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European Journal of Applied Sciences – Vol. 11, No. 5
Publication Date: October 25, 2023
DOI:10.14738/aivp.115.15698
Ousmane, F., Goïta, Y., Koné, A., Mariko, M., Traore, B., Dramé, S. I., Doumbia, N., Fomba, M., Bissan, A. T., Dabo, A., Diallo, M.,
Bamba, O., Koné, A., Karambiry, M. Koné, H., Kouriba, B., & Traoré, A. (2023). Clinico-Biological Aspects of Undernutrition in
Diabetic Patients Hospitalized in The Medical Department of The Mali Hospital. European Journal of Applied Sciences, Vol - 11(5).
431-442.
Services for Science and Education – United Kingdom
Clinico-Biological Aspects of Undernutrition in Diabetic Patients
Hospitalized in The Medical Department of The Mali Hospital
Faridatou Ousmane
Faculty of Pharmacy, University of Sciences, Techniques and Technologies
of Bamako, Mali
Yaya Goïta
Faculty of Pharmacy, University of Sciences, Techniques and Technologies
of Bamako, Mali, and medical biology and anatomopathology laboratory
department Diagnosis of Covid-19, University Hospital Center Mali
Hospital, Bamako, Mali
Amadou Koné
Department of Medicine, and Endocrinology, University Hospital Center
Mali Hospital, Bamako, Mali and National Center for Scientific and
Technological Research (CNRST) and Faculty of Medicine and Dentiste,
University of Sciences, Techniques and Technologies of Bamako, Mali
Modibo Mariko
Department of Medicine, and Endocrinology, University Hospital Center
Mali Hospital, Bamako, Mali and Faculty of Medicine and Dentiste,
University of Sciences, Techniques and Technologies of Bamako, Mali
Bah Traore
Department of Medicine, and Endocrinology, University Hospital Center
Mali Hospital, Bamako, Mali
Sidiki Ibrahim Dramé
Medical biology and anatomopathology laboratory department Diagnosis
of Covid-19, University Hospital Center Mali Hospital, Bamako, Mali and
Faculty of Medicine and Dentiste, University of Sciences, Techniques and
Technologies of Bamako, Mali
Nanko Doumbia
Department of Medicine, and Endocrinology, University Hospital Center
Mali Hospital, Bamako, Mali and National Center for Scientific and
Technological Research (CNRST)
Minkoro Fomba
National Center for Scientific and Technological Research (CNRST)
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European Journal of Applied Sciences (EJAS) Vol. 11, Issue 5, October-2023
Aboubacar Tiétié Bissan
Faculty of Pharmacy, University of Sciences, Techniques and Technologies
of Bamako, Mali
Abdoulaye Dabo
Medical biology and anatomopathology laboratory department Diagnosis
of Covid-19, University Hospital Center Mali Hospital, Bamako, Mali
Mamadou Diallo
Medical biology and anatomopathology laboratory department Diagnosis
of Covid-19, University Hospital Center Mali Hospital, Bamako, Mali
Oussamatou Bamba
Medical biology and anatomopathology laboratory department Diagnosis
of Covid-19, University Hospital Center Mali Hospital, Bamako, Mali
Adama Koné
Medical biology and anatomopathology laboratory department Diagnosis
of Covid-19, University Hospital Center Mali Hospital, Bamako, Mali
Moussa Karambiry
Medical biology and anatomopathology laboratory department Diagnosis
of Covid-19, University Hospital Center Mali Hospital, Bamako, Mali
Halidou Koné
Medical biology and anatomopathology laboratory department Diagnosis
of Covid-19, University Hospital Center Mali Hospital, Bamako, Mali
Bourèma Kouriba
Faculty of Pharmacy, University of Sciences, Techniques and Technologies
of Bamako, Mali
Assa Traoré
Faculty of Medicine and Dentiste, University of Sciences, Techniques and
Technologies of Bamako, Mali
ABSTRACT
Introduction: Undernutrition is a frequent and often unrecognized pathology in the
hospital environment. Its consequences are significant both medically and
financially, as it increases hospital length of stay, morbidity and mortality. The aim
of this study was to assess the clinical and biological aspects of undernutrition in
diabetic patients hospitalized in the medical department of the Mali Hospital.
