PhilSPEN Online Journal of Parenteral and Enteral Nutrition

(Article 5 | POJ_0017) January 2010 - January 2012

A Position Paper by the Hospital Malnutrition and Clinical Nutrition Program Task Force, Philippines

The value of implementing a clinical nutrition program and nutrition support team (NST) to address the problem of malnutrition in the hospitals of the Philippines

Introduction | Conclusion | References | Back to Total Names Codes

Submitted: March 12, 2011 | Posted: August 10, 2011


Hospital Malnutrition and Clinical Nutrition Program Task Force, Metro Manila, Philippines

  • Philippine Society of Parenteral and Enteral Nutrition (PHILSPEN)
  • Clinical Nutrition Fellowship Training Program, St. Luke's Medical Center, Quezon City, Philippines
  • Master of Science in Clinical Nutrition, Philippine Women's University

Corresponding Author: Luisito O. Llido, MD; Email:

KEYWORDS: Hospital malnutrition, nutrition team, BMI, SGA



Nutrition of the patient has become an important indicator of quality care in the institution especially the hospital. The need for systems that will improve patient care through inclusion of an effective nutritional management program has become an issue in the Philippine hospital care set up where efficient utilization of resources is recognized to be a key in maintaining hospital operations together with achieving optimum outcomes in patient care. The development of the clinical nutrition program which is effectively implemented by a nutrition support team has become the current issue in the fight against malnutrition worldwide hence it is the objective of this paper to encourage the development of clinical nutrition programs and nutrition support teams in the hospitals in the Philippines. The following are the objectives of this proposal:

  1. To develop a cadre of competent professionals who will be implementing the clinical nutrition program
  2. To address the problem of malnutrition in the hospital setting through the following specific goals:
    a. To decrease the number of complications

    b. To decrease morbidity and mortality

    c. To improve patient care

    d. To improve quality of life of the patients especially the critically ill and geriatric patient population

Malnutrition in the hospital is worldwide and exists in every hospital in the Philippines

Malnutrition is usually associated with a body mass index (BMI) of <18.5 (underweight) or a BMI of 30 and above (obese). [1] An SGA grade of “C” with the nutrition assessment tool, Subjective Global Assessment (SGA), indicates severe malnutrition. [2] The worldwide prevalence of malnutrition in the hospital is between 38%-52%. (Table 1)[3-7]. A prevalence of malnutrition survey in 2008 done by the Philippine Society of Parenteral and Enteral Nutrition (PHILSPEN) showed that 48-53% of hospitalized patients in the country are malnourished. [8-9] Worse, the premiere public hospital of the country showed a 42% severe malnutrition rate. (Table 2) [9] With these data the ultimate conclusion would be: every hospital in the Philippines has malnourished patients.



Malnutrition is associated with increased complications and hospital cost

Malnutrition predisposes hospitalized patients to develop complications like infection especially in the elderly population [10] or post-operative complications like prolonged wound healing or infectious complications [11-12]. Malnutrition in the critically ill patients is associated with increased frequency of single or multi-organ dysfunction which if not corrected would lead to single or multi-organ failure [12-13]. Morbidity and mortality would increase even after discharge from the hospital. [14] All these problems would precipitate increased utilization of resources, services, and eventually prolonged hospital stay [15]. The ultimate outcome is increased cost which would be a major source of pressure on the hospitals’ finances.

Malnutrition detection and management is associated with decreased complications and better outcome: better patient care and savings for both patient and institution

Severe malnutrition when identified early and managed accordingly would lead to better outcome for the patient’s overall disease management. This is specifically seen in surgical patients where the pre-operative nutritional build-up or post-operative nutrition delivery was adequate and led to lesser complications and mortality. [16] Critical care patients whose nutrition intake was increased showed reduced mortality rates by as much as 40% as shown by a large critical care nutrition study done in 2008. [17] Geriatric patients also had lower mortality rates after hospital discharge when their nutritional status was improved through better care which included nutrition. [14] 
Quality of life improved when nutrition was maintained as in enteral nutrition in cancer patients (radiology oncology) placed with gastrostomy for adequate nutritional intake. [18] Similar results were seen when patients were provided either with parenteral nutrition or in combinations with oral supplementation or tube feeding [19]. Immune status, which has a key role in wellness or in increasing complications through depressed or heightened inflammatory state, is directly influenced by nutrition. Emotionally depressed patients had lower immune status manifested by decreased natural killer cell activity [20], but when nutrition was improved through provision of adequate intake or and/or nutraceuticals (currently referred to as pharmaconutrition) like glutamine, immune status bounced back to effective levels. [21]

