Iranian Journal of Medical Sciences

Document Type: Original Article(s)


1 Nutrition and Food Sciences Research Center, Department of Clinical Nutrition, School of Nutrition and Food Sciences, Shiraz University of Medical Sciences, Shiraz, Iran

2 Shiraz Anesthesiology and Critical Care Research Center, Department of Anesthesia, Nemazee Teaching Hospital, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran

3 Department of Epidemiology, School of Health, Shiraz University of Medical Sciences, Shiraz, Iran

4 Department of Anesthesia, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran; Vice Chancellor for Clinical Affairs, Shiraz University of Medical Sciences, Shiraz, Iran


Background: Malnutrition is an important factor in the survival of critically ill patients. The purpose of the present study was to assess the nutritional status of patients in the intensive care unit (ICU) on the days of admission and discharge via a detailed nutritional assessment. Methods: Totally, 125 patients were followed up from admission to discharge at 8ICUs in Shiraz, Iran. The patients’ nutritional status was assessed using subjective global assessment (SGA), anthropometric measurements, biochemical indices, and body composition indicators. Diet prescription and intake was also evaluated.Results: Malnutrition prevalence significantly increased on the day of discharge (58.62%) compared to the day of admission (28.8%) according to SGA (P<0.001). The patients’ weight, mid-upper-arm circumference, mid-arm muscle circumference, triceps skinfold thickness, and calf circumference decreased significantly as well (P<0.001). Lean mass weight and body cell mass also decreased significantly (P<0.001). Biochemical indices showed no notable changes except for magnesium, which decreased significantly (P=0.013). A negative significant correlation was observed between malnutrition on discharge day and anthropometric measurements. Positive and significant correlations were observed between the number of days without enteral feeding, days delayed from ICU admission to the commencement of enteral feeding, and the length of ICU stay and malnutrition on discharge day. Energy and protein intakes were significantly less than the prescribed diet (26.26% and 26.48%, respectively).Conclusion: Malnutrition on discharge day increased in the patients in the ICU according to SGA. Anthropometric measurements were better predictors of the nutritional outcome of our critically ill patients than were biochemical tests.