Methodology: A survey was carried out on 65 diabetic patients admitted to hospital
between April 5, 2022 and November 4, 2022. The diagnosis of undernutrition was
based on the 2021 Haute Autorité de Santé (HAS) diagnostic criteria, and the
severity of undernutrition was assessed using the International Obesity Tast Force
(IOTF) curves in children (<18 years) and albumin measurement in adult diabetic
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Ousmane, F., Goïta, Y., Koné, A., Mariko, M., Traore, B., Dramé, S. I., Doumbia, N., Fomba, M., Bissan, A. T., Dabo, A., Diallo, M., Bamba, O., Koné,
A., Karambiry, M. Koné, H., Kouriba, B., & Traoré, A. (2023). Clinico-Biological Aspects of Undernutrition in Diabetic Patients Hospitalized in The
Medical Department of The Mali Hospital. European Journal of Applied Sciences, Vol - 11(5). 431-442.
URL: http://dx.doi.org/10.14738/aivp.115.15698
patients (18 years and over). The survey method consisted in collecting information
on the clinical and biological aspects of undernourished diabetic patients. Results:
This Study showed that the age of our patients ranged from 7 to 82 years, with an
average age of 50.96 ± 22.44 years. Females predominated over males, with 52%
and 48% respectively. Type 2 diabetes predominated, with a frequency of 75%
versus 25% for type 1 diabetes. The mean albumin level was 26.81 ± 5.53 g/l, with
moderate to severe undernutrition at 33.96% and 64.15% respectively. Severe
undernutrition was 83%, compared with 17% of moderate undernutrition in
diabetic children, according to International Obesity Tast Force (IOTF) curves. The
mean BMI was 19.57 ± 4.39 kg/m2. From this study, we could conclude that the
decrease in albumin levels was correlated with the high frequency of
undernutrition in diabetic patients. It would be interesting to assess the nutritional
status of diabetic patients on admission, in order to avoid the morbidity and
mortality associated with undernutrition.
Keywords: undernutrition, diabetes, serum albumin, Mali.
INTRODUCTION
Undernutrition is a pathological condition resulting from insufficient protein-energy intake to
cover the body's metabolic needs (1). In hospitalized patients, it affects almost one in two
patients on admission, and its management remains inadequate despite recent progress (2). Its
prevalence is between 30% and 50% among patients admitted to hospital (2). A NHANES study
reports a higher prevalence of over 20% of undernutrition in diabetics, or over 30% risk of
undernutrition (3), leading to muscular weakening, altered general condition, delayed wound
healing, reduced immunological performance and diminished capacity to adapt and resist
aggression (4). In diabetics, this phenomenon is of particular concern, as it can lead to a
worsening of the complications associated with the disease. Indeed, diabetes is a metabolic
disorder characterized by chronic hyperglycemia resulting from a defect in insulin secretion
and/or action (5). Glycemic imbalance has been shown to lead to protein undernutrition. This
is partly explained by a reduction in insulin availability and/or action, due to insulin resistance
in skeletal muscle (6). This undernutrition associated with diabetes is thought to have a major
impact on bone metabolism, muscle function and immune function (7). If not treated early, the
affected person will be drawn into a downward spiral that could lead to death (7). For many
years, undernutrition was regarded as an ancillary medical problem. Indeed, for most nursing
staff, a hospitalized patient was only admitted for his or her main pathology; all other
treatments were only minor. As a result, undernutrition was all too often relegated to the
background (8). As a result, many emerging countries are ignoring this major public health
problem (9,10). In Western countries, the considerable additional costs associated with
undernutrition (11) should lead healthcare professionals in emerging countries to take this
problem seriously.
In Mali, no study has been reported on the prevalence of undernutrition in diabetic subjects.
This led us to conduct this study, the aim of which was to evaluate the clinico-biological aspects
of undernutrition in diabetic patients hospitalized in the medical department of the Mali
hospital.
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MATERIALS AND METHODS
Ethical aspects: the study was conducted in accordance with the ethical standards set out in the
Declaration of Helsinki (1983). Inclusion in the study was carried out in accordance with the
rules of the legislation in force at the hospital in Mali, and with strict respect for the
confidentiality of patients' identities and the results of their analysis.
