Clinical Nutrition and Human Rights. An International Position Paper

The International Working Group for Patients' Right to Nutritional Care presents its position paper regarding nutritional care as a human right intrinsically linked to the right to food and the right to health. All people should have access to food and evidence-based medical nutrition therapy including artificial nutrition and hydration. In this regard, the hospitalized malnourished ill should mandatorily have access to screening, diagnosis, nutritional assessment, with optimal and timely nutritional therapy in order to overcome malnutrition associated morbidity and mortality, while reducing the rates of disease-related malnutrition. This right does not imply there is an obligation to feed all patients at any stage of life and at any cost. On the contrary, this right implies, from an ethical point of view, that the best decision for the patient must be taken and this may include, under certain circumstances, the decision not to feed. Application of the human rights-based approach to the field of clinical nutrition will contribute to the construction of a moral, political, and legal focus to the concept of nutritional care. Moreover, it will be the cornerstone to the rationale of political and legal instruments in the field of clinical nutrition.

Clinical nutrition and human rights. An international position paper

The International Working Group for Patients' Right to Nutritional Care presents its position paper regarding nutritional care as a human right intrinsically linked to the right to food and the right to health. All people should have access to food and evidence-based medical nutrition therapy including artificial nutrition and hydration. In this regard, the hospitalized malnourished ill should mandatorily have access to screening, diagnosis, nutritional assessment, with optimal and timely nutritional therapy in order to overcome malnutrition associated morbidity and mortality, while reducing the rates of disease-related malnutrition. This right does not imply there is an obligation to feed all patients at any stage of life and at any cost. On the contrary, this right implies, from an ethical point of view, that the best decision for the patient must be taken and this may include, under certain circumstances, the decision not to feed. Application of the human rights-based approach to the field of clinical nutrition will contribute to the construction of a moral, political and legal focus to the concept of nutritional care. Moreover, it will be the cornerstone to the rationale of political and legal instruments in the field of clinical nutrition.

Hospital malnutrition in northeast and southeast Asia: A systematic literature review

BACKGROUND & AIMS

Hospital malnutrition is a prevalent yet frequently under-recognised condition that is associated with adverse clinical and economic consequences. Systematic reviews from various regions of the world have provided regional estimates of the prevalence of malnutrition and the magnitude of the associated health and economic burden; however, a systematic assessment of the prevalence and consequences of hospital malnutrition in northeast and southeast Asia has not been conducted.

METHODS

We performed a systematic literature search for articles on hospital malnutrition in 11 Asian countries published in English between January 1, 1997 and January 15, 2018. Studies reporting data on the prevalence, clinical consequences, or economic impact of hospital malnutrition in an adult inpatient population with a sample size ≥30 were eligible for inclusion.

RESULTS

The literature search identified 3207 citations; of these, 92 studies (N = 62,280) met the criteria for inclusion. There was substantial variability in study populations and assessment methods; however, a majority of studies reported a malnutrition prevalence of >40%. Malnutrition was associated with an increase in clinical complications, mortality, length of hospitalisation, hospital readmissions, and healthcare costs.

CONCLUSIONS

Hospital malnutrition is a highly prevalent condition among hospitalised patients in northeast and southeast Asia. Additionally, poor nutritional status is associated with increased morbidity and mortality and increased healthcare costs. Further research aimed at improving the identification and proactive management of hospitalised patients at risk for malnutrition is necessary to improve patient outcomes and alleviate the burden on local healthcare budgets.

Characters of Nutrition Status and Energy-delivery Patterns of the University-based Surgical Intensive Care Units in Thailand (Multi-center THAI-SICU Study)

Aim

The authors aimed to describe nutrition status and energy-delivery characters in multi-center THAI-SICU study.

Material and Methods

Eligible patients admitted in SICU were 1,686 after excluding 563 of 2,249 participants owing to very short stay or non-alive within 24 hours after admission and missing data. The study was a posthoc analysis and multicenter descriptive design. The analytic methods described categorical data in percentage and the continuous data in the median with interquartile range. Variables divided into baseline characteristics and nutrition data before SICU admission, and the pattern of energy delivery in SICU. Statistical significance accepted as a p-value less than 0.05.

