Journal of Human Nutrition and Dietetics
RESEARCH PAPER
Impact of nutritional status/risk and post-operative
nutritional management on clinical outcomes in patients
undergoing gastrointestinal surgery: a prospective
observational study
K. Narendra1 N. Kiss,1 C. Margerison,1
1
Institute for Physical Activity and Nutrition, Deakin University, Geelong, Australia
2
Austin Health, Heidelberg, Victoria, Australia
Keywords
complications, gastrointestinal surgery, hand grip
strength, length of stay, malnutrition.
Correspondence
K. Narendra, Institute for Physical Activity and
Nutrition, Deakin University, 221 Burwood Hwy,
Burwood, Victoria 3125, Australia.
Tel.: +61 421654558
E-mail: karthika.narendra@gmail.com
How to cite this article
Narendra K., Kiss N., Margerison C., Johnston
B.& Chapman B.2020Impact of nutritional status/
risk and post-operative nutritional management
on clinical outcomes in patients undergoing
gastrointestinal surgery: a prospective
observational study. J Hum Nutr Diet. https://doi.
org/10.1111/jhn.12763
Introduction
Patients undergoing gastrointestinal (GI) surgery have a
high prevalence of malnutrition, ranging from 48% to
77% in the literature (1–4). Several factors predispose GI
ª 2020 The British Dietetic Association Ltd.
B. Johnston2 & B. Chapman2
Abstract
Background: Malnutrition is prevalent in patients undergoing gastrointesti-
nal (GI) surgery and has been linked to adverse outcomes. The present
study aimed to determine the association between early post-operative
nutritional status/risk, post-operative nutritional management and clinical
outcomes.
Methods: A prospective observational study was conducted in GI surgical
patients with a minimum 3-day post-operative length of stay (LOS). Data
on patient demographics, nutritional status/risk, post-operative nutritional
management and clinical outcomes were collected. Four markers of nutri-
tional status and risk were assessed: preoperative weight loss, nutrition risk,
malnutrition status and hand grip strength. Clinical outcomes included:
post-operative LOS, complication and readmissions rates. Multivariate linear
and logistic regression were used to test for associations with clinical out-
comes.
Results: One hundred and fifteen patients (55% female) with mean (SD)
age of 60.8 (16.2) years were included. Median (IQR) post-operative LOS
was 8.0 days (4.5–11.5), 37% of participants developed at least one compli-
cation post-operatively and 24% were readmitted within 30-days of dis-
charge. Mean number of nil-by mouth (NBM) days post-operatively was 0.7
(1.2) and the average time to commence feeding was 3.3 (2.2) days after
surgery. Poor nutritional status/risk between days 3–5 post-operatively
assessed through all four markers was associated with longer post-operative
LOS (all P < 0.05). No association was found between number of NBM
days, time to feeding and clinical outcomes.
Conclusion: Poor early post-operative nutritional status/risk is associated
with longer post-operative LOS in patients undergoing GI surgery, which
may facilitate simple identification of patients at high priority for nutritional
intervention. The present study highlights the heterogeneity in post-opera-
tive nutritional management practices.
surgical patients to malnutrition, including the underlying
disease, high incidence of cancer and the catabolic effect
of the surgical procedure itself (1–4). In addition, common
GI side effects such as nausea, vomiting, anorexia, GI
obstruction and malabsorption can further exacerbate
1
 Malnutrition associated with longer hospital stay
malnutrition (1–4). Traditional and outdated surgical prac-
tices including nil-by mouth (NBM) status after surgery,
and prolonged provision of fluid-only diets can also con-
tribute to inadequate intake in this group, when nutri-
tional status is already compromised (5–8).
Enhanced Recovery After Surgery (ERAS) is an evi-
dence-based protocol designed to promote early recovery
and reduce the stress response after GI surgery (5,8–10). A
key nutritional component of ERAS is the early com-
mencement of solid food emphasising the need to avoid
prolonged periods of fasting and fluid-only diets after GI
surgery (5,8–10). Although, ERAS is typically used in elec-
tive procedures, the nutritional components of ERAS can
be implemented independently of a formal hospital wide
ERAS protocol for benchmarking best practice nutritional
management practices after GI surgery in both elective
and non-elective patients. However, implementation of
the nutritional components of ERAS is inconsistent both
in Australia and internationally, and little is known
regarding current nutritional management practices and
their impact on patients’ clinical outcomes (7,11,12).
Although there are studies that suggest poor nutritional
status in the GI surgical population is associated with
adverse outcomes including increased rates of complica-
tions and longer hospital length of stay (LOS), the impact
of disease severity have not been accounted for in statisti-
cal analysis (1–4). Clinical outcomes have predominantly
been limited to LOS and surgical complications; post-dis-
charge outcomes such as readmission rate have not been
extensively studied despite the financial implications for
health services (1–4).
In addition, reduced muscle mass, an important phe-
notypic characteristic of malnutrition and its impact on
clinical outcomes is an emerging area of interest. Sarcope-
nia is defined as a syndrome characterised by progressive
loss of skeletal muscle mass and strength (13). A 2018
meta-analysis of 29 studies (n = 7176) demonstrated that
preoperative sarcopenia was associated with greater risk
of developing complications (13). Although there is well
established association between sarcopenia and incidence
of complications in patients undergoing GI surgery, diag-
nosis of sarcopenia in the literature is inconsistent and
primarily employs resource-intensive techniques such as
computerised tomography, magnetic resonance imaging
and dual-energy X-ray absorptiometry. Little is known of
the impact of reduced muscle function on clinical out-
come after surgery. Hand grip strength (HGS) is a simple
bedside tool that has gained recognition as a good mea-
sure of muscle function and contributes to the diagnosis
of sarcopenia (14–16). The use of HGS has also been rec-
ommended in the recently published Global Leadership
Initiative on Malnutrition (GLIM) consensus statement,
which acknowledges reduced muscle mass as phenotypic
2 ª 2020 The British Dietetic Association Ltd.
K. Narendra et al.
criterion of malnutrition and supports the use of HGS as
part of complete nutrition assessment (17). Understanding
factors associated with poor clinical outcomes will inform
targeted strategies to improve nutritional status, clinical
outcomes and overall quality of life in patients undergo-
ing GI surgery. The present study aimed to determine the
association between early post-operative nutritional sta-
tus/risk, post-operative nutritional management and clini-
cal outcomes.
Materials and methods
The present prospective observational study was under-
taken at a tertiary teaching hospital in Melbourne, Aus-
tralia. Patients admitted to the colorectal, hepatobiliary
and upper GI surgery units were screened daily by lead
investigators to identify eligible patients. The unit list
contained: admission date, reason for admission, type
and date of surgical procedure (if any). All patients who
had undergone colorectal, hepatobiliary and upper GI
surgery, and remained an inpatient for ≥3 days after sur-
gery over a 3-month period between end of April and
start of August 2018, were included. The 3-day inpatient
stay after surgery was a necessary inclusion criterion to
effectively assess post-operative nutritional progress.
Patients were excluded if they were discharged within
3 days of surgery, were from a non-English-speaking
background where an interpreter or family member were
unavailable to consent, declined participation, or were in
the intensive care unit at time of recruitment. Retrospec-
tive local data from January to March 2018 (inclusive)
indicated that 539 procedures were carried out over a 3-
month period in the three GI surgical units and, of those,
259 patients remained in hospital for ≥3 days with the
majority being discharged within the third post-operative
day. We aimed to achieve 75% inclusion rate and antici-
pated recruitment of 194 patients. All eligible patients
were approached on the ward and provided verbal con-
sent to participate. The study was approved by the
Human Research Ethics Committee at Austin Health and
Deakin University.
Demographic and surgical characteristics
Age, gender, surgical procedure, reason for surgery and
admission status were collected from medical records.
Nutrition priority were classified into two categories by
the researchers at recruitment; priority one and priority
two. Priority one patients were those undergoing more
extensive surgery and/or with a diagnosis that indicated
high nutrition risk and/or requirement for intensive
nutrition support post-operatively. Priority two patients
were those patients who underwent less complex surgery
 K. Narendra et al. Malnutrition associated with longer hospital stay

