Prevalence of Hospital Malnutrition in Latin America: The Multicenter ...

APPLIED NUTRITIONAL INVESTIGATION
Prevalence of Hospital Malnutrition in Latin
America: The Multicenter ELAN Study
INTRODUCTION
M. Isabel T. D. Correia, MD, PhD, and Antonio Carlos L. Campos, MD, PhD, for the
ELAN Cooperative Study
From Belo Horizonte, Brazil
OBJECTIVE: We determined the nutrition status and prevalence of malnutrition as determined by the
Subjective Global Assessment in Latin America, investigated the awareness of the health team with regard
to nutrition status, evaluated the use of nutritional therapy, and assessed the governmental policies
regulating the practice of nutritional therapy in each country.
METHODS: This cross-sectional, multicenter epidemiologic study enrolled 9348 hospitalized patients older
than 18 y in Latin America. Student’s t test and chi-square tests were used to analyze univariate analysis
and multiple logistic regression analysis, respectively.
RESULTS: Malnutrition was present in 50.2% of the patients studied. Severe malnutrition was present in
11.2% of the entire group. Malnutrition correlated with age (60 y), presence of cancer and infection, and
longer length of hospital stay (P 0.05). Fewer than 23% of the patients’ records contained information
on nutrition-related issues. Nutritional therapy was used in 8.8% of patients (6.3% enteral nutrition and
2.5% parenteral nutrition). Governmental policies ruling the practice of nutritional therapy exist only in
Brazil and Costa Rica.
CONCLUSIONS: Hospital malnutrition in Latin America is highly prevalent. Despite this prevalence,
physicians’ awareness of malnutrition is weak, nutritional therapy is not used routinely, and governmental
policies for nutritional therapy are scarce. Nutrition 2003;19:823–825. ©Elsevier Inc. 2003
KEY WORDS: nutrition assessment, malnutrition, nutrition awareness, nutritional therapy
Hospital malnutrition has been a worldwide reality and challenge.
Its prevalence has been reported to be in the range of 30% to 50%.
A recent study in Latin America indicated that 48.1% of hospitalized
patients are malnourished, with severe malnutrition being
present in 12.6% of the entire group. 1 There are several risk factors
associated with the development of this carential syndrome, of
which low socioeconomic status, disease per se, older age, and
depression can be mentioned. 1,2 Malnutrition has a negative impact
on the patients’ outcome by increasing morbidity, mortality,
length of hospital stay, and costs. 3–9 Despite its high prevalence,
malnutrition is seldom recognized and identified by medical
teams. 1,10,11 As a consequence, nutritional therapy is underprescribed,
thus increasing the problem.
In Latin America, a continent characterized by contrasts, where
huge populations live in poverty, there are scarce resources dedicated
to health issues and, as a consequence, there is a lack of
hospital beds. Therefore, it is extremely important to optimize the
use of available beds. Adequate nutritional treatment in an attempt
to prevent malnutrition-related morbidity and mortality may be an
option to decrease hospital length of stay and costs. By decreasing
hospitalization time, more hospital beds likely would become
available to increase the number of patients receiving health care.
However, the prevalence of hospital malnutrition has been addressed
in only a few countries. Further, nutritional therapy is not
included in governmental health care policies in most countries.
Therefore, the Latin American Federation of Parenteral and Enteral
Nutrition (FELANPE) carried out a multicenter study, the
ELAN Project, to assess the nutrition status of hospitalized patients
Correspondence to: M. Isabel T. D. Correia, MD, PhD, Rua Gonçalves
Dias 332, Apto. 302, Belo Horizonte MG 30140-090, Brazil. E-mail:
isabel_correia@uol.com.br
in Latin America. ELAN means Latin American Nutrition Study in
Portuguese and Spanish.
METHODS
This was a multicenter trial, designed and carried out by members
of FELANPE in 13 countries: Argentina, Brazil, Chile, Costa Rica,
Cuba, Dominican Republic, Mexico, Panama, Paraguay, Peru,
Puerto Rico, Venezuela, and Uruguay. The protocol of the previous
Brazilian study (Ibranutri) was thoroughly followed. 1,12 In
each country, a national coordinator was named, and this person
with other participants were trained by one of the authors
(M.I.T.D.C.). Nutrition assessment was performed with the Subjective
Global Assessment (SGA), and the evaluation protocol
used by Destky et al. 13 was followed. This is an essentially clinical
assessment tool that covers various aspects of a patient’s nutritional
history from body weight changes to functional capacity
alterations. All the questions are important in categorizing nutrition
status, but it was suggested that the most important factors to
be considered should be changes in body weight and the severity
of the disease. Body weight loss in the previous 6 mo greater than
5% is considered mild, that between 5% and 10% is considered
moderate, and that greater than 10% is considered severe. The
more severe the disease is, the greater the stress and, hence, the
greater the metabolic requirements. During the training sessions
and to fully comply with the SGA, several real patient cases were
presented and discussed among participants. Those who participated
in data collection were physicians, dietitians, nurses, pharmacists,
and students of different professions. The SGA was
validated before the beginning of the Brazilian study with the
coefficient test, and an agreement rate of 86.8% was obtained. 12
The inclusion criteria for hospitals were 1) to be a general
hospital, 2) a hospital with at least 200 beds, and 3) consent to
participation by the hospital administration and the institutional
Nutrition 19:823–825, 2003
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824 Correia and Campos Nutrition Volume 19, Number 10, 2003
ethical committee. The enrolled patients were older than 18 y and
had not been hospitalized within the 6 mo before the study.
