excesses or imbalances Malnutrition is a debilitating and highly prevalent condition
in a person’s intake of energy and/or nutrients.1 It is in the acute hospital setting. It is estimated that at least one-
classified into undernutrition, which include stunting, third of patients have some degree of malnutrition upon
wasting, underweight and micronutrient deficiencies or admission to the hospital. If left untreated, approximately
insufficiencies; and overweight, obesity and diet-related two thirds of these patients will experience a further
non-communicable diseases such as heart disease, stroke, decline in their nutritional status during in-patient stay.4
diabetes and cancer. Using current WHO BMI guidelines, Its prevalence in the hospital setting has been widely
it is usually associated with a body mass index (BMI) documented in the literature to be between 20% to 50%.5
of less than 18.5 kg/m2 (underweight) or 30 kg/m2 and
above (obese).2 In the Philippine setting, the prevalence of malnutrition
among hospitalized patients is between 48 to 53%. With
Hospitalized patients, regardless of their BMI, typically these data, it is concluded that every hospital in the
suffer from undernutrition because of reduced food intake Philippines has malnourished patients.6 Patients with
________________________________________

ISSN 0857-1074 (Print) | eISSN 2308-118x (Online) Corresponding author: Freyja Diana A. Ramos, MD
Printed in the Philippines Fellow, St. Luke’s Medical Center – Global City
Copyright © 2021 by Ramos et al. Rizal Drive corner 32nd Street and 5th Avenue,
Received: February 22, 2021. Accepted: July 29, 2021. Taguig City, 1634 Metro Manila
Published online first: August 20, 2021. Tel. No.:8-789-7700 local 2086
https://doi.org/10.15605/jafes.036.02.12 E-mail: freyjadiana@yahoo.com
ORCiD: https://orcid.org/0000-0001-8395-3293

* This paper was presented in the Philippine Society for Parenteral and Enteral Nutrition (PhilSPEN) Annual Convention, Mandaluyong City, Philippines, November 25,
2019 and placed second during the oral presentations.

172 www.asean-endocrinejournal.org Vol. 36 No. 2 November 2021

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License (https://creativecommons.org/licenses/by-nc/4.0/).
Association between Malnutrition and Clinical Outcomes among T2DM Patients Freyja Diana Ramos, et al 173

diabetes mellitus are susceptible to malnutrition due It is not clear what level of malnutrition is associated
to disease complications such as poor dentition, eating with poor hospital outcome specifically in patients with
disorders, alterations in bowel movement or gastroparesis diabetes in the local setting. We studied the association of
and cognitive disorders. Malnutrition in patients with degrees of malnutrition and hospital outcomes in terms of
diabetes was highly prevalent in the acute hospital setting, length of stay and mortality among hospitalized patients
in which 37% had moderate risk, and 63% had high with diabetes in the medical ward of a tertiary institution.
risk for malnutrition. Fifty-five percent of patients had In addition, we analyzed confounding factors affecting
mild to moderate malnutrition, and 45% of patients had nutritional status in these patients and correlated them
severe malnutrition.7 to the degrees of malnutrition.

