Nutritional Care Program Research Articles

Proposal for An Algorithm for Screening for Undernutrition in Hospitalized Children.

The prevalence of disease-related undernutrition in hospitalized children has not decreased significantly in the last decades in Europe. A recent large multicentric European study reported a percentage of underweight children ranging across countries from 4.0% to 9.3%. Nutritional screening has been put forward as a strategy to detect and prevent undernutrition in hospitalized children. It allows timely implementation of adequate nutritional support and prevents further nutritional deterioration of hospitalized children. In this article, a hands-on practical guideline for the implementation of a nutritional care program in hospitalized children is provided. The difference between nutritional status (anthropometry with or without additional technical investigations) at admission and nutritional risk (the risk of the need for a nutritional intervention or the risk for nutritional deterioration during hospital stay) is the focus of this article. Based on the quality control circle principle of Deming, a nutritional care algorithm, with detailed instructions specific for the pediatric population was developed and implementation in daily practice is proposed. Further research is required to prove the applicability and the merit of this algorithm. It can, however, serve as a basis to provide European or even wider guidelines.

Multiple-micronutrient supplementation for women during pregnancy.

The aim of this bi-monthly column is to highlight Cochrane Systematic Reviews of relevance to pregnancy and childbirth and to stimulate discussion on the relevance and implications of the review for practice. The Cochrane Collaboration is an international organisation that prepares and maintains high quality systematic reviews to help people make well-informed decisions about healthcare and health policy. A systematic review tries to search for, appraise and bring together existing research to answer a specific research question. The Cochrane Database of Systematic Reviews (CDSR) is published monthly online. Residents in countries with a national licence to The Cochrane Library, including the UK and Ireland, can access the Cochrane Library online, free of charge, through www.thecochranelibrary.com.

Malnutrition in a tertiary care hospital

Sir, The recent report on malnutrition in a tertiary care hospital is very interesting.[1] Chakravarty et al., concluded that “almost two-fifth of patients admitted were malnourished in this tertiary care hospital and that there is an urgent need to develop a comprehensive nutritional care program in many such Indian intensive care units.”[1] In fact, the nutritional problem is a common thing, but forgotten for the admitted patients in any settings. The important issue is the concern on the care provider on the nutritional status of patients.[2] A recent report by Kowanko et al. showed an important problem that “although nurses considered nutritional care to be important many had difficulty in raising its priority above other nursing activities, as a result of time constraints and multitasking issues.”[3] There should be a system for nutritional assessment of all admitted patients and special individualized plan should be set. Reid and Allard-Gould reported that “adequate nutritional screening and interventions have been demonstrated to be cost-effective resulting in fewer complications, faster recovery, shorter hospital stays and reduced hospital expenditures.”[4]

Impact of an intervention nutrition program during prenatal on the weight of newborns from teenage mothers.

The nutritional care for teenage mothers had been studied as a factor that influences the course of pregnancy and neonatal outcomes, especially in birth weight. Evaluate the effect of a prenatal intervention nutrition program, with early start of the nutritional care and individualized attendance on teenage mother newborns' weight. Not randomized study of intervention performed with 746 teenage mothers (14 to 19 years old), subdivided in historic control group (GI; n= 542) and intervention group (GII; n= 204). The dependent variable was the low birth weight (LBW). The independent variables assessed were: sociodemographic (mother age, skin color, instruction level and sanitation conditions), anthropometric (mother's height, pre-gestational nutritional study and adequacy of gestational weight gain), obstetric (gestational age in first prenatal consultation, number of pregnancies, childbirths and abortions, interdelivery and inter-gestational intervals), prenatal attendance (number of prenatal and nutritional attendance consultations) and conditions of the newborn (birth weight and duration of the pregnancy). Data were analyzed by Poisson regression with robust variance. The average of maternal age at delivery was 17,5 years old (standard deviation 1,59). The percentage of LBW considerably reduced from 11,3% in GI to 2,9% in GII (p < 0,001). We observed in the multivariate model that the teenage mothers who have not received the intervention presented 3,5 more prevalence (GI, RP adjusted 3,5; IC95% 1,49-8,44) to give birth to a low weight newborn. The participation of the teenage mother in the prenatal nutrition care program proposed here contributed to the reduction of the low weight of newborns.