Obstetric and pediatric patients were excluded. Patients were randomly
assigned weekly throughout the study until the completion
of the predetermined sample size for each country. Sample size
was based on the population of each country, although, in some
countries such as in Cuba, the number of patients enrolled was
larger because it was their interest to include more patients. In
contrast, in Mexico, due to local problems, the number of patients
evaluated was insufficient to fully reflect the prevalence of malnutrition
in that country.
The statistical analyses were performed with SPSS 6.12 (1995;
SPSS, Chicago, IL, USA). The statistical analysis included frequency
distributions of all variables. The odds ratio was calculated
to determine the association between risk factors and malnutrition.
For continuous variables, Student’s t test was used; for univariate
analysis, the chi-square test was used. Statistical significance was
defined as P 0.05. The variables identified as risk factors for
malnutrition by the univariate analysis were then entered in a
multiple regression analysis model.
RESULTS
TABLE I.
PATIENT DISTRIBUTION ACCORDING TO COUNTRY
Country n patients
Argentina 1000
Brazil 4000
Chile 525
Costa Rica 199
Cuba 1361
Dominican Republic 132
Mexico 335
Panama 700
Paraguay 230
Puerto Rico 126
Peru 352
Venezuela 188
Uruguay 200
There were 9348 patients enrolled whose mean age was 52.2
18.4 y, and 51% were men. The distribution according to the
country is presented in Table I. Malnutrition was diagnosed in
50.2% of patients, with severe malnutrition in 11.2% of the entire
sample. The prevalence of malnutrition in each country can be
seen in Table II. Despite the high prevalence of malnutrition,
reference to the nutrition status of the patients was registered in
only 23.1% of the medical records. The usual weight was mentioned
in only 28.5% of cases. Weight at hospital admission was
obtained in only 26.5% of patients, and height was measured in
32.9%. Scales were available (within 50 m of the patient’s bed) in
74.9% of cases. Serum albumin was recorded in 26.5% of the
patients’ medical records. There were no statistically significant
differences between countries in terms of these data. Age older
than 60 y, the presence of infection or cancer, length of hospitalization
previous to the nutritional assessment, and internal medicine
patients were identified in the univariate analysis as significant
risk factors for malnutrition (Table III). These variables were
entered into the multivariate logistic regression model, which
confirmed the association between these variables and malnutrition
(outcome variable), as shown in Table IV.
Despite this high prevalence of malnutrition, nutritional therapy
was being prescribed to few patients: oral supplementation to 683
patients (7.3%); enteral nutrition to 530 (5.6%), and parenteral
nutrition to 217 (2.3%).
Brazil and Costa Rica are the only countries where there are
governmental policies concerning nutritional teams and the practice
of nutritional therapy. In Brazil these policies became mandatory
nationwide in 1998, after the publication of the first results
of the Brazilian (Ibranutri) study. 1 In the Dominican Republic,
Paraguay, and Uruguay, the government does not pay for the
nutritional therapy used, which is considered the responsibility of
the hospitals.
DISCUSSION
Malnutrition is still highly prevalent among hospitalized patients
in Latin America in the beginning of the new millennium. Whereas
the Brazilian study 1,12 that encompassed 4000 patients was carried
out in 1996, the other surveys showing identical overall rates of
malnutrition were carried out between 1998 and 2000. These
results are similar to others reported in the literature, in a different
period. 11,14–17
TABLE III.
VARIABLES CONSIDERED RISK FACTORS FOR MALNUTRITION
(UNIVARIATE ANALYSIS)
Risk factor
Malnourished
(%)
TABLE II.
PREVALENCE OF MALNUTRITION ACCORDING TO COUNTRY
Country
Moderate/severe
malnutrition (%)
Well nourished
(%) Relative risk (CI)
Age 60 y 53.0 47.0 1.55* (1.43–1.73)
Internal medicine 52.1 47.9 1.57* (1.43–1.73)
Infection 60.9 39.9 2.40* (2.16–2.60)
Cancer 65.6 34.4 2.68* (2.39–3.23)
LOS 2 d 33.0 67.0
LOS 2–7 d 42.7 53.7 1.51* (1.31–1.73)
LOS 7–14 d 49.1 50.9 1.95* (1.68–2.26)
LOS 14 d 59.7 40.3 3.00* (2.61–3.45)
* P 0.05.