An average of 10% loss of lean body mass results in Definition of terms

immune suppression and increases the risk of infection, A. Nutritionally at risk is defined based on the NRS tool,
15% to 20% loss will impair wound healing, and a 30% loss with at least one of the following three criteria:
leads to the development of spontaneous wounds, such 1. BMI <18.5 kg/m2 or ≥30 kg/m2
as pressure ulcers, an increased risk of pneumonia, and a 2. Weight loss within the last 3 months
complete lack of wound healing.4 Malnutrition is associated 3. Severely ill, i.e., head injury, cancer, Intensive
with many adverse outcomes including depression of the Care Unit (ICU) patients, sepsis, burns (>50 total
immune system, impaired wound healing, muscle wasting, body surface area or TBSA), bone marrow or solid
longer lengths of hospital stay, higher treatment costs transplantation, severe acute pancreatitis, patients
and increased mortality.8 on regular hemodialysis or peritoneal dialysis
B. Well-nourished or normal is a nutritional status defined
Patients who were admitted with some degree of by a nutritional risk level score of zero (Appendix).
malnutrition, and those patients who experienced a C. Moderately-malnourished or moderate malnutrition is
decline in nutritional status during their admission, had a nutritional status defined by a nutritional risk level
significantly longer hospital stay by an average of 4 days score of 1 to 2.
than patients both admitted and discharged as well- D. Severely-malnourished or severe malnutrition is a
nourished.9 nutritional status defined by a nutritional risk level
of 3 and above.
Due to the high prevalence of malnutrition and adverse
outcomes in the hospital setting, every patient admitted Objective
should be screened for malnutrition risk. Nutrition Risk To determine the association of nutritional status with
Screening (NRS) is the first step in identifying patients length of hospital stay and mortality among adult patients
at risk for malnutrition. It uses recent weight loss, BMI with type 2 diabetes mellitus.
and reduced dietary intake, combined with a subjective
assessment of disease severity. Such subjective grading of METHODOLOGY
illness severity may not accurately reflect current nutritional
status and this tool does not allow for definitive diagnosis Patients
of malnutrition. However, it has been recommended for use This study included non-critically ill adult patients with
in hospitalized patients and may be useful for prompting type 2 diabetes mellitus aged 19 years and above, admitted
the initiation of nutrition support.10 Patients who were for at least 24-hours in the medical ward. We excluded
screened to be nutritionally at-risk are further evaluated patients initially admitted in the intensive care unit (ICU)
using nutritional assessment tool/s to label and classify within the first 24-hours, patients admitted for executive
malnourished patients. check-up or chemotherapy, pregnant and surgical patients,
and type 1 DM. This study was approved by the Institutional
Subjective Global Assessment (SGA) is a tool used to confirm Ethics and Review Board with reference number CT-18251
the result of NRS. There are five questions focusing on on 21 February 2019.
history of unintentional weight loss over the past six months,
dietary intake change, gastrointestinal symptoms of more Design
than 2 weeks, functional capacity and metabolic demands This was a retrospective analytical study that involved
of the underlying condition. Physical examination explores patients admitted in the medical ward of St. Luke’s Medical
muscle, fat mass, and the existence of edema. Each feature Center – Global City in Taguig City, Philippines from
is noted as normal, mild, moderate, or severe according to January 1, 2018 to December 31, 2018. All patients admitted
clinician’s subjective impression. The nutritional status is in the hospital were screened for nutrition risk by the
classified as well-nourished, moderately-malnourished, or nurse-on-duty using the NRS. Patients who were found
severely-malnourished.5 to be nutritionally at risk on admission were assessed by
the Clinical Nutrition Service (CNS) to determine their
Malnutrition was prevalent on admission and discharge, nutritional status (Appendix). Patients’ nutritional status
and malnourished patients were older, suffered more are then recorded in the database of the CNS. Eligible
serious disease, had comorbidities, and had longer hospital subjects were selected from this database.
stay and higher risk of mortality.9 Particularly among
patients with diabetes, the factors associated with high Nine hundred forty-five patients were eligible for the study.
nutritional risk for malnutrition were abnormal BMI, Out of the 945 patients, 506 had incomplete laboratory
lower albumin, and lower total lymphocyte count (TLC).7 results including one with type 1 diabetes and were thus
excluded. A total of 439 patients were included in the
study. The data collected from the CNS database were the

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174 Freyja Diana Ramos, et al Association between Malnutrition and Clinical Outcomes among T2DM Patients

