EVALUATION OF CALORIC INTAKE, KNOWLEDGE, AND PRACTICES ON POSTOPERATIVE REFEEDING IN DIGESTIVE SURGERY IN NGAOUNDERE HOSPITALS, ADAMAWA REGION, CAMEROON
Tsague Marthe Valentine1 , Nguimbou Richard Marcel2 , Ngaha Damndja Wilfred2 ,
Sineche Ngunte Raoul1 , Modjo Gabriel Archange3 , Ngadjui Ngodjoum Donald Roger1 ,
1Department of Biomedical Sciences, Faculty of Sciences, University of Ngaoundere, Ngaoundere, Cameroon.
2Department of Food Sciences and Nutrition, ENSAI, University of Ngaoundere, Ngaoundere, Cameroon.
3Yaounde Emergency Center, Yaounde, Cameroon.
4Department of Surgery and Specialities, Faculty of Medicine and Biomedical Sciences, University of Yaounde, Cameroon.
Background and objective: Insufficient caloric intake among postoperative digestive surgery patients, linked to a lack of knowledge and practices regarding their re-feeding, is a frequent health problem in developing countries. The aim of this study was to assess the caloric intake of postoperative digestive surgery patients, as well as the knowledge and practices related to their refeeding in two hospitals in the city of Ngaoundere.
Methods: This was an observational, analytical, cross-sectional, prospective cohort study over a 5 months period from June to November 2022, focusing on the patients, the diets of post-digestive surgery patients, their nurses, and the operating theatre nursing staff. Caloric targets were defined as those with mean intakes above 15 kcal/kg/day at day 3 and 25 kcal/kg/day at discharge.
Results: A total of 134 patients, 240 caretakers, 20 nursing staff, and 614 dieters (meals) were included in the study. Males were more represented, with rates of 82.1%, 56.7%, and 75% for patients, nurses, and staff respectively. 25.4% of day-3 caloric targets and 24.6% of discharge caloric targets were met. The Kruskal-Wallis test was used to investigate daily variations in means for each macronutrient, the difference being significant at p<0.05. Lack of information and practice on the composition of a porridge, food frequency score, feeding chronology, and lack of nursing practice on the part of operating room nursing staff, were the main reasons observed.
Conclusion: The dietary balance in postoperative digestive surgery patients and the practices of re-feeding are deficient in the 2 hospitals in the town of Ngaoundere, suggesting an in-depth study of the dietary consequences they may have, such as undernutrition.
Keywords: Digestive surgery, knowledge and practices, Ngaoundere hospitals, postoperative, refeeding, undernutrition.
INTRODUCTION
Insufficient caloric and/or protein intake in relation to the body's needs is a heavy burden in developing countries1. It is all the more marked in healthcare settings, with 15% to 60% of hospitalized patients suffering from it depending on the type of admission2. In surgical wards, the figures are even higher, with 40-50% of patients affected, due to increased caloric requirements caused by increased catabolism and anorexia, the intensity and duration of which are proportional to the severity of the surgical procedure3,4. In Cameroon, very few or no studies have addressed the problem of calculating caloric intake in surgical inpatients. The persistence of this deficiency in caloric intake is associated with other exogenous factors responsible for undernutrition, some of which are linked to the patient's comorbidities, such as extreme age, cancers, sepsis, chronic digestive pathologies, HIV and factors linked to carcinological treatments, corticosteroid therapy exceeding one month and the polymedication5 in postoperative patients: hence the need to carry out an assessment of caloric intake in the latter. The poor exploration of the dietary sector among postoperative digestive surgery patients in the Cameroonian context is the reason that prompted us to conduct the present study with the aim of assessing the caloric intakes of postoperative, refeeding digestive surgery patients in two hospitals in the city of Ngaoundere.
MATERIALS AND METHODS
Total 134 patients, were collected 100 from Ngaoundere Patience Clinic and 34 from Ngaoundere Regional Hospital; 255 patients’ attendants, 15 of whom were lost to follow-up. Of the remaining 240 attendants, 174 were from Ngaoundere Patience Clinic and 66 from Ngaoundere Regional Hospital of 20 post-operative attendants (none lost to follow-up), including 6 from Ngaoundere Patience Clinic and 14 from Ngaoundere Regional Hospital; 650 meals, of which 36 could not be characterized. Of the 614 meals, 454 came from Ngaoundere Patience Clinic and 160 from Ngaoundere Regional Hospital. Four representative soups were analyzed.
