Filipinos can indulge in schadenfreude and take heart that malnutrition in hospitals is not exclusive to developing countries. Dr. Gabriel Jasul, endocrinologist and clinical nutritionist, says that even developed countries have a problem with underfeeding in hospitals. In Germany and Spain, one of every four hospitalized patients is malnourished;1, 2 in Australia, one in every three.3 Almost half of hospitalized patients in the Netherlands are malnourished, and this reaches as high as two out of every three patients in Canada.4, 5

    Poor nutrition and disease feed on each other. Hospitalized patients are under conditions that increase metabolic stress: illness, infection, inflammation, trauma, and surgery. These conditions all increase one's resting energy expenditure-how many calories one burns at rest.6 The change in nutritional requirements varies from patient to patient, says Jasul. A simple fever can increase one's nutritional requirement by 10 percent, while a severe burn patient may need as much as 200-percent more than normal.

    Several studies have shown that malnutrition increases morbidity and mortality, lengthens hospital stay, and increases hospital costs. In studies of over 1,327 hospitalized adults, malnourished patients stayed 90-percent longer in hospitals than well-nourished patients. Hospital charges were 35- to 75-percent higher for malnourished patients.7

    Malnutrition is especially common among geriatric patients, with a study showing that dietary habits can significantly predict poor hospitalization outcomes.8 Children, whose growth also requires increased metabolic needs, are not spared. The World Health Organization notes that "malnutrition remains one of the most common causes of morbidity and mortality throughout the world." An estimated nine percent of the world's children have low weight-for-height measurements.9 Dr. Jossie Rogacion, a consultant at the University of the Philippines-Philippine General Hospital's (UP-PGH) pediatric gastroenterology and nutrition section, estimates that 90 percent of patients admitted into the hospital's pediatric wards are malnourished. "In other hospitals, relatively more nourished ang population nila kasi we get the worst cases here," she adds.

Holistic view

    Despite evidence that malnutrition plays a huge role in determining the outcome of hospitalized patients, nutrition is still not given enough emphasis during medical and clinical training. Seeing that a lot of doctors lacked training on nutrition, Jasul took it upon himself to pursue fellowship training in clinical nutrition/nutrition support at the Brigham and Women's Hospital, Harvard Medical School in Boston, Massachusetts, after completing his residency and fellowship training in endocrinology.

    He explained that as an endocrinologist, he was already trained to view patients as a whole and not just an organ system, so studying nutrition was "corollary" to his being an endocrinologist. As a training officer at the section of endocrinology of St. Luke's Medical Center (SLMC) and clinical associate professor of medicine at UP-PGH, Jasul tries to incorporate nutrition into his lectures or case-management hours whenever he can.

    He thinks that we need "more workshops, more time spent on case management and discussion groups with nutrition cases. Kailangan i-focus talaga from med school pa lang." He noted that not all doctors are comfortable with writing dietary prescriptions, which should not be the case. "It should start from the doctors because the doctors are the team captains," he said, adding that dietary prescriptions should come from the doctor.

    Rogacion believes that it is important "for the health-care provider to be aware that nutrition also plays a central part in the management of patients, whatever the underlying condition, particularly children, kasi these are growing children. Aside from the needs imposed by the disease itself, meron pa rin siyang need for growth."

    She is concerned that nutrition is just being relegated to the background. Most of the residents are oriented on the disease but patients should be treated using a more holistic approach, she says, because nutrition is basic when it comes to management of patients.

    Fortunately, awareness in this part of the world seems to be growing. In 2000, SLMC started its fellowship training in nutrition support under the leadership of Dr. Luisito Llido, head of the SLMC Center for Weight Management and Clinical Nutrition and vice president of PhilSPEN.

Risk assessment

    Dealing with malnutrition first requires proper identification of patients. In pediatrics, anthropometric measurements are normally part of the physical examination and are easily identified. Patients at UP-PGH who are severely malnourished to begin with, such as those with chronic diarrhea or cerebral palsy, are referred right away to the gastroenterology and nutrition section upon admission. Those who develop malnutrition during the course of their stay, such as the chronically ill and postoperative patients, are referred as needed.

    At SLMC, patients undergo nutrition screening as soon as they are admitted. The hospital has an alert system in place in case the patient needs to be referred. Between 2000 and 2003, the computerization of the nutrition-support process saw an increase height and weight entries into patient records from 30 to 90 percent, referrals to the nutrition-support team from 37 to 100 percent, and patient coverage by nutrition support services from 38.8 to 83 percent. Aside from identifying malnutrition in all admitted patients, this study also identifies those "at risk of developing malnutrition."10

    Asprer emphasized that an assessment of risk is more important than actual nutritional status. He explained that hospitalization will have a lesser impact on a malnourished person who is hospitalized for minor illness as opposed to a well-nourished cancer patient who needs surgery and will not be able to feed for some time.