age, sex, diagnosis/reason for admission, co-morbidities, The prevalence of malnutrition among the 439 hospitalized
anthropometric measurements, route of feeding, NRS, SGA, patients with type 2 diabetes in the study was 83.8%. The
LOS, and hospital outcomes (discharged or deceased). The proportion of moderately-malnourished and severely-
white blood cell (WBC) count, glycosylated hemoglobin malnourished patients were 50.3% and 33.5%, respectively.
(HbA1c), and serum albumin of these patients were taken Older mean age was observed as the degrees of malnutrition
from the Healthcare System record of the hospital. The increased. In terms of BMI, most of the patients were
total lymphocyte count was calculated using the formula normal and obese I (both 27.3%), and a few were obese
TLC = WBC x lymphocyte count %. III (4.3%). Enteral tube route of feeding was noted in the
malnourished group and none in the well-nourished group
Sample size estimation (Table 1). Among the variables, age group, BMI category,
Sample size was calculated based on the comparison of feeding route, metabolic derangement and neoplasm (as
the length of hospital stay among severely malnourished reasons for admission), and presence of co-morbidities
and well-nourished patients. Assuming that mean length (specifically cancer and lung disease) were the confounders
of hospital stay among severely malnourished patients is of nutritional status (p<0.05).
5.1 ± 4.9 SD days and for well-nourished patients, 2.9 ± 1.9
SD days,7 with an alpha error of 5%, power of 95% and one- Overall, the average LOS of patients was 6.7 days.
tailed alternative hypothesis, sample size calculated is 62 Pairwise comparison showed that severely-malnourished
per group or 186 for three groups. Controlling for 4 more patients had significantly longer LOS than patients
variables in the analysis, with an additional 20% for each who were moderately-malnourished and well-nourished.
control variable, final sample size required is 336. Furthermore, moderately-malnourished patients had
significantly longer LOS than well-nourished patients
Data analysis (Table 2). Ten (2.3%) patients died as observed in the study.
Descriptive statistics was done using the mean and standard The proportion of deceased patients is also significantly
deviation for quantitative variables and frequencies and different among the 3 groups: 9 (6.1%) patients and 1 (0.5%)
proportions for categorical variables. patient died from the groups of severely-malnourished
and moderately-malnourished patients, respectively. No
Determination of the association between nutritional deaths occurred in the group of well-nourished patients
status and length of hospital stay was analyzed using (Table 2).
univariate and multivariate statistics. ANOVA/t-test and
linear regression were used for categorical and continuous Body mass index (BMI) and malnutrition were the factors
independent variables, respectively, in the univariate significantly affecting length of stay. Holding nutritional
analysis. Multiple linear regression was then utilized in the status constant, for every one unit increase in BMI, the
multivariate analysis using forward elimination. LOS decreased on the average by 0.2 day, or for every 5
units increase in BMI, the LOS decreased on the average
Determination of the association of nutritional status by 1 day. Holding BMI constant, LOS increased on the
and mortality was also analyzed using univariate and average by about 2.2 days in severely-malnourished
multivariate statistics. Malnutrition status was categorized patients compared to well-nourished patients (Table 3).
as severely and moderately-malnourished in the analyses.
Chi-square test and logistic regression for categorical and In the univariate analysis, feeding route, admission for
continuous independent variables, respectively were done neoplasm, low albumin levels, and malnutrition were
in the univariate analysis. Crude odds ratio and the 95% significantly associated with mortality. The odds of
confidence interval were also calculated. Multiple logistic dying among patients on oral feeding were 0.13 or 87%
regression was then utilized in the multivariate statistics less likely than patients on enteral tube feeding. Patients
using backward elimination. admitted for neoplasm had more than 4 times the odds of
dying compared to those who were not admitted for this
To control for confounders, different demographic and reason (Table 4).
clinical profiles were tested for their association with
nutritional status in the univariate analysis using Chi- Other reasons for admission were ear, throat and
square test and ANOVA/t-test. Variables with p-value less systemic infections, veno-occlusive disease, syncope,
than 0.30 were included in the multivariate analysis. hypersensitivity reaction, neurodegenerative disorders
and hematologic conditions.
Analysis was done using Stata v.14. P-value less than 0.05
was considered significant. The following reasons for admission had relative risks (RR)
to be discharged alive: urinary tract infection [RR=1.02
RESULTS (95% CI=1.01-1.04, p=0.496)], acute gastrointestinal disease
[RR=1.03 (95% CI=1.01-1.04, p=0.262)], cerebrovascular
Four hundred thirty-nine patients were included in the disease [RR=1.02 (95% CI=1.01-1.04, p=0.592)], skin
study, of whom 61.5% were males. The mean age was infections [RR=1.02 (95% CI=1.01-1.04, p=0.534)], acute
67.4 years and mean BMI was 28.2 kg/m2. Only 5.9% of musculoskeletal disease [RR=1.02 (95% CI=1.01-1.04,
the patients were fed via enteral tube feeding (nasogastric p=0.562)], and others [RR=1.03 (95% CI=1.01-1.04, p=0.362)].
tube or gastrostomy tube), and the rest were fed per orem.
The most common reason for admission was pneumonia/ The following co-morbidities had relative risks to be
respiratory insufficiency (20.7%). Most (96.1%) of the discharged alive: genitourinary [RR=1.02 (95% CI=1.01-
patients had co-morbidities with cardiovascular (72.2%) 1.04, p=0.576)], endometabolic [RR=1.03 (95% CI=1.01-1.04,
being the most common (Table 1). p=0.257)], neurologic [RR=1.03 (95% CI=1.01-1.04, p=0.268)],