Prevalence of malnutrition in a tertiary care hospital in India

Introduction:Malnutrition adversely affects clinical outcome of hospitalized patients. This observational prospective study was done to assess the prevalence of malnutrition and its grade among patients admitted in a mixed intensive care unit (ICU) of a tertiary care hospital in order to help devise a comprehensive nutrition program for the malnourished.Materials and Methods:A total of 500 sequential patients admitted to the ICU were screened on admission over a year period for malnutrition using the Subjective Global Nutritional Assessment (SGNA) score. Distribution of the degree of malnutrition according to co-morbidities was also documented.Results:Of the total, 198 (39.6%) patients were malnourished, including one patient qualifying as severely malnourished; 68% patients were male, however, there was no statistically significant difference between nutrition status between sexes. Hypertension, diabetes, and cancer were the three most commonly encountered co-morbidities among the malnourished. A total of 86% of all cancer patients admitted were malnourished against only 12% of trauma patients.Conclusion:This study showed that almost two-fifth of the patients admitted were malnourished in this tertiary care hospital and that there is an urgent need to develop a comprehensive nutritional care program in many such Indian ICUs.

Clinical impact of systematic nutritional care in adults submitted to allogeneic hematopoietic stem cell transplantation

Background: The development of nutrition care programs for patients undergoing hematopoietic stem cell transplantation is necessity in view of the rapid and aggressive consequences frequently seen with this procedure. Patients require constant care to reduce complications and to contribute to the success of therapy. Methods: In an attempt to ascertain the impact of systematic nutritional care on patients submitted to allogeneic hematopoietic stem cell transplantation, the present study assessed the nutritional and clinical status, use of parenteral nutrition, and complication and mortality rates in two groups of patients, who were submitted to transplantation between April 2003 and December 2004 (Non-intervention Group - NIG; n = 57) and between March 2006 and January 2008 (Intervention Group - IG; n = 34). Results: There were no significant differences between groups in terms of clinical or nutritional profiles. Additionally, the length of hospital stay and complication and mortality rates were similar for both groups. However, time on parenteral nutrition during treatment was shorter for the IG [median 6.5 days (range: 1-28) for related donor recipients and 11 days (range: 1-21) for unrelated donor recipients] than for the NIG [median 20.5 days (range, 4-73) for patients submitted to myeloablative conditioning and 18.5 days (range: 11-59 days) for those submitted to nonablative conditioning]. Conclusion: The implementation of a nutritional follow-up and therapy protocol for adult patients submitted to hematopoietic stem cell transplantation shortens the duration of parenteral nutrition. It certainly has an impact on hospitalization costs and, potentially, on the rate of complications, even though this was not demonstrated in this study.

The Coach Is In: Improving Nutritional Care in Nursing Homes

This article describes and evaluates a long distance coaching course aimed at improving nutritional care in nursing homes (NHs). The course was structured to provide more support than traditional training programs offer. In a series of 6 monthly teleconferences led by an expert in NH nutritional care, participating NH staff received step-by-step instructions for implementing an evidence-based nutritional management program. After each session, participants were asked to implement the care step they had just learned. Coaching calls helped facilitate implementation. Staff in 18 NHs in 12 states completed the course. Evaluation data were collected using a resident data form, pre- and post-training quizzes, a participant course evaluation survey, and a supervisor's report. NH staff attended an average of 4.8 teleconferences, with 5 staff members typically attending each teleconference. Average quiz scores increased 30% (p < .0001) from pre- to post-training. A majority of course participants (N = 35) said they would participate in a similar course (82.9%) and would recommend the course (80%). Just under half preferred the coaching course to a more traditional 1- to 2-day conference. Nine of 12 reporting supervisors said their facility planned to continue the new nutritional care program. The 10 NHs that submitted resident data assessed an average of 5 residents using the recommended protocols. We recommend the coaching course format. Dissemination outcomes may improve if resources currently used for short-duration training activities are used instead on coaching activities that support NHs over extended periods.

