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

BACKGROUND & AIMS: To improve hospital health care delivery by identifying malnutrition in all admitted patients and following up those identified to be malnourished and "at risk of developing malnutrition" a hospital nutrition support program based on the JCAHO system was initiated in 1999. Two major problems were encountered: first, the inability to perform a nutrition surveillance process due to failure by the staff to implement existing nutrition screening tools and second, the lack of awareness and support from the medical staff in this initiative. Two solutions were implemented in 2000: computerization of the nutrition screening and nutrition support process and synchronizing this with the whole nutrition support program. METHODS: A computer program was developed which performs BMI-based nutrition screening, produces lists of all malnourished patients, and computes the different formulas for either nutritional requirement or parenteral and/or enteral formulation. It also generates patient status reports based on encoded data from the nutrition support team, which prioritized these patients for management based on the data output. RESULTS: From 2000 to 2003, improvement was seen in these areas: entry of height and weight in the patient record increased from 30% to 90%; nutrition surveillance shows nutritional status distribution to be: normal (58%), underweight (9%), overweight (25%), and obese (8%), referrals to the nutrition support team based on the screen notification increased from 37% to 100%, patient coverage by nutrition support services increased from 7374 (38.8%) in 2000 to 11,369 (83%) in 2003, and critical care patients seen increased from 10% in 2000 to 99% in 2003. More improvement is needed in physician response to nutrition support recommendations, which still remains low (11.2-24%). CONCLUSIONS: Computerization helps to improve nutrition support delivery in the hospital, but more cooperation and support from the medical staff is still needed for better results.     

Integrated NHANES: uses in national policy

The National Nutrition Monitoring and Related Research Program (NNMRRP) arose from Congressional concern about lack of information regarding the occurrence in the American population of undernutrition and diet-related risk factors for chronic diseases. Congressional appropriations and executive branch decisions about budget priorities have been the major determinants of the scope and number of nutrition monitoring surveys and surveillance activities fielded and therefore the information available for policy and research uses. The nutrition data collected in the NNMRRP are used by federal agencies, the private sector and academia for a variety of purposes, including public policy (e.g., development and evaluation of monitoring and surveillance, regulatory and nutrition programs), normative standards (e.g., growth charts, reference data for hematological and biochemical indicators of nutritional status or Dietary Reference Intakes) and research (e.g., cross-sectional, longitudinal and time-trends studies of dietary and nutritional status, health status, disease morbidity and mortality). Although the importance of the NNMRRP to national policy is difficult to quantify, in a 5-y period 97 proposed and final regulations citing NNMRRP data were published in the Federal Register by federal agencies responsible for nutrition and food safety programs. The NNMRRP-derived dietary and nutritional status data are essential information for quantitative risk assessments increasingly relied on by regulatory agencies as the basis for programmatic decisions and regulations development. Users of NNMRRP data in government agencies, academic institutions and the private sector have come to recognize the value of data from the surveys and surveillance systems for a wide variety of programmatic and research purposes.     

Research needs for human nutrition in the post-genome-sequencing era.

The sequencing and annotation of the human genome and the genomes of other model organisms offer new tools and new opportunities for human nutrition research in the 21st century. Basic research continues to be the key foundation for formulating solid nutrition recommendations for the public, but the basis for establishing human nutrient recommendations today suffers because of lack of good biomarkers and because of weak federal funding for nutrition research. In the context of this post-human genome-sequencing era, tantalizing opportunity exists in seven areas-four basic and three applied: 1) identification of molecular biomarkers for nutrient status; 2) characterization of single polynuclear polymorphisms (SNPs) associated with nutrition; 3) development of a national genome array nutrition database; 4) use of models at all phylogenetic levels for nutrition research; 5) application of post-genome-sequencing tools to study diet and human health, including phytonutrients and genetically modified foods; 6) application of these tools to the role of nutrition in pathogenesis of human disease; and 7) development of a funding base for research on exercise and human health.     