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Association between Malnutrition and Clinical Outcomes among T2DM Patients Freyja Diana Ramos, et al 175

Table 1. Baseline demographics and clinical profile of patients

Well-nourished Moderately-malnourished Severely-malnourished Overall
p-value
n=71 (16.2%) n=221 (50.3%) n=147 (33.5%) n=439
Age, mean years ± SD 55.9 ± 15.14 69.0 ± 12.70 70.6 ± 13.42 67.4 ± 14.27 <0.001**
Age groups (years), n (%) <0.001
Young adult (19-35) 6 (8.5) 3 (1.4) 1 (0.7) 10 (2.3)
Middle aged (36-55) 25 (35.2) 28 (12.7) 23 (15.6) 76 (17.3)
Older adult (56-64) 20 (28.2) 43 (19.5) 23 (15.6) 86 (19.6)
Young elderly (65-74) 7 (9.9) 79 (35.7) 70 (47.6) 156 (35.5)
Old elderly (≥75) 13 (18.3) 68 (30.8) 30 (20.4) 111 (25.3)
Sex, n (%) 0.161
Male 50 (70.4) 128 (57.9) 92 (62.6) 270 (61.5)
Female 21 (29.6) 93 (42.1) 55 (37.4) 169 (38.5)
BMI, mean kg/m2 ± SD 33.6 ± 5.23 27.4 ± 6.10 26.8 ± 6.78 28.2 ± 6.63 <0.001**
BMI class (kg/m2), n (%)
Normal (18.5-<25) 3 (4.2) 69 (31.2) 48 (32.7) 120 (27.3) <0.001
Underweight (<18.5) 0 (0.0) 9 (4.1) 14 (9.5) 23 (5.2)
Overweight (25-<30) 8 (11.3) 71 (32.1) 35 (23.8) 114 (26.0)
Obese I (30-<35) 36 (50.7) 51 (23.1) 33 (22.4) 120 (27.3)
Obese II (35-<40) 20 (28.2) 10 (4.5) 13 (8.8) 43 (9.8)
Obese III (≥40) 4 (5.6) 11 (5.0) 4 (2.7) 19 (4.3)
Feeding route, n (%) <0.001
Oral 71 (100.0) 217 (98.2) 125 (85.0) 413 (94.1)
Enteral tube 0 (0.0) 4 (1.8) 22 (15.0) 26 (5.9)
Reasons for admission, n (%)
AKI/insufficiency 5 (7.0) 21 (9.5) 17 (11.6) 43 (9.8) 0.562
Pneumonia/respiratory insufficiency 12 (16.9) 44 (19.9) 35 (23.8) 91 (20.7) 0.456
UTI 5 (7.0) 8 (3.6) 6 (4.1) 19 (4.3) 0.460
Acute GI disease 10 (14.1) 22 (10.0) 16 (10.9) 48 (10.9) 0.624
CVD 0 (0.0) 7 (3.2) 5 (3.4) 12 (2.7) 0.301
Metabolic derangement 11 (15.5) 12 (5.4) 11 (7.5) 34 (7.7) 0.022
CAD 6 (8.5) 18 (8.1) 9 (6.1) 33 (7.5) 0.731
HTN/heart failure 9 (12.7) 15 (6.8) 10 (6.8) 34 (7.7) 0.237
Skin infection 3 (4.2) 5 (2.3) 8 (5.4) 16 (3.6) 0.269
Neoplasm 2 (2.8) 49 (22.2) 14 (9.5) 65 (14.8) <0.001
Acute MS disease 3 (4.2) 7 (3.2) 4 (2.7) 14 (3.2) 0.839
Others 5 (7.0) 14 (6.3) 14 (9.5) 33 (7.5) 0.517
Comorbidities, n (%)
Without comorbidities 8 (11.3) 6 (2.7) 3 (2.0) 17 (3.9) 0.002
With comorbidities 63 (88.7) 215 (97.3) 144 (98.0) 422 (96.1)
Cancer 2 (2.8) 85 (38.5) 35 (23.8) 122 (27.8) <0.001
Cardiovascular 47 (66.2) 166 (75.1) 104 (70.7) 317 (72.2) 0.307
Lung disease 5 (7.0) 22 (10.0) 25 (17.0) 52 (11.8) 0.048
Gastrointestinal 1 (1.4) 15 (6.8) 10 (6.8) 26 (5.9) 0.213
Kidney disease 18 (25.4) 79 (35.7) 61 (41.5) 158 (36.0) 0.066
Genitourinary 3 (4.2) 6 (2.7) 4 (2.7) 13 (3.0) 0.790
Endometabolic 12 (16.9) 22 (10.0) 15 (10.2) 49 (11.2) 0.244
Neurologic 5 (7.0) 21 (9.5) 21 (14.3) 47 (10.7) 0.192
Rheumatologic 2 (2.8) 2 (0.9) 6 (4.1) 10 (2.3) 0.128
Hematologic 1 (1.4) 3 (1.4) 0 (0.0) 4 (0.9) 0.362
Dermatologic 0 (0.0) 1 (0.5) 0 (0.0) 1 (0.2) 0.610
Total lymphocyte count, mean mm3 ± SD 2045.3 ± 839.09 1761.7 ± 1602.49 1889.7 ± 4356.06 1850.4 ± 2781.74 0.741**
Albumin, mean g/dL ± SD 3.8 ± 3.69 3.1 ± 0.71 2.8 ± 0.67 3.1 ± 1.64 <0.001**
HbA1c, mean % ± SD 8.3 ± 2.25 7.2 ± 1.56 7.1 ± 1.65 7.3 ± 1.76 <0.001**
AKI=acute kidney injury. BMI=body mass index. CAD=coronary artery disease. CVD=cerebrovascular disease. DM=diabetes mellitus.
GI=gastrointestinal. HbA1c=glycosylated hemoglobin. HTN=hypertension. MS=musculoskeletal. UTI=urinary tract infection. SD=standard deviation.
**compared using one-way analysis of variance (ANOVA) (the rest were compared using chi-square)