Intervention

    Although awareness and proper identification of malnutrition are important, none of them would matter without appropriate intervention.

    Rogacion says doctors should be aggressive when it comes to dealing with patient nutrition, otherwise, the patient's immunity will go down, which may prolong hospital stay. If necessary, patients need to be fed, unless there are contraindications, she adds.

    Jasul adds: "The most important message is to really use the gut-to use enteral nutrition whenever possible. [That's the most] physiologic."

    Aside from having fewer side effects, enteral feeding is much more affordable than parenteral nutrition or administration of nutrients through means other than the digestive system. Jasul estimates the cost of enteral feeding at PhP1,000 to PhP2,000 per day compared with PhP8,000 to PhP10,000 a day for parenteral feeding.

    This is also Rogacion's main problem: "how to sustain nutritional support if the patient cannot tolerate oral feeding."

    It all boils down to money.

    Rogacion says they hardly do parenteral even if they want to because of the cost.

    Fortunately, the WHO's Management of Severe Malnutrition: A Manual for Physicians and Other Senior Health Workers offers ways to keep the costs of enteral nutrition down. The protocol includes formulations called F75 and F100. F75 has 75 kcal/100mL and is used in the initial phase of treatment while F100 has 100kcal/100mL and is used in the rehabilitation phase.9

    Rogacion shares its basic ingredients are very affordable: skim milk, sugar, and oil. "We find good results for that. Yung mga pasyenteng binibigyan niyan, tumataba talaga! Yun yung ginagamit on an outpatient basis, para naman naa-afford nila yung formulation."

    Another problem that they face in the ward, according to Rogacion, is making sure the patients get their prescribed calories. Oftentimes, they keep on increasing calorie count because the patient is not gaining weight, only to find out that the patient's food is being consumed by the companion. A quick fix is to prescribe osterized food because all of it goes to the patient and cannot be eaten by the caregiver.

    Other problems include the resistance to gastrostomy feeding and technical problems. Relatives are wary about having a tube leading straight to a child's stomach and would rather keep their children on nasogastric tubes, which Rogacion says can only be kept for a maximum of two weeks. There are also concerns about the lack of available equipment such as feeding tubes and feeding pumps, which lead to other problems like food contamination. M

1. Ockenga J, Freudenreich M, Zakonsky R, et al. Nutritional assessment and management in hospitalized patients: implication for DRG-based reimbursement and health care quality. Clin Nutr 2005; 6: 913-919.

2. Planas M, Audivert S, Pérez-Portabella C, et al. Nutritional status among adult patients admitted to an university-affiliated hospital in Spain at the time of genoma. Clin Nutr 2004; 5:1016-1024.

3. Middleton MH, Nazarenko G, Nivison-Smith I, Smerdely P. Prevalence of malnutrition and 12-month incidence of mortality in two Sydney teaching hospitals. Intern Med J 2001; 8: 455-461.

4. Naber TH, Schermer T, de Bree A, Nusteling K, et al. Prevalence of malnutrition in nonsurgical hospitalized patients and its association with disease complications. Am J Clin Nutr 1997; 66: 1232-1239.

5. Singh H, Watt K, Veitch R, Cantor M, Duerksen DR. Malnutrition is prevalent in hospitalized medical patients: are housestaff identifying the malnourished patient? Nutrition 2006; 22:350-354.

6. The Merck Manuals Online Medical Library. www.merck.com/mmpe/sec01/ch003/ch003a.html.

7. Gallagher-Allred CR, Voss AC, Finn SC, McCamish MA. Malnutrition and clinical outcomes: the case for medical nutrition therapy. J Am Diet Assoc 1996; 96: 361-369.

8. Kagansky N, Berner Y, Koren-Morag N, Perelman L, et al. Poor nutritional habits are predictors of poor outcome in very old hospitalized patients. Am J Clin Nutr 2005; 82: 784-791.

9. World Health Organization. Management of severe malnutrition: a manual for physicians and other senior health workers. 1999. (www.whqlibdoc.who.int/hq/1999/a57361.pdf).

10. Llido L. The impact of computerization of the nutrition support process on the nutrition support program in a tertiary care hospital in the Philippines: Report for the years 2000-2003. Clin Nutr 2006; 25: 91-101.

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