and would not typically require immediate post-operative (Table 1). SGA diagnosis was dichotomised into two cate-
dietetic involvement. gories for data analyses: well nourished (SGA- A) and
malnourished (SGA B and C).
HGS was measured using a hand grip dynamometer
Early post-operative nutritional status/risk
(Takei, Ltd., Niigata, Japan) in accordance with standard-
Four markers of nutritional status/risk: Preoperative ised positioning and the instructions prescribed by the
weight loss, nutrition risk using the validated Malnutri- American Society of Hand Therapists (20). Participants
tion Screening Tool (MST), malnutrition status using were seated or lying in bed with their arm in a comfort-
the validated Subjective Global Assessment (SGA) and able position and instructed to perform a maximal con-
muscle function via HGS measurement were collected at traction of the dynamometer using their non-dominant
either day 3, 4 or 5 post-operatively (Table 1) (18,19). hand. Three consecutive measurements were taken with
This range in data collection was chosen to account for 30 s rest in between, and the highest reading (kg) was
data collection falling over a weekend (non-data collec- recorded as the maximum HGS score (14). Verbal encour-
tion days) and is defined as baseline in the present agement and feedback were provided throughout. HGS
study and considered the early post-operative period. score was classified as impaired or not impaired, with
This reflects the earliest point in time where patients are impaired HGS defined as one or more SDs below the
typically referred, screened and assessed by dietitians mean from age, gender and side-specific normative data
post-operatively. (Table 1) (14).
Preoperative weight loss in the 6 months preceding
surgery was collected from the patient at baseline and
Post-operative nutritional management
dichotomised into two categories <5% loss and ≥5% loss.
Weight loss of ≥5% was considered a marker of poor The diet codes assigned to each patient, from the day of
nutritional status (Table 1) (17). MST was completed by surgery to the day of discharge, were collected from the
nursing staff within 24 h of admission and documented electronic meal ordering system. Using these data, num-
in the electronic medical record. Patients were classified ber of NBM days and time taken to commence solids or
as either ‘at nutrition risk’ (MST score ≥2) or ‘not at nutrition support [enteral (EN) or parenteral nutrition
nutrition risk’ (MST score <2) (Table 1). SGA and HGS (PN)] was determined. Time to commence solids, EN or
were performed by dietitians at baseline. SGA was per- PN was collectively defined as commencement of feeding.
formed according to Detsky et al. (19), and patients were Clear and free fluid diet codes were considered to provide
given a diagnosis of A (well nourished), B (mild–moder- minimal nutrition and not considered as feeding for the
ately malnourished) or C (severely malnourished) purpose of the present study. The occurrence of post-op-
erative dietetic assessment and intervention was collected
from medical records and the date of first dietitian assess-
ment was used to determine the number of days taken to
Table 1 Summary of nutrition risk/assessment markers
be seen by a dietitian post-operatively.
Nutrition risk/ Nutrition The percentage of energy and protein requirements
assessment tools: parameters: Classification: met post-operatively at baseline via oral (solids and flu-
Malnutrition • Recent Score ≥ 2 = At risk of ids via a 24 h recall as performed by a dietitian), EN or
Screening Tool weight change malnutrition PN (via fluid balance charts) was determined. Patients’
(MST): • Change in estimated daily energy and protein requirements were
appetite determined using the European Society for Clini-
Preoperative weight • Six-month ≥5% preoperative weight cal Nutrition and Metabolism (ESPEN) guideline for
loss weight history loss = Poor nutritional
clinical nutrition in surgery (21). Energy and protein
status
Subjective Global • Six-month SGA A = Well nourished
requirements at the lower end of the moderately hyper-
Assessment (SGA): weight history SGA B = Mild-moderate metabolic patient category range were used unless docu-
• Dietary malnutrition mented otherwise from a dietitian in the medical
intake SGC C = Severe records: 125–145 kJ (1 kcal = 4.186 kJ), and 1.2–1.5 g
• Physical malnutrition protein per body weight (kg). These data were used to
examination determine whether nutritional adequacy was achieved at
• Functional
baseline. For the purpose of the present study, adequate
impairment
Hand grip strength • Muscle ≥1 Standard deviation below
nutrition was defined as meeting ≥75% of both energy
(HGS): function z-score = impaired HGS and protein requirements either via oral intake, EN or
PN.