Seriate prealbumin and C-reactive protein measurements in monitoring nutritional intervention in hospitalized patients: a prospective observational study

Protein-energy malnutrition (PEM) in hospitalized patients is associated with poor outcomes. Prealbumin (PAB) has been shown to be a potentially useful tool in PEM assessment. PAB plasma concentrations are closely related to nutritional state and nutritional intervention. However, PAB is also inversely correlated to C-reactive protein (CRP), making difficult the interpretation of PAB changes during tratment of severely ill patients with inflammation and/or infection. Methods: To assess the confounding role of CRP we investigated the role of two seriate measures of PAB and CRP in monitoring the response to nutritional intervention in 83 hospitalized patients enrolled in a nutritional care program (group 1). Data were also collected from 60 patients with low PAB not enrolled in any nutritional program (group 2). Results: When nutritional needs were not satisfied (nutritional intake/needs ratio <75%) we found no PAB increase, whereas there was a significant PAB increase in patients with adequate intake (mean delta-PAB 4.2 mg/dL). Covariance analysis showed a statistically significant mean PAB increase of 2.38 mg/dL in the adequate intake subset, value controlled for the confounder delta-CRP (p < 0.005). In the inadequate intake subset and in group 2 an improvement in CRP status was not associated with a proportional improvement in PAB levels. Conclusions: Although the complex interplay between PAB and inflammation cannot be completely solved, we suggest that in subjects receiving an adequate nutritional support a significant improvement of PAB can be considered, at least partially, a real marker of nutrional improvement.

Nutritional Status and Eating Behavior of Lactating Women in Daejeon

Nutrients intake status of 73 lactating women, that is 45 breast feeding (BF), 13 formula feeding (FF) and 15 mixed feeding (MF), living in Daejeon was investigated. Self-recorded food intakes for two weekdays and eating behaviors using questionnaires were surveyed from May to August 2008. Subjects aged 29.2 ± 3.4 years and their infants aged 8.2 ± 3.2 months. Body mass index of the subjects was 21.0 ± 3.2. Of the subjects 23.3% were employed. Daily energy intake was 1953 ± 391 kcal. Mean adequacy ratio (MAR) was 0.77 ± 0.14 and was higher in FF (0.86 ± 0.13) than in BF (0.76 ± 0.11) and MF (0.72 ± 0.18). Nutrients that over 50% of the subjects took less than estimated average requirement were vitamin A, riboflavin, folate, vitamin C and calcium. And index of nutritional qualities of those 5 nutrients were below one Forty six and sixths percent (46.6%) of the subjects showed GMFVD = 11111 pattern of five food group intakes and 57.5% took meals three times daily, 56.2% skipped often breakfast, and 64.4% dined out two times and more per week. Subjects having lower MAR (< 0.72, n = 24), compared with those having higher MAR (≥ 0.83, n = 24), showed more skipping daily meals and less frequency of eating-out, and took less legumes, vegetables, fishes, and milk. As the results, intakes of calcium, vitamin A, riboflavin, folate, and vitamin C were insufficient in lactating women, especially in BF and MF mothers. Meal skipping and low intakes of dairy foods, legumes, vegetables, and fishes might have adverse influences on nutritional status of lactating women. Accordingly, nutrition care program for lactating women should be focused on intake of three meals daily and a variety of food. (Korean J Community Nutr 16(1) : 37~50, 2011)

Development of supplemental nutrition care program for women, infants and children in Korea: NutriPlus+