Results

The average age was 64 (52-76) years with 57% male. The median of serum albumin level at admission (interquartile range, IQR) was 2.8 (2.2-3.4). There was 46 -47 percent of nutrition risk patient. Less than 10 percent of the patient had enteral (EN), parenteral (PN) or their combination before admission. History of weight loss and appetite loss was 27-31 percent. However, seventy percent of the patient could not define the duration of the symptom. EN was initiated early, but the tendency of full feeding was 7-10 days. At that period, supplemental PN was added around 30 percent of total calories. The composition of PN was quite low in these study which contains only 15-16 percent of total calories. The average energy delivery was 20 kcal/kg/day (the recommendation is 25-30 kcal/kg/day).

Conclusion

The patient's nutrition status before SICU admission was at risk of 46-47% and weight loss and appetite loss might unreliable in ICU setting. EN is started early with gradually increase up to 7-10 days. The average total calories requirement is lower than a recommendation.

Prevalence of Pressure Ulcer and Nutritional Factors Affecting Wound Closure Success in Thailand

Introduction:

The authors aimed to estimate the prevalence of pressure ulcers and to explore the nutritional effects of the prognostic factors on successful pressure ulcer closure in a public tertiary care hospital in Thailand.

Patients and Methods:

The study was a retrospective cohort analysis of seven-year census (2008 - 2014) at Surin hospital in Thailand. There were 424 of total 240,826 patients aged over than 15 years admitted to surgery, orthopedics and medicine wards during the study period with documented pressure ulcers (ICD 10TM). We analyzed four hundred and ten patients after excluding 14 patients with non-pressure ulcers (due to burning/ diabetic/ ischemic neuropathic ulcers, and less than 24 hours of admission) and loss medical record. We selected independent factors from demographic data, nutritional factors, pressure ulcer characteristics, and management data. The outcome of interest was successful pressure ulcer closure. The analysis method was the semi-parametric Cox regression model and reported as Hazard Ratios (HR) with 95% confidence interval (95% CI).

Results:

The total hospital admission was 240,826 patients between 2008 - 2014. 410 patients were developing pressure ulcers, of these, 7% (28/410) success in ulcer closure, and 77% (314/410) failure in closure requiring for additional procedures (excisional debridement). The rest of patients (16%, 68/410) was non-operative care. The prevalence of pressure ulcers was 1.7 per 1,000 person-year. The multivariable model found that only the Nottingham Hospital Screening Tool (NS) score was a statistically significant nutritional variable, and additional subgroup analysis of two models of sepsis and spinal cord co-morbidities was also significant. Adjusted hazard ratios (HR) for NS score = 0.355 (95% CI: 0.187, 0.674), p=0.002), for sepsis = 0.312 (95% CI: 0.140, 0.695), p=0.004), and for spinal cord co-morbidity = 0.420 (95% CI: 0.184, 0.958), p=0.039).

Conclusions:

The annual prevalence was 1.7 per 1,000 persons. NS score was strongly associated with ulcer closure success.

Development of gender- and age group-specific equations for estimating body weight from anthropometric measurement in Thai adults

BACKGROUND

Many medical procedures routinely use body weight as a parameter for calculation. However, these measurements are not always available. In addition, the commonly used visual estimation has had high error rates. Therefore, the aim of this study was to develop a predictive equation for body weight using body circumferences.

METHODS

A prospective study was performed in healthy volunteers. Body weight, height, and eight circumferential level parameters including neck, arm, chest, waist, umbilical level, hip, thigh, and calf were recorded. Linear regression equations were developed in a modeling sample group divided by sex and age (younger <60 years and older ≥60 years). Original regression equations were modified to simple equations by coefficients and intercepts adjustment. These equations were tested in an independent validation sample.