  1. - Sungurtekin H, Sungurtekin U, Oner O, Okke D. Nutrition assessment in critically ill patients. Nutr Clin Pract. 2008;23:635-41. doi: 10.1177/0884533608326137. PubMed PMID: 19033223.
  2. - Kubrak C, Jensen L. Malnutrition in acute care patients: a narrative review. Int J Nurs Stud. 2007;44:1036-54. doi: 10.1016/j.ijnurstu.2006.07.015. PubMed PMID: 16996065.
  3. - Martin CM, Doig GS, Heyland DK, Morrison T, Sibbald WJ, Southwestern Ontario Critical Care Research N. Multicentre, cluster-randomized clinical trial of algorithms for critical-care enteral and parenteral therapy (ACCEPT). CMAJ. 2004;170:197-204. PubMed PMID: 14734433; PubMed Central PMCID: PMC315525.
  4. - Rodriguez L. Nutritional status: assessing and understanding its value in the critical care setting. Crit Care Nurs Clin North Am. 2004;16:509-14. doi: 10.1016/j.ccell.2004.06.009. PubMed PMID: 15571939.
  5. - Griffiths RD, Bongers T. Nutrition support for patients in the intensive care unit. Postgrad Med J. 2005;81:629-36. doi: 10.1136/pgmj.2005.033399. PubMed PMID: 16210458; PubMed Central PMCID: PMC1743378.
  6. - Wischmeyer PE. Malnutrition in the acutely ill patient: is it more than just protein and energy? South Afr J Clin Nutr. 2011;24:S1-S7.
  7. - Jolliet P, Pichard C, Biolo G, Chiolero R, Grimble G, Leverve X, et al. Enteral nutrition in intensive care patients: a practical approach. Clin Nutr. 1999;18:47-56. doi: 10.1054/clnu.1998.0001. PubMed PMID: 10459065.
  8. - Huang YC, Yen CE, Cheng CH, Jih KS, Kan MN. Nutritional status of mechanically ventilated critically ill patients: comparison of different types of nutritional support. Clin Nutr. 2000;19:101-7. doi: 10.1054/clnu.1999.0077. PubMed PMID: 10867727.
  9. - Thomas JM, Isenring E, Kellett E. Nutritional status and length of stay in patients admitted to an Acute Assessment Unit. J Hum Nutr Diet. 2007;20:320-8. doi: 10.1111/j.1365-277X.2007.00765.x. PubMed PMID: 17635309.
  10. - Ryu SW, Kim IH. Comparison of different nutritional assessments in detecting malnutrition among gastric cancer patients. World J Gastroenterol. 2010;16:3310-7. doi: 10.3748/wjg.v16.i26.3310. PubMed PMID: 20614488; PubMed Central PMCID: PMC2900724.
  11. - Elia M, Russell C, Stratton R, Todorovic V, Evans L, Farrer K. The "MUST" explanatory booklet [Internet]. England: British association of parentral and enteral Nutrition; 2003 November [Revised 2011 November; cited 2012 October 11]. Available from:
  12. - Mahdavi AM, Safaiyan A, Ostadrahimi A. Subjective vs objective nutritional assessment study in children: a cross-sectional study in the northwest of Iran. Nutr Res. 2009;29:269-74. doi: 10.1016/j.nutres.2009.03.009. PubMed PMID: 19410979.
  13. - Makhija S, Baker J. The Subjective Global Assessment: a review of its use in clinical practice. Nutr Clin Pract. 2008;23:405-9. doi: 10.1177/0884533608321214. PubMed PMID: 18682592.
  14. - Kreymann KG, Berger MM, Deutz NE, Hiesmayr M, Jolliet P, Kazandjiev G, et al. ESPEN Guidelines on Enteral Nutrition: Intensive care. Clin Nutr. 2006;25:210-23. doi: 10.1016/j.clnu.2006.01.021. PubMed PMID: 16697087.
  15. - Enteral Feeding [Internet]. Malaysia; Anesthesia program & Cawangan Kualiti Penjagaan Kesihatan Malaysia. [cited 2006 Aug 18]. Available from:
  16. - Kyle UG, Kossovsky MP, Karsegard VL, Pichard C. Comparison of tools for nutritional assessment and screening at hospital admission: a population study. Clin Nutr. 2006;25:409-17. doi: 10.1016/j.clnu.2005.11.001. PubMed PMID: 16356595.
  17. - Tsai JR, Chang WT, Sheu CC, Wu YJ, Sheu YH, Liu PL, et al. Inadequate energy delivery during early critical illness correlates with increased risk of mortality in patients who survive at least seven days: a retrospective study. Clin Nutr. 2011;30:209-14. doi: 10.1016/j.clnu.2010.09.003. PubMed PMID: 20943293.
  18. - Fontes D, Generoso Sde V, Toulson Davisson Correia MI. Subjective global assessment: a reliable nutritional assessment tool to predict outcomes in critically ill patients. Clin Nutr. 2014;33:291-5. doi: 10.1016/j.clnu.2013.05.004. PubMed PMID: 23755841.
  19. - Norman K, Pichard C, Lochs H, Pirlich M. Prognostic impact of disease-related malnutrition. Clin Nutr. 2008;27:5-15. doi: 10.1016/j.clnu.2007.10.007. PubMed PMID: 18061312.
  20. - Hosseini S, Amirkalali B, Nayebi N, Heshmat R, Larijani B. Nutrition status of patients during hospitalization, Tehran, Iran. Nutr Clin Pract. 2006;21:518-21. doi: 10.1177/0115426506021005518. PubMed PMID: 16998150.
  21. - McClave SA, Martindale RG, Vanek VW, McCarthy M, Roberts P, Taylor B, et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr. 2009;33:277-316. doi: 10.1177/0148607109335234. PubMed PMID: 19398613.