Onto the world-fastest ageing of society, the world-lowest fertility rate prompted a development of various policies and programs for a betterment of the population in Korea. Since the vulnerability of young children of low socio-economic class to malnutrition was clearly shown at the in-depth analysis of the 2001 Korea National Health and Nutrition Examination Survey data, an effort to devise supplemental nutrition care program for pregnant/breastfeeding women, infants and preschool children was initiated. The program was designed to offer nutrition education tailored to fit the needs of the participants and special supplementary foods, using USDA WIC program as a benchmark. Based on the dietary intake of those age groups, target nutrients were selected and their major food sources were searched through nutrient content of foods and dietary pattern analysis. As a result, we developed 6 kinds of food packages using combinations of 11 different food items. The amount of each item in a food package was determined to supplement the intake deficit in target nutrients. Nutrition education in NutriPlus+ aims to improve the nutrition knowledge, attitude, and dietary behaviors of the participants, and is provided through group lessons, individual counseling sessions and home visits. Breastfeeding is promoted with top priority in education for the health of both mother and baby. The eligibility guidelines were set for residency, household income, age, pregnancy/breastfeeding and nutritional risk such as anemia, stunting, underweight, and/or inadequate nutrient intake. Income eligibility was defined as household income less than 200 percent of the Korean poverty guidelines. A pilot study to examine the feasibility of program implementation was run in 3 public health centers in 2005 and expanded to 15 and 20 in the following 2 years. The result of 3-year pilot study will be reported separately along with the ultimate nationwide implementation of the NutriPlus+ in 2008.

Outcomes of Screening And Nutritional Intervention Among Older Adults in Healthcare Facilities

A nutritional screening and early intervention program was administered to older adults in a subacute care facility. The study group was recruited among patients aged 65 or older, who were admitted to the geriatric and rehabilitation units of two hospitals. Two simple, reliable, and valid tools were used to screen subjects for the risk or presence of malnutrition. Those determined to be at high nutritional risk (n=62) were included in the study. Dietitians then conducted a full nutritional assessment and implemented a nutritional care plan for these subjects. Weekly follow-up was completed to measure oral intake, weight, and biochemical indices. A Short-Form 36 Health Survey was administered upon admission and discharge. Results showed significant increases in energy (p=0.0001) and protein (p=0.01) intakes, and in serum albumin (p=0.001), prealbumin (p=0.003), transferrin (p=0.024), and hematocrit (p=0.026) levels. There was also a significant increase in seven of the eight dimensions of the health-related quality of life questionnaire (p<0.05). Outcomes improve when older adults are screened for the risk or presence of malnutrition and receive an early nutritional care program.

Individualized nutritional care for a pediatric patient: case report

This nutritional care program was carried through with a pediatric patient having Chronic Renal Insufficiency, Hemolytic-UremicSyndrome, and Arterial Hypertension, chosen due to the necessity of favoring her clinical condition, due to the high rates of morbiditymortalityin renal children. The aim of this work is to promote growth, development, and survival with life quality. This clinical-case typeexperimental research had as subject a 5-year boy years. For doing this, we examined data from the hospital record such as pharmacotherapyand results of the requested exams. An Alimentary Inquiry was applied, and we evaluated and calculated the Alimentary Record. Nutritionaldiagnosis was defined by the evaluation of biochemical and anthropometric parameters. After dietary planning, nutritional and clinicalnecessities of the patient were considered to promote adaptations to the hospital diet. The analysis of the domiciliary record suggests thatinadequate alimentary consumption favored the clinical diagnosis. Nutritional evaluation identified a risk of malnutrition regarding proteinintake. Due to the patient’s inapetence, the offered oral diet was modified, promoting a better acceptance of food without, however, reachingthe ideal consumption of nutrients. The persistent inadequateness of ingestion favors weight loss and a higher nutritional depletion andreduces the patient’s survival. The study shows this way the necessity of a continuous nutritional assistance, suggesting that oral nutritionalsupplements be offered.