Table 2. Length of stay and number of patients deceased according to nutritional status
Well-nourished Moderately-malnourished Severely-malnourished Overall
p-value
n=71 (16.2%) n=221 (50.3%) n=147 (33.5%) n=439
LOS, mean days ± SD 4.1 ± 3.55 6.5 ± 6.03 8.3 ± 8.14 6.7 ± 6.66 <0.001*
Deceased, n (%) 0 (0.0) 1 (0.5) 9 (6.1) 10 (2.3) 0.001**
LOS=length of stay. *compared using one-way analysis of variance (ANOVA) **compared using chi-square

Table 3. Multivariate analysis of the association between rheumatologic [RR=1.02 (95% CI=1.01-1.04, p=0.625)],
factors and length of stay (number of days) hematologic [RR=1.02 (95% CI=1.01-1.04, p=0.759)],
Beta Coefficients dermatologic [RR=1.02 (95% CI=1.01-1.04, p=0.879)].
p-value
(95% CI)
Body mass index -0.2 (-0.29 – -0.10) <0.001 For every one unit increase in albumin, the odds of dying
Normal vs severely-malnourished 2.2 (0.49 – 3.95) 0.012 decreased by 63%. No mortality was recorded in the well-
Normal vs moderately-malnourished 1.2 (-0.40 – 2.74) 0.142 nourished group, hence only malnourished groups were
analyzed. Severely-malnourished patients had more than
14 times the odds of dying compared to moderately-
malnourished patients (Table 4). In the multivariate analysis

