Abstract

The Self-Global Assessment (SGA) is a clinical nutrition assessment method widely used to assess the nutritional status of adults for clinical and research purposes. This tool facilitates the identification of clinically significant malnutrition and enables the monitoring of nutritional changes. Its practicality and comprehensive approach make it valuable for nutritional screening of a diverse patient population. This study aimed to validate the SGA criteria in identifying malnutrition and examine its association with illness, social factors, and length of hospital stay. The research focused on exploring how nutritional status relates to these variables and their impact on patient outcomes. This study was conducted from October 2023 to March 2024 in Makkah and included a random sample of 75 hospitalized patients. The cohort consisted of 40 men (53.3%) and 35 women (46.6%), with a mean age of 57.9 ± 12.9 years, and an age range of 18–75 years. Data collection included structured interviews using standardized SGA questionnaires, complemented by comprehensive physical and clinical examinations to determine the patients' nutritional status. Results revealed that morbidity was significantly affected by subcutaneous fat loss, muscle wasting, weight loss, and poor food intake (P < 0.05). Nutritional status, as assessed by SGA, showed significant associations with these clinical factors and related socioeconomic variables. Among the participants, 55 patients (73.3%) were classified as well-nourished, while 18 (24%) and 2 (2.7%) were classified as moderately and severely malnourished, respectively. Of note, the length of hospital stay was significantly longer in malnourished patients than in their well-nourished counterparts (P < 0.05). Malnutrition was found to be prevalent among hospitalized patients, with clear associations with sociodemographic variables, increased morbidity, and length of hospital stay. Early detection and timely nutritional interventions are critical to mitigate these negative effects. The Scale of Malnutrition (SGA) has proven to be a reliable, sensitive, and specific tool for early detection and assessment of malnutrition in various patient populations, confirming its suitability for routine use in clinical settings.

1. Introduction

Malnutrition is a pervasive global health issue that affects both community-dwelling individuals and hospitalized patients. Among those with acute or chronic illnesses, malnutrition exerts a detrimental effect on clinical outcomes by impairing physical function, delaying recovery, increasing susceptibility to infections, and prolonging hospital stays ¹. The term "malnutrition" encompasses all forms of nutritional imbalance, including both undernutrition and overnutrition, which lead to measurable negative consequences on body composition, physiological function, and overall clinical outcomes ². Malnutrition may arise from various contributing factors. Inadequate dietary intake remains a primary cause; however, increased metabolic demands associated with disease states, complications from underlying medical conditions—such as malabsorption syndromes—and excessive nutrient loss further exacerbate the risk. Frequently, a combination of these elements interacts to precipitate and sustain a state of malnutrition, underlining the importance of early detection and intervention.Studies have shown that patients who receive appropriate nutritional support have shorter hospital stays and fewer hospital-acquired infections and complications ³. Regular nutritional screening during hospitalization will provide early awareness, diagnosis, and effective treatment. A nutritional assessment tool should be cost-effective, reliable, easy to apply, reproducible, and have high sensitivity and specificity rates for diagnosing malnutrition. Early detection of malnutrition and provision of appropriate treatment will improve quality of life ⁴. Nutritional screening and the provision of appropriate nutrition are fundamental patient rights in any healthcare setting. Nutrition has been recognized as the second most significant predictor of long-term prognosis, underscoring its vital role in patient recovery and overall health outcomes ⁵. Failure to identify and diagnose malnutrition can result in the oversight of essential nutritional support during illness, thereby exacerbating morbidity and complicating treatment. Studies have shown that proactive nutritional interventions significantly improve patient outcomes while simultaneously reducing treatment-related costs, particularly among individuals with severe malnutrition ⁶. Accurate assessment of nutritional status is critical to formulating effective medical nutrition therapy. Numerous assessment tools and scoring methods are available to identify patients at risk of malnutrition ⁷. Among these, the Subjective Global Assessment (SGA) stands out as a reliable and validated screening tool. It utilizes a combination of seven key medical history elements and clinical findings to evaluate a patient’s nutritional status comprehensively ⁸. The SGA’s simplicity and practicality make it highly versatile, allowing it to be administered not only by healthcare professionals, including paramedical staff, but also as a self-assessment tool for patients ⁹. Its ease of use ensures widespread applicability in various clinical settings, promoting early detection and timely intervention for malnutrition.Importantly, because malnutrition is linked to diminished quality of life, the SGA’s utility extends beyond curative treatments to include palliative care settings. Patients are categorized as well-nourished, moderately nourished, or severely malnourished based on their clinical findings and medical history ¹⁰. The SGA tool has been validated in various clinical contexts, including among 75 patients, confirming its safety, affordability, reliability, and ease of use ^{11, 12}. Its robust clinical validity supports its widespread application in hospital environments, especially for early identification of malnutrition and the development of targeted nutritional interventions.

