AUTHORS:

The Unrisk Study Group, Philippine Society of Parenteral and Enteral Nutrition

INSTITUTIONS WHERE RESEARCH WAS CONDUCTED:

Selected government and private hospitals in the Philippines (See List of Participating Hospitals in Appendix A)

 

ABSTRACT | Back

Background: Hospital malnutrition still exists and there is a need to identify the factors that lead to this problem in the Philippines.

Objective:

1. To determine the prevalence of malnutrition in selected hospitals in the Philippine
2. To determine which of the hospital population is/are at risk of underfeeding? Are the statistics similar in either private or government institutions?
3. To determine key factors that contribute to hospital malnutrition

Methodology: A one-day survey on the status of nutrition in hospitalized patients was designed by members of PhilSPEN in partnership with a medical nutrition company in the Philippines. It was called the “UNRISK Survey”. Essential data are the following: body mass index, calorie and protein counting. Underfeeding was pegged at 60% of computed intake. Statistical analysis used were percentages, T-Test or Wilcoxon test for numerical data and significance was pegged at p < 0.05.

Results: 47 hospitals participated in the study (85% private and 15% government) covering 1,927 patients. BMI: underweight = 246 (13%), normal = 1,058 (55%), overweight = 452 (23%), obese = 171 (9%). Malnutrition rate in the participating hospitals: 417/1,927 or 22%.  Malnutrition rate government hospitals = 66/288 or 22.9%; in private hospitals = 359/1,549 or 23.2%; There were more underweight patients in the government hospitals and more overweight and obese patients in the private hospitals. 74% of underweight patients had intake < 60%; weight loss was present in 39% loss of intake in 50% of patients and chewing/eating difficulties in 21%. Underfeeding rate in private hospitals was 25.4% versus 22.9% in government hospitals.

Conclusion: The “UNRISK” tool has shown the following: prevalence of hospital malnutrition is 22% with 12% to18% underweight, 74% of underweight patients had intake less than 60% of calculated and 39% of all patients had weight loss before and during hospital admission.

KEYWORDS: Body mass index, BMI, unrisk, hospital, malnutrition, underfeeding

INTRODUCTION | Back

Malnutrition and underfeeding are identified factors that contribute to poor outcomes in hospitalized patients. [1-3] In the Philippines this observation was also noted not only by the local nutrition groups, but also by the medical nutrition industry. [4,5] Ten years after the first publication of the prevalence of malnutrition in the hospital in the Philippines [6] PhilSPEN and Abbott Nutrition Philippines reached the conclusion that there was a need to update on the current status of nutrition care among hospitalized patients. These partnered to do a nutrition survey project on hospitalized patients, including the out-patient department, throughout the country.

These are the issues that were raised: 1) What is the prevalence of underweight patients admitted in the hospital and in the out-patient department based on the BMI (Body Mass Index)? 2) Are there more malnourished patients in the government hospitals compared to the private hospitals? 3) Is there underfeeding in the hospitals today? Which patient population is at risk of underfeeding? 4) Is the food intake in the government hospitals less than in private hospitals? Regarding the outpatient department: 1) Under which subspecialty is the incidence of underfeeding greatest? 2) Which department has the least underfed patients? On the issue of obese and non-underweight patients: 1) Are there underfed obese patients? 2) Are there more at risk patients who are otherwise billed as normal (=BMI between 18.5 and 30) as shown from short term unintentional weight loss, decreased food intake, difficulty in eating/swallowing, or actual intake as measured by the plate method? [7]

METHODOLOGY | Back

A one-day survey on the status of nutrition in hospitalized patients was designed by members of PhilSPEN in partnership with Abbott Nutrition Philippines. This was dubbed the “UNRISK Survey”.  The final “UNRISK” questionnaire is shown in Figure 1. It had the following questions: A) Did you experience weight loss unintentionally within the past three (3) months? B) Did you have decreased food intake for the past three (3) months? C) Do you often have difficulty eating/chewing or swallowing food? D) Which of these plates best represent your usual daily food intake? (Figure 2)

The survey process from identification of the participating institutions to the final synthesis of the survey results is shown below. (Figure 3)

RESULTS | Back

1. Profile of participating hospitals: (See Appendix A for complete list of participating hospitals)

• Overall hospital profile (Table 1)

2. Patient profile based on BMI groups and type of hospital (Table 2)

Table 2: BMI in government or private hospitals



Legend: gov_med: medical patients in government hospitals; gov_surg: surgical patients in government hospitals; priv_med: medical patients in private hospitals; priv_surg: surgical patients in private hospitals | UW=underweight, NOR=normal, OW=overweight, OB=obese

• Government Hospitals (n=7 or 15% of total)

  • Patients covered: (medical, n=146; surgical, n=142; Total=288)
• Private Hospitals profiles (n=40 or 85% of total)

  • Patients covered: (medical, n=888; surgical, n=661; Total=1,549)

3. BMI profile of patients in the different institutions:

• Private or government hospitals (Figure 4)

There are more underweight patients in the government hospitals while there are more overweight and obese patients in the private hospitals.