ª 2020 The British Dietetic Association Ltd. 3

 Malnutrition associated with longer hospital stay
Clinical outcomes
The primary clinical outcome was post-operative LOS.
Other clinical outcomes included complications and read-
mission rates. Complications were collected from medical
history as documented by the surgical team and included
ileus, leak, infection, abdominal collection, wound dehis-
cence and return to theatre. Post-operative LOS was cal-
culated from the date of surgery and date of discharge,
collected from medical records. At 30 days post-dis-
charge, patient’s medical records were reviewed, and any
unplanned readmission was recorded.
Statistical analysis
Data were analysed using SPSS, version 25 (IBM Corp.,
Armonk, NY, USA). P < 0.05 was considered statistically
significant. Categorical data were expressed as number
and percentage of participants. Normally distributed con-
tinuous data were expressed as the mean (SD); otherwise,
they were expressed as the median [interquartile range
(IQR)]. Multivariate linear regression was used to assess
associations with post-operative LOS and multivariate
logistic regression was used to assess associations with
complications and readmissions. Log transformation of
the variable LOS was performed because the data did not
meet the assumptions of a linear regression model; there-
fore, both raw and exponential beta-coefficients were
reported (22). All analyses in the present study were
adjusted for known confounders: age, cancer diagnosis
and nutrition priority (1–4).
Results
During the study period, 147 patients met the inclusion
criteria. Of these, 10 remained in the intensive care unit
at time of data collection and 22 had missing baseline
data; therefore, 115 patients were included in the final
analyses (Fig. 1). Baseline data were collected on day
three post-operative in majority of the patients (68%). A
smaller proportion of patients, 21% and 11%, had base-
line data collected on days 4 and 5, respectively. Of the
115 patients, 51 (44%) were admitted to the colorectal
unit with bowel resection the most common type of sur-
gical procedure (25%). The majority of procedures were
elective (64%), were considered priority two (76%) and
were not for a diagnosis of cancer (64%) (Table 2).
Early post-operative nutritional status/risk and post-
operative nutritional management
Nineteen percent of patients experienced ≥5% weight loss
in the 6 months preceding surgery, with 33% of patients
4 ª 2020 The British Dietetic Association Ltd.
K. Narendra et al.
identified at nutrition risk as per MST and 27% diag-
nosed as malnourished as per SGA (Table 3). Just under
half of the participants had impaired HGS (43%). Fifty-
four percent of patients received post-operative dietetic
assessment and intervention (Table 3). On average,
patients were kept NBM for less than 1 day [0.72
(1.2) days]; however, there was large variation in the
number of NBM days ranging from 0 to 7 days (Table 3).
The average time taken to commence feeding was 3.3
(2.2) days with two patients taking up to 9 days. The
majority of patients (83%) did not achieve adequate
nutrition at baseline (Table 3).
Clinical outcomes
The median post-operative LOS was 8.0 days (4.5–11.5)
and 37% (n = 43) of patients developed at least one com-
plication post-operatively. The most common complica-
tions recorded were infections (27%), followed by post-
operative ileus (13%), abdominal collection (7%), leak
(5%), wound dehiscence (2%) and return to theatre
(1%). Twenty-four percent (n = 28) of patients were
readmitted to hospital within 30 days after discharge.
Early post-operative nutritional status/risk, post-
operative nutritional management and associations with
clinical outcomes
All four markers of poor nutritional status/risk: ≥5% pre-
operative weight loss, at nutrition risk (as per MST), mal-
nutrition (as per SGA ranking B or C) and impaired
HGS were independently associated with longer post-op-
erative LOS (all P < 0.05) (Table 4). No association was
found between any of the four nutritional markers and
complication (Table 5) or readmission rates (Table 6).
Patients who had post-operative dietetic involvement
were two times more likely to experience longer post-op-
erative LOS (P < 0.001) (Table 4) and four times more
likely to have post-operative complications (Table 5). No
association was found between either the number of
NBM days post-operatively or the time to commence
feeding and clinical outcomes (Tables 4, 5 and 6).
Discussion
The present study demonstrates that poor early post-op-
erative nutritional status/risk, assessed by multiple mark-
ers, was independently associated with longer post-
operative LOS in GI surgical patients. This is one of few
studies to show that HGS, a simple, quick and a cost-ef-
fective tool, could be utilised within 3–5 days post-opera-
tively in GI surgical patients to identify patients more
likely to experience a longer LOS. Longer LOS has been
 K. Narendra et al.
Figure 1 Flow chart of the recruitment process.
associated with increased healthcare costs and reduced
quality of life in hospitalised patients, meaning that early
identification of patients at risk of longer LOS is vital for
ensuring appropriate nutritional interventions are imple-
mented that work towards improving patient outcomes
and reducing economic burden.
These findings are consistent with previous research
where poor nutritional status/risk in hospitalised patients
is associated with an increased LOS in both surgical and
non-surgical population groups (1,3,6,23–25). Although the
association between preoperative weight loss and longer
post-operative LOS agrees with existing studies in GI sur-
gical patients, studies have frequently utilised ≥10% pre-
operative weight loss as a marker of poor nutritional
status (26–29). The present study has highlighted that even
a modest 5% preoperative weight loss is associated with a
longer post-operative LOS. Current guidelines for nutri-
tional management of surgical patients recommend that
any patient identified with ≥10% weight loss in the pre-
ceding 6 months should be referred for 7–14 days
ª 2020 The British Dietetic Association Ltd.
Malnutrition associated with longer hospital stay
preoperative nutritional intervention and surgery delayed
if necessary (5). Our findings suggest that further investi-
gation into preoperative nutrition intervention in patients
with even modest preoperative weight loss is warranted
to determine potential benefit to patient outcomes.
The lack of association between any of the four mark-
ers of nutritional status/risk and post-operative complica-
tions may be related to the low prevalence of
malnutrition and nutrition risk within this study, which
may have reduced the ability to detect an association.
However, it should also be noted that the confidence
intervals for these outcomes are relatively wide. Only 27%
of the patients in the present study were malnourished
according to the SGA, which is less than rates of between
44% and 77% reported previously in studies in the GI
surgical population with cancer where an association with
post-operative complications has been found (3–6,30). Two
prospective trials, NURIMAS pancreas and liver, pub-
lished in 2017 and 2019, respectively, also showed no sig-
nificant association between nutritional risk assessed by
5
 Malnutrition associated with longer hospital stay K. Narendra et al.