2. Materials and Methods

This study was conducted to evaluate the level of medical care on patient satisfaction with medical and nutritional health services in the Makkah Al-Mukarramah region in the Kingdom of Saudi Arabia. Ethical approval for this study was obtained from the Medical Research Ethics Committee in Makkah Al-Mukarramah, the Kingdom of Saudi Arabia. Informed consent was obtained from each participant before filling out the questionnaire for the purpose of the study, ensuring that all research data were treated anonymously and that they were volunteers to accept or refuse participation. The following was clarified:

•Disclosure of details of the nature and protocols of the study.

•The potential risks and benefits associated with it were clearly explained.

•Confirmation of voluntary participation in the research.

•Confirmation of free will to withdraw from the study at any time.

•Ensuring confidence in the result.

A comprehensive list of wards at Al-Noor Hospital in Makkah Al-Mukarramah was obtained in accordance with the study’s inclusion criteria. The eligible wards were classified into two primary categories: medical and surgical. Each category was further divided into specialized sub-wards to ensure comprehensive representation of patient populations.

The surgical category comprised the following four sub-wards:

1. Gastroenterology

2. Urology

3. Thoracic Surgery

4. Neurosurgery

The medical category included the following four sub-wards:

1. Cardiology and Neurology

2. Infectious Diseases

3. Hematology

4. Hematology and Nephrology

The study sample size was allocated proportionally to these departments to reflect patient distribution accurately. Participant recruitment continued until the predetermined sample size was achieved, ensuring balanced representation across all selected wards.

This study included Saudi and non-Saudi patients, aged 18 years and above, between October 2023 and March 2024, who gave their consent to participate in the survey among a random sample (75 patients) at Al Noor Specialist Hospital in Makkah Al Mukarramah. All participants met the following inclusion criteria:

1) Of either sex (male or female).

2) Age 18 years or above.

3) Hospitalized.

4) Not receiving enteral or parenteral nutrition.

The study was conducted on a total of 75 patients who met the inclusion criteria. All participants underwent a comprehensive evaluation comprising three key components: medical history, physical examination, and anthropometric measurements.

1. Medical History:

2. Physical Examination:

3. Anthropometric Measurements:

Hospital nutritional assessment is a comprehensive approach designed to determine a patient’s nutritional status through various methods. It serves as a crucial predictor of the length of hospital stay and is among the most widely used techniques for evaluating nutritional health. Accurate assessment enables timely interventions that improve patient outcomes and reduce healthcare costs. One of the most effective and practical tools for this purpose is the Subjective Global Assessment (SGA). The SGA evaluates nutritional status based on two primary components:

•Medical history: Including weight changes, dietary intake, gastrointestinal symptoms, and functional capacity.

•Physical examination: Focused on identifying muscle wasting, subcutaneous fat loss, edema, and ascites.