• Medical and surgical patients (Table 3)





• Overall there are more underweight than obese patients in the hospital population (13% versus 9%, Figure 5).

4. Quality of Information Obtained (Table 4)

• In the overall context the quality of information obtained from all institutions were quite high (97% to 98%) indicating good compliance in data encoding and submission.

5. BMI and Food Intake:

• Inadequate intake in medical patients (Table 5)





• Inadequate intake in surgical patients (Table 6)





The above data on BMI and actual intake (Tables 5 and 6, Figures 6 and Figure 7) show that the underweight patients had the most number of inadequate intake (< 60% and <40%). This is happening in both medical and surgical cases.

6. Answers to Questions #1 to #3 of the "Unrisk" Survey:  (Table 7)

These data (Figure 8) contributed to the worsening nutritional status of all admitted patients whether medical or surgical:

1. weight loss (=39%)
2. loss of appetite or loss of intake (=50%)
3. feeding difficulty like chewing (=21%)

7. Results to Question #4 - patients with intake of 60% or less compared to computed requirements

This graph (Figure 9) shows that 74% or 2/3 of all underweight patients had intake less than 60% before and while in the hospital. This is less in normal BMI and overweight patients. Patients who are least underfed are the obese (34%).

8. Summary Observations on the Hospital In-Patients:

• One in ten (1/10) or 10% of all in-patients is underweight.
• Two in ten (2/10) or 20% of all in-patients have difficulty chewing and swallowing their food.
• Four in ten patients (4/10) or 40% of all in-patients have unintentional weight loss.
• Five in ten (5/10) or 50% of all in-patients have decreased food intake.
• Seven out of ten (7/10) or 70% of all underweight patients have intake 60% or less while in the hospital.

9. Out Patient Department (OPD) Patients

• Outpatient “UNRISK” Study focuses on which subspecialty are patients underfed



• Observations:
• Most of the patients surveyed were from the internal medicine section with the cardiology patients (35%) numbering the most responses.
• Most of the underfed underweight BMI patients were from the general practice and rheumatology sections.
• Surgical and general practice patients were the most underfed in the normal BMI group.
• Most of the underfed overweight BMI patients were from the pulmo and surgery sections.
• The least number of underfed patients were from the obese BMI group.

 

DISCUSSION: | Back

All data gathered from the participating hospitals comprise almost 98% of the data requirements thus indicating robustness of the data and information collected. (Table 4) There were fewer government hospitals compared to the private hospitals which participated in the survey (15% versus 85%) indicating that the interest of private institutions in updating themselves in the practice of clinical nutrition in the hospital setting is of a higher level compared to that of the government sector. (Table 1 and 2)

These are the issues clarified by the “UNRISK” survey: underweight patients, nutritional status in the hospital and out-patient department and finally quality and quantity of intake within the hospital population.

Prevalence of malnutrition: (Tables 1, 2 and 3, Figure 4)
Defining malnutrition as the combination of underweight and obese, this is the malnutrition rate in the participating hospitals: 417/1,927 or 22%.  In the government hospitals it is 66/288 or 22.9% while in the private hospitals it is 359/1,549 or 23.2%; there is not much difference as far as the overall malnutrition rate is concerned. This is due to the higher prevalence of malnourished medical patients in the private hospitals (=208/888 or 23.4%), and a higher prevalence of malnourished surgical patients in the government hospitals (=38/142 or 26.8%).

Prevalence of underweight patients:
The survey showed that, based on the BMI, the prevalence of underweight patients ranged between 12% to 18% within the hospital population. These are the data: government-medical = 14%, government-surgical = 18%; private–medical = 12%, private-surgical = 14%. There are more underweight patients in the government hospitals compared to the private hospitals: medical = 14% versus 12% and surgical = 18% versus 14%) (Figure 4 and Tables 2 and 3).

In the out-patient department it is the degree of inadequate intake at 60% or below which is utilized to determine which departments have the worst patient population. (Table 8) Among the underweight patients the highest underfed group was in the General Practice, Rheumatology and Family Medicine departments. In the normal BMI group the worst fed were in the Surgery, General Practice, Cardiology and Pulmonology departments. In the overweight BMI group the most underfed were in the Pulmonology, Surgery, Family Medicine and Cardiology departments. The obese BMI group had the lowest number of underfed patients

Food intake and prevalence of underfeeding in the hospitals: (Tables 5, 6 and Figures 6, 7 and 9)
In the government hospitals the underfeeding rate of 60% or less among medical patients is 34/146 or 23.3%; among surgical patients it is 32/142 or 22.5%; total underfeeding of 60% or less is 66/288 or 22.9%. In the private hospitals the underfeeding rate of 60% among medical patients is 239/848 or 28.2%; in the surgical patients it is 145/661 or 21.9% while the total underfeeding rate of 60% is 384/1509 or 25.4%.