Table 2 Participant demographic and surgical characteristics Table 3 Early post-operative nutritional status/risk and post-operative
(n = 115) nutritional management (n = 115)

Characteristic Value Markers of nutritional status/risk Value

Age (years), mean (SD) 60.8 (16.2) Preoperative weight loss, n (%)
Gender, n (%) <5% weight loss 93 (81)
Male 52 (45) 5–10% weight loss 9 (8)
Female 63 (55) ≥10% weight loss 13 (11)
Weight (kg)* 75.3 (17.1) MST classification, n (%)
BMI classification (BMI kg m–2), n (%) Not at nutrition risk (score ≥2) 72 (63)
Underweight (<18.5 kg m–2) 3 (3) At nutrition risk (score < 2) 38 (33)
Healthy weight (18.5–25.0 kg m–2) 44 (38) Missing 5 (4)
Overweight (25.0–30.0 kg m–2) 45 (39) SGA ranking, n (%)
Obese (>30.0 kg m–2) 21 (18) Well nourished (SGA – A) 84 (73)
Missing 2 (2) Mild-moderately malnourished (SGA – B) 24 (21)
Surgical unit, n (%) Severely malnourished (SGA – C) 7 (6)
Colorectal 51 (44) HGS (kg), median (IQR), n = 103
Hepatobiliary 42 (37) Male, median (IQR) 32.6 (25.2–40.1)
Upper GI 22 (19) Female, median (IQR) 16.2 (11.5–20.9)
Surgical procedure, n (%) HGS classification, n (%)
Bowel resection 29 (25) Not impaired 54 (47)
Hernia repair 17 (15) Impaired 49 (43)
Sub/total colectomy 14 (13) issing 12 (10)
Hepatic resection 8 (7)
Division of adhesion 7 (6) Post-operative nutritional management Value
Gastrectomy 5 (4)
Pancreatectomy 5 (4) Post-operative dietetic assessment and intervention, n (%)
Other 30 (26) Yes 62 (54)
Nutrition priority, n (%) No 53 (46)
Priority one 28 (24) Time taken to commence feeding, mean (SD) 3.3 (2.2)
Priority two 87 (76) Number of NBM days, n (%)
Admission status, n (%) 0–1 96 (83)
Elective 74 (64) 2–3 15 (13)
Emergency 41 (36) 4–5 3 (3)
Surgery for cancer, n (%) 6–7 1 (1)
No 74 (64) Nutritional adequacy, n (%)
Yes 41 (36) Yes 20 (17)
No 95 (83)
Abbreviations: BMI, body mass index; Nutrition priority: priority one
patients were those undergoing more extensive and complex surgery Abbreviations: HGS, hand grip strength; IQR, interquartile range;
and/or with a diagnosis that indicated high nutrition risk and, or MST, Malnutrition Screening Tool; NBM, nil-by mouth; SGA, Subjec-
requirement for intensive nutrition support post-operatively; priority tive Global Assessment.
two patients were those patients who underwent less complex sur- Preoperative weight loss refers to any unintentional weight loss in the
gery and would not typically require immediate post-operative dietetic six months preceding surgery. Impaired HGS was defined as HGS
involvement. score that is 1 or more SD below the normative mean. Time taken to
*Two missing values (n = 113) commence solids, enteral or parenteral was collectively defined as
time taken to commence feeding. Nutritional adequacy is defined as
achieving ≥ 75% estimated energy and protein requirements.
multiple different markers including SGA and post-opera-
tive complications. In both NURIMAS studies, the rate of
complications (22%) and the malnutrition prevalence remaining on fluid-only diet for several days. There was
measured via SGA (2.2%–18.3%) were much smaller than also considerable variation in the period of time patients
those previously reported in the literature.(31,32) spent NBM, ranging from 0–7 days, as well as the time to
The average time that patients were kept NBM was less commence feeding. This indicates that key ERAS compo-
than 1 day and the average time taken to commence nents, which recommend avoiding prolonged periods of
feeding (via solids, EN or PN) was 3 days. This indicates post-operative fasting and provision of fluids only diets
(5,8,21,33)
that, despite patients not being kept fasted for significant , are not being consistently applied in this setting.
periods, there were delays in progressing to solids or In the present study, a clear fluid or free fluid diet is
commencing nutrition support (EN or PN), with patients grossly inadequate for nutrition requirements, providing