All of these improvements are the results of optimum patient care, which produced outcomes of reduced morbidity and mortality, reduction in the cost of delivering specialized services like parenteral nutrition [22], and ultimately, increased savings for both patient and hospital.

A clinical nutrition program with a nutrition support team (NST) delivers the most effective malnutrition management in the hospital setting with positive outcomes:

The clinical nutrition program, also called the nutrition support process, has the following components: (1) nutrition screening of all admitted patients, (2) nutritional assessment of all identified “nutritionally at risk patients”, (3) nutrition care plan development for the patients identified to be priority for care by the nutrition support team (NST), (4) implementation of the nutrition care plan by the different members of the nutrition support team (NST), (5) monitoring of the nutrition delivery process by the different members of the NST, and (6) re-evaluation or termination of the nutrition delivery process as deemed fit by the NST. [23]

This highly specialized and complex management system is best run by a nutrition support team or NST which is a group composed of a physician, dietitian, nurse, and pharmacist, who underwent specialized training for this type of service. [24-26] The physician is the team leader and he/she integrates nutrition care into the over-all management process with the dietitian, nurse, and pharmacist contributing their specific expertise.

The team delivers total nutrition care to the patient using standards recommended by the Philippine Society of Parenteral and Enteral Nutrition (PHILSPEN)[23] and developed by the American Society of Parenteral and Enteral Nutrition (ASPEN) (Figure 1). [27] Currently the NST is the de-facto “gold standard” when it comes to delivering nutrition support in the hospital setting. [24] A current observation of PHILSPEN is: hospitals with active and effective NST’s have been organized and run by graduates of the fellowship program in clinical nutrition. Those whose teams were appointed by the hospital administration but did not undergo formal training in clinical nutrition failed and this trend has been going on for the past ten to fifteen years in the Philippines. [28]


The minimum requirements to qualify for the position as NST member are the following:

1) Physician – licensed to work as physician in the Philippines and a graduate of the fellowship program in clinical nutrition, currently available only at St. Luke’s Medical Center, Quezon City, Metro-Manila, Philippines [29]; preferably a fellow of the Philippine Board of Clinical Nutrition [30] and member of PHILSPEN.

2) Clinical dietitian – licensed to practice as dietitian in the Philippines and a graduate of the Master of Science of Clinical Nutrition program, currently available only at the School of Nutrition, Philippine Women’s University, Taft Avenue, Metro-Manila, Philippines [31]; preferably a member also of PHILSPEN.

3) Nurse – licensed to practice as nurse in the Philippines and a graduate of the Master of Science of Clinical Nutrition program, currently available only at the School of Nutrition, Philippine Women’s University, Taft Avenue, Metro-Manila, Philippines [31]; preferably a member of PHILSPEN and with minimum number of units in the certification for attending basic nutrition support course(s) for nurses organized by PHILSPEN.

4) Clinical Pharmacist – licensed to practice as pharmacist in the Philippines and has training as clinical pharmacist in any institution accredited to teach clinical pharmacy in the Philippines, has minimum number of units in the certification for attending basic nutrition support course(s) for pharmacists organized by PHILSPEN.

Organizational Set Up of the Clinical Nutrition Program
This is the set up of the clinical nutrition program.


In the overall scheme of this set up if all members of the nutrition support team (NST) are available, the clinical nutrition physician is the de-facto team leader of the program, however, if he is not available the clinical dietitian becomes the team leader and the rest of the group are the support group.

How does the Clinical Nutrition Program run?

