Prevalence of malnutrition Prevalence of malnutrition in the hospitalin the hospital

Implications of malnutrition and how to Implications of malnutrition and how to manage the problemmanage the problem

Objectives of the presentationObjectives of the presentation

To define malnutritionTo define malnutritionTo present the problem of malnutrition in the To present the problem of malnutrition in the hospitalhospitalTo present the consequences of malnutrition in To present the consequences of malnutrition in patient care and impact of nutrition carepatient care and impact of nutrition careTo present the nutrition support processTo present the nutrition support process

What is malnutrition?What is malnutrition?Deficiency or excess in nutrition reserves of the Deficiency or excess in nutrition reserves of the body which would affect:body which would affect:

Body compositionBody compositionFunctions of daily livingFunctions of daily living

Nutrition components affected are:Nutrition components affected are:Macronutrients (Protein, fat, carbohydrates)Macronutrients (Protein, fat, carbohydrates)Micronutrients (Electrolytes, vitamins, trace elements)Micronutrients (Electrolytes, vitamins, trace elements)

Manifestations:Manifestations:UndernutritionUndernutritionOvernutritionOvernutrition

Year Author Location Prevalence

1974 Bistrian US 50%1977 Hill England 44%

1979 Weinsier US 48%1984 Agradi Italy 34%1993 Larsson Sweden 27%1994 McWhirter Scotland 40%1995 Fernando Philippines 48%

1997 Waitzberg Brazil 47%

Malnutrition exists in every hospital: Malnutrition exists in every hospital: internationalinternational

Malnutrition exists in every hospital: Malnutrition exists in every hospital: local (Philippines)local (Philippines)

HospitalHospital BMI < 18.5BMI < 18.5 BMI > 30BMI > 30 SGA SGA ““CC””

Marikina, RizalMarikina, Rizal 38%38% 15%15% --

LipaLipa City, City, BatangasBatangas 48%48% --

Quezon CityQuezon City 22%22% 20%20% --

ManilaManila -- -- 42%42%

• Amang Rodriguez Medical Center (n = 61)

• Mary Mediatrix Medical Center (n = 2,345)

• St. Luke’s Medical Center (n = 41,676)

• Philippine General Hospital (n = 151)

Malnutrition exists in every hospital: Malnutrition exists in every hospital: one center one center –– all unitsall units

69% Adequate Nutritional State

21% ModeratelyMalnourished

10% Severely Malnourished

Detsky AS et al. JPEN J Parenter Enteral Nutr 1987; 440-446.

Types of malnutrition in hospitalized Types of malnutrition in hospitalized patientspatients

Is it easy to perform a prevalence of Is it easy to perform a prevalence of malnutrition study?malnutrition study?

How the first prevalence of How the first prevalence of malnutrition was done (St. Lukemalnutrition was done (St. Luke’’s)s)Project involved 25 peopleProject involved 25 people

6 dietitians (hospital staff)6 dietitians (hospital staff)10 volunteer dietitians (from a school of nutrition)10 volunteer dietitians (from a school of nutrition)5 physicians5 physicians4 nurses4 nurses

Tools usedTools usedBody mass indexBody mass indexSerum albuminSerum albuminClinical examination Clinical examination –– ““eyeballingeyeballing”” the patientthe patient

Project completed in three (3) weeksProject completed in three (3) weeks

Hospital malnutrition: St. LukeHospital malnutrition: St. Luke’’s datas data

1995 1995 48%48%NeuroNeuro 78%78%Geriatric 75%Geriatric 75%Pulmonary 67%Pulmonary 67%Cancer 64%Cancer 64%ICU ICU 58%58%Surgical 52%Surgical 52%Medical 47%Medical 47%Orthopedic 43%Orthopedic 43%Pediatric 32%Pediatric 32%

1998 1998 34%34%Cancer 53%Cancer 53%Pulmonary 52%Pulmonary 52%Orthopedic 48%Orthopedic 48%Pediatric 38%Pediatric 38%Medical 36%Medical 36%NeuroNeuro 30%30%ICU 27%ICU 27%Surgical 25%Surgical 25%Geriatric 21%Geriatric 21%

Prevalence of Malnutrition in St. Luke’s Medical Center, 1995 & 1998

BMI, clinical exam, albumin (25 people: 5 phys, 6 ClinDn, 10 volDn, 4 nurses; 3 weeks)

BMI (15 people, 3 days)

Malnutrition = UW, OW w/ BMI >27, OB

Conclusion and realizationConclusion and realization

Performing a prevalence of malnutrition is not Performing a prevalence of malnutrition is not easy using the usual toolseasy using the usual toolsPrevalence determination has to be completed Prevalence determination has to be completed within the expected time frame within the expected time frame –– 24 hours24 hoursApproaches:Approaches:

Computerize the processComputerize the processPerform in small groups one at a time, then combine Perform in small groups one at a time, then combine the data expressed in percentagesthe data expressed in percentagesUse sampling from all representative areasUse sampling from all representative areas

Nutrition committee organized

Diet manual completed

TPN team organized

TPN team became NST

First prevalence of malnutrition

survey

Second prevalence of malnutrition

survey

Nutrition support program (JCAHO)

Computerizationimplemented

• nutrition support monitoring sheet• progress notes• communication with attending MD

• outcome documentation

1984

1986 1988

1992

1995

1998

1999

2000

Lone ranger phase:dietitian then physician

Team without administration support

Dietitian writes order sheet,calorie count

The St. Luke’s NST journey

Prevalence of malnutrition influences NST development

The tools for prevalence determinationThe tools for prevalence determination

Body Mass IndexBody Mass Index<18.5 underweight<18.5 underweight18.5 18.5 –– 24.9 normal24.9 normal25 25 –– 29.9 overweight29.9 overweight30+ obese30+ obese

Severe weight lossSevere weight loss>5% in 1 month>5% in 1 month>7.5% in 3 months>7.5% in 3 months>10% in 6 months>10% in 6 months

Nutrition screening tool: NRS 2002Nutrition screening tool: NRS 2002

STEP 1 - Initial ScreeningQuestions Yes No

• Is BMI < 20.5?

• Has the patient lost weight within the last three (3) months?

• Did the patient have a reduced dietary intake in the last week?

• Is the patient severely ill (e.g. in intensive therapy)?

□ Current Status: No nutritional risk

□ If YES to any question go to STEP 2

Pediatric nutrition

screening forms

Computerization

Is prevalence of malnutrition doable?Is prevalence of malnutrition doable?

ConclusionConclusion

Malnutrition exists in all institutionsMalnutrition exists in all institutionsPrevalence of malnutrition determination is Prevalence of malnutrition determination is not easy not easy –– you need to be innovativeyou need to be innovative