  22. - Rubinson L, Diette GB, Song X, Brower RG, Krishnan JA. Low caloric intake is associated with nosocomial bloodstream infections in patients in the medical intensive care unit. Crit Care Med. 2004;32:350-7. doi: 10.1097/01.CCM.0000089641.06306.68. PubMed PMID: 14758147.
  23. - Strack van Schijndel RJ, Weijs PJ, Koopmans RH, Sauerwein HP, Beishuizen A, Girbes AR. Optimal nutrition during the period of mechanical ventilation decreases mortality in critically ill, long-term acute female patients: a prospective observational cohort study. Crit Care. 2009;13:R132. doi: 10.1186/cc7993. PubMed PMID: 19671136; PubMed Central PMCID: PMC2750190.
  24. - Pichard C, Kreymann G, Weimann A, Herrmann H, Schneider H. O015 early energy supply decreases icu and hospital mortality: a multicentre study in a cohort of 1209 patients. Clin Nutr Supplements. 2008;3:7. doi: 10.1016/S1744-1161(08)70017-6.
  25. - Villet S, Chiolero RL, Bollmann MD, Revelly JP, Cayeux RNM, Delarue J, et al. Negative impact of hypocaloric feeding and energy balance on clinical outcome in ICU patients. Clin Nutr. 2005;24:502-9. doi: 10.1016/j.clnu.2005.03.006. PubMed PMID: 15899538.
  26. - Kim H, Stotts NA, Froelicher ES, Engler MM, Porter C, Kwak H. Adequacy of early enteral nutrition in adult patients in the intensive care unit. J Clin Nurs. 2012;21:2860-9. doi: 10.1111/j.1365-2702.2012.04218.x. PubMed PMID: 22845617.
  27. - Ibrahim EH, Mehringer L, Prentice D, Sherman G, Schaiff R, Fraser V, et al. Early versus late enteral feeding of mechanically ventilated patients: results of a clinical trial. JPEN J Parenter Enteral Nutr. 2002;26:174-81. doi: 10.1177/0148607102026003174. PubMed PMID: 12005458.
  28. - Charvat J, Kratochvil J, Martinkova V, Masopust J, Palova S. Experience with early enteral nutrition application in critically ill patients in medical intensive care unit. Cas Lek Cesk. 2008;147:106-11. PubMed PMID: 18383962.
  29. - Nematy M, Mohajeri SAR, Moghadam SA, Safarian M, Norouzy A, Parizadeh SMR, et al. Nutritional status in intensive care unit patients: a prospective clinical cohort pilot study. Med J Nutrition Metab. 2012;5:163-8. doi: 10.1007/s12349-011-0071-x
  30. - Izquierdo Fuentes MT, Miranda Parlon MC, Diaz Nunez J, Mora Muniz V, Martinez Estalella G, Bueno Corral JM. Assessment of changes in body composition in critically ill patients. Enferm Intensiva. 2010;21:113-9. doi: 10.1016/j.enfi.2009.11.002. PubMed PMID: 20199886.
  31. - Faisy C, Rabbat A, Kouchakji B, Laaban JP. Bioelectrical impedance analysis in estimating nutritional status and outcome of patients with chronic obstructive pulmonary disease and acute respiratory failure. Intensive Care Med. 2000;26:518-25. doi: 10.1007/s001340051198. PubMed PMID: 10923724.
  32. - Robert S, Zarowitz BJ, Hyzy R, Eichenhorn M, Peterson EL, Popovich J, Jr. Bioelectrical impedance assessment of nutritional status in critically ill patients. Am J Clin Nutr. 1993;57:840-4. PubMed PMID: 8503350.
  33. - Langhans C, Weber-Carstens S, Schmidt F, Hamati J, Kny M, Zhu X, et al. Inflammation-induced acute phase response in skeletal muscle and critical illness myopathy. PLoS One. 2014;9:e92048. doi: 10.1371/journal.pone.0092048. PubMed PMID: 24651840; PubMed Central PMCID: PMC3961297.
  34. - Jin B, Li YP. Curcumin prevents lipopolysaccharide-induced atrogin-1/MAFbx upregulation and muscle mass loss. J Cell Biochem. 2007;100:960-9. doi: 10.1002/jcb.21060. PubMed PMID: 17131360; PubMed Central PMCID: PMC3099528.
  35. - Reid MB, Li YP. Tumor necrosis factor-alpha and muscle wasting: a cellular perspective. Respir Res. 2001;2:269-72. PubMed PMID: 11686894; PubMed Central PMCID: PMC59514.
  36. - Huijgen HJ, Soesan M, Sanders R, Mairuhu WM, Kesecioglu J, Sanders GT. Magnesium levels in critically ill patients. What should we measure? Am J Clin Pathol. 2000;114:688-95. doi: 10.1309/0Q7F-QTGM-6DPD-TLGY. PubMed PMID: 11068541.
  37. - Ryzen E. Magnesium homeostasis in critically ill patients. Magnesium. 1989;8:201-12. PubMed PMID: 2682045.
  38. - Chernow B, Bamberger S, Stoiko M, Vadnais M, Mills S, Hoellerich V, et al. Hypomagnesemia in patients in postoperative intensive care. Chest. 1989;95:391-7. doi: 10.1378/chest.95.2.391. PubMed PMID: 2914492.
  39. - Rubeiz GJ, Thill-Baharozian M, Hardie D, Carlson RW. Association of hypomagnesemia and mortality in acutely ill medical patients. Crit Care Med. 1993;21:203-9. doi: 10.1097/00003246-199302000-00010. PubMed PMID: 8428470.
  40. - Raguso CA, Dupertuis YM, Pichard C. The role of visceral proteins in the nutritional assessment of intensive care unit patients. Curr Opin Clin Nutr Metab Care. 2003;6:211-6. doi: 10.1097/01.mco.0000058592.27240.95. PubMed PMID: 12589191.