These are the specific procedures and specialist(s) involved in the different procedures of the clinical nutrition program:

1) Nutrition screening: On admission all patients undergo a nutrition screening process from which the malnourished and/or “nutritionally at risk” of developing malnutrition and nutrition related complications are identified. A nutrition screening form was developed by PHILSPEN which is available from the PHILSPEN website. [26] This is performed by all nurses who are in charge of the patients with supervision by the dietitian and nurse members of the NST. To obtain details of the process go to the PHILSPEN website: then scroll down to “Part 1: Main content of pdf file” and click on this file.

2) Nutrition assessment of the identified “nutritionally at risk” patients: These patients are seen by the physician and clinical dietitian who then classify the patients as mild to severe nutrition risk. The severe nutrition risk patients are given recommendations on nutrition management. It is best practice if the hospital makes it a requirement to have all severely malnourished and high risk patients be followed up by the nutrition support team. [27]

3) The nutrition care plan is composed of: nutrition requirement determination, nutrition formula design, nutrition access decision, and manner of nutrient delivery. It is run through a nutrition care plan form which guides the attending physician through the nutrition management process. The form is usually accomplished by all the members of the team.

4) The nutrition care process is then delivered by each member of the team: nutrition formulation by the clinical dietitian (enteral nutrition) or the clinical formulation (parenteral nutrition) and nutrient delivery by the nurse.

5) Monitoring of the delivery process is then performed by all members of the team.

6) Based on the findings and evaluation of the whole monitoring process, revision of the nutrition care plan or termination and shifting to the normal use of the gastrointestinal tract is done after discussions and concurrence by all members of the team.

All these procedures are required to be documented for evaluation purposes of the nutrition care process and for the patient’s record purposes. The current goal of hospitals to have an international standards accreditation from agencies like the Joint Commission International will be greatly helped by the implementation of a clinical nutrition program run by a nutrition support team. [32]

The set up of the Nutrition Support Team or the Clinical Nutrition Section in relationship to the Dietary Department:

The Dietary Department has been established and regulated by Republic Act 2674 in its overall role in the hospital set up. It deals in all areas of food formulation and delivery whether “therapeutic” or “standard” and mandates the minimum number of dietitians required per specific number of beds in the hospital. The Clinical Nutrition Section was organized out of the need to address nutrition management of the intensive care, surgical, oncology, or “difficult to manage” patients which require close interaction with the physician, dietitian, nurse, and pharmacist or in effect a “nutrition support team”. This group of patients may be small in number, but they incur the highest utilization of hospital resources due to the nature of their illness. The current training of the regular dietitian cannot meet this need.
Thus the clinical nutrition section supplements/completes the role of the dietary department in its overall role in hospitalized patient care. The multidisciplinary function of the team has been described to emphasize its role as intermediary in the complex care of the intensive care or “difficult to manage” patient group by the medical and the rest of the hospital staff. Its role within the dietary department is as a sub-section and in the context of direct patient care, under the clinical nutrition services run by the medical staff.

The Nutrition Support Team and clinical nutrition program: evidence of effectiveness in delivering both preventive and best practice outcome to patient care in the hospital setting:

Before 2008 the existing nutrition support teams in the Philippines were mainly in some hospitals in Metro-Manila and Batangas numbering seven [9]. In spite of the few numbers the following clinical nutrition processes were accomplished:

a) Nutrition surveillance: prevalence of malnutrition/focus on specific group of patients
Nutrition surveillance became standard practice when the prevalence of malnutrition was noted to be worldwide. [3-7] Knowing who the normal and malnourished patients admitted in the hospital made better appreciation of what to further provide for the patients while they are either for wellness or for disease management. Awareness of who the “nutritionally at risk” patients are made care of these patients better through prioritization of services and inclusion of nutrition in the whole patient care process. Computerizing the whole process has made the whole process more comprehensive and sustainable. [33] The whole process is run effectively by a nutrition support team (NST) as shown in two private tertiary care hospitals in the Philippines. [39]

b) Nutritional assessment and risk levelling of patients identified to be “at risk”
Performing nutritional assessment and risk levelling of patients especially surgical patients has made it possible to actually predict post-operative complications as shown by a recent study done in the Department of Surgery in Chinese General Hospital. [12]

c) Nutrition management in critical care improved by the NST:
The development of the NST has identified the problems of poor intake of ICU geriatric patients, which was not identified before, [34] and the NST has made an improvement in the critical care patients’ intake compared to the set up without an NST [35]. This was corroborated by a recent survey of nutrition in critical care patients done in an international setting. [17] Even the nutrient intake in pediatric intensive unit (PICU) patients was shown by the NST to be inadequate [36] thus making the issue of inadequacy of intake in critical care something to be looked into. It may be more frequent than previously thought.