Need and Importance of Nutrition Informatics in India: A Perspective

Nutrition informatics (NI) is the effective retrieval, organization, storage, and optimum use of information, data and knowledge for food-and-nutrition-related problem-solving and decision-making. There is a growing opportunity to facilitate technology-enabled behavioral change interventions to support NI research and practice. This paper highlights the changing landscape of food and nutrition practices in India to prepare a NI workforce that could provide some valuable tools to address the double burden of nutrition. Management and interpretation of data could help clarify the relationships and interrelationships of diet and disease in India on both national and regional levels. Individuals with expertise in food and nutrition may receive training in informatics to develop national informatics systems. NI professionals develop tools and techniques, manage various projects and conduct informatics research. These professionals should be well prepared to work in technological settings and communicate data and information effectively. Opportunities for training in NI are very limited in developing countries. Given the current progress in developing platforms and informatics infrastructure, India could serve as an example to other countries to promote NI to support achieving SDGs and other public health initiatives.     

Malnutrition in the critically ill child: the importance of enteral nutrition

Malnutrition affects 50% of hospitalized children and 25-70% of the critically ill children. It increases the incidence of complications and mortality. Malnutrition is associated with an altered metabolism of certain substrates, increased metabolism and catabolism depending on the severity of the lesion, and reduced nutrient delivery. The objective should be to administer individualized nutrition to the critically ill child and to be able to adjust the nutrition continuously according to the metabolic changes and evolving nutritional status. It would appear reasonable to start enteral nutrition within the first 24 to 48 hours after admission, when oral feeding is not possible. Parenteral nutrition should only be used when enteral nutrition is contraindicated or is not tolerated. Energy delivery must be individually adjusted to energy expenditure (40-65 kcal/100 calories metabolized/day) with a protein delivery of 2.5-3 g/kg/day. Frequent monitoring of nutritional and metabolic parameters should be performed.     

A potential role of anti-poverty programs in health promotion

Poverty is one of the most pervasive risk factors underlying poor health, but is rarely targeted to improve health. Research on the effects of anti-poverty interventions on health has been limited, at least in part because funding for that research has been limited. Anti-poverty programs have been applied on a large scale, frequently by governments, but without systematic development and cumulative programmatic experimental studies. Anti-poverty programs that produce lasting effects on poverty have not been developed. Before evaluating the effect of anti-poverty programs on health, programs must be developed that can reduce poverty consistently. Anti-poverty programs require systematic development and cumulative programmatic scientific evaluation. Research on the therapeutic workplace could provide a model for that research and an adaptation of the therapeutic workplace could serve as a foundation of a comprehensive anti-poverty program. Once effective anti-poverty programs are developed, future research could determine if those programs improve health in addition to increasing income. The potential personal, health and economic benefits of effective anti-poverty programs could be substantial, and could justify the major efforts and expenses that would be required to support systematic research to develop such programs.     

Measures of food insecurity/security

ABSTRACT Nutrition education has the potential to play an important role in ensuring food security and improving nutritional status. Therefore, food security is recommended for inclusion in nutrition education evaluation efforts. Considerable progress has been made in developing brief tools that can be used to measure food security at the household level. These tools are reliable in population-based surveys, and some studies have found that measures of food security are associated with nutrient intake. Hence, these tools can be valuable in monitoring, in community needs assessment, and in planning. These tools may also have the potential for use in evaluating nutrition education activities; this potential will be enhanced by research into the capacity of these tools to identify changes within households over time as a result of nutrition education and their sensitivity and reliability in doing so.     

Forty years of USAID health cooperation in Bolivia. A lose–lose game?

The present article proposes an analysis of the USA–Bolivia relationships in the health sector between 1971 and 2010 based on a grey and scientific literature review and on interviews. We examined United States Agency for International Development (USAID) interventions, objectives, consistency with Bolivian needs, and impact on health system integration. USAID operational objectives—decentralization, fertility and disease control, and maternal and child health—may have worked against each other while competing for limited Ministry of Health resources. They largely contributed to the segmentation and fragmentation of the Bolivian health system. US cooperation in health did not significantly improve health status while the USAID failed to properly tackle anti‐drugs, political, and economic US interests in Bolivia. Copyright © 2012 John Wiley & Sons, Ltd.     