Type of Study and Participants
This was a prospective, analytical study carried out in the Medicine and Medical Biology and
Anatomopathology Laboratory departments of Mali Hospital. The study included 65 diabetic
patients hospitalized in the Medicine Department of Mali Hospital from April to November
2022. Eligible patients were selected according to the following inclusion criteria:
Undernourished diabetic patients hospitalized in the Mali Hospital Medicine Department,
regardless of type of diabetes, sex or age.
Sample Collection and Parameters Studied
A survey form specially designed for this study enabled us to collect information on the
sociodemographic, clinical and biological aspects of undernutrition in diabetic patients. The
form comprises a series of questionnaires completed by undernourished diabetic patients. We
recorded age, sex and clinical aspects of undernutrition, namely anorexia, apathy, physical
asthenia, weight loss and body mass index (BMI).
Albumin levels (35-54 g/L) were measured in patients aged 18 and over to determine the
degree of undernutrition. Creatinine levels (male: 70-115 μmol, female: 44-80 μmol/L) and
creatinine clearance (80-120 ml/min) calculated by the CKD-EPI formula were determined to
assess renal function. HbA1c (3.5-6%) was measured to assess glycemic control. And finally, C- reactive protein (0 - 6 mg/L) was measured to determine whether there was an inverse
correlation between albumin and CRP.
Blood samples were taken from hospitalized patients who had been in a young state from 8 a.m.
to 12 noon. Blood samples collected in heparin tubes for albumin, creatinine, blood glucose and
CRP analysis were centrifuged at +4°C for 10 minutes at 3500 rpm/min. The EDTA tube
specimen was used for blood count and HbA1c analysis.
International Obesity Tast Force (IOTF) curves in diabetic children (<18 yrs) were used to
determine undernourished cases and the degree of undernutrition in them. The diagnosis of
undernutrition was based on the 2021 Haute Autorité de Santé (HAS) diagnostic criteria.
Analytical Procedure
The Mindray BS-480 analyzer was used for albumin determination. The colorimetric method,
also known as the Bromocresol Green (BCG) dye method, was used for albumin determination.
BCG added to plasma produces a bluish-green color that absorbs light at a wavelength of 605
nm. The amount of light absorbed is proportional to the concentration of albumin in the plasma.
The Pentra C400 analyzer was used to measure blood glucose, creatinine and C-reactive
protein. The glucose oxidase enzymatic method was used to measure blood glucose levels.
Glucose oxidase catalyzes the transformation of glucose into gluconic acid and hydrogen
peroxide (H202). The colorimetric indicator is quinoneimine, which is generated from 4-
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Ousmane, F., Goïta, Y., Koné, A., Mariko, M., Traore, B., Dramé, S. I., Doumbia, N., Fomba, M., Bissan, A. T., Dabo, A., Diallo, M., Bamba, O., Koné,
A., Karambiry, M. Koné, H., Kouriba, B., & Traoré, A. (2023). Clinico-Biological Aspects of Undernutrition in Diabetic Patients Hospitalized in The
Medical Department of The Mali Hospital. European Journal of Applied Sciences, Vol - 11(5). 431-442.
URL: http://dx.doi.org/10.14738/aivp.115.15698
aminoantipyrine (4-AAP) and sodium P-hydroxybenzoic acid by hydrogen peroxide under the
catalytic action of peroxidase (Trinder reaction). The intensity of the coloration measured on a
spectrophotometer is proportional to the glucose concentration.
Creatinine levels were measured using the colorimetric Trinder enzymatic method. The
enzymes creatinase and sarcosidase hydrolyze endogenous creatine, which is converted to
peroxide and then eliminated by catalase. Catalase is inhibited by sodium azide, and
creatininase and 4-Amino-antipyrine (4-AA) are added. Thus, only creatine generated from
creatininase is sequentially hydrolyzed by creatinase and sarcosine oxidase to produce
hydrogen peroxide. This hydrogen peroxide is measured by coupling with a peroxide- catalyzing reaction, which forms a colored complex with N-ethyl-n-sulphopropyl-mtoluidine
(TOPS)/4-AA.
The immunoturbidimetric method was used to measure CRP. It involves measuring the amount
of specific protein in a biological sample by detecting the variation in turbidity caused by the
reaction between the specific antibody and the target antigen. In the case of CRP, the analyzer
uses a reagent containing anti-CRP antibodies and latex particles. When the CRP-containing
sample is added to the reagent, the antibodies bind to the CRP, forming aggregates which
increase the turbidity of the solution. The amount of CRP is then measured as a function of the
change in turbidity.