d) Improvement of nutrient intake in the “nutritionally at risk” patients:
The capability of the NST to improve the intake of “nutritionally at risk” geriatric and pediatric patients is due to the implementation of a nutrient monitoring system which enables daily calorie counts and nutrient balances, thus making all caregivers aware of the patient’s nutritional status and intake. [33] A report given at the PENSA congress in Manila in 2007 showed the NST was able to improve the poor intake of ICU patients and immediately place the patients’ intake at adequate levels or 75% of the computed requirements. [36] Another reason why intake improved was due to the reduction of NPO or “nothing per orem” orders and immediate resumption of diet once the indication for NPO was addressed. [37]

e) Reduction in hospital costs due to improvement of outcome due to nutrition management of both patient body composition and nutrition services:
Cost evaluation through comparison in malnourished and well nourished patients showed decreased cost in patients with pneumonia, intestinal surgery, and post-surgical complications. [15] Parenteral nutrition is expensive, however, when a nutrition support team is involved, the costs related to its preparation and use decreased. [22]

f) Standardization of forms for use in the nutrition management process: Standard forms have been designed by PHILSPEN and validated by members of the NST committee of the society with the main goal of computerizing the data gathering process in all areas of the nutrition support process (like malnutrition surveillance, profiling of admitted patients, cost effective assessment, and other nutrition related data). [12,16] All of this information will guide PHILSPEN and interested persons or societies in making decisions or recommendations on policies or strategies that will improve the lot of the hospitalized and eventually the intermediate/home care patient. [47]


The value of the clinical nutrition program and NST presence in the hospital setting:

In summary, the ability to identify the “nutritionally at risk” patient early in the management phase and to predict complications due to risk levelling tools make the NST and the clinical nutrition program valuable preventive measures that would avoid any untoward problems that arise out severe malnutrition or poor nutrition management. Active inclusion of nutrition in the course of the patient management would also be more of benefit to the patient rather than a liability. [24,25] Every hospital, therefore, with a viable clinical nutrition program will have the following impact on patient care: preventive and interventional services, “best practice”, and cost effectiveness.

The next realization is, in order to be effective, the program needs to be run by people who are trained and certified to be competent in the practice of clinical nutrition. Fortunately there are two areas where these people can be trained: the clinical nutrition fellowship training program mainly for physicians at St. Luke’s Medical Center (established in year 2001) [29] and the Master of Science in Clinical Nutrition in Philippine Women University (started in year 2006) [38]. Early this year (2009), the credentialing body for clinical nutrition, Philippine Board of Clinical Nutrition or PBCN officially credentialed the first batch of Diplomates in Clinical Nutrition. [30]

The role of the PHILSPEN and clinical nutrition fellowship training program:

After year 2008 the number of NST’s in the Philippines increased dramatically to 18 or 22% (18 out of the 83 hospitals that need NST’s in the Philippines, Figure 2). [38] This is the result of the efforts of PHILSPEN in partnership with the medical nutritional companies in the Philippines.


The following accomplishments came out of this 10-year collaboration:

1. Development of a nutrition surveillance system: Through the initiative of PHILSPEN, a simplified nutrition screening tool was developed to screen all patients admitted to the hospital who are “nutritionally at risk”. A list of these patients is given to the NST which follows up these patients. Nutritional assessment is done to determine which patients are “low, moderate, or high risk” and the necessary recommendations are given. The form used was also developed by PHILSPEN based on the Subjective Global Assessment tool, which was validated for use internationally. [2] Forms for adult and pediatric patients are available from the PHILSPEN website. [26] For the hospitals which can afford, computerization of nutrition surveillance can be done as shown by a private hospital in the Philippines. [33] The nutritional assessment form was validated and it was found to be easy to use and predicted complications well. [12,16]

2. Nutrition intervention: defining the components of the nutrition care plan and implementing these has led to better nutrient delivery to the “nutritionally at risk” patients. A key factor is the use of “easy to use” forms which show the percentage intake of the patient thus guiding the attending MD on the status of nutrition management of his patient. Two studies done by the NST showed inadequate intake in geriatric patients in the ICU [34], which improved when the NST took over [35].