Type, period, and setting of study
A cross-sectional, observational, analytical, and prospective cohort study was carried out. It was carried out in the “Ngaoundere Patience Clinic” and Ngaoundere Regional Hospital in from June to November 2022.
Study population
The study population consisted of postoperative patients in the post-surgical care departments of the selected hospitals, their meals, patient caretakers, and the nursing staff working in the surgical department.
Selection Criteria
Included in our study were all patients who had undergone emergency or scheduled digestive surgery during the study period, and who had given their consent, all the patient caretakers who spent less than 24 hours at the patient's bedside, who had spent at least 24 hours at the bedside and who had given their consent, all nursing staff in the surgical department had given their consent, and all enteral and parenteral meals were included. Not included in our study were patients who had undergone digestive surgery but died, patients who were malnourished prior to surgery, nursing staff who were lost to follow-up, and enteral and parenteral meals consumed by patients but which could not be characterized during their stay, and all liquid meals that were not representative of the dosing phase.
Data Collection
The sampling of patients, patient caretakers, nursing staff, and meals was based on exhaustive, non-probabilistic, and consecutive recruitment. The data were selected among patients who had undergone emergency or scheduled digestive surgery, all the patient caretakers who spent less than 24 hours at the patient's bedside, and all nursing staff in the surgical department. Signed informed consent was obtained from each participant. Before the data collected were anonymized to protect patient privacy. A structured interview was set up to collect the following information:
The methodological approach used to assess the nutritional intake targets and debts of enteral and parenteral patients was divided into 4 phases: the characterization phase, the sampling and preservation phase, the dosing phase, and the macronutrient and calorie calculation phase.
Total Carbohydrate=100-[Water content (%) + Protein content (%) + Lipid content (%) + Ash content (%)
Energy value (Kcal/100g) = Carbohydrate content (%) × 4 (Kcal) + Protein content (%) × 4 (Kcal) + Fat content (%) × 9 (Kcal)
The macronutrient and calorie calculation phase. Following the determination of macronutrient contents, the energy value of the dishes was calculated using the coefficients of Atwater and Benedict19,20 according to formula.
The dosing phase: The water content is determined by obtaining a constant weight after heating to 130°C9,10. The hexane extraction technique for lipids uses the Soxhlet11,12. The Kjeldah method is used to determine total protein concentration13,14. Incineration in a muffle furnace (Nabertherm®) at 550°C for 4h15,16 measures ash content. Total carbohydrate content was calculated17,18 using the following formula.
Ethical considerations
All the procedures of the study were approved by authorization of the Department of Biomedical Sciences of the Faculty of Sciences of the University of Ngaoundere 022/1002/UN/R/DFS/CD-SBM from May 19, 2022. Ngaoundere Regional Hospital and “The Patience Clinic”, and authorization was obtained from the Regional Delegation of the Ministry of Health N° 598 AR/RA/DSP/BEP/NGE from July 15, 2022 to recruit participants for this study.
Statistical analysis
The Sphinx Plus.V5 software allowed us to establish the survey questionnaire forms; Microsoft Excel 2016 to collect answers, calculate caloric and macronutrient contents, and establish graphs; finally, the XLSAT 2016 software allowed us to make statistical analyses such as statistical description (by numbers and frequencies for qualitative variables, means, standard deviations and extremes for quantitative ones); Kruskal Wallis test to compare the means Values of p<0.05 were considered statistically significant.
Limitations of the study
Due to the short survey period, we were unable to visit all hospitals in Ngaoundere. Additional analyses such as albumin levels at hospital discharge remain an indicator of undernutrition. Finally, the energy value of all meals consumed during the hospitalization of postoperative patients should be estimated in order to correct the caloric debts of each patient.
RESULTS AND DISCUSSION
Sociodemographic characteristics
Our study was carried out on 134 patients, 240 nurses, and 20 patient caretakers. The predominant sex was male, or 82.09%, 56.71%, and 75% for patient caretakers, and nursing staff respectively. This may be explained by the fact that, during our study period, the majority (for patients) of pathologies encountered were strangulated and non-strangulated hernias (29.85%), the latter affecting men more than women. Our results are superior to the study conducted by Adébayo et al.4 in Benin, who found 57.78% male predominance. Among patients, the most represented age bracket was [18-70] years, either 73.35% (105); the majorities 62.68% (84) were married and 65.67% (88) were Muslims. Among patients caretakers, the majority were [18-28] years old, or 30.83% (74). The majority were farmers (34.17%, 82), undereducated (34.17%, 82), married (60%, 144), and Muslim (60.42%, 145). Among operating theater staff, the majority were aged [28-38], either 35% (7) or 50% (10) were nurses (Table 1).