Thérapeutique nutritionnelle chez l'hémodialysé

Malnutrition is common among hemodialysis patients and increases morbidity and mortality rates in this setting. Food intake may be improved when impaired gastric emptying or bacterial growth in small intestine are found and treated. The use of megestrol, an appetite stimulant, has been studied in few patients only. In several studies, nutritional oral supplements have been shown to improve nutritional markers. However, these studies have separately used amino acids or energy supplements with inadequate methodology. Moreover, no data are available for the evolution of morbidity and mortality of hemodialysis patients using such treatments. Intradialytic parenteral nutrition (IDPN) improves appetite and the nutritional status of the patients. According to retrospective data, it improves the morbidity and mortality rates. The choice of the patients who may benefit from this expensive treatment depends on precise nutritional criteria. The dialysate itself may be used as a nutritional fluid. Amino acid delivery through this route is possible, but only preliminary data are available. Hence several treatments to improve malnutrition in hemodialysis patients do exist and must be used. Active research remains necessary in this field to forestall malnutrition.     

Linking evaluation and program development. The case of AHCPR-supported clinical practice guidelines

Within a research organization such as the Agency for Health Care Policy and Research (AHCPR), the process of evaluating program performance must often be integrated with a larger research and development agenda. The blending of evaluation and program development (research and development activities undertaken to build expertise and knowledge in a specific programmatic area) can both strengthen the quality of a program and enhance the science of evaluation research. This article describes AHCPR's evaluation strategy and highlights evaluation activities for the agency's clinical practice guideline program. A case study is presented to illustrate the unique methodological challenges in guideline evaluation, the creation of new tools and approaches for evaluating clinical quality, and the benefits of linking evaluation research with program development.     

Calcium Supplementation to Prevent Preeclampsia: Translating Guidelines into Practice in Low-Income Countries

The WHO issued a strong recommendation that pregnant women be provided calcium supplements to prevent preeclampsia. This is the first recommended nutritional intervention to prevent this condition, a leading cause of maternal mortality globally. As health systems seek to implement this new intervention, a number of issues require further clarification and guidance, including dosage regimen, supplement formulation, and alignment with other antenatal nutritional interventions. We summarize key evidence on the above points and offer our views on good practices. Most developing countries have low calcium intake, so where habitual calcium intake is unknown, calcium supplements are likely beneficial. In our view, policymakers and program planners should consider adopting doses between 1.0 and 1.5 g elemental calcium/d, depending on the local average and variation in dietary calcium intake, logistical feasibility, and acceptability in the target population. Prudent practice would entail daily administration as calcium carbonate administered in divided doses of not >500 mg elemental calcium per dose. For ease of prescribing and adherence, calcium [as with iron and folic acid (IFA)] should be administered routinely to pregnant women from the earliest contact in pregnancy until delivery. Calcium’s acute inhibitory effect on iron absorption translates to minimal effects in clinical studies. Therefore, to simplify the regimen and facilitate adherence, providers should not counsel that calcium and IFA pills must be taken separately. Although further research will shed more light on clinical and programmatic issues, policies can be implemented with ongoing revision as we continue to learn what works to improve maternal and newborn health.     

Nutritional impact of acquired immune deficiency syndrome: a unique counseling opportunity

The acquired immune deficiency syndrome (AIDS) presents a challenge for dietitians. Changes in the immune system have a potentially detrimental effect on nutritional status as a result of conditions such as anorexia, infection, diarrhea, and drug side effects. Conversely, poor nutrition status may adversely alter the immune systems. Dietary guidelines for the management of these conditions and additional obstacles are discussed. When counseling patients with AIDS, the dietitian needs to be aware of and sensitive to alternative therapies, to evaluate their effectiveness, and to assist in determining their place in the patient's treatment. Psychosocial factors that could influence nutritional status, such as dementia, unemployment, and isolation, must also be taken into consideration. A nutrition program has been established to address the needs of AIDS patients at AIDS Project Los Angeles-Necessities of Life Program (APLA-NOLP), a food distribution center. The goal of the program is to maintain or improve the client's nutritional status by providing education and counseling. The nutrition program has been enthusiastically received, and the outcome of the program on the nutritional status of the participants is currently under study. The dietitian is in a unique position to intervene by providing resource information, food preparation tips, and individualized nutrition plans. It is imperative that the dietitian become familiar with the AIDS disease process and its implications for nutritional status to be considered an expert in the nutrition management of such patients.     