CI, confidence interval; LOS, length of hospital stay
Severe
malnutrition (%)
Argentina 61.9* 12.4*
Brazil 48.1* 12.6*
Chile 37.0 4.6
Costa Rica 50.3* 18.1*
Cuba 39.0† 10.1*
Dominican Republic 60.3* 9.5*
Mexico 64.0* 13.0*
Panama 40.5† 5.5†
Paraguay 40.9† 10.0*
Puerto Rico 39.2* 12.8*
Peru 50.0* 17.0*
Venezuela 48.7* 16.6*
Uruguay 51.0* 17.0*
* P 0.05.
† Not significant.

Nutrition Volume 19, Number 10, 2003 Prevalence of Hospital Malnutrition in Latin America
825
TABLE IV.
VARIABLES CONSIDERED RISK FACTORS FOR MALNUTRITION
ACCORDING TO MULTIVARIATE ANALYSIS
Variable OR CI
Age 60 y 1.38* 1.28–1.54
Internal medicine 1.66* 1.49–1.86
Presence of infection 2.30* 2.04–2.59
LOS 2.55* 2.19–3.02
Presence of cancer 2.94* 2.55–3.39
* P 0.05.
CI, confidence interval; LOS, length of hospital stay; OR, odds ratio
Nutrition assessment was performed with the SGA instead of
the classic anthropometric measurements. 13 This method may be
controversial because the SGA is essentially a clinical tool. The
differences we found in the severity of malnutrition in Chile and
Panama might be explained by a bias induced by the observers
who could have underestimated or overestimated the degree of
malnutrition. SGA was chosen after having been tested in the pilot
study, when agreement across interviewers was greater than 80%
with the coefficient. 12 Similar results were found by others,
indicating that the SGA, when used appropriately by trained teams,
can be a reliable tool to assess nutrition status and predict morbidity,
mortality, and length of hospital stay. 3,13,16
Several risk factors contribute to the development of malnutrition,
such as low socioeconomic status, older age, the disease per
se, length of hospital stay, and lack of medical awareness. 1,2,11,18 In
Latin America, most of these variables were confirmed as statistically
significant risk factors for deteriorating nutrition status. As
reported in other series, medical awareness is one of the factors
that might contribute to the worsening of nutrition status of hospitalized
patients, especially of those in the hospital for longer
periods. 1,3,11,17 Lack of medical awareness might be a consequence
of the absence of formal nutritional education in graduate and
postgraduate training in most medical schools. In Latin America,
similar to what happens worldwide, very few Medical programs
include nutrition as a discipline of the medical curriculum. 19 This
is later reflected in the lack of attention to nutritional issues. The
ELAN study showed that the number of patients weighed and
measured at admission was extremely low, despite the availability
of scales near the patients’ beds. Also, references to nutrition status
as simple as “reports having lost weight,”“skinny,” and “malnourished”
were reported in the medical records in fewer than 25% of
the patients, which led us to conclude that this is definitely not an
issue considered throughout the patient’s stay in the hospital.
Despite the high prevalence of malnutrition, nutritional therapy
was seldom prescribed to patients, thus reinforcing the fact that
nutrition-related issues are not part of the patients’ routine care.
To worsen the situation, in most countries, there are no official
guidelines concerning nutrition teams and the practice of nutritional
therapy. Brazil and Costa Rica are the exceptions. In Brazil,
for example, governmental regulations became mandatory after the
presentation of the Ibranutri results to the Ministry of Health by the
Brazilian Society of Parenteral and Enteral Nutrition. 20,21
In conclusion, hospital malnutrition in Latin America is highly
prevalent and should be addressed as an important health issue.
Strategies should be created to stimulate governmental policies
and educational attitudes, similar to what has been done in Brazil.
The national societies with FELANPE will have a key role in this
task by using the ELAN results to reinforce the need to face the
challenge of hospital malnutrition and its devastating
consequences.
ACKNOWLEDGMENTS
The authors acknowledge the investigation leaders (country national
coordinators) of the ELAN Collaborative Study: Adriana
Crivelli, MD (Argentina), Alfredo Matos, MD (Panama), Gabriela
Parallada, MD (Uruguay), Gertrudis Baptista, RD (Venezuela),
Horácio Massotto, MD (Costa Rica), Jesús Barreto, MD (Cuba),
Juan Kehr, MD (Chile), Rafael Figueredo, MD (Paraguay), Sergio
Echenique, MD (Peru), Victor Sánchez, MD (Mexico), Victoria
Soñé, MD (Dominican Republic), Zulma Gonzalez, MD (Puerto
Rico), and their teams who so promptly accepted the task of
collecting data and interviewing the patients. They thank
FELANPE’s affiliate societies that supported the idea and stimulated
the teams to carry out the study. They also thank Ms. Inara
Fonseca for statistical support.
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