6 ª 2020 The British Dietetic Association Ltd.

 K. Narendra et al. Malnutrition associated with longer hospital stay

Table 4 Association between early post-operative nutritional status/risk, post-operative nutritional management and post-operative LOS

Adjusted b-coefficient Adjusted exponent b 95% CI Exp b 95% CI P value

Markers of nutritional status/risk

Preoperative weight loss
<5% loss Reference 0.014
≥5% loss 0.35 1.42 0.07, 0.63 1.08, 1.88
MST classification*
Not at nutrition risk Reference <0.001
At nutrition risk 0.40 1.49 0.18, 0.62 1.20, 1.85
SGA ranking
Well nourished (SGA A) Reference <0.001
Malnourished (SGA- B or C) 0.54 1.71 0.30, 0.77 1.35, 2.15
HGS classification†
Not impaired Reference 0.006
Impaired 0.31 1.36 0.34, 0.18 0.71, 1.19
Post-operative nutritional management
Post-operative dietetic assessment and intervention
No Reference
Yes 0.64 1.90 0.46, 0.82 1.59, 2.28 <0.001
Number of NBM days 0.05 1.05 0.04, 0.14 0.96, 1.15 0.276
Time to commence feeding (days) 0.02 1.02 0.04, 0.07 0.97, 1.07 0.500

Abbreviations: CI, confidence intervals; HGS, Hand Grip Strength; LOS, length of stay; MST, Malnutrition Screening Tool; NBM, nil-by mouth;
SGA, Subjective Global Assessment.
Model adjusted for age, cancer diagnosis, nutrition priority. Preoperative weight loss refers to any unintentional weight loss in the six months pre-
ceding surgery. Impaired HGS was defined as HGS score that is 1 or more SD below the normative mean. Time taken to commence solids, enteral
or parenteral was collectively defined as time taken to commence feeding. Numbers in bold indicate statistically significant results.
*Five missing values (n = 110).
†
Twelve missing values (n = 103).

only 1100 kJ (4 g protein) and 3000 kJ (24 g protein),
respectively. Additional oral nutrition supplements pre-
scribed by a dietitian may bridge this gap; however, this
relies on patients being referred for specific nutrition
intervention and places this group at risk of accumulation
of considerable calorie and protein deficit.
Although there remains inconsistent implementation of
the nutritional component of ERAS, in comparison with
previous studies conducted in Australia, an earlier initia-
tion of post-operative feeding recommendations was
observed in the present study. This may explain the lack
of association between the number of NBM days and
time to commence feeding with LOS and post-operative
complications in the present study compared to the pre-
vious literature. In a retrospective study of 95 patients in
Australia, GI surgical patients who experienced a longer
LOS and those who developed complications were fasted
for an average of 2.1 days post-operatively and took
7 days to commence feeding, which is substantially longer
than the present study (3). Similarly, in another retrospec-
tive study of 69 subjects in Australia, GI surgical patients
who developed prolonged post-operative ileus as a com-
plication remained either NBM or on clear fluids for up
to 6.6 days post-operatively (6). Despite the commence-
ment of solids or alternative nutrition support within an
average of 3 days post-operatively in the present study,
nutritional adequacy was not achieved in the vast major-
ity of patients (83%) at baseline. The inadequate nutri-
tional intake in this patient group is consistent with
reports from previous studies suggesting that this remains
an area requiring improvement and that further explo-
ration of the barriers to achieving optimal nutrition in
these patients is necessary (3,34,35).
Just over half the participants had post-operative diete-
tic involvement, despite the majority of patients being
categorised as lower priority (priority two) for nutrition
intervention at admission. This suggests that surgical pro-
cedures historically considered as having a lower nutri-
tional risk may actually require dietetic input post-
operatively and that a large number of patients are being
referred post-operatively from nursing or medical staff
compared to those screened by dietitians at baseline as
requiring immediate dietetic input. Post-operative dietetic
involvement was associated with longer post-operative
LOS and complications. This was not an unexpected find-
ing because it emphasises that the most malnourished
and complicated patients are requiring the highest level
of dietetic input.
No association was found between early post-operative
nutritional status/risk or post-operative nutritional

ª 2020 The British Dietetic Association Ltd. 7

 Malnutrition associated with longer hospital stay K. Narendra et al.