Clinical nutrition in danish hospitals: a questionnaire-based investigation among doctors and nurses.

Specific nutrition standards are now developed by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in order to improve the nutritional status in hospitalized patients. We investigated the use of clinical nutrition in Danish hospitals and compared it with the standards of JCAHO by doing a questionnaire-based investigation among doctors and nurses randomly selected in 40 hospitals including internal medicine, gastroenterology, oncology, orthopedic departments and intensive care units (ICU).Overall, 857 (43.4%) responded to the questionnaire (doctors: 395, nurses: 462). Seventy-seven percent stated that nutritional assessment ought to be performed on admission, but only 24% stated that it was a routine procedure. Forty percent found it difficult to identify risk-patients, and 52% needed specific screening tools. Twenty-two percent registered body weight in all patients, and 18% registered nutrient intake routinely. Eighty-four percent found that a nutrition plan should be described in the patient record, but 39% found it difficult to set up an individual plan, and 79% expressed a need for specific guidelines. Eighty-four percent would only accept a patient being on isotonic glucose and/or electrolyte infusion for < 5 days (42% for < 2 days), and 33% would only accept a weight loss of 5% before active nutrition was initiated. About 50% would be restrictive in supplying enteral or parenteral nutrition to patients with impaired liver or kidney function. Twenty-seven percent did not use active nutritional therapy at all. Seventy-six percent found that nutritional assessment should be performed during hospital stays, but only 23% monitored the nutritional status. Sixty-eight percent stated that responsibility should be assigned to one or more persons, but this was the case in only 20%The use of clinical nutrition in Danish hospitals did not fulfill the standards for nutrition support according to the criteria established by JCAHO. Special efforts should be aimed at education, specific screening tools and introduction of guidelines in clinical nutrition.     

Managing clinical integration in integrated delivery systems: a framework for action

An integrated delivery system (IDS) in healthcare must coordinate patient care across multiple functions, activities, and operating units. To achieve this clinical integration, senior management confronts many challenges. This paper uses a cross-functional-process (CFP) framework to discuss these challenges. There are ten CFPs that fall into three categories: planning processes (strategy formulation, program adaptation, budget formulation), organizational processes (authority and influence, client management, conflict resolution, motivation, and cultural maintenance), and measurement and reporting processes (financial and programmatic). Each process typically spans several functional units. Senior management must consider how to improve both the functioning of each CFP, as well as its "fit" with the other nine. The result can be greater clinical integration, improved cost management, and more coordinated care for enrollees.     

Improving results for nutrition: a commentary on an agenda and the need for implementation research

Research and implementation often exist in separate worlds. To improve results for nutrition, the nutrition research community needs to go beyond "what" works to understand "how" it works. If they do not, nutrition research risks becoming irrelevant to the needs of those who actually make policies and implement programs. Researchers must prioritize research on effectiveness of policies and programs. They should incorporate knowledge and tools of social sciences, including economics, sociology, political science, and management into their work. They should pay greater attention to environmental and institutional variables and understand change strategies, knowledge utilization, and policy processes. Fundamentally, research on implementation should use a systematic approach to produce generalizable evidence and conceptual models, tools, and methods that are communicated effectively to policymakers and programmers. Nutrition researchers need not expand far beyond their disciplinary comfort zone to do this, but they do need to build bridges with other fields to have greater success in addressing nutritional challenges.     