The SGA classifies nutritional status into three main categories:

•SGA A: Well-nourished

•SGA B: Mild to moderate malnutrition

•SGA C: Severe malnutrition

The questionnaire and SGA were conducted by a dietitian through a face-to-face interview. The questionnaire study was conducted during the patients' stay in the hospital under study. In the SGA assessment, the patient's nutritional assessment score is obtained by summing the data obtained from each question box. SGA-A indicates that the patient is well-nourished or active. SGA-B means suspected malnutrition while SGA-C is used to express severe malnutrition. According to the final score. Table 1 shows the most important symptoms on the basis of which patients are divided into the three categories.

Data analysis was conducted using the Statistical Package for the Social Sciences (SPSS) software. The analysis included descriptive statistics to summarize the distribution of study variables. Categorical (nominal) variables were compared using the Chi-square (χ²) test,allowing for the evaluation of associations between qualitative data. For continuous (quantitative) variables, comparisons were performed using the independent t-test to assess differences between groups. A 95% confidence interval (CI) was applied to estimate the precision of the results, with statistical significance determined at a P-value < 0.05. This threshold was used to ensure robust and reliable interpretation of the data while minimizing the likelihood of Type I errors.

3. Results

The study included 40 men and 35 women (53.3% and 46.6%, respectively). The mean age the participants were 57.9 ± 12.9 years and the age range was 18–75 years. The majority were from rural areas (57.3%) (n = 43) patients were admitted to the internal medicine ward (72%) (n = 54) and only 28% (n = 21) to the intensive care unit, about 25.3% of the Post graduate. 44% .the participants were Employed workers, about 48% were non-manual workers and about 8% were students. As shown in Table 2.

The study findings demonstrated that 73.3% (n=55) of the 75 patients assessed were well-nourished, whereas 24% (n=18) were categorized as moderately malnourished or suspected of malnutrition, and 2.7% (n=2) were identified as severely malnourished according to the Subjective Global Assessment (SGA). This distribution underscores the prevalence of malnutrition within the patient population and the need for early nutritional assessments. Table 3. Illustrate the relationship between nutritional status and the length of hospital stay among adult patients. Nutritional status was compared using two groups: SGA A (well-nourished) versus SGA B+C (moderately and severely malnourished). The data indicated that patients hospitalized for 1–20 days were approximately twice as likely to be malnourished compared to those with shorter stays of 1–10 days (P < 0.05). This trend was more pronounced with extended hospitalizations, where patients admitted for 1–30 days had nearly a four-fold increase in malnutrition risk compared to those hospitalized for 1–10 days (P < 0.05). These findings highlight a clear association between prolonged hospitalization and an increased likelihood of malnutrition. Extended stays often correlate with more severe medical conditions, delayed recovery, or increased metabolic demands, all of which can contribute to nutritional deterioration. Therefore, implementing early nutritional interventions for patients expected to stay longer may play a vital role in improving clinical outcomes and reducing hospital-related complications.

The results of the SGA application showed that the percentage of males suffering from malnutrition or at risk of malnutrition was higher than females, and the percentage of married people suffering from malnutrition was higher than the percentage of unmarried people. The high rate of malnutrition was observed among patients admitted to the internal medicine department, and although admission to the intensive care unit increases the risk of complications, it was lower than the rate of internal medicine patients. Also, living in rural areas rather than in urban areas had a greater share and the presence of chronic diseases. There was no significant relationship in chronic diseases, age and residence. But there was a significant relationship in the rest of the variables (P < 0.05). As shown in Table 4.

Table 5 showed that the incidence rate of some diseases appeared at high rates, the most important of which was in the surgery ward (50.7%), and on the contrary, the lowest rate was in the accident and appendix department (4%). Also, the diseases that led to hospitalization, such as diabetes, were 13.0%, and gallstone diseases were the highest rate (14.7%), and the rest were less prevalent. The length of stay differed according to the rate of the disease.