A Novel Dysphagia Diet Improves the Nutrient Intake of Institutionalized Elders

Objectives Dysphagia affects 35% to 60% of the institutionalized elderly population. This study aimed at evaluating the nutrient intake of frail institutionalized elderly persons with dysphagia and to assess the impact of Sainte-Anne’s Hospital Advanced Nutritional Care program on dietary intake and weight. Design A 12-week intervention study. Subjects/setting Ninety-three individuals residing in a Montreal, Canada, long-term care facility who were aged at least 65 years were evaluated. Seventeen subjects with a body mass index (BMI; calculated as kg/m 2) <24 or weight loss >7.5% within 3 months and with dysphagia were included. Intervention The treated group (n=8; aged 82.5±4.41 years, weight 55.9±12.1 kg, BMI 22.4±3.93) received Sainte-Anne’s Hospital reshaped minced- or pureed-texture foods with thickened beverages where required. The control group (n=9; aged 84.6±3.81 years, weight 54.3±7.49 kg, BMI 21.2±2.31) maintained traditional nourishment. Main Outcome Measures Macronutrient and micronutrient intake, weight, and BMI were measured at baseline, 6 weeks, and 12 weeks. Statistics Student t tests were performed to evaluate change within and between groups. Results The treatment and control groups were similar at baseline, having a mean age of 82.5±4.41 years vs 84.6±3.81 years and BMI of 22.4±3.93 vs 21.2±2.31, respectively. The average weight in the treated group increased compared to the control group (3.90±2.30 vs –0.79±4.18 kg; P=0.02). Similarly, the treated group presented an increased intake of energy, proteins, fats, total saturated fats, monounsaturated fats, potassium, magnesium, calcium, phosphorus, zinc, vitamin B-2, and vitamin D compared to control subjects ( P<0.05). Conclusion Institutionalized elderly patients with dysphagia can eat better and increase body weight via a diversified, modified in texture, and appealing oral diet that meets their nutrition needs.

Outcomes of Continuous Process Improvement of Nutritional Care Program Among Geriatric Units

Up to 65% of elderly patients are protein-calorie undernourished at admission or acquire nutritional deficits while hospitalized. The aims of this project were: (a) to assess the quality of care concerning nutrition among Belgian geriatric units, (b) to include more routinely nutritional assessments and interventions in comprehensive geriatric assessment, and (c) to assess the impact of nutritional recommendations on nutritional status and on the length of hospitalization. Method. We studied 1139 patients consecutively admitted to 12 geriatric units of general hospitals prospectively for 6 months (from January through June 2001). All patients underwent a comprehensive geriatric assessment. For the first 3 months, the nutritional status of the patients on admission and at discharge were assessed without particular recommendations for nutritional intervention. A standardized nutritional intervention was proposed for the last 3 months. Median value of the Mini Nutritional Assessment test score was 18 points (range 9-29), mean admission's serum prealbumin concentration was 0.185 +/- 0.076 g/L, and C-reactive protein was 5.3 +/- 7.5 mg/100 ml. Hospitalization stay was significantly lower during the interventional period than during the observational period. A higher mean serum prealbumin concentration variation was observed during the interventional period as compared to the observational period. Nutritional assessment should be part of routine clinical practice in elderly hospitalized patients. A comprehensive screening tool for assessment of nutritional status is needed that is clinically relevant and cost effective to perform. If malnutrition is suggested by such screening tests, then a supplemental conventional nutritional assessment should be performed before treatment is planned.

Outcomes of continuous process improvement of a nutritional care program incorporating TTR measurement.

Early assessment of protein calorie malnutrition (PCM) can improve the outcome for hospitalized patients by allowing the initiation of nutrition support if required. In addition, monitoring nutritional status during the hospital stay can identify a decline in or improvement of PCM so that alterations to treatment regimens can be made if needed. The visceral protein albumin is the traditional laboratory indicator of PCM. In the past decade another protein has been lauded as a superior marker that can be used in conjunction. We undertook several studies to test the effectiveness of TTR as an aid in nutritional assessment. We found TTR to be a sensitive measure of nutritional status, allowing for earlier assessment and intervention, thus reducing length of stay and other hospital associated costs. Based on these findings, our hospital generated and implemented a multidisciplinary nutrition care program. Transthyretin is an integral portion of this program; levels are determined on admission and repeated twice weekly until discharge.