In the private medical hospitals underfeeding by 60% intake is highest in the underweight group (=38.1%), next is the normal (=26.4%), then the overweight (=22.2%). It is quite high in the obese (=27.2%). In the private surgical groups underfeeding by 60% is highest in the underweight (=29.2%), followed by the normal (=26.5%), then the overweight (=12.4%), and obese (=13.6%). In the private hospitals it is the underweight which has the highest risk of underfeeding.

In the government hospitals the BMI group with the risk of underfeeding of 60% among medical patients is the underweight (=9.5%), with the normal having the highest at 26.9%, overweight at 24% and obese at 14.3%. In the surgical group underfeeding of 60% or less is highest among the underweight (=46.2%), in the normal it is 16%, in the overweight it is 17.4% and the obese 16.7%. In the government hospitals it is also the underweight which has the highest risk of underfeeding.

Surprisingly the underfeeding rate of 60% or less is higher among the private hospitals compared to the government hospitals (25.4% versus 22.9%) debunking the common observation that there is less food provided in the government hospitals. However, it is all about the patient’s capacity to eat, not the amount of food on the plate.

Underfeeding in the outpatient department: (Table 8)
Underfeeding is greatest in the Surgery and General Practice department, particularly among the normal (47%), in the Cardiology, Pulmonary and Gastroenterology department, underfeeding is also higher among the normal (46% and 43%), in the Internal Medicine and Neurology department, underfeeding is also high among the normal (41% and 39%). In the General Practice department, underfeeding is highest particularly among the underfed (38%) and in the Pulmonary department, it is highest among the overweight (27%). The departments with the least underfed patients were in the General Practice and Rheumatology particularly among the obese. Essentially the obese patients had the least underfeeding problems regardless of the department involved.

Factors that contribute to increased malnutrition in the hospital setting:
There is a need to closely follow up the underweight patients since these are the ones who will get more malnourished as they stay in the hospital. Firstly, they are the ones who don't eat adequately (only reaching 60% of requirements) and secondly, they are the ones who had the least intake (based on the plate method. Figure 9) The need for closer monitoring of intake is also pointed out by the data which show underfeeding in all BMI groups ranging between 20% and 40% in medical and surgical patients. Finally unintentional weight loss is documented by the survey to be present in 39% of all patients, loss of intake/appetite in 50% of patients and factors that impeded intake like chewing or swallowing difficulties in 21% of patients. (Figure 8) Awareness of this information will help in developing approaches in preventing or addressing malnutrition in the hospital setting.

CONCLUSION: | Back

The “UNRISK” tool has shown the risk of underfeeding in the hospital in-patient and out-patients and helped identify factors that will lead to the development of patient malnutrition in the hospital hospital. These are the main findings: prevalence of hospital malnutrition is 22% with 12% to18% underweight, 74% of underweight patients had intake less than 60% of calculated and 39% of all patients had weight loss before and during hospital admission.

REFERENCES: | Back

1. 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. PhilSPEN Online Journal of Parenteral and Enteral Nutrition; Issue January 2010 - January 2012: 42-54. Available at: http://www.dpsys120991.com/POJ_0017.html. Accessed August 12, 2015.
2. Ocampo R B, Camarse CM, Kadatuan Y, et al. Predicting post-operative complications based on surgical nutritional risk level using the SNRAF in colon cancer patients - a Chinese General Hospital & Medical Center experience. Phil J Surg Spec 2008; 63 (4): 147-53. Available at http://www.dpsys120991.com/POJ_0012.html. Accessed August 12, 2015.
3. Cederholm T, Jägrén C, Hellström K. Outcome of Protein-Energy Malnutrition in Elderly Medical Patients. Am J Med 1995; 98: 67-74.
4. The practice of clinical nutrition in the Philippines: from the 1980's to 2010. PhilSPEN web site. Available at: http://www.dpsys120991.com/history.php. Accessed August 12, 2015.
5. First hospital nutrition state of the art summit: Abbott Nutrition. Available at http://anhi.org/articles/1st-hospital-nutrition-state-of-the-art-summit-manila-philippines. Accessed July 18, 2015.
6. Fernando R and Llido LO. Prevalence of malnutrition in a tertiary care hospital in Metro-Manila. PhilSPEN Online Journal of Parenteral and Enteral Nutrition. http://www.dpsys120991.com/1_Fernando_Llido_et_al.pdf. Accessed August 12, 2015.
7. The Plate Method. Available at: http://dtc.ucsf.edu/pdfs/PlateMethod.pdf . Accessed August 13, 2015.

Appendix A: List of all participating hospitals in the "UNRISK" Survey | Back to Results

Abstract | Introduction | Methodology | Results | Discussion | References | Back to Total Names Codes