In this Table 6 showed the nutritional variables were compared, showing the highest percentage of the sample, approximately (74.7%) did not have any significant change in body weight according to SGA rating (A) , as for the food intake changes, about(72%) of the sample did not show any significant change with rate of SGA (A), and about (24%) of the sample show a food intake reduction as (B) rating and (4%) of them showed starvation and disability to eat with SGA rating (C). Also show about (66.7%) had mild subcutaneous fat loss with the rate of SGA (B) and (14.7%) of sample had sever (C) and about (18.7%) of sample did not show any subcutaneous fat loss and (61.3%) also had mild Muscle wasting. these variables were statistically significant among the variables (P < 0.05).

4. Discussion

This study aimed to investigate the relationship between socioeconomic factors and the prevalence of malnutrition among patients aged 18 to 75 years residing in Mecca. The findings revealed that 26.7% of participants experienced malnutrition or were at risk of developing it, highlighting the significant influence of socioeconomic conditions on nutritional status. The nalysis demonstrated that several social determinants, particularly rural residency and advanced age, played a pivotal role in elevating the risk of malnutrition. Most participants hailed from rural regions and belonged to the elderly demographic, emphasizing the vulnerability of these groups. Notably, the prevalence rate identified in this research aligns with existing literature. For instance, a Spanish study utilizing the Subjective Global Assessment (SGA) tool reported a malnutrition prevalence of 46% ¹³. This comparison underscores the global relevance of socioeconomic influences on nutrition. Further supporting this connection, another investigation documented the progression of malnutrition during hospital stays. Patients assessed later during hospitalization exhibited a higher likelihood of developing moderate to severe malnutrition compared to those evaluated shortly after admission ¹⁴. This finding underscores the importance of early nutritional screening upon hospital entry to mitigate deterioration. Age emerged as a critical factor in this study. Participants aged 60 years and older showed a pronounced tendency towards malnutrition, often accompanied by increased complication risks. Gender differences were also significant, with male patients exhibiting a higher propensity for malnutrition-related complications. These findings mirror previous research that identified older men, particularly those aged 60 and above, as a high-risk group for nutritional decline ¹⁵. Another notable investigation evaluated the nutritional status of female patients admitted to orthopedic departments and compared them to age-matched women from the general population. Despite focusing on females, the study concluded that malnutrition was notably more prevalent among males, positioning male gender as an independent and significant risk factor ¹⁶. Other demographic factors such as age, gender ^{17, 18}, marital status, educational attainment ¹⁹, and household income ²⁰ have consistently been linked to variations in nutritional health.The underlying causes of malnutrition discovered in this research often stem from inadequate nutrient intake, predominantly driven by challenging socioeconomic conditions. Limited financial resources restrict access to sufficient energy, proteins, and other essential nutrients, creating a cycle of nutritional inadequacy. This scenario is exacerbated by disease-related malnutrition, where patients experience diminished appetite, absorption issues, digestion disorders, and health deterioration, often complicated further by the side effects of medical treatments ²¹. This study utilized the Subjective Global Assessment (SGA) to determine the nutritional status and prevalence of malnutrition among patients. The SGA, recognized for its simplicity and clinical relevance, serves as an effective screening tool that evaluates both objective and subjective criteria. These criteria encompass a wide range of clinical symptoms associated with malnutrition, ultimately facilitating the classification of malnutrition into various levels of severity. In a multi-center investigation involving patients from 47 hospitals, the prevalence of malnutrition was reported at 44.9% ²². Consistent with these findings, Fernandez et al. documented a malnutrition rate of 62.1% among hospitalized individuals ²³. Similarly, Kontorek et al. conducted a survey of 815 inpatients and identified a malnutrition prevalence of 44.6% ²⁴. Contrasting these results, Olivares et al. reported a comparatively lower rate of 19.5% in their patient cohort ²⁵. Raslan et al. explored the predictive capacity of the SGA in determining malnutrition-related clinical outcomes and found that 38.9% of patients were classified under moderate or severe malnutrition categories (SGA B or C) ²⁶. Within the context of the present study, the malnutrition rate was established at 26.7%, aligning with a substantial portion of the previous literature.While both objective and subjective criteria offer valuable insights into patients’ nutritional status, reliance on a single set of indicators may introduce limitations. Therefore, it is strongly recommended to integrate both assessment modalities to ensure a comprehensive evaluation ²⁷. In this study, 73.3% of participants were categorized as well-nourished, while 24% were deemed moderately malnourished or at risk, and 2.7% were identified as severely malnourished according to the SGA classification system. Further analysis revealed that 74.7% of the sample reported no significant changes in body weight or dietary intake. However, 24% experienced a noticeable decline in food consumption, and 4% exhibited severe hunger and an inability to eat. Subcutaneous fat loss was evident in 66.7% of patients, with 14.7% experiencing severe depletion, whereas 18.7% maintained normal fat reserves. Muscle wasting was notably prevalent, affecting 61.3% of the cohort.