Outcomes of continuous process improvement of a nutritional care program incorporating serum prealbumin measurements

It has been reported that the risk of protein-calorie malnutrition (PCM) for hospitalized patient populations can be as high as 50%. Left undiagnosed, PCM can lead to serious consequences, including increased morbidity and mortality. Visceral protein albumin is the traditional laboratory indicator of PCM. In the past few years, however, several other visceral proteins have been lauded as superior markers. We undertook several studies to test the effectiveness of using one of these, prealbumin, as an aid in nutritional assessment. We found prealbumin to be a sensitive measure of nutritional status, allowing for earlier assessment and intervention, and thus reducing length of stay. Based on these findings, our hospital has generated and implemented a multidisciplinary nutrition care program that meets the 1995 Joint Commission on Accreditation of Healthcare Organizations' Nutrition Care Standards. Prealbumin testing is an integral portion of this program; levels are determined on admission and repeated semiweekly until discharge. Use of this program has led to improved patient care and financial benefit to the hospital.

Iron Deficiency: Contemporary Scientific Issues and International Programmatic Approaches

Iron deficiency is a common nutritional disorder in developing countries and contributes significantly to reduced work productivity and economic output as well as to increased morbidity and mortality. There are well established biochemical tests for assessing iron status in developed countries. However, cost and interference from infectious conditions make it difficult to assess iron status in many developing country settings. Examination of the hemoglobin distribution in the population and assessment of the hemoglobin response to supplementation are alternative approaches to defining iron status and the nature of anemia. Prevention and control of iron deficiency requires the combined approach of dietary improvement, fortification of a common staple food when feasible, and appropriate iron supplementation for infants and pregnant women. In all these intervention activities, operational research is needed to improve effectiveness. In addition, controlling iron deficiency requires coordination with other nutrition and primary health care programs as part of an integrated approach to improved health and nutrition of the population.

Identifying patients at nutritional risk and determining clinical productivity: Essentials for an effective nutrition care program

The primary purpose of this article is to establish procedures for identifying patients at nutritional risk, determining diagnosis-related groups, and measuring clinical productivity, therefore establishing staffing needs. Two studies were done to identify patients at nutritional risk: a 1-day survey of the medical/surgical units and a prospective-retrospective chart study. These studies determined which patients were at risk and the DRG category. Thirty percent of the DRGs had documented nutrition intervention. Clinical productivity was measured during a 4-week time management study. Staffing needs were determined from the data collected, from the percent of patients deemed at risk, and from an analysis of the time study. Dietitians were assigned to those patients identified as high risk and dietetic technicians assigned to patients at moderate nutritional risk. Although there is a need for standardization of nutrition care, it must be emphasized that each institution has special requirements because of its particular patient population and the philosophies of the dietary and medical staff.

Program evaluation for effective resource management and accountability

A means of determining the effectiveness of public programs as a basis for justifying resource allocation to these programs is urgently needed. Program evaluation can provide the data base required for program decision-making and modification. A ten-step model for planning and carrying out an evaluation is suggested as a guideline for program personnel who may be assigned to evaluation responsibilities. Nutrition professionals must become aware of the increasing need for evaluation and of the procedures for conducting the evaluation process within programs for which they are responsible. Failure to provide documentation of adequate, on-going evaluation of effectiveness may lead to a loss of resources for the program and, ultimately, to the demise of the nutritional care program.

Spin-off cost/benefits of expanded nutritional care ,

Eight years ago, in caring for persons with diabetes at Grady Memorial Hospital, Atlanta, priority was given to the use of oral hypoglycemic agents and insulin, with only minimal attention to nutrition. In 1971, an "expanded nutritional care program" was instituted, with emphasis on nutritional education and follow-up. Use of oral agents was discontinued, and, since 1972, less insulin has been used. The new dietary program, with dietitians playing a key role, includes a one-week total fast, stringent low-calorie diets, individualized dietary planning and instruction, and careful follow-up monitoring. Comparative pre-1971 and current data show: a 50 per cent reduction in lower extremity amputations, less diabetic ketoacidosis, fewer hospitalizations, weight reduction of 40 per cent with no increase in plasma glucose (in a 127-patient cohort with complete follow-up), and a savings to the hospital of more than $96,000 in the cost of medications and $3,700,000 in hospitalizations in eight years.