Table 5 Association between early post-operative nutritional status/ risk, post-operative nutritional management and complications

Logistic regression

No complications With complications Adjusted OR 95% CI P value

Markers of nutritional status/risk

Preoperative weight loss, n (%)
<5% loss 58 (62) 35 (38) Reference 1.000*
≥5% loss 14 (64) 8 (36) 1.11 0.41, 3.02
MST classification, n (%)†
Not at nutrition risk 49 (68) 23 (32) Reference 0.078
At nutrition risk 20 (52) 18 (48) 2.13 0.92, 4.95
SGA ranking, n (%)
Well nourished (SGA = A) 55 (59) 29 (41) Reference –
Malnourished (SGA = B or C) 17 (55) 14 (45) 1.82 0.76, 4.39 0.180
HGS classification, n (%)‡
Not impaired 40 (72) 15 (28) Reference 0.190
Impaired 28 (58) 20 (42) 1.76 0.75, 4.13
Post-operative nutritional management
Post-operative dietetic assessment & intervention, n (%)
No 41 (77) 12 (23) Reference 1.61, 8.70 0.002
Yes 31 (50) 31 (50) 3.75
Number of NBM days, mean (SD) 0.6 (1.0) 1.0 (1.4) 1.16 0.84, 1.60 0.372
Time to commence feeding (days), mean (SD) 3.0 (2.0) 3.5 (2.0) 1.06 0.88, 1.27 0.544

Abbreviations: CI, confidence interval; HGS, hand grip strength; MST, Malnutrition Screening Tool; NBM, nil-by mouth; OR, odds ratio; SGA, Sub-
jective Global Assessment.
Model adjusted for age, cancer diagnosis, nutrition priority. Preoperative weight loss refers to any unintentional weight loss in the six months pre-
ceding surgery. Impaired HGS was defined as HGS score that is 1 or more SD below the normative mean. Time taken to commence solids, enteral
or parenteral was collectively defined as time taken to commence feeding. Numbers in bold indicate statistically significant results.
*Fisher’s exact test for preoperative weight loss. Binary logistic regression for all other variables.
†
Five missing values (n = 110).
‡
Twelve missing values (n = 103).

management and 30-day readmission rate in the present
study. Few studies have explored the relationship between
nutritional status/risk and readmissions in surgical
patients, and those that have report inconsistent findings.
Two studies conducted in general surgical patients
reported no significant association between poor nutri-
tional status and readmissions, with the results reported
by Kassin et al. (36) and Chima et al. (37) indicating that
post-operative complications were largely contributing to
readmissions. The lack of association in the present study
could be related to a combination of low readmission
rates, fewer complications and few cases of malnutrition
overall, which may have reduced the ability to detect an
association. In a similar retrospective study, malnourished
GI surgical patients had significantly higher rates of
unplanned readmissions compared to their well-nour-
ished counterparts; however, this was no longer statisti-
cally significant when adjusted for age and cancer stage
(38)
. Factors associated with readmission appear to be
multifactorial and remain poorly understood in the litera-
ture. The impact of inadequate nutritional intake and
nutritional status at discharge on readmission rates has
not been well studied and remains as an area for further
research.
There are several limitations to the present study. The
modest sample size may have contributed to a reduced
strength and ability to detect associations with certain
outcome variables. Given that this was an observational
study aiming to investigate trends and associations of
usual practice, no power calculations were conducted.
HGS measurements were taken between 3 and 5 days
post-operatively and do not consider the potential impact
of anaesthesia, pain and the presence of cannula post-op-
eratively. Therefore, the prevalence of impaired HGS may
be over represented. Clinical judgement needs to be exer-
cised when deciding upon its use following surgery. In
addition, it was beyond the scope of the present study to
control for all potential confounders, such as involvement
from other allied health disciplines, co-existing comor-
bidities and adherence to additional elements of the ERAS
protocol, which may have impacted on the patients’ clini-
cal outcomes.
The outcomes from the present study could support
health professionals with respect to identifying GI surgical

8 ª 2020 The British Dietetic Association Ltd.

 K. Narendra et al. Malnutrition associated with longer hospital stay

Table 6 Association between early post-operative nutritional status/risk, post-operative nutritional management and readmissions

Logistic regression

No readmissions Readmissions Adjusted OR 95% CI P value

Markers of nutritional status/risk

Preoperative weight loss, n (%)
<5% loss 73 20 Reference 0.89, 7.46 0.170*
≥5% loss 14 8 2.57
MST classification, n (%)†
Not at nutrition risk 54 18 Reference 0.33, 2.24 1.000*
At nutrition risk 29 9 1.37
SGA ranking, n (%)
Well nourished (SGA = A) 66 18 Reference 0.79, 5.38 0.145
Malnourished (SGA = B or C) 21 10 2.05
HGS Classification, n (%)‡
Not impaired 44 11 Reference 0.65, 4.53 0.277
Impaired 34 14 1.71
Post-operative nutritional management
Post-operative dietetic assessment and intervention, n (%)
No 43 10 Reference
Yes 44 18 1.71 0.69, 4.22 0.247
Number of NBM days, mean (SD) 0.69 (1.18) 0.82 (1.31) 1.03 0.73, 1.46 0.871
Time to commence feeding (days), mean (SD) 3.44 (2.11) 2.86 (2.34) 0.89 0.72, 1.10 0.279