Assessment of nutritional intake goals and debts of enteral and parenteral patients
Nutritional characterization and diet dosage
Figure 1A showed that the most consumed food group was soup at 52.28% (apple, fish, meat, soy porridge, and corn porridge) with 25.26%, which is normal since this is the recommended food form for postoperative patients. Figure 1B showed that the majority of patients had a low Food Diversity Score because they consumed less than 2 food groups (78.37%). This is due to the fact that the most consumed soup was corn porridge (46.15%). Of the 4 soups measured, maize porridge had a high carbohydrate content (82.07g/100g DM), but the lowest energy content (395.91 kcal/100g DM), with low protein (5.75g/100g DM) and lipid (4.96g/100g DM) contents.
This is due to the fact that no other protein or lipid elements were added to its composition (Figure 1C).
Patients consumed an average of 7.089 kcal/kg/day of calories containing 1.26g/kg/day of mostly carbohy-drates; 0.21g/kg/day of protein and 0.13g/kg/day of fat. This was far from the study done by Preiser21 which found an average calorie intake of 18.5±9.6 kcal/ kg/day. This is explained by the fact that the most consumed soup which was corn porridge, has a low energy intake (395.91kcal) and a low Food Diversity Score.
Caloric content and macronutrients of operated patients
Of 134 patients surveyed, carbohydrates were the most consumed macronutrient with a peak on day 12 of 3.17 g/kg/day followed by day 3 of 2.55 g/kg/day for 59 and 132 patients with 12 and 3 days of hospitalization respectively (Figure 2A). The caloric peak was 19.45 g/kg/day on day 12 followed by 15.37 g/kg/day on day 3 for 59 and 132 patients with 12 and 3 days of hospitalization, respectively (Figure 2B). The Kruskal-Wallis test shows us that the means for each macronutrient varied very significantly by day p<0.0001.
Of 134 patients surveyed, carbohydrates were the most consumed macronutrient, with a peak on day-12 of 3.17 g/kg/day followed by day 3 of 2.55g/kg/day for 59 and 132 patients respectively, who had been hospitalized for 12 and 3 days (Figure 2A). Peak caloric intake was 19.45 g/kg/day on day 12, followed by 15.37g/kg/day on day 3, for 59 and 132 patients respectively with 12 and 3 days of hospitalization (Figure 2B). The Kruskal-Wallis test showed us that the means for each macronutrient varied very significantly by day p<0.0001. Patients consumed an average of 7.089 kcal/kg/day of calories, containing 1.26g/kg/day of main carbohydrates, 0.21g/kg/day of protein, and 0.13g/kg/day of fat. This was a far cry from Clara's 2014 study, which found an average calorie intake of 18.5±9.6 kcal/kg/day. This can be explained by the fact that the most widely consumed soup was Corn Porridge, which has a low energy intake (395.91 kcal) and a low Food Diversity Score.
The majority of patients had not reached their caloric-carbohydrate-lipid-protein goal at day-3, which was 15kcal/kg/day- 2.25g/kg/day- 0.5g/kg/day-0.5g/kg/ day. Thus, only 24.63%; 30.60%; 11.94%; 14.93% respectively for caloric, carbohydrate, lipid, and protein objectives were reached. Also, the majority of patients had not reached their caloric-carbohydrate-lipid-protein objective at discharge, which was set at 25 kcal/kg/day-3.75g/kg/day- 0.8g/kg/day- 1.2g/kg/day. Thus, only 25.37%; 29.10%; 11.19%; 14.96% for caloric, carbo-hydrate, lipid, and protein targets respectively were achieved. This would be a departure from the 2020 Preiser21 study in France which found 53% at day-3 and 54.5% at discharge of patients who achieved their caloric goal. This is because the patients had a very low average caloric intake. Thus, patients who did not reach their caloric goals on day-3 or at discharge had an average of 12.36 kcal/kg/day as a caloric debt on day-3 and were discharged with an average caloric debt of 17.61 kcal/kg/day which is very high.