Is Institutional Delivery Protective Against Neonatal Mortality Among Poor or Tribal Women? A Cohort Study From Gujarat,India

Objectives In low-income settings, neonatal mortality rates (NMR) are higher among socioeconomically disadvantaged groups. Institutional deliveries have been shown to be protective against neonatal mortality. In Gujarat, India, the access of disadvantaged women to institutional deliveries has increased. However, the impact of increased institutional delivery on NMR has not been studied here. This paper examined if institutional childbirth is associated with lower NMR among disadvantaged women in Gujarat, India. Methods A community-based prospective cohort of pregnant women was followed in three districts in Gujarat, India (July 2013–November 2014). Two thousand nine hundred and nineteen live births to disadvantaged women (tribal or below poverty line) were included in the study. Data was analyzed using multivariable logistic regression. Results The overall NMR was 25 deaths per 1000 live births. Multivariable analysis showed that institutional childbirth was protective against neonatal mortality only among disadvantaged women with obstetric complications during delivery. Among mothers with obstetric complications during delivery, those who gave birth in a private or public facility had significantly lower odds of having a neonatal death than women delivering at home (AOR 0.07 95% CI 0.01–0.45 and AOR 0.03, 95% CI 0.00–0.33 respectively). Conclusions for Practice Our findings highlight the crucial role of institutional delivery to prevent neonatal deaths among those born to disadvantaged women with complications during delivery in this setting. Efforts to improve disadvantaged women’s access to good quality obstetric care must continue in order to further reduce the NMR in Gujarat, India.     

The nutrition transition is underway in India

Nutrition research in India has previously focused on the serious problem of undernutrition related to nutrient deficit and high rates of infection. Recent data from the National Family Health Survey 1998/99 (NFHS 2), however, identified a significant proportion of Indian women as overweight, coexisting with high rates of malnutrition. This paper examines the emerging nutrition transition for women living in rural and urban communities of Andhra Pradesh, India. NFHS 2 provides nationally representative data on women's weight and height. In this paper, we examine representative data from the state of Andhra Pradesh (n = 4032 women). Logistic regression analyses are applied to the data to identify socioeconomic, regional and demographic determinants of overweight and thinness. The major nutrition problem facing women continues to be undernutrition, with 37% having a low body mass index [(BMI) < 18.5 kg/m(2)]; 8% of these women are severely malnourished (BMI < 16 kg/m(2)). However, 12% of the women can be classified as overweight (BMI > 25 kg/m(2)) and 2% are obese (BMI > 30 kg/m(2)). Furthermore, in the large cities of the state in which 4% of the sample live, 37% of women are overweight or obese, whereas in the rural areas in which 74% reside, 43% have a low BMI. Women from lower socioeconomic groups are also significantly more likely to have a low BMI. Findings from the logistic regression models reveal socioeconomic status to be a more important predictor of both over- and underweight than location of residence.     

Nutrient Status Assessment in Individuals and Populations for Healthy Aging—Statement from an Expert Workshop

A workshop organized by the University Medical Center Groningen addressed various current issues regarding nutrient status of individuals and populations, tools and strategies for its assessment, and opportunities to intervene. The importance of nutrient deficiencies and information on nutrient status for health has been illustrated, in particular for elderly and specific patient groups. The nutrient profile of individuals can be connected to phenotypes, like hypertension or obesity, as well as to socio-economic data. This approach provides information on the relationship between nutrition (nutrient intake and status) and health outcomes and, for instance, allows us to use the findings to communicate and advocate a healthy lifestyle. Nutrition is complex: a broader profile of nutrients should be considered rather than focusing solely on a single nutrient. Evaluating food patterns instead of intake of individual nutrients provides better insight into relationships between nutrition and health and disease. This approach would allow us to provide feedback to individuals about their status and ways to improve their nutritional habits. In addition, it would provide tools for scientists and health authorities to update and develop public health recommendations.     

Archimedes: a bold step into the future

The increasing adoption of electronic health records (EHRs) enables the development of new tools to guide clinical research, clinical protocol development, and national policy formulation. Archimedes is an example of a new generation of tools that go beyond identifying past problems with medical devices and pharmaceuticals or failures with health care delivery to predicting potential problems and identifying new treatments and approaches that can improve care. Although the arrival of this new generation of tools raises some concerns, the tools' great potential for improving care must be carefully considered.