Abbreviations: CI, confidence interval; HGS, hand grip strength; MST, Malnutrition Screening Tool; NBM, nil-by mouth; OR, odds ratio; SGA, Sub-
jective Global Assessment.
Model adjusted for age, cancer diagnosis, nutrition priority. Preoperative weight loss refers to any unintentional weight loss in the six months pre-
ceding surgery. Impaired HGS was defined as HGS score that is 1 or more SD below the normative mean. Time taken to commence solids, enteral
or parenteral was collectively defined as time taken to commence feeding.
Numbers in bold indicate statistically significant results.
*Fisher’s exact test for preoperative weight loss. Binary logistic regression for all other variables.
†
Five missing values (n = 110).
‡
Twelve missing values (n = 103).

patients at high risk of longer post-operative LOS using a
number of different nutrition assessment and risk tech-
niques. The early identification of patients at higher risk
of prolonged LOS may facilitate effective nutrition inter-
vention and improve clinical outcomes. We observed that
inconsistent post-operative nutritional management prac-
tices continue to occur; however, in the present study
post-operative feeding practices were more closely aligned
with ERAS recommendations compared to previous stud-
ies. Future studies could consider assessing nutritional
status at the time of admission to better measure changes
to nutritional status across post-operative LOS, as well as
explore the type and timing of the pre- and post-opera-
tive dietetic interventions required to attenuate nutri-
tional decline and improve clinical outcomes.
Transparency declaration
The lead author affirms that this manuscript is an honest,
accurate and transparent account of the study being reported.
The reporting of this work is compliant with STROBE guide-
lines. The lead author affirms that no important aspects of
the study have been omitted and that any discrepancies from
the study as planned have been explained.
Acknowledgments
We thank Gavin Abbott from the Institute for Physical
Activity and Nutrition, Deakin University, for his input
regarding the statistical analysis, as well as all of the surgi-
cal dietitians from Austin Health for their assistance and
involvement with the data collection.
Conflict of interest, source of funding and
authorship
The authors declare that they have no conflicts of interest.
No funding declared.
KN carried out the data collection, data analysis and drafted the
manuscript. NK and CM assisted with study design, data analysis
and drafting of the manuscript. BJ and BC conceived the study,
and were involved with data collection, data analysis and drafting
of the manuscript. All authors critically reviewed the manuscript
and approved the final version for submitted for publication.