The Mindray H50P analyzer was used to measure glycated hemoglobin A1 (HbA1c). High- performance liquid chromatography (HPLC) was the principle of the assay method. HPLC uses
a chromatography column to separate the different haemoglobin fractions present in the
sample, including HbA1c.Once the different fractions have been separated, HbA1c is detected
and quantified using a specific detector. The amount of HbA1c present in the sample is
expressed as a percentage of total hemoglobin.
Univariate Statistical Analysis
The chi2 statistical test and the Fisher's exact test according to numbers were used to compare
categorical variables. The Anova test was used to compare means. Differences were considered
significant if the probability (p) was p ≤ 0.05.
RESULTS
In this study, 52% of cases were predominantly female, compared with 48% male. The sex ratio
was 0.91. Denutrated diabetic patients admitted to the medical ward were divided into age
groups according to the HAS 2021 diagnostic criteria. Patients aged between 18 and 69
accounted for 60% of cases, followed by those aged 70 and over (21.54%). The under-18 age
group accounted for 18.48%. The mean age of included patients was 50.96 ± 22.44 years, with
a minimum of 7 years and a maximum of 82 years. For a total of 65 patients, type 2 diabetes
accounted for 75% (n=49) versus 25% (n=16) of type 1 diabetes. With regard to the etiologies
of undernutrition in diabetic patients, infection ranked highest, with a rate of 87.69%. Among
diabetic complications, foot wounds accounted for 55.38% of causes of undernutrition.
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Table I: Distribution of undernourished diabetic patients according to clinical signs of
undernutrition
Clinical signs Workforce(N=65) Frequency
Emaciation 59/65 90,77%
Physical Asthenia 52/65 80%
Anorexia 49/65 75,38%
Apathy 35/65 53,85%
The clinical signs of undernutrition were weight loss in 90.77% of cases, followed by physical
asthenia (80%), anorexia (75.38%) and apathy (53.85%).
Table II: Distribution of malnourished diabetic patients by body mass index (BMI)
BMI Number of staff (Average ± standard deviation) Frequency
Underweight 27 (15.59 ± 2.25 kg/m2
) 42,62%
Normal 25 (21.16 ± 1.86 kg/m2
) 37,25%
Overweight 10 (26.32 ± 1.38 kg/m2
) 15,1%
Not determined 3 4,53%
Total 65 100%
The mean BMI was 19.57 ± 4.39 kg/m2, with extremes of 10.81 kg/m2 and 28.51 kg/m2. Most
of the undernourished diabetic patients in this study were underweight (42.62%), with a mean
of 15.59 ± 2.25 kg/m2. Overweight was estimated at 15.1%, with a mean of 26.32 ± 1.38 kg/m2.
BMI was not determined in 4.53% of stroke patients, due to a lack of materials for weight
measurement in bedridden patients. Assessment of the severity of undernutrition using the
International Obesity Tast Force (IOTF) curves in children (<18 years) showed that most
undernourished diabetic children were severely undernourished (83%), compared with 17%
with moderate undernutrition.
Figure 1: Distribution of undernourished diabetic children according to severity of
undernutrition using the International Obesity Tast Force (IOTF) curves for children.
0
2
4
6
8
10
12
14
N=12
<17IOTF <18,5IOTF
Severe
undernutrition
N=10 (83%)
Moderate
undernutrition
N=2 (17%)
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Ousmane, F., Goïta, Y., Koné, A., Mariko, M., Traore, B., Dramé, S. I., Doumbia, N., Fomba, M., Bissan, A. T., Dabo, A., Diallo, M., Bamba, O., Koné,
A., Karambiry, M. Koné, H., Kouriba, B., & Traoré, A. (2023). Clinico-Biological Aspects of Undernutrition in Diabetic Patients Hospitalized in The
Medical Department of The Mali Hospital. European Journal of Applied Sciences, Vol - 11(5). 431-442.
URL: http://dx.doi.org/10.14738/aivp.115.15698
A reduction in food intake ≥ 50% for more than a week compared with usual food intake was
observed in 83% of our patients. Patients who maintained usual food intake accounted for 17%.