3. Increased awareness of the value of nutrition support: As more studies with positive outcomes of nutrition in disease management came up, the following responses, from plans to actual implementation, by the medical staff, professional groups, and medical nutrition industry have arisen: a) workshops in nutrition support were done throughout the country (FRANC workshops of Fresenius Kabi Asia Pacific, TNT of Abbott Nutrition International, Aesculap of BBraun, and IONS of Nestle Philippines), b) clinical nutrition policy and guidelines were adopted in hospital departments, c) more focus on follow up of patients with nutrition related problems like documenting impact of nutrition support on patient care was accomplished, d) workshops in nutrition support are now sponsored by other medical professional societies (practice focused), and e) implementation talks for pediatric clinical nutrition training.

4. Credentialing: programs that equip NST members to deliver “optimum” nutrition care delivery to the patient through training and credentialing are now available. First, a two year Clinical Nutrition Fellowship training program designed for physicians was established in St. Luke’s Medical Center [29]; second, a 33 unit Master of Science in Clinical Nutrition designed for the multidisciplinary clinical nutrition team was set up as a Philippine Women’s University – St. Luke’s Medical Center partnership [38]; and third, the establishment of the Philippine Board of Clinical Nutrition, which credentialed the first batch of Diplomates of the Philippine Board of Clinical Nutrition (PBCN) was done. [30]

5. Sustainability of the NST and clinical nutrition practice in the health care institutions: The involvement of hospital administration in making NST and nutrition support a standard component of patient care will definitely put everything in place. Installing the following systems would further reinforce the process: a) Reimbursement of the services and nutritional products given to the patient through the national health insurance system (PHILHEALTH) and National Formulary, b) cooperative ventures between the hospitals, PHILSPEN, and the medical nutritional industry in the area of continuing education programs, research, and services improvement, and c) to professionalize the program by only allowing personnel with master’s or diplomate titles to head or supervise these nutrition care services.

The role of Philippine Women’s University and Master of Science in Clinical Nutrition [38]

With the realization that the practice of clinical nutrition requires more advanced learning in both basic nutrition and hospital based practice, a new master of science in clinical nutrition course was developed in collaboration with the St. Luke’s Medical Center Clinical Nutrition Fellowship Training Program. This 44 unit course was designed for physicians, dietitians, nurses, and pharmacists. Even non-nutrition related graduates who are interested in clinical nutrition management or medical nutrition business could also enrol in this program. The focus is on hospital based clinical nutrition practice thus full involvement in medical decision making and treatment is included in the curriculum. Nutrition is therefore integrated in the total patient care process. Graduates of the program are trained to be competent in the following areas: management of the clinical nutrition program, implementation of the program, NST development, and administrative functions especially in the clinical nutrition department.


In conclusion, malnutrition in the hospital is a major health issue that needs to be addressed since it involves social responsibility, professional competence, and financial accountability of the hospital industry of the Philippines. It needs a structured clinical nutrition program to be able to meet the problem effectively and an NST to run the whole program efficiently. The evidence regarding the value of NST is solid and as currently realized in the hospital, institutions all around the world (as expressed by the mother societies in the specific continents: US, Europe, Asia, and the Americas including Australia) [40-44], it needs to be implemented in all hospitals if possible.

We therefore recommend the following action points:

a) To have a clinical nutrition program set up in every health care institution in the Philippines, especially hospitals, which becomes a realistic goal if it comes with an implementation order and supervision from the government, specifically the Department of Health,

b) To require an NST in every hospital in order to make the program run effectively nationwide,

c) To have the NST be composed of a multidisciplinary team with the following composition: physician, dietitian, nurse, and pharmacist all of who have been designated specific credentialing by the Philippine Board of Clinical Nutrition.



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Introduction | Conclusion/Recommendation | References | Back to Total Names Codes