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176 Freyja Diana Ramos, et al Association between Malnutrition and Clinical Outcomes among T2DM Patients

Table 4. Univariate analysis of the association between appetite, eating dependencies, dysphagia, delirium and
factors and nutritional status with mortality constipation.11,12 Most of the patients admitted were male,
Unadjusted Odds however sex was not a significant factor for nutritional
p-value
Ratio (CI 95%) status. The most common reasons for admission were
Age group pneumonia/respiratory insufficiency, neoplasm, and acute
Elderly vs non-elderly 2.66 (0.55-12.51) 0.209
gastrointestinal disease. Only neoplasm was associated
Sex
Male vs female 2.55 (0.54-12.15) 0.224 with mortality but not length of stay. More than 96% of
Feeding route patients had co-morbidities, and cardiovascular disease
Oral vs enteral tube 0.13 (0.03-0.55) 0.001 was the most prevalent co-morbid condition. However,
BMI this did not significantly affect the nutritional status and
Normal vs other categories 0.95 (0.85-1.05) 0.282 hospital outcome.
Reasons for admission
AKI/insufficiency vs none 1.02 (0.13-8.28) 0.982
Pneumonia/respiratory insufficiency 0.42 (0.05-3.35) 0.397 In general, hyperglycemia on admission has been associated
vs none with poorer outcomes.13 In our study, however, glycemic
UTI vs none - - control based on HbA1c showed that a lower value was
Acute GI disease vs none - -
CVD vs none - - observed with more severe malnutrition. More chronically
Metabolic derangement vs none 1.33 (0.16-10.85) 0.787 ill patients such as those with debilitating diseases and
CAD vs none 3.21 (0.65-15.77) 0.130 cancer may have better glycemic control related to reduction
HTN/heart failure vs none 3.10 (0.63-15.22) 0.142
Skin infection vs none - -
in food intake, presence of liver and/or kidney dysfunction.
Neoplasm vs none 4.02 (1.10-14.67) 0.023 Furthermore, factors affecting the level of hemoglobin such
Acute MS disease vs none - - as anemia and renal insufficiency may have contributed to
Others vs none - -
these findings. Therefore, our study suggests that admission
Co-morbidities
With vs without 0.98 (0.96-0.99) 0.521
HbA1c may not be a robust predictor of mortality or length
Cancer vs none 1.76 (0.49-6.34) 0.383 of stay in the face of malnutrition.
Cardiovascular vs none 1.55 (0.33-7.42) 0.578
Lung disease vs none 0.82 (0.10-6.64) 0.855
Among the different factors, age group, BMI category,
Gastrointestinal vs none 1.80 (0.22-14.74) 0.581
Kidney disease vs none 1.80 (0.51-6.33) 0.350 feeding route, admission for metabolic derangement and
Genitourinary vs none - - neoplasm, presence of cancer and lung co-morbidities,
Endometabolic vs none - - albumin and HbA1c were the confounders of nutritional
Neurologic vs none - -
Rheumatologic vs none - - status. However, in the univariate and multivariate
Hematologic vs none - - analyses, in addition to malnutrition in the hospital
Dermatologic vs none - - setting (i.e., moderately-malnourished and severely-
Total lymphocyte count 1.00 (1.00 -1.00) 0.298 malnourished), only BMI significantly affected and was
Albumin 0.37 (0.17-0.81) 0.013 negatively correlated with LOS, while feeding route,
HbA1c 0.86 (0.56-1.32) 0.490
admission for neoplasm, and low albumin levels were
Nutritional status 14.35 (1.80-114.49) 0.001
Severely-malnourished vs significantly associated with mortality.
moderately-malnourished
Well-nourished patients had the highest mean BMI among
the 3 groups. Moderately-malnourished patients had higher
mean BMI than severely-malnourished patients. Higher
Table 5. Association between malnutrition and mortality BMI was associated with shorter LOS but not associated
Nutritional status Adjusted Odds Ratio (CI 95%) p-value
with mortality based on the results of the study. Patients
Severely-malnourished vs 8.91 (1.04-76.18) 0.046
moderately-malnourished
with type 2 diabetes tended to be more overweight or obese
at baseline. Chronically-ill patients may have experienced
weight loss possibly due to poor intake or appetite,
depression, hypercatabolic state, systemic inflammation,
however, only malnutrition was significantly associated etc., hence lower BMI compared to patients with more
with mortality. Those severely-malnourished had almost acute conditions. This may have contributed to higher BMI
9 times the odds of dying compared to moderately- seen among patients with diabetes, who had shorter LOS.
malnourished patients (Table 5). Severe malnutrition was also associated with longer LOS.