Figure 2: Distribution of malnourished diabetic patients according to food bolus reduction.
Table III: Biological characteristics of undernutrition in diabetic patients.
Parameters Averages ± Standard deviations
[Minimum-Maximum]
Reference values
Albuminemia (g/l) 26.81 ± 5.53
[11.50-38.10]
35.20-52.30 g/L
CRP (mg/l) 68.68 ± 65.30
[0,01-218]
< 6 mg/L
Creatinine (μmol/l) 66.12 ± 46.01
[9,72-326,9]
-Male: 71-115μmol/L
-Female: 53-106μmol/L
Clearance (ml/min) 133.12 ± 76.04
[14-524,79]
80-120 ml/min
Blood glucose (g/l) 2.96 ± 1.58
[0.30-7.6]
< 1.26 g/L
HbA1c (%) 10.22 ± 3.62
[3,2-16,95]
3,5-6%
Haemoglobin level (g/dl) 9.10 ± 2.42 g/dL
[3,50-13]
12-16 g/dL
For the biological characteristics of undernutrition in diabetics, we obtained: a mean albumin
level of 26.81 ± 5.53 g/L. The mean CRP was 68.68 ± 65.30 mg/L. The mean creatinine level
was 66.12 ± 46.01 μmol/L, with a mean clearance of 133.12 ± 76.04 ml/min. Carbohydrate
homeostasis was unbalanced, with a mean HbA1c level of 10.22 ± 3.62% and a mean blood
glucose level of 2.96 ± 1.58. Mean hemoglobin was 9.10 ± 2.42 g/dL.
NO
(N=11)
17%
YES
(N=54)
83%
N=65
NO YES
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Ousmane, F., Goïta, Y., Koné, A., Mariko, M., Traore, B., Dramé, S. I., Doumbia, N., Fomba, M., Bissan, A. T., Dabo, A., Diallo, M., Bamba, O., Koné,
A., Karambiry, M. Koné, H., Kouriba, B., & Traoré, A. (2023). Clinico-Biological Aspects of Undernutrition in Diabetic Patients Hospitalized in The
Medical Department of The Mali Hospital. European Journal of Applied Sciences, Vol - 11(5). 431-442.
URL: http://dx.doi.org/10.14738/aivp.115.15698
Table VII: Relationship between CRP levels and foot wounds.
There was a statistically significant association between CRP levels and foot wounds.
DISCUSSION
We conducted a prospective, cross-sectional study in the Department of Medicine in
collaboration with the biomedical and anatomopathology laboratory of Mali Hospital. The
study concerned diabetic patients of all types, sex and age, and focused on undernutrition. A
total of 65 diabetic patients were recruited, representing a hospital frequency of 39.39%.
Females represented 52% of our sample, with a sex ratio of 0.91. The presence of more risk
factors for undernutrition in the female sex could explain this female predominance. This
female predominance was also obtained by Mahjoub et al, (12) and Omri et al, (13) with 53%
and 56% respectively. The fact that the average age of women is higher than that of men, at
53.29 ± 25.64 years and 48.41 ± 23.70 years respectively, could partly explain why women are
more likely than men to suffer from protein-energy undernutrition. Disturbances in the
regulation of protein metabolism, a poor metabolic response to diet, are linked to a lack of
qualitative and quantitative protein intake in the elderly, and to insulin resistance in peripheral
tissues (14). The balance between protein synthesis and degradation processes determines the
evolution of protein mass, which in turn depends on lean body mass (15).
Our study reported an average age of 50.96 ± 22.44 years. According to the literature, advanced
age accompanied by from a significant increase in the frequency of undernutrition, particularly
protein-energy undernutrition due to reduced dietary intake, caused by physiological changes
and increased needs during pathologies (more frequent in this aging terrain) insufficiently
compensated by intakes (16) could explain this average age of fifty years. This result differs
from that of Omri et al. who found an average age of 71.09 ± 5.19 years (13). This difference in
mean age may be explained by the fact that their study was based on the evaluation of
undernutrition in elderly diabetic subjects (65 years and over), whereas ours included all
diabetic patients, regardless of age and type of diabetes.
The nosological type of diabetes found was type 2 in 75% of cases, followed by type 1 in 25%.