Comparative data from other regions highlight both consistencies and discrepancies with these findings. A study conducted in Riyadh, Saudi Arabia, revealed that 19.4% of elderly participants were malnourished ²⁸. Such variations may be attributed to differences in sample selection methods and demographic distributions. The association between advancing age and increased malnutrition risk was corroborated in the current study. This trend is further supported by evidence indicating that older adults (aged >60 years) typically exhibit diminished muscle mass coupled with elevated fat accumulation, predisposing them to heightened nutritional vulnerability ²⁹. These findings align with research conducted in Jeddah, which demonstrated a heightened prevalence of malnutrition among older adults due to age-related sensory changes. Diminished senses of smell, sight, and taste often contribute to reduced appetite and lower food intake ³⁰. Additionally, gastrointestinal alterations common with aging can impair nutrient absorption and digestion, exacerbating malnutrition risks. Hospital stay duration emerged as a significant factor in malnutrition prevalence. Patients hospitalized for 1–20 days were approximately twice as likely to be malnourished as those admitted for 1–10 days, while stays extending to 1–30 days quadrupled the malnutrition risk. This observation aligns with prior studies indicating that patients at risk of malnutrition tend to have prolonged hospitalizations, with malnourished patients averaging 40% longer stays. Notably, individuals with severe malnutrition experienced hospital stays that were five times longer compared to well-nourished counterparts ³¹. A substantial body of literature has sought to elucidate the connection between malnutrition and hospital length of stay. Chronic conditions and severe illnesses often precipitate appetite loss, while the physiological stress of inflammation and catabolic processes intensifies nutritional decline ³². These factors collectively contribute to extended hospitalizations, which, in turn, escalate healthcare costs for medical institutions ³³. Longer hospital stays not only strain hospital resources but also elevate the risk of nosocomial infections, impede patient flow, and delay access to optimal care. Furthermore, patients enduring prolonged admissions frequently require heightened nursing care due to increased infection rates, higher complication risks, and diminished functional capacity ³⁴. Beyond financial and logistical implications, malnutrition during hospitalization significantly contributes to elevated morbidity and mortality rates ³⁵. In the context of this study, prolonged hospital stays were directly correlated with malnutrition as classified by the SGA, reinforcing the crucial link between nutritional status and patient outcomes. These findings underscore the imperative of early nutritional assessments and interventions to mitigate malnutrition’s far-reaching consequences.

5. Conclusion

Malnutrition has widespread effects on physiological functions. It is associated with high morbidity and mortality rates in hospitalized patients and significantly increases healthcare costs. A simple screening tool could identify patients at risk, allowing appropriate treatment to be initiated; this could significantly improve clinical outcomes and reduce healthcare expenditures. The results of this study indicate the need for further efforts to improve the nutritional conditions of hospitalized patients. Furthermore, it is crucial to identify effective methods for preventing and treating malnutrition in hospitals to shorten length of stay, improve patient quality of life, and enhance treatment effectiveness.

ACKNOWLEDGMENTS

This study was supported by the Medical Research Ethics Committee in Makkah, Saudi Arabia. Informed consent was obtained from each participant before completing the study questionnaire.

Conflict of Interest

The author declares no conflict of interest. He is responsible for data collection, analysis, interpretation, manuscript writing, and the decision to publish the results.

References