DISCUSSION All well-nourished patients were fed through oral route

or by mouth. Feeding through enteral tube was only
A total of 83.8% of hospitalized patients with type 2 observed in the malnourished groups. Patients who were
diabetes were malnourished in our study. This is much fed by enteral tube had higher odds of dying compared to
greater than previously reported prevalence rates of patients who were fed by mouth. Based on their clinical
hospital malnutrition in general (48-53%).6 This suggests profiles, patients who were on tube feeding were more
that patients with type 2 diabetes have a higher prevalence likely to be chronically-ill and have co-morbidities, hence
of malnutrition in the hospital setting. these patients tended to be malnourished, predisposing
them to higher risk of poor hospital outcomes. Among the
Most of the patients were elderly, and increasing age reasons for admission, neoplasm was associated with 4
was associated with higher degrees of malnutrition. times the odds of dying. Malignant neoplasms are known
Elderly patients are at risk for malnutrition due to to be associated with depressed immune system, reduced
frailty, polypharmacy, general health decline including appetite and hypercatabolism, which can significantly
physical disability, dementia, cognitive decline, poor affect nutritional status.

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Association between Malnutrition and Clinical Outcomes among T2DM Patients Freyja Diana Ramos, et al 177

Higher levels of albumin were associated with reduced to well-nourished patients by an average of 2.2 days.
mortality in our study. Hypoalbuminemia has traditionally Mortality was observed only in malnourished patients.
been seen as a marker for poor nutritional status. However, Artificial feeding route, admission for neoplasm, lower
it is now posited rather to reflect an inflammatory state.14 albumin levels, and malnutrition were associated with
Inflammation often results in hypercatabolism with mortality. Lower HbA1c levels were seen in malnourished
increased protein and caloric requirements. Measuring patients, but did not correlate with length of stay or
albumin levels may be useful for diagnosing inflammation mortality. Greater degrees of malnutrition were associated
and assessing nutrition risk by identifying patients at with higher mortality.
risk for adverse outcomes if adequate nutrition is not
administered.15 As inflammation resolves, albumin levels Acknowledgments
increase and nutrition risk is thus reduced. We also The authors would like to thank their institution for its support,
confirmed that malnutrition in hospitalized type 2 diabetes and for providing them their biostatisticians, Maria Joy Taneo
and Macario Reandelar Jr., MD, MSPH, FPAFP, who have
was associated with mortality. No mortality was reported
greatly helped and contributed in the statistical analyses of their
among well-nourished patients. Mortality rate was highest research data.
in the severely-malnourished group with almost 9 times the
odds of dying than the moderately-malnourished group. Statement of Authorship
All authors certified fulfillment of ICMJE authorship criteria.
This study analyzed the association between HbA1c
and other factors affecting nutritional status to hospital Author Disclosure
outcomes among patients with type 2 diabetes. Contrary The authors declared no conflicts of interest.
to other published literature, we observed that TLC was
not associated with poor nutritional status. We confirmed Funding Source
None.
the results of other studies done in elderly patients (who
comprise the majority of our study population) that References
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and malnutrition.16 Our study was limited only to type who.int/news-room/fact-sheets/detail/malnutrition
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66BE650C194DDD6687E0CEC6FF12&originRegion=eu-west-1&o-
Severely-malnourished patients had longer LOS compared riginCreation=20210815062934.

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APPENDIX

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