ª 2020 The British Dietetic Association Ltd. 9

 Malnutrition associated with longer hospital stay
REFERENCES
1. Loan BTH, Nakahara S, Tho BA et al. (2018) Nutritional
status and postoperative outcomes in patients with
gastrointestinal cancer in Vietnam: a retrospective cohort
study. Nutrition 48, 117–121.
2. Young LS, Huong PTT, Lam NT et al. (2016) Nutritional
status and feeding practices in gastrointestinal surgery
patients at Bach Mai Hospital, Hanoi, Vietnam. Asia Pac J
Clin Nutr 25, 513–520.
3. Garth AK, Newsome CM, Simmance N et al. (2010)
Nutritional status, nutrition practices and post-operative
complications in patients with gastrointestinal cancer. J
Hum Nutr Diet 23, 393–401.
4. Sungurtekin H, Sungurtekin U, Balci C et al. (2004) The
influence of nutritional status on complications after
major intraabdominal surgery. J Am Coll Nutr 23, 227–
232.
5. Weimann A, Braga M, Carli F et al. (2017) ESPEN
guideline: Clinical nutrition in surgery. Clin Nutr 36, 623–
650.
6. Rees J, Bobridge K, Cash C et al. (2018) Delayed
postoperative diet is associated with a greater incidence of
prolonged postoperative ileus and longer stay in hospital
for patients undergoing gastrointestinal surgery. Nutr Diet
75, 24–29.
7. Barker Lisa A & Crowe TC (2015) Nutritional
management of gastrointestinal surgical patients in
Victoria’s public hospitals. Nutr Diet 72, 240–246.
8. Varadhan KK, Neal KR, Dejong CHC et al. (2010) The
enhanced recovery after surgery (ERAS) pathway for
patients undergoing major elective open colorectal surgery:
a meta-analysis of randomized controlled trials. Clin Nutr
29, 434–440.
9. Wischmeyer PE, Carli F, Evans DC et al. (2018) American
Society for enhanced recovery and perioperative quality
initiative joint consensus statement on nutrition screening
and therapy within a surgical enhanced recovery pathway.
Anesth Analg 127, e95.
10. Gustafsson UO, Scott MJ, Schwenk W et al. (2013)
Guidelines for perioperative care in elective colonic
surgery: enhanced recovery after surgery (ERAS) society
recommendations. World J Surg 37, 259–284.
11. Lyon A, Solomon MJ & Harrison JD (2014) A qualitative
study assessing the barriers to implementation of enhanced
recovery after surgery. World J Surg 38, 1374–1380.
12. Wykes K, Taylor K & Wilkinson SA (2013) An
investigation into the perioperative nutritional
management of open colorectal surgery patients in major
Australian hospitals: a comparison with the ERAS
guidelines. Nutr Diet 70, 175–180.
13. Simonsen C, De Heer P, Bjerre ED et al. (2018)
Sarcopenia and postoperative complication risk in
gastrointestinal surgical oncology: a meta-analysis. Ann
Surg 268, 58–69.
10
K. Narendra et al.
14. Sousa-Santos AR & Amaral TF (2017) Differences in
handgrip strength protocols to identify sarcopenia and
frailty - a systematic review. BMC Geriatr 17, 238.
15. Flood A, Chung A, Parker H et al. (2014) The use of hand
grip strength as a predictor of nutrition status in hospital
patients. Clin Nutr 33, 106–114.
16. Norman K, Stob€aus N, Gonzalez MC et al. (2011) Hand
grip strength: outcome predictor and marker of nutritional
status. Clin Nutr 30, 135–142.
17. Cederholm T, Jensen GL, Correia M et al. (2018) GLIM
criteria for the diagnosis of malnutrition - a consensus
report from the global clinical nutrition community. Clin
Nutr 38, 1–9.
18. Ferguson M, Capra S & Bauer J (1999) Development of a
valid and reliable malnutrition screening tool for adult
acute hospital patients. Nutrition 15, 458–464.
19. Baker JP, Detsky AS, Wesson DE et al. (1982) Nutritional
assessment. N Engl J Med 306, 969–972.
20. Joy M, Gary S & Kristin V (2015) American Society of
Hand Therapists. 3rd ed. Mount Laurel, NJ: American
Society of Hand Therapists.
21. Weimann A, Braga M, Harsanyi L et al. ESPEN guidelines
on enteral nutrition: surgery including organ
transplantation. Clin Nutr 25, 224–244.
22. Feng C, Wang H, Lu N et al. (2014) Log-transformation
and its implications for data analysis. Shanghai Arch
Psychiatry 26, 105–109.
23. Leandro-Merhi VA, De Aquino JL & Sales Chagas JF
(2011) Nutrition status and risk factors associated with
length of hospital stay for surgical patients. J Parenter
Enteral Nutr 35, 241–248.
24. Barker LA, Gout BS & Crowe TC (2011) Hospital
malnutrition: prevalence, identification and impact on
patients and the healthcare system. Int J Environ Health
Res 8, 514–527.
25. Shaw-Stiffel TA, Zarny LA, Pleban WE et al. (1993) Effect
of nutrition status and other factors on length of hospital
stay after major gastrointestinal surgery. Nutrition 9, 140–
145.
26. Bozzetti F, Gianotti L, Braga M et al. (2007) Postoperative
complications in gastrointestinal cancer patients: the joint
role of the nutritional status and the nutritional support.
Clin Nutr 26, 698–709.
27. Pronio A, Di Filippo A, Aguzzi D et al. (2008) Treatment
of mild malnutrition and reduction of morbidity in major
abdominal surgery: randomized trial on 153 patients. Clin
Ter 159, 13–18.
28. Yamamoto T, Shimoyama T, Umegae S et al. (2019)
Impact of preoperative nutritional status on the incidence
rate of surgical complications in patients with
inflammatory bowel disease with vs without preoperative
biologic therapy: a case-control study. Clin Transl
Gastroenterol 10, e00050.
29. da Silva Leide, Nunes F, Calado Ferreira Pinheiro Gadelha
P et al. (2014) Nutritional status and its impact on time
ª 2020 The British Dietetic Association Ltd.
 K. Narendra et al.
and relocation in postoperative complications of
abdominal patients undergoing surgery. Nutr Hosp 30,
629–635.
30. Susan JW, Pui CC, Lilian T et al. (2016) Hand grip
strength as a potential nutritional assessment tool in long-
term care homes. J Aging Res 1, 1–11.
31. Probst P, Haller S, Bruckner T et al. (2017) Prospective
trial to evaluate the prognostic value of different
nutritional assessment scores in pancreatic surgery
(NURIMAS Pancreas). Br J Surg 104, 1053–1062.
32. Probst P, Fuchs J, Schoen MR et al. (2019) Prospective
study to evaluate the prognostic value of different
nutritional assessment scores in liver surgery. NURIMAS
Liver (DRKS00006340). Hepatobiliary Surg Nutr.
33. Dorcaratto D, Grande L & Pera M (2013) Enhanced
recovery in gastrointestinal surgery: upper gastrointestinal
surgery. Dig Surg 30, 70–78.
ª 2020 The British Dietetic Association Ltd.
Malnutrition associated with longer hospital stay
34. Byrnes A, Worrall J, Young A et al. (2018) Early post-
operative diet upgrade in older patients may improve
energy and protein intake but patients still eat poorly: an
observational pilot study. J Hum Nutr Diet 31, 818–824.
35. Kondrup J, Johansen N, Plum LM et al. (2002) Incidence
of nutritional risk and causes of inadequate nutritional
care in hospitals. Clin Nutr 21, 461–468
36. Kassin MT, Owen RM, Perez SD et al. (2012) Risk factors
for 30-day hospital readmission among general surgery
patients. J Am Coll Surg 215, 322–330.
37. Chima CS, Barco K, Dewitt MLA et al. Relationship of
nutritional status to length of stay, hospital costs, and
discharge status of patients hospitalized in the medicine
service. J Am Diet Assoc. 97, 975–978.
38. Mosquera C, Koutlas NJ, Edwards KC et al. (2016) Impact
of malnutrition on gastrointestinal surgical patients. J Surg
Res 205, 95–101.
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 Graphical Abstract
The contents of this page will be used as part of the graphical abstract
of html only. It will not be published as part of main.

The present study aimed to determine the association between early post-operative nutritional status/risk, post-operative nutri-
tional management and clinical outcomes. Four markers of nutritional status/risk were utilised. Poor early post-operative nutri-
tional status/risk assessed through all four markers predicted longer post-operative length of stay in patients undergoing
gastrointestinal surgery, facilitating simple identification of patients at high priority for nutritional intervention.