This could be explained by the fact that, according to the IDF, type 2 diabetes remains and
continues to be frequent, manifesting itself most often with ageing and also increasingly in
younger adults in view of their sedentary lifestyle. A preference for sugary foods, overweight
(17), lifestyle changes and the westernization of our cultures have been cited in several
publications as factors in the onset of metabolic and cardiovascular diseases (18,19).
In our series of determinations of biological parameters, carbohydrate homeostasis was
unbalanced in 63.28% of our patients, with a mean HbA1c level of 10.22 ± 3.62%. This result is
Diabetic foot
CRP rate No Yes Total
0-10 mg/l 10(34,48%) 4(11,11%) 14(21,54%)
11-49 mg/l 12(41,38%) 6(16,67%) 18(27,69%)
50-327 mg/l 7(24,14%) 26(72,22%) 33(50,77%)
Total 29(100%) 36(100%) 65(100%)
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comparable with those of Omri et al, (13) and Mizouri et al, (20) who found mean glycated
haemoglobin A1 levels of 10.25 ± 1.8% and 10.2% respectively. This glycaemic imbalance could
be explained by the presence of hypercatabolism, during which pro-inflammatory cytokines
stimulate the secretion of TSH, glucagon and cortisol, thereby reducing insulin secretion (21).
Also, in these malnourished subjects, the onset of an inflammatory syndrome could lead to
stress-related hyperglycaemia (22).
The mean body mass index was 19.57 ± 4.39 kg/m2 in the population studied. This normal
average BMI in no way excludes an underlying state of undernutrition. This is also probably
why undernutrition in a subject with a normal BMI is easily overlooked, even in the context of
a chronic disease such as diabetes (23). Changes in body composition are the most striking
evidence of this paradox, since the reduction in muscle mass and the increase in fat mass are
not always accompanied by a marked reduction in body weight, hence the difficulty in defining
this protein-energy loss in obese, overweight or normal-weight subjects (23). In spite of this
paradox, we found in the diabetic patients included a combination of exogenous and
endogenous undernutrition by reduction of the food bolus (83%) due to anorexia (75.38%) and
by hypercatabolism due to infections (87.69%) could explain this decrease in albumin levels
with 26.81 ± 5.53 g/l in the study population. In fact, the body responds to any severe
aggression with a hypercatabolism syndrome resulting in an over production of
proinflammatory cytokines which stimulate the cells defending against the aggression and
modify the metabolism to supply these cells with nutrients which, in the absence of sufficient
food intake, are drawn from the body's nutritional reserves. This is associated with a change in
hepatic synthesis of proteins in the acute phase of inflammation, which are necessary for the
defence and healing processes (24).
We reported no significant difference between CRP and albumin (P=0.2731). The mean CRP
obtained in this study was 68.68 ± 65.30 mg/l. This result is not comparable with that of Veyrie
et al (25), who found mean albumin and CRP levels of 24 ± 3 g/l and 108 ± 86 mg/l respectively.
This increase in CRP could be linked to the high frequency of infections found in 87.69% of our
patients, with a statistically significant difference P = 0.0001. Compared with the study by
Veyrie et al (25), which only included diabetic patients with a foot sore, our study included
diabetic patients with or without a foot sore, with a statistically significant difference of P =
0.0006 between CRP and diabetic foot. This inflammation correlated with an increase in CRP
and a decrease in albumin in patients with a foot wound has been reported in the literature
(26), explaining a change in CRP concentration according to the type of wound grade in
diabetics.
CONCLUSION
The diabetic population is at increased risk of undernutrition because of the impact of this
disease on metabolism and glycaemia regulation. We observed a significant association
between clinical and biological nutritional parameters, in particular albumin, and the
occurrence of an inflammatory syndrome. Our study showed that the frequency of hospital
undernutrition is high in diabetic subjects. Overall, this study highlights the importance of
regularly assessing the nutritional status of hospitalized diabetic patients, given the
complications that undernutrition can cause.
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followed in the day hospital. Nutr Clin Metabolism. 2016 Sep 1;30(3):226.
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Clin Metabolism. 2005 Sep 1;19(3):138–42.
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1;43(2):67-71.
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2023 Aug 9]. pp. 1075-90. Available from: https://doi.org/10.1007/978-2-287-33475-7_79
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