Mean calorie and macronutrient levels on day-3 and discharge
On average 8.22 [0-41.92] Kcal/kg/day were consumed on day-3 and 10.9 [0.81-56.26] Kcal/kg/day at discharge. All post-op patients were grade I and II patients, as daily intake over 7 days was < 60% (Table 2).
Nutritional goals
The majority of patients had not reached their caloric-carbohydrate-lipid-protein goals set at 15kcal/kg/day-2.25g/kg/day- 0.5g/kg/day- 0.5g/kg/day for day-3 respectively and at 25kcal/kg/day- 3.75g/kg/day- 0.8g/ kg/day-1.2g/kg/day respectively for discharge. Thus only 25.37%; 29.10%; 11.19%; 20.90% respectively for caloric, carbohydrate, lipid, and protein goals at day-3 (Figure 3A) and 24.63%; 30.60%; 11.94%; 20.90% respectively for caloric, carbohydrate, lipid, and protein goals at discharge (Figure 3B) were achieved. These results are in line with those of Preiser, who worked on the evaluation of nutritional management in the surgical intensive care units at the Nancy University Hospital Center in 2014 in Benin.
Caloric and macronutrient balance
Patients who did not reach their caloric goals on day-3 or at discharge had an average caloric debt of 12.36 kcal/kg/day on day-3 and were discharged with an average caloric debt of 17.61 kcal/kg/day (Table 3).
Knowledge and practices of health care staff and patient caretakers on post-digestive surgery refeeding
The nurses were more informed about the beginning of the feeding (100%), the type of food (95.83%), and had good practices (97.91% of the nurses waited for the gas to be released and 91.66% gave the best type of food to the patients). On the other hand, regarding the other parameters such as the composition of slurry, the Food Frequency Score, and the chronology of feeding, the caretaker was not sufficiently informed about it and therefore had non-conforming practices. These data correlated very well with staff knowledge and practice, as the higher the rate of staff knowledge and practice, the higher the rate of staff information and practice. For the aspect of knowledge and practices of the personnel with regard to the needs of feeding and hydration expressed by the patient, the majority of the personnel had knowledge of it, or 15/20 for the most minimal knowledge or the evaluation of the ingesta, but on the other hand, the practices left something to be desired, or 0/20 of the person who always calculated the BMI and the caloric needs of the patients, and 2/20 of the person who drew up the nursing care plans (Table 4).
Lack of information and practices of the nurses on the composition of porridge, the Food Frequency Score, the chronology of feeding, and the lack of practices of the operating room staff on the nursing care plans, the evaluation of the BMI, and the calculation of the caloric intake of the patients were mostly observed. This can be explained by the fact that the majority of under-educated people at the bedside are not able to remember the instructions given by the staff. For the staff, the presence of non-nursing staff within the operating team is not equipped with knowledge of the nursing care plan but is considered as such. And also the laziness developed by some nursing staff in the past years.
CONCLUSION
The patients were predominantly male, aged between [18-70] years, married, and of the Muslim religion. The majority of dishes consumed by patients were from the soup group, in this case, corn porridge, which is not very diversified in terms of Food Diversity Score and has a low energy and protein content, unlike fish soup or other diets. This is the reason why the majority of patients did not reach their carbohydrate, lipid, and protein caloric objectives on day-3 and at discharge and left the ward with more caloric debts than boluses. Also, there was a lack of information and practices of the nurses on the constitution of porridge, the Food Frequency Score, the chronology of feeding, and the lack of practices of the personnel in function in the operating room on the nursing care plan, the evaluation of body mass index and the calculation of the caloric intake of the patients.
ACKNOWLEDGEMENTS
The authors would like to thank the Professor Nguimbou Richard Marcel, for his commitment to this study.
AUTHOR’S CONTRIBUTION
Nguimbou Richard Marcel, Tsague Marthe Valentine, Sineche Ngunte Raoul: Methodology; Sineche Ngunte Raoul, Modjo Gabriel Archange, Nguimbou Richard Marcel: Analysis and interpretation of data; Sineche Ngunte Raoul, Tsague Marthe Valentine, Ngadjui Ngodjoum Donald Roger: Manuscript writing; Nguimbou Richard Marcel, Ngaha Damndja Wilfred Critical revision; Sineche Ngunte Raoul, Nguimbou Richard Marcel: Statistical analysis; Ze Minkande Jacqueline: Study supervision.
CONFLICT OF INTEREST
The authors have no conflict of interest.
REFERENCES