RESULTS

A total of 2000 volunteers were included in this study. These were randomly separated into two groups (1000 in each modeling and validation group). Equations using height and one covariate circumference were developed. After the covariate selection processes, covariate circumference of chest, waist, umbilical level, and hip were selected for single covariate equations (Sco). To reduce the body somatotype difference, the combination covariate circumferences were created by summation between the chest and one torso circumference of waist, umbilical level, or hip and used in the equation development as a combination covariate equation (Cco). Of these equations, Cco had significantly higher 10% threshold error tolerance compared with Sco (mean percentage error tolerance of Cco versus Sco [95% confidence interval; 95% CI]: 76.9 [74.2-79.6] versus 70.3 [68.4-72.3]; P < 0.01, respectively). Although simple covariate equations had more evidence errors than the original covariate equations, there was comparable error tolerance between the types of equations (original versus simple: 74.5 [71.9-77.1] versus 71.7 [69.2-74.3]; P = 0.12, respectively). The chest containing covariate (C) equation had the most appropriate performance for Sco equations (chest versus nonchest: 73.4 [69.7-77.1] versus 69.3 [67.0-71.6]; P = 0.03, respectively). For Cco equations, although there were no differences between covariates using summation of chest and hip (C+Hp) and other Cco but C+Hp had a slightly higher performance validity (C+Hp versus other Cco [95% CI]: 77.8 [73.2-82.3] versus 76.5 [72.7-80.2]; P = 0.65, respectively).

CONCLUSION

Body weight can be predicted by height and circumferential covariate equations. Cco had more Sco error tolerance. Original and simple equations had comparable validity. Chest- and C+Hp-containing covariate equations had more precision within the Sco and Cco equation types, respectively.

Height prediction from anthropometric length parameters in Thai people

Height is an important clinical parameter. However, there were no specific measurements available for particular clinical situations. Although many anthropometric measurements were suggested, no formula was recommended in Thailand. The objective of this study was to develop a formula for height prediction with acceptable validity. Two thousand volunteers were included and were divided consecutively according to both age and gender. Model and validation groups were further separated independently. Linear regression was analyzed to create a predictive formula. Ten parameters were included and analyzed. Of these, demispan, sitting height and knee height were selected with a correlation coefficient of more than 0.5 and significant F test in all age groups and genders. All single parameters and the highest predictive value of double (sitting and knee height) and triple regression models (demispan, sitting and knee height) were proposed and these were modified into a simple formula. After validation of both formulas the correlation, quantitative error and relative error were comparable. The simple formula had more than 90% precision with an error of up to 10 cm in the validation group (89.7 to 99.0% in range). Of these, knee height had the least predictive error in all subgroups. The double and triple models had decreased error only in the younger group. In summary, anthropometric parameters with demispan, sitting height, knee height and combination could be applied to height prediction in the adult Thai with acceptable error. These formulas should be applied only in people who could not be directly measured.

The variations of body mass index and body fat in adult Thai people across the age spectrum measured by bioelectrical impedance analysis

Background

The measurements of body mass index (BMI) and percentage of body fat are used in many clinical situations. However, special tools are required to measure body fat. Many formulas are proposed for estimation but these use constant coefficients of age. Age spectrum might affect the predicted value of the body composition due to body component alterations, and the coefficient of age for body fat prediction might produce inconsistent results. The objective of this study was to identify variations of BMI and body fat across the age spectrum as well as compare results between BMI predicted body fat and bioelectrical impedance results on age.

Methods

Healthy volunteers were recruited for this study. Body fat was measured by bioelectrical impedance. The age spectrum was divided into three groups (younger: 18–39.9; middle: 40–59.9; and older: ≥60 years). Comparison of body composition covariates including fat mass (FM), fat free mass (FFM), percentage FM (PFM), percentage FFM (PFFM), FM index (FMI) and FFM index (FFMI) in each weight status and age spectrum were analyzed. Multivariable linear regression coefficients were calculated. Coefficient alterations among age groups were tested to confirm the effect of the age spectrum on body composition covariates. Measured PFM and calculated PFM from previous formulas were compared in each quarter of the age spectrum.

Results

A total of 2324 volunteers were included in this study. The overall body composition and weight status, average body weight, height, BMI, FM, FFM, and its derivatives were significantly different among age groups. The coefficient of age altered the PFM differently between younger, middle, and older groups (0.07; P = 0.02 vs 0.13; P < 0.01 vs 0.26; P < 0.01; respectively). All coefficients of age alterations in all FM- and FFM-derived variables between each age spectrum were tested, demonstrating a significant difference between the younger (<60 years) and older (≥60 years) age groups, except the PFFM to BMI ratio (difference of PFM and FMI [95% confidence interval]: 17.8 [12.8–22.8], P < 0.01; and 4.58 [3.4–5.8], P < 0.01; respectively). The comparison between measured PFM and calculated PFM demonstrated a significant difference with increments of age.

Conclusion

The relationship between body FM and BMI varies on the age spectrum. A calculated formula in older people might be distorted with the utilization of constant coefficients.